NTSB Safety Recommendation Letter P-97-006 through P-97-008

Page 1Official PDFNational Transportation Safety Board Washington, D.C. 20594 Safety Recommendation Date: January 6, 1998 In reply refer to: P-97-6 through -8 Miss Kelley Coyiier Acting Administrator Reseal cli and Special Piogranis Administration U S. Department of Transportation Washington, DC 20590 About 8:30 a.m. on Noveinber 21. 1996, because of a propane gas leak, a commercial building in San .Juan, Puerto Rico. exploded. Thirty-three people were killed, and more than 80 were injured The building was i n Rib Piedlas. a shopping district in San .Juan The structure was a six- story mixture of offices and stores owned by Humberto Vidal, Inc. The company’s administrative offices occupied the third, fourth. fifth, and sixth floors, and the first and second floors housed a,jewelry store. a record store. and a shoe store.’ The National Transportation Safety Board determines that the probable cause of the propane gas explosion, which was fueled by an excavation-caused gas leak, i n tlie basement of the Huinberto Vidal, liic , office building was the failure of San Juan Gas Company, Inc., (SJGC) to oversee its employees’ actions to ensure timely identification and correction of unsafe conditions and strict adheience to operating practices and the failure of the SJGC to provide its employees with adequate training. Also contributing to tlie explosion was the failure of the Research and Special Programs AdministratioidOffice of Pipeline Safety (OPS) to oversee effectively the pipeline safety proprani in Puerto Rico, the failure of the Puerto Rico Public Service Coinmission (PSC) to require the SJGC to conect identified safety deficiencies. and the failure of Enron Corp. to oversee adequately the operation of the S.JGC, ’ For more information, read Pipeline Accident Report-Son . J I I ~ Gus Conipanv. Inc /Enron Corp Propane Gus Explo,sio~t in Salt .hion, Piroro Rico, on Novcvtber 21. I996 (NTSBIPAR-97IOl) 6789C#

Page 22 Contributing to the loss of life was the failure of the SJGC to adequately inform citizens and businesses of the dangers of propane gas and the satety steps to take when a gas leak is i suspected or detected. ’, Well before the accident, the PSC inspectors had identified, documented, and formally notified the SJGC of probable violations. However, while the SJGC did not totally ignore the notices, its responses indicate that it saw little urgency about making corrections. The PSC’s 1992 and 1993 inspections documented 16 and 20 probable violations, respectively; five violations were the same for both years. At the OPS’s urging in 1993, the PSC levied a small monetary penalty against the SJGC in 1994 In 1995, PSC inspectors documented more than 80 probable violations. A PSC inspector testified at the June 1997 public lieai,ing that he had discussed the 1995 inspection results with SJGC management; however, the PSC could pioduce no documents proving that it had either notified the SJGC or told the PSC commissioners ofany need to take formal action against the SJGC. ‘The PSC did not tale any formal action against the SJGC for failing to correct the probable violations; and in 1996. PSC inspectors documented more than 50 probable violations. Mole than 30 were the S a m as those documented in 1995, Again, the PSC was unable to produce written documentation showing that the SJGC had been notified,. ‘The OPS is responsible for evaluating the PSC’s pipeline safety program. At the June 199’7 Public Inquiry, the OPS southein region director, whose ~esponsibilities include overseeing Puerto Rico, advised that it is essential to the sciccess of a program, as well as a requirement of the certification, that the agency be able to enforce the regulations by levying civil penalties as appropriate. Ne also said that if a State finds violations but does not notify the operator and follow up to make sure the violations are cori,ected, the OPS will call the deficiency to the attention ofthe PSC. The region director said that the PSC’s pr’ogram has iqxoved steadily since 1992. “Today, there is more support from the PSC commissioners for the pipeline safety program, and this is especially true for the past couple of‘ years since one commissioner pledged his cooperation to the OPS and his support for the pipeline safety staff.” Each year, the OPS evaluates the PSC’s performance during the previous year. During the 1970s and 1980s, the OF’S sent letters to the PSC specifying the deficiencies in SJGC operations and followed up with the PSC to ensure that corrective action had been taken. Based on the OPS’s letters to the PSC in the l990s, the OPS concentrated, almost to the exclusion of all other needs, on obtaining equipment to enable PSC staff to better perform its inspections and on establishing an excavation-damage prevention piogram for Puerto Rico, Although the OPS has been trying to improve the PSC’s pipeline safety program, since 1993, the OPS has given the PSC’s pipeline safety program high scores despite significant deficiencies. The problem was compounded by the OPS’s letters to the PSC’s president; the letters gave no indication the program needed significant improvements, such as the development of written procedures to guide its staff on documenting and notifying an operator of probable violations or the development of an effective enforcement program. i#

Page 33 The OPS did notify tlie PSC in 199; of its concern about the PSC’s 1992 inspection findings of 16 probable violations, and it advised the PSC that it should seriously consider using civil penalties to force the S.JGC to make corrections As a result, the PSC did levy a monetary penalty. Since then however, the OPS has not recommended that the PSC tale any enforcement actions, even after the Rio Piedras explosion. Based on its latest evaluation, the 1996 evaluation, the OPS awarded the PSC a rating of 97 for its pipeline safety program, including giving it the highest possible rating for its compliance program. The OPS awarded these ratings even though the PSC in 1996 had told the SJGC that it had more than 50 probable violations, of which 30 had been identified in 1995, and the PSC had not taken any formal action to force the SJGC to make corrections. The Safety Board agtees with the OPS that the States iisiially can provide more resources than the OPS does for monitoring pipeline operations and that when possible, tlie responsibility for monitoring should remain with the State. However. the 013 retains overall responsibility; and through its monitoring of State programs. it must ensure that pipelines are operated in a manner that provides adequate public safety The Safety Board also agrees that the OPS should work with the States to help them maintain aiid improve their programs. However at no time should the OPS’s objective of keeping States i n the pipeline safety program tale precedence over its responsibility for ensui.iiig that pipeline systems are safely operated and maintained to preserve public safety. Each year, after the OPS had evaluated the PSC‘s pipeline safety progiam, it scored the program‘s effectiveness and gave the PSC president a numerical glade. The PSC’s enforcement program received the maximum allowable points i n each of the 3 years, For the past 3 years, the PSC’s pipeline safety program received overall scores of 95. 97. and 97, respectively. The scores would indicate little. if any. need for improvement The S a k t y Board concludes that the OPS’s evaluation scores for the I’SC before lie Rio Piedras explosion misled the PSC commissioners about the need to bring enforcement action against the S.lGC When a State program is not iiunctioning, the OPS must fill the gaps; any time public safety is being coinpromised, the OPS mist act. The Safety Board believes that in view of the events preceding tlie Rio Piedras explosion, the OPS iiiiist improve its State pipeline safety certification program., The OPS must develop written guidance aiid criteria that its personnel can use to evaluate State programs objxtively, and the OPS must require States to be prompt in correcting identified program deficiencies. The inadequacy of the training that the SJGC gave its employees was an important factor in the Rio Piedras accident. The Safety Board has had a long standing concern about the quality of the training pipeline employees receive and about whether the training ensures that tlie employees are able to do their jobs. Ten years ago, in a Februaiy 18, 1987, report,’ the Safety Board recommended that RSPA: ’ National Transportation Safety B o a d Pipeline Accident Report. Tc.sus Eusrem Gas Pipeline Coinpapy Riipfrires and Fires at Bearrimit, K~IIIIICIY uii Alxd ?7, IW.5 urd L.micosrer, Koirlrcky, on February 21. 1986 (NTSB/PAR-87/0 I )#

Page 44 Amend 49 CFR Parts 192 and 195 to require that operators of pipelines develop and conduct selection, training, and testing programs to annually qualify employees for correctly cariying out eacli assigned responsibility which is necessary for complying with 49 CFR Parts 192 or 195 as appropriate. In March 1987, RSPA published an Advance Notice of Proposed Rule Making, Pipeline Operator QualiJicutions (Docket No. PS-94, Notice I), which said: .This notice, issued in advance of' a proposed rule, invites public comment on the need for additional regnlations 01' a certification piogram regarding the qualification of personnel who design. construct. operate, or maintain gas or hazardous liquid pipelines,. 'The Board responded in May. saying that it had issued 110 recommendations about the training of pipeline workers. The Board had issued the reconmendations as the result of various pipeline accidents between 19'75 and 1986, and the recomiiiendations covered a wide variety of training deficiencies that applied to a bioad segiiient of pipeline activities 'The Safety Board advised that it had found training deficiencies that were either contributing or directly causal to pipeline accidents in nearly every facet of activity investigated. including operations, construction, and emergency iesponse, It noted that training and performance criteria for the pipeline operating community needed to be developed and implemented so that the effectiveness of the training and the performance of' the operator could be measured 'The Board said that without such measures it would be hard to determine objectively whether training had improved an employee's perfommice and whether the olJjectives of'the training had been met. In its comments to the Advance Notice of Proposed Rule Making and directly bearing on the SJGC investigation. the Safety Boa1.d told RSPA that it needed to require pipeline operators to: *identify each employee whose successful accomplishment of assigned responsibilities or taslts was a necessary part of an operator's actions to comply with tlie Federal pipeline safety regulations; operforni analyses to identify tlie taslts. jobs, and responsibilities each employee had that related to Federal pipeline safety regulations: .identify specific training methods to be einployed to provide each employee with enough knowledge to effectively carry out applicable jobs, taslts, and responsibilities identified in the analyses; *identify methods to be used in evaluating the effectiveness of the training, including the identification of standards for acceptance; and .document the training provided for each employee and training evaluations.#

Page 55 On May 1 I , 1993, the Safety Board reminded RSPA that it had been more than 5 years since the Board had recommended establishing employee qualification standards and that implementing the recommendation should have been one of RSPA’s top priorities. The Board affirmed that it remained firmly convinced that the recommended training, qualification, and testing requirements and standards were essential. As a result of RSPA’s inaction, Safety R.ecommendation P-87-2 was classified “Open-Unacceptable Response.” On .July 27, 1994, RSPA issued a Notice of Proposed Rulemalting (NPRM) proposing the qualification standards for pipeline employees. On November 9, 1994, the Safety Board responded to the NPRM, comneiiting on tlie proposal and urging RSPA to expedite completion of tlie rulemaking. RSPA received I .3 I comnients 017 its proposal; and almost 2 years later, on June 25, 1996, it withdrew tlie proposal in favor of conducting a procedure known as “Negotiated Rulemalting.”’ In its ,lune 26. 1996. Notice of Intent. RSPA stated that “Coininenters to the NPR.M stated that the proposal \vas too presci,iptive and that many references to training requirements should be modified to place the focus ofthe NPRM on actual qualifications, not the nierliods of achieving it.” RSPA selected a committee to represent the “interests” affected by actions that it may take on employee qualification requirements. In April 1997, the committee began drafting a new rule proposal, but has not completed its task. The committee has addressed provisions for employee performance assessment and recordlteeping. By requiring the evaluation of employees’ pei foimance, the committee addressed the Safety Board‘s concern that the qualifications of employees of pipeline facilities be judged on the basis of objective, demonstrable forms of evaluation. The committee will also recommend that an evaluation of an employee’s performance be required if the employee is involved in a reportable incident to which his actions may have contributed I n August 1997, the committee had its fourth meeting. The goal \vas to obtain consensus among committee members on a draft regulation concerning operator qualifications and to review and revise the outline for the nilemaking preamble The Safety Board continues to urge RSPA to espedite tlie completion of rillemalting action to achieve this essential safety objective, Another factor in tlie accident was the SJGC’s method of handling abandoned gas lines. The Humberto Vidal building was on the corner of JosC de Diego and Camelia Soto., Before the accident, more than 20 pipes and conduits were beneath Cainelia Soto, some meant for future use, some being used, and others that had been abandoned. Tile investigators found that many of tlie abandoned pipes and conduits had not been plugged or otherwise sealed, and combustible-gas indicator tests showed that escaping propane gas had probably flowed along one or inore o f the active and abandoned pipes and conduits under Camelia Soto until it reached the building. ’ “The negotiated rule process assists i n the developiiieni of die NPRM. allowing all affected parties IO present tlieir views IO reach a consensus, thus avoiding litigation and disagreement once the rule is finalized. By using this process OPS has agreed 10 publish the coiiiniiitee’s consensus Also. tlie overall contents of the regulation are the responsibility of the committee, However, by paiticipating in tliis process. the Office of Pipeline Safety does not give up its responsibility lo promulgate tlie tinal rule ” Taken from tlie draft suinmary ininutes of the April 23, 24, 1997, advisory committee meeting#

Page 66 During the investigation, investigators found several buried facilities for which the maps and related records were nonexistent, out of date, or iiiconiplete For 2 days, the SJGC was unable to find its drawings of tlie plastic gas line under Canielia Soto, and some records it produced of gas sewrice lines in tlie area were not ftilly descriptive Additionally, no one was able to locate any records that showed the purpose or ownership of tlie 2-inch-diameter plastic conduit found in contact with the gas service line undei the street that was parallel to Jose de Diego,. 'Therefore, the National Tianspoitation Safety Boaid issues tlie following recommendations to the Research and Special Programs Administration: Modify your monitoring of State pipeline safety prograins to ensure that the States are timely i n monitoiing tlie coriection of identified satety deficiencies and to ensure that they iinplenient enfoicenient action as necessary.(P-97-6) Complete a final rule on employee qualification. ti.aiiiing. and testing standards within one year Require opeiators to test employees on tlie safety procedures they are expected to follow and to demonstrate that they can correctly perfoim the work, (P-97-7) Require that San Juaii Gas Company. Inc,, tale action necessaiy to ensure that abandoned pipelines air piopei,ly clisconnected. piii.ged of pi'opane, and adequately secured to pre\ ent the iransmission o l Hammable vapors and gases, and to ensure that abandoned pipelines are properly identified on maps. (P-97-8) Also, tlie Safety Board issued Safety Reco~n~iienclations P-97-5 to the U.S. Secretary of Tiansportation, P-97-9 and -10 to the Puerto Rico Public Service Commission, P-97-11 and -12 to Emon COIP., slid P-97-13 to IHsatli CoIisLdtants, I I ~ C Please refer to Safety Recoinmendations P-97-6 tliioiigh -8 i n youi reply. If you need additional information, you may call (202) 3 14-3 14. Chairnian HALL, Vice Cliairrnan FRANCIS, and Members HAMMERSCHMIDT', GOGLIA, and BLACK concuned in these recommendations. Chairnian l I#