NTSB Safety Recommendation P-97-002

NTSB safety recommendation P-97-002.

THE NTSB RECOMMENDS THAT THE ENRON CORPORATION: PROMPTLY DEVELOP & IMPLEMENT FOR SAN JUAN GAS COMPANY EMPLOYEES WHO PERFORM OPERATIONAL & SAFETY-SENSITIVE RESPONSIBILITIES A TRAINING PROGRAM THAT IS BASED ON AN EVALUATION OF TASKS ASSIGNED, SO THAT IT IMPARTS THE TECHNICAL & PROCEDURAL INFO NEEDED TO CORRECTLY PERFORM THEIR DUTIES, & THAT INCORPORATES A MEANS OF MEASURING THE EFFECTIVENESS OF THE TRAINING PROVIDED.

Priority: CLASS II

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: 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: San Juan Gas developed and implemented a comprehensive training program that known as the San Juan Gas Company Training and Qualification System. The training program is task oriented and more fully described in Mr. White's letter of May 2, 1997. A complete copy of the training program materials was sent to the Safety Board for review during September 1997.

Addressee Organization Type: P-Private Industry

Communication Date: 1997-02-28

Communication Type: Official Correspondence

Communication Contents: THE LETTER OF RECOMMENDATION ACKNOWLEDGES THAT THE SAN JUAN GAS COMPANY EMPLOYEES HAD RECEIVED TRAINING IN LEAK DETECTION & REPAIR BUT THE EMPLOYEES WORK HAS SHOWN THAT THE TRAINING WAS NOT EFFECTIVE. THEIR PERFORMANCE IN RESPONSE TO THE GAS ODOR REPORTS FROM 100 CALLE JOSE DE DIEGO SHOWED THAT THE LACKED BASIS SKILLS IN KNOWING HOW TO PERFORM EFFECTIVE LEAK DETECTION WORK. IN STATEMENTS TO BOARD INVESTIGATORS, EMPLOYEES ACKNOWLEDGED THAT THEY HAD NOT BEEN TESTED BEFORE THE EXPLOSION TO ENSURE THAT THEY CORRECTLY UNDERSTOOD THE LEAK DETECTION PRINCIPLES TAUGHT TO THEM. EVEN THOUGH THE EMPLOYEES INTERVIEWED HAD ADDITIONAL LEAK DETECTION TRAINING AFTER THE EXPLOSION & HAD TAKEN & PASSED TESTS ON THAT TRAINING, THEY CONTINUED TO MAINTAIN THAT LEAKAGE TESTS SHOULD BE PERFORMED IN BAR HOLES AT 18 INCHES DEEP OVER THE GAS MAINS WITHOUT REGARD TO THE DEPTH OF THE GAS MAIN. SUCH LEAK TEST PROCEDURES WOULD BE INADEQUATE TO DISCOVER ALL AREAS OF LEAKAGE FROM THE GAS MAINS & THEY ARE NOT CONSISTENT WITH THE TRAINING MATERIAL INSTRUCTIONS USED BY THE CONSULTANT. WITH RESPECT TO EMPLOYEE TRAINING ON OPERATING PRACTICES, EMPLOYEES ACKNOWLEDGED THAT THEY WERE TOLD TO READ THEM, BUT THEY ADVISED THAT THEY WERE NEVER TESTED TO DETERMINE IF THEY CORRECTLY UNDERSTOOD WHAT WAS EXPECTED OF THEM.

Addressee Organization Type: P-Private Industry

Communication Date: 1997-05-02

Communication Type: Official Correspondence

Communication Contents: THE RESPONSE ADVISING THAT SAN JUAN GAS IS IN THE PROCESS OF DEVELOPING & IMPLEMENTING A COMPREHENSIVE TRAINING PROGRAM THAT WILL GOVERN CURRENT & ALL FUTURE TRAINING OF SAN JUAN GAS EMPLOYEES. THE FOUR OVERALL PHASE OF TRAINING IN THE PROGRAM WILL BE IMPLEMENTED THROUGH THE COMBINED EXPERTISE OF COMPANY (ENRON) PERSONNEL & OUTSIDE EXPERTISE. IT WILL CONSIST OF A COMBINATION OF FUNDAMENTAL SKILLS TRAINING IN THE USE OF BASIC WORK TOOLS & EQUIPMENT, PROFESSIONAL TECHNICAL SCHOOLS FOR KEY PERSONNEL & ON-THE JOB TRAINING PROGRAMS DEVELOPED BY EXPERIENCED OR PROFESSIONALLY TRAINED EMPLOYEES. THE FOUR PHASES ARE: ORIENTATION & MANDATORY SAFETY, & HEALTH TRAINING; FUNDAMENTALS TRAINING; COMPANY OVERVIEW; & JOB SPECIFIC TRAINING. THE DEVELOPMENT OF THE FIRST & SECOND PHASES IS COMPLETE. THE THIRD PHASE IS VIRTUALLY COMPLETE. DEVELOPMENT OF THE FOURTH PHASE IS UNDERWAY. THE COMPREHENSIVE PROGRAM USES WRITTEN TESTS, FIELD SKILLS VERTIFICATION, & PERIODIC REVIEW TO MEASURE THE EFFECTIVENESS OF THE PROGRAM.

Addressee Organization Type: P-Private Industry

Communication Date: 2002-07-29

Communication Type: Official Correspondence

Communication Contents: The Safety Board also reviewed the SJG letter of May 2, 1997, regarding action taken to implement Safety Recommendation P-97-2. SJG had advised the Board that it was developing and implementing a comprehensive training program. The program governs current and all future training of SJG employees, as well as every aspect of SJG operations. The overall phases of the training program were implemented through the combined expertise of SJG company experts and outside consultants, including equipment manufacturers, gas distribution industry company experts, and professional technical school staff. The program consists of fundamental skills training in the use of basic work tools and equipment, professional technical schools for key personnel, and on-the-job training programs developed by experienced or professionally trained employees. The training program includes four phases: orientation and mandatory safety and health training; fundamentals training; company overview; and job specific training. Further, the comprehensive training uses written tests, field skills verification, and periodic reviews to measure program effectiveness, conducted by designated subject matter experts identified by SJG from within its own ranks or from gas industry consulting firms when appropriate. Accordingly, because SJG has revised its training program and implemented a means to measure its effectiveness, Safety Recommendation P-97-2 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-97-2 ASKED ENRON CORPORATION PROMPTLY DEVELOP & IMPLEMENT FOR SAN JUAN GAS COMPANY EMPLOYEES WHO PERFORM OPERATION & SAFETY-SENSITIVE RESPONSIBILITES A TRAINING PROGRAM THAT IS BASED ON AN EVALUATION OF TASKS ASSIGNED, SO THAT IT IMPARTS THE TECHNICAL & PROCEDURAL INFO NEEDED TO CORRECTLY PERFORM THEIR DUTIES, & THAT INCORPORATES A MEANS OF MEASURING THE EFFECTIVENESS OF THE TRAINING PROVIDED. TESTIMONY AT THE JUNE 2-5. 1997, PUBLIC HEARING ADVISED THAT THE COMPREHENSIVE TRAINING & VERTIFICATION PROGRAM CALLED FOR IN THIS RECOMMENDATION WILL BE COMPLETED SOON. P-97-2 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESONSE," PENDING DETAILED PROGRAM REVIEW BY THE THE SAFETY BOARD STAFF.

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.