NTSB Safety Recommendation P-97-011

NTSB safety recommendation P-97-011.

THE NTSB RECOMMENDS THAT THE ENRON CORP.: REQUIRE SAN JUAN GAS COMPANY INC., TO INCLUDE PROCEDURES IN ITS EMERGENCY PLAN THAT ITS EMPLOYEES CAN USE IN DETERMINING WHETHER A BUILDING OR AREA SHOULD BE EVACUATED WHEN A GAS LEAK IS SUSPECTED.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 1998-01-06

Adopted Date: 1997-12-23

Overall Date Closed: 1999-04-16

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.

Ntsbnumber: DCA97MP004

Report Number: PAR-97-01

Addressee Name: Enron Corporation

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 1999-04-16

Addressee Organization Type: P-Private Industry

Communication Date: 1998-01-09

Communication Type: Official Correspondence

Communication Contents: (Letter Mail Controlled 3/30/98 2:32:20 PM MC# 980033) THIS LETTER RESPONDS TO YOUR LETTER DATED 1/6/98 TO KENNETH L. LAY CONTAINING THE BOARD'S RECOMMENDATIONS P-97-11 P-97-12 REGARDING SAN JUAN GAS COMPANY, INC. (SAN JUAN GAS). SAN JUAN GAS CONTINUES TO DISAGREE WITH THE BOARD'S CONCLUSION THAT THE TRAINING & JOB PERFORMANCE OF SAN JUAN GAS' EMPLOYEES WAS INADEQUATE & WAS A "CAUSE" OF THE RIO PIEDRAS EXPLOSION. CONTRARY TO THE BOARD'S CONTENTION, SAN JUAN GAS EMPLOYEES DID KNOW THE DEPTH OF GAS LINE & PROBED DEEP ENCOUGH TO TEST PROPERLY FOR COMBUSTIBLE GAS. THERE IS NO CREDIBLE EVIDENCE THAT PROPANE GAS FROM SAN JUAN GAS' SYSTEM IN FACT CAUSED THE EXPLOSION. EVEN THE BOARD CONCEDES THAT THE GAS LEAK THAT IT CONTENDS RESULTED IN THE EXPLOSION WAS CAUSED BY THIRD PARTIES WHO DAMAGED THE SAN JUAN GAS LINE & FAILED TO NOTIFY SAN JUAN GAS. MOREOVER, THE BOARD ADMITS THAT IT FOUND NO PATH BY WHICH THE PROPANE GAS FROM THIS LEAK COULD HAVE ENTERED THE HUMBERTO VIDAL BUILDING. WITH REGARD TO THE RECOMMENDATIONS IN YOUR LETTER, SAN JUAN GAS HAS IN PLACE PROCEDURES WHICH ARE CONSISTENT WITH THE RECOMMENDATIONS. THIS INFO WAS PREVIOUSLY COMMUNICATED TO THE NTSB STAFF. SAN JUAN GAS SUBMITTED ITS OPERATING PROCEDURE MANUAL WHICH CONTAINS THE COMPANY'S EMERGENCY PROCEDURES ON 6/21/97. SAN JUAN GAS PREVIOUSLY OUTLINED THE REQUIREMENTS OF ITS TRAINING PROGRAM IN A 5/2/97 LETTER TO THE BOARD, & SUBSEQUENTLY SUBMITTED THE COMPLETE TRAINING PROGRAM TO NTSB STAFF ON 9/2/97.

Addressee Organization Type: P-Private Industry

Communication Date: 1999-03-03

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 3/8/99 4:17:31 PM MC# 990211 REGARDING P-97-11, YOUR LETTER STATES THAT PROCEDURE 7.00 INCLUDES ALL OF THE ELEMENTS DISCUSSED IN THE BOARD'S REPORT. WITH RESPECT TO YOUR ADDITIONAL COMMENTS ON P-97-11, SAN JUAN GAS CURRENTLY HAS IN PLACE PROCEDURES WHICH ARE CONSISTENT WITH THE RECOMMENDATION TO THE EXTENT THAT IT IS APPROPRIATE TO DETERMINE A RESPONSE TO A LEAK CALL BASED ON INFORMATION FROM COMPLAINANTS. PROCEDURE 7.00 AND THE ODOR COMPLAINT FORM SET FORTH THE GUIDELINES FOR RECEIVING AN ODOR COMPLAINT CALL AND FOR PROVIDING AN APPROPRIATE RESPONSE TO THE CALLER, INCLUDING WHEN APPROPRIATE, ADVICE TO EVACUATE A BUILDING IMMEDIATELY, BEFORE TESTING FOR A GAS LEAK OCCURS. THE PERSON RECEIVING THE CALL WILL PROVIDE ADVICE THAT TAKES INTO ACCOUNT THE INFORMATION REPORTED BY THE CALLER. IN ADDITION, THE DISPATCHER DETERMINES THE APPROPRIATE RESPONSE TO THE CALL TAKING INTO ACCOUNT THE INFORMATION FROM THE CALLER. BASED ON CAREFUL CONSIDERATION AND INPUT FROM TECHNICAL PERSONNEL SAN JUAN GAS, INC. HAS CONCLUDED THAT THE ACTIONS OF GAS COMPANY PERSONNEL ON SCENE CANNOT BE DICTATED SOLELY BY INFORMATION RECEIVED FROM COMPLAINANTS. TO THE EXTENT APPLICABLE, THE GAS COMPANY PERSONNEL WILL INCORPORATE INORMATION FROM THE COMPLAINANTS INTO THEIR INVESTIGATION AND ASSESSMENT. WHILE THE GAS COMPANY PERSONNEL ON SCENE MAY MAKE INQUIRIES ABOUT THE LOCATION AND STRENGTH OF THE ODOR, THESE PERSONNEL MUST FOLLOW A SYSTEMATIC PROCEDURE BASED ON THE CRITERIA IN INVESTIGATING A GAS LEAK, RATHER THAN TAKING ACTION BASED SOLELY ON THE COMPLAINANTS' SUBJECTIVE CLAIMS. UNLIKE THE RECIPIENT OF THE ODOR COMPLAINT CALL AND THE DISPATCHER, GAS COMPANY PERSONNEL THAT RESPOND TO INVESTIGATE AN ODOR COMPLAINT ARE ON SCENE AND THEREFORE ARE BEST ABLE TO CONDUCT AN INDEPENDENT EVALUATION OF THE ODOR COMPLAINT IN ORDER TO DETERMINE THE APPROPRIATE RESPONSE. AS DESCRIBED IN PROCEDURE 7.01, PERSONNEL ENGAGED IN INVESTIGATING LEAK CALLS ARE QUALIFIED BY TRAINING AND EXPERIENCE TO IMMEDIATELY RECOGNIZE A HAZARDOUS LEAK SITUATION AND TO ADVISE A CUSTOMER OR THE GENERAL PUBLIC TO EVACUATE A BUILDING AND/OR SOME SPECIFIC OUTSIDE AREA BEFORE OR DURING LEAK INVESTIGATIONS WHERE WARRANTED. THESE ON-SCENE PERSONNEL WILL ALSO BARRICADE A LEAK AREA, RE-ROUTE TRAFFIC AROUND THE AREA, AND TAKE ANY PRECAUTIONS NECESSARY TO PREVENT THE IGNITION OF GAS. SAN JUAN GAS COMPANY PERSONNEL ARE REQUIRED TO PLACE THE HIGHEST PRIORITY ON THE PROTECTION OF THE GENERAL PUBLIC FROM POSSIBLE HAZARDS. THESE PERSONNEL TAKE ACTION THAT IS CONSISTENT WITH SUCH A PRIORITY BASED ON THE BEST AVAILABLE INFORMATION, WHICH MAY INCLUDE, BUT IS NOT LIMITED TO , INFORMATION FROM COMPLAINANTS.

Addressee Organization Type: P-Private Industry

Communication Date: 1998-09-30

Communication Type: Official Correspondence

Communication Contents: THE BOARD HAS REVIEWED THE REVISED SECTION OF THE SAN JUAN GAS OPERATING PROCEDURES MANUAL (EMERGENCIES), SPECIFICALLY PROCEDURE NO. 7.00, "RECEIVING THE ODOR COMPLAINT CALLS," & PROCEDURE NO. 7.01, "INVESTIGATING ODOR COMPLIANT CALLS," THE REVISIONS OF PROCEDURE NO. 7.00 INCLUDE ALL OF THE ELEMENTS DISCUSSED IN THE BOARD'S REPORT. HOWEVER, PROCEDURE NO. 7.01, SUBSECTION 3.1.1, SHOULD ALSO INCLUDE GUIDANCE ON THE ACTIONS TO BE TAKEN BY GAS COMPANY PERSONNEL ON-SCENE WHILE TESTING FOR A GAS LEAK. THE CHOICE OF ACTIONS SHOULD BE BASED ON CUSTOMERS' COMPLAINERS' SYMPTOMS, NUMBER OF COMPLAINTS, & SO FORTH. THERE, PENDING FURTHER INFO FROM ENRON ON THE GUIDANCE FOR ON-SCENE PERSONNEL, P-97-11 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

Addressee Organization Type: P-Private Industry

Communication Date: 1999-04-16

Communication Type: Official Correspondence

Communication Contents: THE BOARD IS PLEASED TO LEARN THAT THE SJGC NOW HAS PROCEDURES IN PLACE THAT ARE CONSISTENT WITH THE RECOMMENDATION TO THE EXTENT THAT IT IS APPROPRIATE TO DETERMINE A RESPONSE TO A LEAK CALL BASED ON INFORMATION FROM COMPLAINANTS. THE BOARD UNDERSTANDS AND CONCURS WITH THE FINDINGS FROM TECHNICAL PERSONNEL THAT THE ACTIONS OF GAS COMPANY PERSONNEL ON SCENE CANNOT BE DICTATED SOLELY BY INFORMATION RECEIVED FROM COMPLAINANTS. THE BOARD IS PLEASED THAT, TO THE EXTENT APPLICABLE, GAS COMPANY PERSONNEL WILL INCORPORATE INFORMATION FROM THE COMPLAINANTS INTO THEIR INVESTIGATION AND ASSESSMENT. BECAUSE THE SJGC HAS ESTABLISHED SUCH A POLICY AND PROCEDURES WHEN RECEIVING A CALL TO PROVIDE ADVICE AND DETERMINE THE APPROPRIATE RESPONSE TO THE CALL, TAKING INTO ACCOUNT THE INFORMATION FROM THE CALLER, P-97-11 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ACTION."