NTSB Safety Recommendation Letter P-97-013

Page 1Official PDF.... . . . . . .. . . . ... . I_ _-_-_ ~ .-I._ -- --.- __ .~ . .. . . ~ ~. L 09 .?-3fbb National Trailsportation Safety Board Washington, D.C. 20.594 Safety Recommendation w 9- Date: January 6 , 1998 In reply refer to: P-97-13 Mr Graham Midgley President Heath Consultants, Inc 9030 Monroe Road Houston. Texas 7706 I About 8:30 a,m. on November 21, 1996, because of a propane gas leak, a conunercial building in San .Juan, Puerto Rico. exploded. Thirty-three people were killed, and more than 80 were injured. ' The inadequacy of the training of the Sail Juan Gas Company (SJGC) employees contributed substantially to causing the explosion E,niployees cannot do a proper leak survey or pinpoint a gas leak without knowing the lateral location of the gas pipes, the depth of the gas lines, and the depth at which the barlioles slio~ild be made For low-pressure propanelair systems, it is imperative that a crew first know the depth of tlie pipeline and then ensure that the barhole depths reach the pipe depth. The SJGC employees did not know the depth of the gas line and did not sink the barholes deeply enough. Tlie SJGC's training was inadequate in other ways. Tlie company did not assess the performance of its trainees after they had been trained or document its training, The personnel files for the incident crewmembers did include certificates for various training courses, but the files did not indicate the content of the courses or whether the courses were part of a training plan. Tlie Safety Board assessed the development, conduct, and evaluation of training for the SJGC's employees as inadequate, particulatly for tlie people who surveyed, located, and repaired leaks., Tlie major deficiency was the lack of a front-end analysis the of training needed. A front- end analysis includes a job analysis, which is necessary to identify tlie tasks' that the holder of I For more information, lead Pipeline Accident R,eport-Suti .Juan Cas Coinpony, Inc /Enron Carp. Propane Cas fiplorian in Son Jtran, Peerlo Rico. on November 21. 1996 (NTSBIPAR-9710 I ) . ':A task is an action or function performed as part o f a job Tasks are usually readily observable and should be measurable for determining adequacy o f performance 6789C#

Page 22 the job must be able to do. Doing ajob analysis would have identified the individual tasks related to the job, the number of people needed to perform the job, the tools and equipment necessary for performing the work, and any manuals. references, regulations, or company procedures the trainees were required to follow Once a task is identified, it can be converted to a learning objective,” or a goal that the trainee will achieve by taking training,. Learning objectives can be used to measure the effectiveness of the training. After fully describing the learning objectives, the course designer detemines the appropriate course presentation options. Options can include computer-based training, on-the-job training, interactive video, slides, and other media, as well as the standard platform or lecture format. During this design phase, written testing and/or ways to assess student performance can be designed to reflect the agreed upoii 1eai.iiing objectives. I n this way, assurance is provided that all critical job tasks are identified and can be taught and tested. Afier training, the trainee can be tested 0 1 anothei objective means of assessing training effectiveness can be used to determine whether tlre learning objectives have been meet.. The assessment would confirm that the trainee could successfully perform the tasks that have been identified as necessary to do the job TheieFore, the training has been successful and the trainee is prepared for tlie job. Not only does the use of learning objectives provide a way ofassessing the effectiveness oftraining, it keeps tlre training focused on the tasks that the txainee actually has to be able to do in order to perfolm the job Thus, a good front-end analysis of a trainee’s job can save both time and money, Therefore, the National Tiansportation Safety Boatd issues the following recommendation to Heath Consultants. Inc.: IdentiQ, when developing contracted training. the tasks for which the trainees must be trained and develop measures foI assessiny the job performance of the trainees and the effectiveness of the training,, (P-97-13) Also, the Safety Board issued Safety Recoinmendations P-97-5 to the U.S. Secretary of Transportation. P-97-6 through -8 to tlie Research and Special Programs Administration, P-97-9 and -10 to the Puerto Rico Public Service Commission, and P-97-11 and -12 to Emon C.orp. ‘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 recomrrreiidations” (Public Law 93-633). The Safety Board is vitally interested in any action taken as a result of its safety recommendations. Therefore, it would appreciate a response from you regarding action taken or contemplated with respect to the ieconiniendation in this letter. Please refer to Safety Recommendation P-97-13 in your reply, If you need additional information, you may call (202) 3 14-6468. ’ A statement that describes what knowledge the students will have or what they will be able to do upon completion of training. ( I#

Page 33 Chairman HALL, Vice Chairman FRANCIS, and Members HAMMERSCHMIDT, GOGLIA, arid BLACK concurred in this recommendation Chairman#