NTSB Safety Recommendation P-97-003

NTSB safety recommendation P-97-003.

THE NTSB RECOMMENDS THAT THE ENRON CORPORATION: REVISE THE SAN JUAN GAS COMPANY'S PUBLIC EDUCATION PROGRAM SO THAT MEMBERS OF THE PUBLIC UNDERSTAND THE DANGER POSED BY A RELEASE OF PROPANE GAS, CAN TELL WHEN SUCH A RELEASE HAS OCCURRED, & KNOW WHEN STEPS SUCH AS EVACUATING THE AREA OR NOTIFYING THE LOCAL EMERGENCY-RESPONSE AGENCIES ARE APPROPRIATE; INCORPORATE IN THE PROGRAM A MEANS OF MEASURING ITS EFFECTIVENESS. (URGENT)

Priority: CLASS I

Overall Status: Closed - Reconsidered

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: Public Education (Pipeline),Training and Education

Ntsbnumber: DCA97MP004

Report Number: PAR-97-01

Addressee Name: Enron Corporation

Addressee Status: Closed - Reconsidered

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 Mr. White communicated with the Safety Board on a number of occasions with regard to Safety Recommendation P-97-3. In his correspondence, Mr. White described the steps that were being taken by San Juan Gas to carry out its public education program. Additionally, the Board was provided with copies of the public education materials that San Juan Gas distributed to its customers. While diligent in its efforts to carry out a comprehensive public education program, San Juan Gas has not incorporated a means of "measuring its effectiveness" as suggested by the Board. Mr. White pointed out in his letter of December 12, 1997, that the governing pipeline safety regulations do not require an operator to measure the effectiveness of a public education program. See 49 C.F.R. 192.616.

Addressee Organization Type: P-Private Industry

Communication Date: 1997-02-28

Communication Type: Official Correspondence

Communication Contents: THE RESPONSE STATES THAT THE COMPANY IS WORKING WITH LOCAL GOVERNMENT AGENCIES TO INCREASE PUBLIC AWARENESS ON THE DANGERS OF PROPANE RELEASES, HOW TO DETECT THEM & APPROPRIATED EMERGENCY RESPONSE MEASURES.

Addressee Organization Type: P-Private Industry

Communication Date: 1997-05-02

Communication Type: Official Correspondence

Communication Contents: SAN JUAN GAS HAS EMPLOYED A PUBLIC RELATIONS FIRM TO AUGMENT ITS CURRENT PUBLIC EDUCATION PROGRAM. THE PRIMARY OBJECTIVES OF THIS EFFORT ARE TO DEVELOP A COMMUNITY OUTREACH CAMPAIGN TO INFORM AUDIENCE IN A PRACTICAL, PLEASING MANNER ABOUT THE SAFETY USE, HANDLING, & MANAGEMENT OF PROPANE GAS; ESTABLISH AN ON-GOING EDUCATION EFFORT TO KEEP THE COMMUNITY INFORMED ABOUT EFFORTS UNDERTAKEN BY SAN JUAN GAS COMPANY; & IMPLEMENT AN INITAL BENCHMARK STUDY & SUBSEQUENT FOLLOW-UP TO MEASURE THE PROGRAMS EFFECTIVENESS. WHILE AT THE JUNE 2-5, 1997, PUBLIC HEARING, STAFF LEARNED THAT SAN JUAN GAS COMPANY IS PLANNING TO ELIMINATE 200 OF ITS 220 MILE SYSTEM. SAN JUAN GAS COMPANY ALSO HAS FILED WITH THE PUERTO RICO PUBLIC SERVICE COMMISSION A PROPOSAL TO CONTRIBUTE. IT IS NOT CLEAR WHETHER THIS IS TO BE IN LIEU OF OR IN ADDITION TO SAN JUAN GAS HAVING ITS OWN PUBLIC EDUCATION PROGRAM AS REQUIRED BY FEDERAL REGULATIONS.

Addressee Organization Type: P-Private Industry

Communication Date: 1997-09-30

Communication Type: Official Correspondence

Communication Contents: THROUGH SAN JUAN GAS COMPANY, INC., ENRON ADVISES THAT IT HAD PLANNED TO CARRY OUT ITS OWN PUBLIC EDUCATION PROGRAM. HOWEVER ON 5/2/97, THE PUERTO RICO PUBLIC SERVICE COMMISSION APPROVED REDUCING THE 220-MILE GAS SYSTEM TO ONLY 20-MILES & HAVING TO SERVE ONLY COMMERCIAL CUSTOMERS. BECAUSE OF THE REDUCED SYSTEM SIZE & PURPOSE, SAN JUAN GAS COMPANY, INC. IS MODIFYING ITS PUBLIC EDUCATION PROGRAM TO: PROVIDE BY DIRECT MAIL TWICE A YEAR INFO TO CUSTOMERS ABOUT THE USE, HANDLING, & MANAGEMENT OF PROPANE GAS & ONCE A YEAR, PROVIDE ON A TELEPHONE ROLODEX CARD THE STEPS TO TAKE SHOULD A GAS LEAK BE SUSPECTED ALONG WITH A LIST OF EMERGENCY TELEPHONE NUMBERS TO CALL SHOULD THEY SUSPECT A GAS LEAK & PROVIDE A "SCRATCH & SNIFF" BROCHURE TO REMIND CUSTOMERS OF SMELL OF THE ODORANT ADDED TO THE PROPANE GAS; THROUGH DIRECT CONTACT WITH CUSTOMERS, PROVIDE A FLYER CONTAINING SAFETY INFO IN A BULLET POINT FORMAT; ANNUALLY PROVIDE THE ABOVE REFERENCE MATERIALS TO RESIDENTIAL & COMMERCIAL LOCATIONS ADJACENT TO THE REDUCED PIPELINE SYSTEM; & CONTRIBUTE TO AN ISLAND-WIDE PUBLIC EDUCATION PROGRAM COORDINATED BY THE PSC FOR EDUCATING THE PUBLIC ON THE SAFE USE OF PROPANE. THIS LETTER ALSO ADVISED THAT MORE THAN 25,000 "SCRATCH & SNIFF" BROCHURES HAVE ALREADY BEEN DISTRIBUTED TO CUSTOMERS & THE GENERAL PUBLIC.

Addressee Organization Type: P-Private Industry

Communication Date: 1997-12-12

Communication Type: Official Correspondence

Communication Contents: THIS RESPONDS TO YOUR 11/4/97, LETTER TO KEN LAY REGARDING THE PUBLIC EDUCATION PROGRAM OF SAN JUAN GAS COMPANY, INC. OVER THE LAST SEVERAL MONTHS, SAN JUAN GAS HAS UNDERTAKEN THE FOLLOWING PUBLIC EDUCATION PROJECTS: CREATED SCRATCH & SNIFF BROCHURES SPECIFICALLY DEALING WITH ODORIZED PROPANE GAS & DISTRIBUTED APPROXIMATELY 30,000 COPIES OF THE BROCHURE TO SAN JUAN GAS CUSTOMERS & LOCAL GOVERNMENT AGENCIES, BUSINESSES, & CIVIC GROUPS. SEVERAL BROCHURES ARE ENCLOSED. CONTINUED TO DISTRIBUTE TO CUSTOMERS & THE COMMUNITY AN "AVISO IMPORTANTE" BROCHURE WHICH OUTLINES ACTION THAT SHOULD BE TAKEN WHEN THE "ODOR OF GAS" IS DETECTED. A COPY IS ENCLOSED. HELD A SERIES OF EIGHT COMMUNITY MEETING CONCERNING PROPANE GAS SAFETY ISSUES. COMPLETED A BENCHMARK RESEARCH STUDY TO GAUGE THE AWARENESS OF THE PUBLIC, AS WELL AS SAN JUAN GAS CUSTOMERS WITH RESPECT TO PROPANE GAS SAFETY ISSUES. PROPOSED TO THE PUERTO RICO PUBLIC SERVICE COMMISSION THAT EDUCATIONAL MODULE RELATING TO PROPOSED TO THE PUERTO RICO PUBLIC SERVICE COMMISSION THAT EDUCATIONAL MODULES RELATING TO PROPANE GAS SAFETY ISSUES BE DEVELOPED FOR ELEMENTARY, JUNIOR & SENIOR SCHOOLS. PLEDGED $60,000 TO AN EDUCATION FUND TO BE ADMINISTERED BY THE PUERTO RICO PUBLIC SERVICE COMMISSION IN RECOGNITION THAT PROPANE SAFETY EDUCATION IN AN INDUSTRY-WIDE ISSUE. HOSTED THE ONE-CALL DAMAGE PREVENTION SEMINAR FOR LOCAL GOVERNMENT REPRESENTATIVES, CONTRACTORS & OTHER UNDERGROUND UTILITY OPERATORS ON 5/22/97. SPONSORED IN JUNE 1997, THE DOT TRANSPORTATION SAFETY INSTITUTE SEMINAR THAT WAS ATTENDED BY GOVERNMENT AGENCIES, UNDERGROUND UTILITY OPERATORS & FIRST RESPONDERS. ALSO THE PRINTED PUBLIC EDUCATION MATERIALS LISTED IN YOUR LETTER ARE BEING PREPARED. THE DISTRIBUTION OF THESE MATERIALS IS TO COINCIDE WITH COMPLETION OF THE PIPELINE MODERNIZATION PROJECT, WHICH IS TARGETED FOR JULY 1998. WITH REGARD TO AN ASSESSMENT OF THESE VARIOUS EFFORTS AT PUBLIC EDUCATION, WE NOTE THAT THIS IS NOT A REQUIREMENT OF THE PIPELINE SAFETY REGULATIONS, SEE 49 C.F.R. § 192.616. NONETHELESS, SAN JUAN GAS DOES INTEND TO ESTABLISH A FOLLOW-UP MONITORING SYSTEM TO ASSES THE EFFECTIVENESS OF THESE VARIOUS PROJECTS & PROGRAMS.

Addressee Organization Type: P-Private Industry

Communication Date: 1998-05-06

Communication Type: Official Correspondence

Communication Contents: THIS RESPONDS TO THE NTSB LETTER OF 3/12/98 SAN JUAN GAS WILL CONTINUE TO PROMOTE GAS SAFETY THROUGH ITS OWN PUBLIC EDUCATION & AWARENESS PROGRAMS & PROJECTS, AS PREVIOUSLY OUTLINED TO THE BOARD. HOWEVER, SAN JUAN GAS RECONGIZES THAT PROPANE SAFETY EDUCATION IS AN INDUSTRY-WIDE ISSUE. SAN JUAN GAS THEREFORE INTENTS TO WORK WITH PUERTO RICO PUBLIC SERVICE COMMISSION ON VARIOUS ISLAND-WIDE PUBLIC EDUCATION EFFORTS. ALTHOUGH FOLLOW-UP MONITORING OF PUBLIC EDUCATION EFFORTS IS NOT REQUIRED OF THE PIPELINE SAFETY REGULATIONS, SEE 49 CFR 192.616, SAN JUAN GAS WILL WORK WITH T HE COMMISSION IN THE EFFORTS MADE BY THE COMMISSION TO DEVELOP & IMPLEMENT A FOLLOW-UP SYSTEM IN PUERTO RICO. TO THAT END, SAN JUAN GAS WILL BE MAKING AVAILABLE TO THE PUERTO RICO SERVICE COMMISSION THE SUM OF $60,000.

Addressee Organization Type: P-Private Industry

Communication Date: 1998-07-23

Communication Type: Official Correspondence

Communication Contents: THIS RESPONDS TO YOUR LETTER OF 6-24-98. AS STATED IN PREVIOUS CORRESPONDENCE, FOLLOW-UP MEASUREMENT OF PUBLIC EDUCATION EFFORTS IS NOT A REQUIREMENT OF THE DOT PIPELINE SAFETY REGULATIONS, SEE 49 CFR 192.616. HOWEVER, AS TO THE EFFORTS MADE BY THE PUERTO RICO PUBLIC SERVICE COMMISSION TO DEVELOP & IMPLEMENT AN INDUSTRY-WIDE PUBLIC EDUCATION PROGRAM IN PUERTO RICO, I WILL ENDEAVOR TO PROVIDE PERTINENT INFO TO THE BOARD REGARDING SUCH EFFORTS, AS WELL AS INFO REGARDING RESULTS.

Addressee Organization Type: P-Private Industry

Communication Date: 2002-07-29

Communication Type: Official Correspondence

Communication Contents: The Safety Board is aware that Title 49 Code of Federal Regulations 192.616 does not require an operator to measure the effectiveness of a public education program. The Board has asked the Research and Special Programs Administration to amend the federal regulations to provide for such evaluations (Safety Recommendation P-90-21). In light of this consideration and because SJG is discontinuing all but 20 miles of its 220-mile gas pipeline system, Safety Recommendation P-97-3 is classified "Closed--Reconsidered."

Addressee Organization Type: P-Private Industry

Communication Date: 1997-04-10

Communication Type: Official Correspondence

Communication Contents: THE BOARD WOULD APPRECIATE RECEIVING SPECIFIC INFO ON HOW ENRON PLANS TO MODIFY THE CURRENT PROGRAM. IN THE MEANTIME, P-97-3 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

Addressee Organization Type: P-Private Industry

Communication Date: 1997-07-02

Communication Type: Official Correspondence

Communication Contents: THE BOARD LEARNED THAT SAN JUAN GAS HAD TOLD THE PUERTO RICO PUBLIC SERVICE COMMISSION THAT THE COMPANY WOULD CONTRIBUTE TO AN ISLAND-WIDE PUBLIC EDUCATION PROGRAM IF ALL OTHER PETROLEUM GAS COMPANIES WERE REQUIRED TO CONTRIBUTE. FURTHER, THE BOARD LEARNED THAT SAN JUAN COMPANY PLANS TO DISCOUNTINUE USING ALL BUT 20 MILES OF ITS 220-MILE GAS PIPELINE SYSTEM. IT IS NOT CLEAR TO THE BOARD WHAT, IF ANY, EFFECT THESE PROPOSED ACTIONS MAY HAVE ON THE PUBLIC EDUCATION ACTIONS, OF SAN JUAN GAS COMPANY AS DESCRIBED IN MR. WHITE'S LETTER. P-97-3 WILL BE CLASSIFIED "OPEN--ACCEPTABLE RESPONSE" UNTIL THE BOARD HAS HAD OPPORTUNITY TO ASSESS THE PUBLIC EDUCATION PROGRAM THAT IS ACTUALLY IMPLEMENTED.

Addressee Organization Type: P-Private Industry

Communication Date: 1997-11-04

Communication Type: Official Correspondence

Communication Contents: THE BOARD RECALLS THAT THE EDUCATIONAL MATERIALS BEING PROVIDED BEFORE THE EXPLOSION ONLY GAVE ADVICE ON ACTIONS TO TAKE WHEN A "STRONG" GAS ODOR IS DETECTED. ALSO, NO INFO WAS PROVIDED ON INSTANCES IN WHICH LOCAL EMERGENCY RESPONDERS, SUCH AS FIRE DEPARTMENTS, SHOULD BE IMMEDIATELY CALLED FOR ASSISTANCE. WE WOULD APPRECIATE RECEIVING FOR REVIEW A COPY OF THE PUBLIC EDUCATION INFO THAT IS NOW TO BE PROVIDED. THE BOARD ALSO NOTES THAT SAN JUAN GAS COMPANY, INC., PROGRAM DOES NOT INCLUDE ANY MEANS OF ASSESSING ITS OWN ADEQUANCY. THAT ASSESSMENT SHOULD DETERMINE IF THE PROGRAM REACHES, WITH ADEQUATE INFO, ALL PERSONS THAT MAY BE EXPOSED TO THE POTENTIAL RISKS POSED BY THE SURVIVING PIPELINE SYSTEM. THE BOARD ACKNOWLEDGES THAT THE ISLAND-WIDE EDUCATION PROGRAM CAN ASSIST IN ACHIEVING THE DESIRED RESULTS; HOWEVER, BOTH SAN JUAN GAS COMPANY, INC., & THE ISLAND-WIDE PROGRAMS MUST BE MONITORED & PERIODICALLY ASSESSED TO DETERMINE WHETHER THEIR COMBINE RESULTS MEET THE OBJECTIVES CALLED FOR BY THE PIPELINE SAFETY REGULATIONS. PENDING OUR REVIEW OF THE ABOVE-REQUESTED INFO & YOUR REPLY CONCERNING ACTIONS THAT ENRON WILL REQUIRE FOR MONITORING OVERALL PROGRAM EFFECTIVENESS P-97-3 WILL REMAIN CLASSIFEID OPEN--ACCEPTABLE RESPONSE."

Addressee Organization Type: P-Private Industry

Communication Date: 1998-03-12

Communication Type: Official Correspondence

Communication Contents: THE BOARD ASKED THE ENRON REVISE THE SAN JUAN GAS COMPANY'S PUBLIC EDUCATION PROGRAM SO THAT MEMBERS OF THE PUBLIC UNDERSTAND THE DANGER POSED BY A RELEASE OF PROPANE GAS, CAN TELL WHEN SUCH A RELEASE HAS OCCURRED, & KNOW WHEN STEPS SUCH AS EVACUATING THE AREA OR NOTIFYING THE LOCAL EMERGENCY-RESPONSE AGENCIES ARE APPROPRIATE. THE BOARD ALSO ASKED ENRON TO INCORPORATE IN THE PROGRAM A MEANS OF MEASURING ITS EFFECTIVENESS. THE BOARD HAS REVIEWED THE PUBLIC EDUCATION MATERIALS SAN JUAN GAS HAS DISTRIBUTED TO ITS CUSTOMERS & IS IMPRESSED BY THE COMPANY'S EFFORT TO INFORM THE PUBLIC ABOUT THE DANGERS POSED BY A RELEASE OF PROPANE GAS. THE BOARD WOULD, HOWEVER, APPRECIATE FURTHER INFO ON HOW SAN JUAN GAS INTENDS TO ESTABLISH A FOLLOW-UP PROGRAM TO ASSESS THE EFFECTIVENESS OF THE VARIOUS PROGRAMS & PROJECTS IN PUBLIC EDUCATION. THE BOARD WOULD ALSO APPRECIATE LEARNING ABOUT THE RESULTS OF THE MONITORING PROGRAM. PENDING FURTHER RESPONSE FROM SAN JUAN GAS ON THIS ISSUE, P-97-3 REMAIN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

Addressee Organization Type: P-Private Industry

Communication Date: 1998-06-24

Communication Type: Official Correspondence

Communication Contents: THE BOARD IS PLEASED THAT SAN JUAN GAS INTENDS TO WORK WITH THE PUERTO RICO PUBLIC SERVICE COMMISSION ON ISLAND-WIDE PUBLIC EDUCATION EFFORTS & WILL ALSO WORK WITH THE COMMISSION TO DEVELOP & IMPLEMENT A FOLLOW-UP SYSTEM IN PUERTO RICO. ADDITIONALLY, SAN JUAN GAS WILL MAKE $60,000 AVAILABLE TO THE PUERTO RICO PUBLIC SERVICE COMMISSION FOR FOLLOW-UP EFFORTS. THE BOARD WOULD APPRECIATE FURTHER INFO ON HOW SAN JUAN GAS, IN CONJUCTION WITH THE PUERTO RICO PUBLIC SERVICE COMMISSION, WILL ESTABLISH A FOLLOW-UP PROGRAM TO ASSESS THE EFFECTIVINESS OF THE VARIOUS PUBLIC EDUCATION PROGRAMS & PROJECTS. THE BOARD WOULD ALSO WELCOME INFO ABOUT THE RESULTS OF THE PUBLIC EDUCATION MONITORING PROGRAM. PENDING FURTHER RESPONSE FROM SAN JUAN GAS, P-97-3 WILL REMAIN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

Addressee Organization Type: P-Private Industry

Communication Date: 1998-08-27

Communication Type: Official Correspondence

Communication Contents: THE BOARD ALSO ASKED ENRON TO INCORPORATE IN THE PROGRAM A MEANS OF MEASURING IS EFFECTIVENESS. THE BOARD IS AWARE THAT SAN JUAN GAS IS COMMITTED TO WORK WITH THE PUERTO RICO PUBLIC SERVICE COMMISSION ON ISLAND-WIDE PUBLIC EDUCATION EFFORTS & WILL ALSO WORK WITH THE COMMISSION TO DEVELOP & IMPLEMENT A FOLLOW-UP SYSTEM IN PUERTO RICO. IN ADDITION, SAN JUAN GAS WILL ASSIST WITH FUNDING THE PUERTO RICO PUBLIC SERVICE COMMISSION IN THE FOLLOW-UP EFFORTS. THANK YOU FOR YOUR WILLINGNESS TO PROVIDE THE BOARD FURTHER INFO ON HOW SAN JUAN GAS, IN CONJUNCTION WITH THE PUERTO RICO PUBLIC SERVICE COMMISSION, WILL ESTABALISH A FOLLOW-UP PROGRAM TO ASSESS THE EFFECTIVENESS OF THE VARIOUS PUBLIC EDUCATION PROGRAMS & PROJECTS. THE BOARD LOOKS FORWARD TO REVIEWING THIS INFO. PENDING FURTHER RESPONSE FROM SAN JUAN GAS, P-97-3 WILL REMAIN 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.