NTSB Safety Recommendation Letter P-74-010 through P-74-015

Page 1Official PDF- 16 - 6. The E l Paso F i r e Department and the Police Department combined e f f e c t i v e l y t o evacuate the dead and i n j u r e d , t o r e r o u t e t r a f f i c i n t h e a r e a , and t o maintain order. 7 . 49 CFR 192.615(d) does not s p e c i f i c a l l y r e q u i r e p i p e l i n e operators t o use languages other than English i n t h e i r customer education program. 8. Neither the Federal regulations nor industry standards provide guidance t o p i p e l i n e operators concerning replacement or p r o t e c t i o n of disturbed c a s t - i r o n piping. V . PROBABLE CAUSE The National Transportation Safety Board determines t h a t the probable cause of the explosion w a s t h e i g n i t i o n of an accumulation of n a t u r a l gas which had leaked primarily from a broken cast-iron reducer and t o a lesser extent from two corrosion leaks i n the d i s t r i b u t i o n main. The gas m i - grated beneath the concrete road s u r f a c e , permeated t h e a r e a , entered t h e apartment complex v i a the crawl space, and w a s ignited by an undetermined source. The uncovering and disturbing of the cast-iron pipe by t h e gas com- pany i n an unsuccessful search f o r a gas leak 6 days before t h e accident contributed t o the f a i l u r e of the reducer. Contributing to t h e loss of l i f e and the property damage were t h e f a i l u r e of t h e gas company t o l o c a t e or t o confirm p o s i t i v e l y t h e exist- ence of a leak, and t h e f a i l u r e of both t h e tenants and t h e apartment superintendent t o n o t i f y e i t h e r t h e gas company o r t h e f i r e department of t h e gas odors which had been detected previously. V I . RECOEPENDATTONS The National Transportation Safety Board recommends that: 1. The Office of P i p e l i n e Safety of the Department of Transportation: (a) Amend 49 CFR 192 to r e q u i r e t h a t c a s t - i r o n piping o r f i t t i n g s uncovered during construction or maintenance work i n such a way as t o weaken t h e i r support from below be replaced or reinforced t o p r o t e c t a g a i n s t outside f o r c e s which could cause f a i l u r e . (Recommendation No. P-74-10) (b) Amend 49 CFR 192.615(d) t o r e q u i r e t h a t educational programs intended t o enable customers and t h e general public t o recognize and re- p o r t gas emergencies be printed i n English and i n other languages which a s i g n i f i c a n t portion of t h e conmninity served speak and understand. @ecommenda t i on No. P- 74- 11) PAR -574-2.#

Page 2- 17 - 2. American Society of Mechanical Engineers Gas Piping Standards Cormnittee develop guidelines f o r pinpointing t h e location of reported gas leaks. These guidelines should include procedures t o determine t h e degree of hazard t h a t exists as a r e s u l t of t h e reported leak. (Recommendation NO. P-74-12) 3 . The Southern Union Cas Company: (a) I n s t r u c t the maintenance crews concerning t h e hazards of inade- quate support during the f i l l i n g of r e c e n t l y Ecvcavated piping f a c i l i t i e s . (Recommendation No. P-74-13) (b) Improve followup procedures t o a s s u r e that a l l reported leaks are located. (Recornendation No. P-74-14) (c) I n i t i a t e a program of i n s t r u c t i o n for gas customers and t h e general public concerning the p o t e n t i a l hazards of n a t u r a l gas. This pro- gram should include mailing f l y e r s t o customers which include names and telephone numbers to be used i n emergencies and placing educational material i n the news media. This program should, where a p p l i c a b l e , be b i l i n g u a l t o reach both the English and non-English speaking cormrmnities w i t h i n the d i s t r i b u t i o n systems. (Recommendation No. P-74-15) BY THE NATIONAL TRANSPORTATION SAFETY BOARD / S I JOHN H. REED Chairman / s / FRANCIS H. McADAMS klember / s / LOUIS M. THAYER Member / s / WILLIAM R . HALEY Member ras absent and d i d not p a r t i c i p a t e in the I 1 , Bur Member, adoption of t h i s report February 13, 1974#