NTSB Safety Recommendation Letter P-93-006

Page 1Official PDFNational Transportation Safety Board Washington, D. C. 20594 Safety Recommendation Date: January 26, 1993 In Reply Refer To: P-93-6 Mr. Michael Baly, 111 President American Gas Association 1515 Wilson Boulevard Arlington, Virginia 22259 Mr. Robert Cave Executive Director American Public Gas Association 301 Maple Avenue West Vienna, Virginia 22180 On January 17, 1992, while a crew from Peoples Gas Light and Coke Company (Peoples) was doing routine annual maintenance work on a monitor regulator at one of its regulator stations,l high-pressure gas entered a low-pressure system. The as--under as much as 10 psig of pressure--escaped through gas appliances into Xomes and other buildings, where it was ignited by several unidentified sources. The resulting explosion and fires killed 4 people, injured 4, and damaged 14 houses and 3 commercial buildings 2 The National Transportation Safety Board determines that the probable cause of the over-pressure accident and the resulting losses was the failure of Peoples Gas Light and Coke Company t o adequately train its gas aperations section employees in recognizin and correctly responding to abnormal situations, which consequently led to the 8. allure of the gas operations section crew to properly monitor and control the pressure of the gas being supplied to the low-pressure gas system during a routine inspection. Contributing to the cause of the accident was the Research and Special Programs Administration's failure t o promulgate requirements for gas system employee training and qualification standards. 'Peoples' regulator stations consist of a district regulator that reduces high-pressure gas t o low pressure and a monitor regulator that takes over if the district regulator fails Each regulator and its controls are in a separate underground street vault The area in which the accident happened was supplied by two regulator stations--the Erie & Green station and the Chicago & Carpenter station (Peoples' regulator stations are named for the nearby streets ) 2For more detailed i n f o r m a t i o n read Pipeline AccidenUlncident Summary Report (NTSB/PAR-93/0 l/SUM) 5701A#

Page 22 Training of gas operations section (GOS) personnel is primarily on-the-job training supplemented by technical handouts and a manual containing detailed descriptions of work they are to perform. According to a GOS manager, the only training in responding to emergencies that GOS personnel receive is on the job. He said that tie expects the supervisors who work for him to know from experience what to do and that he does not instruct them in how to respond to an over-pressure emergency. GOS employees are not evaluated or tested to see if they are aware of and understand the emergency actions expected of them. The GOS employees who did the work on the monitor regulator acknowledged that they had been trained in regulator inspection and maintenance throu h on-the-job instruction, technical handouts, and a March 1991 2-day class on t ?l e manual that describes the maintenance arid inspection work to be performed. One of the crewmembers involved in the accident stated that he knew from his training that when the water blew out of the manometers, it was because of the presence of high-pressure gas; but none of the crewmembers acknowled ed having been trained in responding to emergencies, including ones involving Yiigh-pressure gas entering a low-pressure system. A review of Peoples' Gas Operatrons Trarning Manual revealed that it does not tell employees how to recognize or respond to those emergency situations they are likely t o encounter It does riot tell supervisors the extent of their authority, nor does it refer to the company's emergency operating plan (EOP). Moreover, the EOP does riot address over-pressure situations or define an emergency situation. The EOP has only one instruction for GOS personnel: "the employee is t o c a l l the superintendent." The Safety Board believes that Peoples should institute formal classroom , both initial arid recurrent, for i t s GOS employees i r i how to recognize and trainin? correct y respond to emergency situations. The Safety Board also believes that the planned revision of the Gas Operations Training Manual should include instructions on how to eliminate or reduce a threat to public safety by taking such actions as closing valves, monitoring pressure, and evacuating people from hazardous locations. The need to improve gas iridustr employee training is not unique to Peoples. it is a national problem. As a result o Y two accidents in Kentucky2 the Safety Boar recommended that the Research arid Special Programs Administration (RSPA): P-87-2 Amend 49 Code of Federal Regulations (CFR) Parts 192 and 195 to require that operators of pipelines develop and conduct selection, training, arid testing programs to annually qualify employees for correctly carr ing o u t each assigned responsibility which is necessary Y or complying with 49 CFR Parts 192 arid 195 asappropriate. 3Pipeline Accident Report-Texas Eastern Gas Pipeline Company Ruptures and Fire at Bed Kentucky, on April27, 1985, and Lancaster, Kentucky, on FebruaryZl, 1986(NTSB/PAR-87/01).#

Page 33 Another issue raised by the accident is the appropriatness of Peoples' valves. When inspecting and maintaining regulators, eline industry, often uses a manually operated bypass accident, instead of an automatic pressure-control Board believes that such a valve is an who is operating it is (1) adequately trained, (2) at the valve, (3) constantly viewing a gauge measuring the outlet pressure, (4) without other duties or obligations, and (5) able to immediately alter the position of the valve as needed to maintain a safe system pressure. On the day of the accident, no crewmember met any of the criteria stated above. The crew, including the crew supervisor, had not been adequately trained, particularly in recognizing and reacting t o excess pressure in a low-pressure distribution system. No one was explicitly responsible for constantly monitoring the downstream pressure, and no one was constantly a t the valve. Although one or more of the crewmembers were in the monitor vault, which also had a valve that could be used to control the gas pressure, they were there to inspect and maintain the monitor rejulator; they were not specifically responsible for monitoring the manometer an adjusting the valve as necessary. With modification, the system pressure could have been automatically controlled by usin a regulator on the bypass line, by using a relief valve on the low-pressure distri % ution system, or by separately bypassing each regulator so that one of the regulators would remain in service while the other was being inspected. The system pressure could have been automatically controlled without modification by performing the inspection when the demand for gas was low, such as during the summer. Had the regulators been inspected a t such a time, the Chicago & Carpenter station probably could have supplied enough gas for the entire River West area; consequently, there would have been no need to use the bypass line. On October 14, 1992, Peoples told the Safety Board that it was taking the following steps: (1) Using a computer-supported analyses system and field observations to identify the stations that can be inspected and maintained without the use of a bypass valve. (2) Revising the maintenance schedules to maximize the number of stations that can be inspected and maintained without the use of a bypass valve. (3) Not inspecting a station until it is modified if, in its unmodified form, the district and monitor regulators cannot be separately bypassed. (4) Designin all new and replacement regulator stations in such a way that the monitor an 8 . district regulators can be separately bypassed. lJntil Peoples completes the above actions, it probably will be necessary to use a bypass at times to maintain pressure in as systems downstream of regulator stations. Even after the modifications have 8 een made, it may be necessary to use bypasses during emergencies. Therefore Peoples should implement procedures that will ensure that over-pressure control is maintained should a bypass line be used during regulator inspections. Peoples should also revise i t s Natural Gas Safety Guidelines to include clear, concise, consistent, prominently-displayed instructions about what a customer should do when confronted with a potential hazard. How quickly people react in an emergenc can si nificantly affect their chances of surviving. Consequently, customers shoul ; I $ be e ucated before an emergencyoccurs about how to recognize and react to it. To that end, Peoples mails bulletins to#

Page 4i t s customers that often include as safety information. Peoples also publishes a booklet, Natural Gas Safety Guide 4 rnes, that is available in three different languages a t the company's neighborhood offices. It is the main form of safety information that Peoples gives its customers. Each receives a copy when his/her gas service is initiated. The booklet contradicts itself in explaining how t o react to a gas emergency. Although the booklet, is obviously well intended, the Safety Board finds it deficient because it presents conflicting advice and because it suggests that the only warriiri of danger that a customer may receive is the odor of ttie escaped gas. Yet some o 4 the customers involved in this accident heard loud, unusual noises coming from their gas appliances and saw pilot or burner flames reach unusual hei hts (up to 12 inches). These customers made these observations before they sme ? led any gas, and in some cases, they never smelled gas. Customers need t o be told that there are numerous warnings about potential danger whether or not they smell gas, and that such warnings should alert them to leave ttie premises and notify the gas company. The Safety Board does not believe that Peoples has done an adequate job of making its customers aware of the safety information in the booklet arid of the importance of that information to their safety After the accident, Safety Board staff received informatiori from 22 gas customers who had been involved. Only 2 of the 22 customers recalled seeing any safety information distributed by Peoples. Six others were unsure whether they had seen any of the information, and the other 14 stated that they had seen none Safety Board staff reviewed Peoples' customer bulletins issued during the last 2 years and found that they did not mention the booklet. Peoples should expect its customers to need periodic reminders about the information in the booklet and its importance. Moreover, Peoples should recognize its responsibility for motivating its customers t o read the booklet arid follow i t s advice The Safety Board previously addressed the issue of public education when it issued Safety Recommerldation P-90-21 to RSPA: Assess existing gas industry programs for educating the public on the dan ers of gas leaks and on reporting gas leaks to determine t % e appropriateness of information provided, the effectiveness of educational techniques used, and those techni ues used in other public education programs and based on i t s ? indin s, amend the public education provisions of the 8 ' Federal regu ations, On October 29, 1992, the Safety Board told RSPA staff it would inappropriate for RSPA t o delegate to an industry association the responsibility assessing public education rograms. RSPA agreed to reconsider what action I might take t o achieve the ogjective of the safety recommendation. According to a December 24, 1992, letter from RSPA, RSPA is preparing an advisory bulletin directing operators to review and assess their continuing education pro rams aimed at their customers and the public. RSPA noted in the letter that it woul 3 . continue towork with the American Gas Association and other trade associations in this regard because it believes that they have a major role to play in assessing the effectiveness of industry public awareness programs and informing operators of espe persuasive approaches. Pending completion of the advisory bulletin and revie#

Page 55 the Safety Board, Safety Recommendation P-90-21 will be classified as "Open-Acceptable Alternate Response." Therefore, the National Transportation Safety Board recommends that the American Gas Association and the American Public Gas Association: Inform member companies of the circumstances of this accident and urge them to (1) review and improve their employee guidance and training programs on recognizing and responding t o abnormal situations, (2) assess t h e appropriateness of their procedures for using bypass valves t o maintain pressure control during regulator inspections, and (3) assess the effectiveness of their programs for educating the public about recognizing and responding to potential gas emergencies. (Class 11, Priority Action) (P-93-6) Also, the Safety Board issued Safety Recommendation P-93-1 through -5 to the Peoples Gas Light and Coke Company. The Safety Board reiterated Safety Recommendation P-87-2 to the Research and Special Programs Administration. The National Transportation Safety Board is an independent Federal agency with the statutory responsibility "to promote transportation safety by conducting independent accident investigations and by formulating safety improvement recommendations" (Public Law 93-633). The Safety Board is vitally interested in any action taken as a result of i t s safety recommendations. Therefore, it would appreciate a response from you regardin action taken or contemplated with respect t o the recommendations in t z i s letter. Please refer to Safety Recommendation P-93-6. VOGT, Chairman, CBUGHLIN, Vice Chairman, and LAUBER, HART, and HAMMERSCHMIDT, Members, concurred in this recommendation. BY: Carl W. Vogt' Chairman#