NTSB Safety Recommendation P-97-013

NTSB safety recommendation P-97-013.

THE NTSB RECOMMENDS THAT THE HEALTH CONSULTANTS, INC.: IDENTIFY, WHEN DEVELOPING CONTRACTED TRAINING, THE TASKS FOR WHICH THE TRAINEES MUST BE TRAINED & DEVELOP MEASURES FOR ASSESSING THE JOB PERFORMANCE OF THE TRAINEES & THE EFFECTIVENESS OF THE TRAINING.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 1998-01-06

Adopted Date: 1997-12-23

Overall Date Closed: 2002-09-20

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, Trainees

Ntsbnumber: DCA97MP004

Report Number: PAR-97-01

Addressee Name: Heath Consultants, Inc.

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2002-09-20

Addressee Organization Type: P-Private Industry

Communication Date: 1998-01-08

Communication Type: Official Correspondence

Communication Contents: HEATH CONSULTANTS INCORPORTED ("HEATH") RECEIVED, WITH APPRECIATION, YOUR LETTER DATED 1/6/98 RELATING TO AN EXPLOSION IN SAN JUAN, PURETO RICO ON 11/21/96. AS YOU KNOW, THE TRAINING OFFERED BY HEATH TO EMPLOYEES OF SAN JUAN GAS COMPANY ("SJGC"] WAS TERMINATED IN APRIL OF 1996. HEATH BELIEVES IT RECOMMENDED THE APPROPRIATE TRAINING &, WHERE REQUESTED, CONDUCTED SUCH TRAINING PROPERLY. HEATH HAS ALSO GIVEN SERIOUS CONSIDERATION OF P-97-13, AS FOLLOWS: HEATH BELIEVES THAT IT HAD FORMULATED & WAS CONDUCTING APPROPRIATE TRAINING IN ACCORDANCE WITH THIS RECOMMENDATION BEFORE ITS SERVICES WERE TERMINIATED IN APRIL OF 1996. HEATH WILL CONTINUE TO ACT IN ACCORDANCE WITH THIS RECOMMENDATION IN THE FUTURE.

Addressee Organization Type: P-Private Industry

Communication Date: 2002-09-20

Communication Type: Official Correspondence

Communication Contents: In your January 8, 1998, response, you indicated that although Heath's training of San Juan Gas Company employees had been terminated in April 1996, you believed that Heath's training had been in accordance with the recommendation. You further assured the Safety Board that Heath would "continue to act in accordance with this recommendation in the future." The Safety Board has reviewed the correspondence on this recommendation and believes that the objective of the recommendation has been met, particularly in light of your previous assurance that your training will be conducted in accordance with our recommendation. For the record, Safety Recommendation P-97-13 has been classified "Closed--Acceptable Action."

Addressee Organization Type: P-Private Industry

Communication Date: 1998-04-15

Communication Type: Official Correspondence

Communication Contents: THE BOARD UNDERSTOOD AT THE TIME THIS RECOMMENDATION WAS ISSUED THAT THE HEATH TRAINING OF SJGC EMPLOYEES WAS COMPLETED IN APRIL 1996. BECAUSE HEATH REGULARLY TRAINS GAS COMPANY EMPLOYEES, THE BOARD URGED THAT IT IDENTIFY THE TASKS FOR WHICH EMPLOYEES MUST BE TRAINED & DEVELOP MEASURES FOR ASSESSING THE EMPLOYEES' JOB PERFORMANCE & THE EFFECTIVENESS OF THE TRAINING RECEIVED. HOWEVER, NO EXPLANATION OF THESE POINTS WAS GIVEN IN YOUR LETTER. THE BOARD WOULD APPRECIATE RECEIVING INFO ON HOW HEATH WILL IDENTIFY THESE TASKS & MEASURE THE EFFECTIVENESS OF THE TRAINING. PENDING YOUR FURTHER RESPONSE P-97-13 WILL REMAIN CLASSIFIED "OPEN--AWAIT RESPONSE."