NTSB Safety Recommendation P-97-001

NTSB safety recommendation P-97-001.

THE NTSB RECOMMENDS THAT THE ENRON CORPORATION: IMMEDIATELY RETRAIN ALL SAN JUAN GAS COMPANY EMPOYEES WHO PERFORM LEAK DETECTION TASKS, INSTRUCTING THEM HOW TO DETERMINE WHETER PROPANE GAS HAS LEAKED FROM THE PIPELINE SYSTEM, WHERE & AT WHAT DEPTH TO TEST THE SUBSURFACE, & HOW TO DEFINE THE LIKELY EXTENT OF GAS MIGRATION; IN ADDITION, IMPLEMENT A MEANS OF MEASURING THE EFFECTIVENESS OF THE TRAINING PROVIDED. (URGENT)

Priority: CLASS I

Overall Status: Closed - Acceptable Action

Issued Date: 1997-02-25

Adopted Date: 1997-02-24

Overall Date Closed: 2002-07-29

Synopsis: ABOUT 8:30 A.M. ON 11/21/96, AN EXPLOSION OCCURRED IN THE HUMBERTO VIDAL SHOE STORE & OFFICE BUILDING AT 100 JOSE DE DIEGO CALLE IN RIO PIEDRAS, PUERTO RICO. LOCAL EMERGENCY AGENCIES RESPONDED & INITIATED SEARCH & RESCUE OPERATIONS, BY 12/5/96 30 FATALITIES HAD BEEN CONFIRMED, & 5 PEOPLE, BELIEVED TO STILL BE IN THE BUILDING RUINS, WERE MISSING. LOCAL AUTHORITIES HAVE SUSPENDED SEARCH EFFORTS UNTIL THE BUILDING CAN BE MADE SAFE FOR RESCUE WORKERS.

Probable Cause: The National Transportation Safety Board determines that the probable cause of the propane gas explosion, fueled by an excavationcaused gas leak, in the basement of the Humberto Vidal, Inc., office building was the failure of San Juan Gas Company, Inc., (1) to oversee its employees’ actions to ensure timely identification and correction of unsafe conditions and strict adherence to operating practices and (2) to provide adequate training to employees. Also contributing to the explosion was (1) the failure of the Research and Special Programs Administration/Office of Pipeline Safety to oversee effectively the pipeline safety program in Puerto Rico, (2) the failure of the Puerto Rico Public Service Commission to require San Juan Gas Company, Inc., to correct identified safety deficiencies, and (3) the failure of Enron Corp. to oversee adequately the operation of San Juan Gas Company, Inc.

Keywords: Leak Detection,Training and Education

Ntsbnumber: DCA97MP004

Report Number: PAR-97-01

Addressee Name: Enron Corporation

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2002-07-29

Addressee Organization Type: P-Private Industry

Communication Date: 2002-03-05

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 03/08/2002 3:02:09 PM MC# 2020270 Action taken by San Juan Gas: In his letter dated May 2, 1997, Mr. Thomas White, then Chairman of the Board of San Juan Gas, stated the following: The San Juan Gas employees completed refresher course programs in December of 1996 and February of 1997. San Juan Gas has since provided to the Safety Board summaries of the material covered in these courses, the names of the employees that have taken the courses and the course test scores for these individuals. San Juan Gas has also sent to the Board copies of the actual leak detection and leak pinpointing tests taken by San Juan Gas operational employees.

Addressee Organization Type: P-Private Industry

Communication Date: 1997-02-28

Communication Type: Official Correspondence

Communication Contents: THE RESPONSE STATES THAT SAN JUAN GAS COMPANY EMPLOYEES HAVE BEEEN TRAINED IN LEAK DETECTION, REPAIR, & OPERATIONAL SAFETY. THE COMPANY MAINTAINS THAT THEIR EMPLOYEES WERE OBSERVED IN THE FIELD BY CONSULTANTS TO MEASURE THE EFFECTIVENESS OF THE LEAK DETECTION TRAINING. MR. WHITE'S LETTER STATES THAT SAN JUAN GAS WILL CONTINUE TO CONDUCT TRAINING & EVALUATE THE EFFECTIVENESS OF SUCH INSTRUCTION IN LINE WITH THE RECOMMENDATION. ALSO WE NOTED THAT THE SAN JUAN GAS MANAGER, MR. GUTIERREZ, WAS QUOTED ON 2/27/97 IN THE SAN JUAN STAR AS SAYING THAT ALL EMPLOYEES ARE GOING TO BE RETAINED USING A METHODICAL PROCESS THAT DOCUMENTS THE TRAINING EACH HAS BEEN GIVEN & THAT DEMONSTRATES THEIR PROFICIENCY.

Addressee Organization Type: P-Private Industry

Communication Date: 1997-05-02

Communication Type: Official Correspondence

Communication Contents: THE RESPONSE STATES THAT SAN JUAN GAS COMPANY EMPLOYEES HAVE RECEIVED FORMAL CLASSROOM TRAINING & WILL CONTINUE TO RECEIVE ON THE JOB TRAINING LEAK DETECTION & REPAIR. PRIOR TO RECEIPT OF THE RECOMMENDATION, SAN JUAN GAS PROVIDED LEAK DETECTION REFRESHER COURSES FOR ITS OPERATIONAL EMPLOYEES. ALSO, SAN JUAN GAS UNDERTOOK DEVELOPMENT & IMPLEMENTATION OF A COMPREHENSIVE, LONG-TERM TRAINING PROGRAM. AT THE BOARD'S 6/2/97 PUBLIC HEARING, MR. WHITE TESITIFIED ON THE NEW TRAINING PROGRAM BEING DEVELOPED & ADDITIONAL INFO ON THIS PROGRAM IS TO BE PROVIDED FOR SAFETY BOARD STAFF REVIEW.

Addressee Organization Type: P-Private Industry

Communication Date: 2002-07-29

Communication Type: Official Correspondence

Communication Contents: The Safety Board has again reviewed the May 2, 1997, letter from Mr. Thomas White, then--Chairman of the Board of SJG. SJG reported in 1997, that between December 1996 and February 1997, SJG developed and implemented a comprehensive, long-term training program. This included a refresher course program, in which experienced personnel from a consulting firm conducted courses in gas leak detection, leak investigation, and leak pinpointing as well as the use, maintenance, and calibration of accepted industry standard devices, such as the gas measurement indicator and the combustible gas indicator. Further, as part of the program, the consultants administered written tests to all class participants and reviewed the results in a follow-up class. In addition to the written tests, the consultants have performed and continue to perform field verification of the skills obtained through training. Accordingly, because SJG has revised its training and implemented a means to measure its effectiveness as requested, Safety Recommendation P-97-1 is classified "Closed--Acceptable Action."

Addressee Organization Type: P-Private Industry

Communication Date: 1997-04-10

Communication Type: Official Correspondence

Communication Contents: THE BOARD ACKNOWLEDGES ENRON'S COMMITMENT TO TRAINING; HOWEVER, NEITHER MR. WHITE NOR MR. GUTIERREZ MAKE CLEAR WHETHER OR HOW THE LEAK DETECTION & OTHER OPERATIONAL TRAINING WILL DIFFER FROM THAT PREVIOUSLY PROVIDED. THE BOARD BELIEVES THAT ENRON PLANS TO PROVIDE EFFECTIVE TRAINING FOR SAN JUAN GAS EMPLOYEES, & WE WOULD APPRECIATE RECEIVING DETAILED INFO ABOUT THE TRAINING PLANS, THE MEANS TO BE USED TO EVALUATE THE EFFECTIVENESS OF THAT TRAINING, & THE TIMEFRAME FOR COMPLETING THE TRAINING. IN THE INTERIM P-97-1 & -2 HAVE BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

Addressee Organization Type: P-Private Industry

Communication Date: 1997-07-02

Communication Type: Official Correspondence

Communication Contents: P-97-1 ASKED ENRON CORPORATION TO IMMEDIATELY RETRAIN ALL SAN JUAN GAS EMPLOYEES WHO PERFORM LEAK DETECTION TASK,S INSTRUCTING THEM HOW TO DETERMINE WHETHER PROPONE GAS HAS LEAKED FROM THE PIPELINE SYSTEM, WHERE & AT WHAT DEPTH TO TEST THE SUBSURFACE, & HOW TO DEFINE THE LIKELY EXTENT OF GAS MIGRATION. THE RECOMMENDATION ALSO ASKED ENRON CORPORATION TO IMPLEMENT A MEANS OF MEASURING THE EFFECTIVENESS OF THE TRAINING PROVIDED. MR. WHITE'S LETTER STATES THAT SAN JUAN GAS OPERATIONS PRESONNEL HAVE ALREADY RECEIVED FORMAL CLASSROOM TRAINING & ARE RECEIVING ON-THE-JOB TRAINING IN LEAK DETECTION & REPAIR. HE ALSO ADVISED THAT SAN JUAN GAS HAS DEVELOPED & IMPLEMENTED A COMPREHENSIVE, LONG-TERM TRAINING PROGRAM. PENDING SAFETY REVIEW OF THIS TRAINING PROGRAM, P-97-1 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

Addressee Organization Type: P-Private Industry

Communication Date: 2001-10-05

Communication Type: Official Correspondence

Communication Contents: To date, the Safety Board has not received any further response from Enron and would appreciate being informed about any additional efforts that have been made to implement Safety Recommendations P-97-1 through -4. Enclosed are copies of our correspondence concerning these recommendations. Please address your response to Ms. Marion C. Blakey, Chairman, National Transportation Safety Board, and refer to the recommendations by number in your response.