# NTSB Safety Recommendation Letter P-78-068 through P-78-075

- **operation:** document
- **citation:** P-78-068 through P-78-075
- **title:** NTSB Safety Recommendation Letter P-78-068 through P-78-075
- **source type:** guidance
- **agency:** National Transportation Safety Board
- **status:** guidance
- **official:** true
- **published on:** 1978-12-29
- **effective on:** 1978-12-29
- **summary:** Official NTSB transmittal letter for safety recommendations P-78-068 through P-78-075, issued 1978-12-29.
- **machine formats:** - **json:** https://regulus.evalyn.ai/document/ntsb-transmittal-letter-p78-68-75.json
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- **app url:** https://regulus.evalyn.ai/document/ntsb-transmittal-letter-p78-68-75
- **source url:** https://www.ntsb.gov/safety/safety-recs/recletters/P78_68_75.pdf
**body:**

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$-/IO NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. ISSUED: Ikcember 29, 1978 Mr. Charlie Rambo P r e s i d e n t Gas Service Company 2460 Pershing Road Kansas City, Missouri 64108 1 i SAFETY RECOMMENDAT I ON ( 5 ) P-78-68 through -75 A t 1:30 p.m., c.d.t., on June 12, 1978, a 10-inch n a t u r a l gas p i p e l i n e orwried by the Gas Service Company (gas company) w a s s t r u c k and ruptured by excavation equipment during c o n s t r u c t i o n of a sewer i n Kansas C i t y , Missouri. The n a t u r a l gas, a t more than 110-psig pressure, escaped from a 5-inch-long hole i n t h e p i p e l i n e . A t 3:15 p.m., the gas i g n i t e d while two gas company employees were cleaning t h e pipe with hand t o o l s b e f o r e i n s t a l l i n g a p i p e r e p a i r clamp. Both men were burned s e r i o u s l y . 1/ One week b e f o r e t h e accident, a gas company i n s p e c t o r had a c c u r a t e l y located t h e p i p e l i n e w i t h an e l e c t r o n i c pipe l o c a t o r . H e placed two yellow l o c a t i o n f l a g s over i t , i 5 f e e t a p a r t , one on each s i d e of t h e sewer easement. On t h e day of t h e a c c i d e n t , t h e c o n t r a c t o r planned t o grade t h e sewer easement i n t h e a r e a where t h e plans showed t h e sewer crossing t h e p i p e l i n e . About 7 a.m., t h e c o n t r a c t o r ' s superintendent i n s t r u c t e d an equipment operator t o d i g a 5-foot-deep and 15-foot-wide "bench" along t h e c e n t e r l i n e of the sewer w i t h a l a r g e d i e s e l C a t e r p i l l a r t r a c t o r , Model 977 Bighloader, from which a medium-size backhoe could excavate down t o the planned 20-foot depth of t h e sewer. The equipment operator was shown t h e l o c a t i o n f l a g on t h e east s i d e of t h e sewer r i g h t - of-way b u t n o t the o t h e r l o c a t i o n f l a g or t h e permanent p i p e l i n e markers, which w e x e p a r t l y obscured by weeds on the p i p e l i n e right-of-way. - - 1/ For more d e t a i l e d information read "Pipeline Accident Report--The Gas Service Company N a t u r a l Gas P i p e l i n e Rupture and F i r e , Kansas City, Missouri, June 12, 1978" (mSB-PAR-78-5) - 2533

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- 2 - A t ll:30 a.m., t h e superintendent c a l l e d the gas company and asked how deep t h e p i p e l i n e w a s buried a t t h e crossing. The gas company engineer t a k i n g t h e call s a i d t h a t although t h e company's newer p i p e l i n e s are buried about 30 inches deep, he d i d n o t know t h e exact depth of the 48-year-old p i p e l i n e . He suggested t h a t t h e superintendent t a l k t o t h e gas company d i s p a t c h e r and request t h a t an i n s p e c t o r b e s e n t t o the job site t o determine t h e e x a c t depth. The superintendent d i d n o t c a l l t h e d i s p a t c h e r as recommended because a l a r g e backhoe, t h e primary p i e c e of excavating equipment, was being used more than 100 f e e t from t h e crossing, and would n o t a r r i v e a t t h e crossing t h a t day. About 2 hours l a t e r , the highloader s t r u c k and ruptured t h e p i p e l i n e a t a depth of 24 inches. The sewer w a s being i n s t a l l e d f o r t h e c i t y of Lee's Summit, Missouri. The c i t y had not i n v i t e d t h e gas company t o the preconstruction meeting with the c o n t r a c t o r and consulting engineer where questions regarding t h e l o c a t i o n and depth of t h e p i p e l i n e s t o be crossed could have been discussed. The gas company had n o t designated a p r o j e c t coordinator t o provide l i a i s o n between the c o n t r a c t o r and t h e gas company's engineering and f i e l d d i v i s i o n s . A p r o j e c t coordinator could have k e p t t r a c k of the c o n t r a c t o r ' s progress, and a l s o could have had t h e weeds removed from t h e p i p e l i n e right-of-way and from around t h e permanent l i n e marker s i g n s . The p i p e l i n e had been i n s t a l l e d before t h e r e were Federal r e g u l a t i o n s specifying m i n i m u m depths of p i p e l i n e s . The c u r r e n t r e g u l a t i o n s c a l l f o r a minimum cover of 36 inches over a p i p e l i n e i n a Class 3 l o c a t i o n . When 8 the p i p e l i n e was exposed f o r maintenance on March 15, 1978, and a Pipe Condition Report Form made o u t , t h e workers f a i l e d t o n o t e i n t h e space provided t h a t t h e depth of t h e p i p e l i n e was only 2 4 inches. Engineering o f f i c e personnel could have reviewed t h e form and recorded on t h e p i p e l i n e map any depths t h a t were l e s s than the c u r r e n t minimum covers. If a record had been made, i t could a l s o have been consulted when the c o n t r a c t o r c a l l e d and requested t h e depth of t h e p i p e l i n e 2 hours before t h e accident. The gas company had designated emergency valves along t h e p i p e l i n e and included t h i s information i n its emergency plan. However, t h e p i p e l i n e r u p t u r e i n i t i a l l y d i d n o t seem l a r g e enough t o warrant c l o s i n g t h e emergency valves and i n t e r r u p t i n g gas s e r v i c e t o s e v e r a l hundred customers along t h e 2 1/2 miles of p i p e l i n e t h a t would be s h u t down i f t h e valves were closed. The gas company's emergency plan d i d n o t s p e c i f y , however, what a "safe" repair p r e s s u r e should be i n t h e event t h e emergency valves were n o t closed and t h e p r e s s u r e w a s c o n t r o l l e d t o maintain customer s e r v i c e . There w a s no f i r e extinguishing equipment a t the accident s i t e t h a t w a s capable of p u t t i n g o u t the f i r e . The gas company's 150-pound extinguisher t h r e e streams of water from t h e firemen's hoses were n o t e f f e c t i v e i n and -_ .. e x t i a g u i s h i n g t h e f i r e a r the SO-psip. gas p r e s s u r e . Rather than i n s t a l l i n g ,p i p e l i n e s t o p p l e s or leaving the gas-fueled fiames t o conrinue t o burn under c o n t r o l l s d c o n d i t i o n s , t h e gas company allowed t h e firemen t o e x t i n g u i s h t h e t h e f i r e 3 y bulldozing d i r t over t h e r u p t u r e when t h e pressure was reduced to 10 p s i g . Because t h e f i r e was extinguished, the escaping gas could have r e i g n i t e d u n t i l the p i p e l i n e was f i n a l l y r e p a i r e d 1 6 hours a f t e r t h e f i r e w a s extinguished.

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Both of t h e men i n j u r e d by t h e f i r e wore s a f e t y goggles and hard h a t s . One of t h e men w a s wearing a short-sleeve uniform s h i r t and t r o u s e r s made of p o l y e s t e r m a t e r i a l . The o t h e r worker w a s wearing c o t t o n pants and a long-sleeve c o t t o n s h i r t . Both men received second- and third-degree burns over 60 percent of t h e i r bodies. However, t h e man w i t h the p o l y e s t e r uniform w a s burned more severely. The use of flame-retardent c l o t h i n g by these men would have reduced t h e s e v e r i t y of their i n j u r i e s . Therefore, t h e National Transportation Safety Board recommends t h a t the Gas Service Company: Improve l i a i s o n with t h e m u n i c i p a l i t i e s and consulting engineers w i t h i n its operating a r e a and r e q u e s t t h a t t h e gas company be n o t i f i e d of a l l preconstruction meetings t o determine i f gas f a c i l i t i e s w i l l be a f f e c t e d by t h e construction a c t i v i t i e s . (Class 11, P r i o r i t y Action) (P-78-68) Improve communications and cooperation between its engineering and f i e l d personnel t o i n s u r e t h a t responsible gas company employees a r e aware of a c o n t r a c t o r ' s questions regarding gas f a c i l i t i e s as t h e c o n t r a c t o r ' s work progresses. (Class 11, P r i o r i t y Action)(P-78-69) Require its personnel t o record a l l information requested on t h e Pipe Condition Report Form. Any p i p e l i n e depths of less than t h e minimum required i n 49 CFR 192.327 should be c a r e f u l l y noted on p i p e l i n e maps and o t h e r records. (Class 11, P r i o r i t y Action) (P-78-7 0) Revise i t s emergency plan t o show what segments of a p i p e l i n e can be taken o u t of dervice f o r r e p a i r s , and e s t a b l i s h t h e maximum s a f e operating pressures f o r r e p a i r s t o such p i p e l i n e s . (Class 11, P r i o r i t y Action)(P-78-71) Revise its emergency plan t o include a l l of t h e l i a i s o n and coordination requirements of 49 CFR 192.615, and provide t r a i n i n g material t o l o c a l f i r e departments about t h e hazards of extinguishing gas f i r e s . (Class 11, P r i o r i t y Action) (P-78-72) Include i n company maintenance procedures t h e requirement t h a t v e g e t a t i o n on p i p e l i n e rights-of-way and around line marker s i g n s be c l e a r e d before construction equipment is used near gas p i p e l i n e s . (Class 11, P r i o r i t y Action)(P-78-73)

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- I - Require the use of flame-retardant material in the uniforms of personnel required to work in gaseous atmospheres. (Class 11, Priority Action)(P-78-74) Train its distribution repair crews to work safely on high-pressure transmission pipelines. (Class 11, Priority Action) (P-78-75) K I N G , Chairman, DRIVER, Vice Chairman, McADAMS and HOGUE, Members, concurred in the above recommendations.
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