NTSB Safety Recommendation Letter P-97-009 through P-97-010

Page 1Official PDFNational Transpartation Safety Board Washington, D.C. 20594 Safety Recom m enda ti on In reply refer to: P-97-9 and -10 Ms Nydia E Rodriguez Maitinez. President Puerto Rico Public Seivice Coniinission Post Office Box 190570 Hato Ray Station San Juan, Puerto Rico 00919-0670 About 8 3 0 a-ni. oil November 21, 1996, because of a propane gas leak, a coininercial building in San Jum, Puerto Rico, exploded Thirty-three people were killed, and more than 80 were injured. The building was in Rio Piedras, a shopping district i n San ,Juan The structure was a six- story mixture of offices and stores onned by Numberto Vidal, Inc. The company's adniiiiistrative offrces occupied the third, foui,th, fifth, and sixth floors, and the first and second floors housed ajeweiry store, a record store. and a shoe stole.' The National Transportation Safety Board determines that the probable cause of the propane gas explosion, which was fueled by an excavation-caused gas leak. in the basement of the Numberto Vidal, Inc., office building was the failure of San .Juan Gas Company, Inc., (SJGC) to oversee its employees' actions to ensitre timely identification and comection of unsafe conditions and strict adherence to operating practices and the failure of the SJGC to provide its employees with adequate training Also contributing to the explosion was the failure of the Research and Special Programs Adiiiinistration/O~fice of Pipeline Safety (OPS) to oversee effectively the pipeline safety program in Puerto Rico, the failure of the Ptrerto Rico Public Service Commission (PSC) to require the SJGC to correct identified safety deiiciencies. and the failure of Eilron Corp. to oversee adequately tlie operation of the SJGC ' For more information, read Pipeline Accident ReportSa17 Juan Gm Co~irpany, Inc/Enron Corp Propane Gas E.rplosion in Sari ,Juan, Piierfo Rico. on Noi~einber 21. 1996 (NTSB/PAR-97/01) 6759C#

Page 22 Contributing to tlie loss of life was the failure of the SJGC to adequately inform citizens and businesses of the dangers of piopane gas and the safety steps to take wlien a gas leak is suspected or detected. I 'The PSC did not have written piocedures to guide its iiispectoi,s on documenting probable safety violations, notifying SJGC management of violations, following tip violations, and telling tlie PSC commissioners wlien formal action was needed to enforce coinpliance Even so, the PSC inspectors did identify, document. and fornially notify the SJGC of probable violations. While the SJGC did not totally ignore tlie 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 tlie same for both years. At the urging of tlie OPS in 1993. the I'SC levied a small monetary penalty against the SJGC in 1994. In 1995, PSC inspectors documented more than 80 piobable violations. In June 1977, the Safety Board held a public hearing about tlie Rio Piedras accident, and at the hearing a PSC inspector testified that he had discussed tlie 1995 inspection results with SJGC management; however, tlie PSC could pioduce no documents proving that it liad either notified the SJGC or told tlie PSC co~i~~iiissionets of any iieed to lake foi,iiial action against tlie SJGC. 'The PSC did not take any foi.mal action against the SJGC for failing to correct the probable violations; and in 1996. PSC iiisiiectors documented more than 50 probable violations. More than .30 were tlie same as those documented i n 1995 Again, tlie PSC was unable to produce written documentation sho\\~ing that the SIGC had been notified; however, a PSC inspector testified that a SJGC iepresentative nccoiiipanied the PSC inspectois on all inspections and was inforiiied about all probable violations Therefore, it would appeal. that in both 1995 and 1996, SJGC management liad the opportunity to leain about tlie PSC's findings On March 13, 1997. the PSC issued an adiiiinistiative order to tlie SJGC about tlie 1996 inspection. 'The order noted that the SJGC had been told about tlie aleas of non-compliance on the day of the inspection and that the problems included corrosion control, operation and maintenance plans, public education. investigation of failures, maximum operating pressure, patrolling, required tests before restoring gas service, abandoning facilities, deactivating facilities, protecting metal pipe, remedial steps, required notifications, and revision of records. The order stated that tlie SJGC was required to eliminate the deficiencies Within 30 days of the order, the SJGC was to send tile PSC a copy of its plans for complying; thus the PSC could evaluate tlie SJGC's progress. On April 3: 1997, an attorney for the SJGC asked the PSC to reconsider its administrative older On April 30, 1997, after reconsidering, tlie PSC ordered the SJGC to comply with tlie administrative order. The PSC's most recent inspections demonstrate that it has recognized the need to inspect SJGC operations more thorouglily; ho\ve\w. until tlie explosion, tlie PSC did not begin to enforce its safety requirements aggi.essively After tlie explosion, the PSC ordered the SJGC to comply with its administrative order, but it did nothing to m a l e the SJGC resolve the probable violations the PSC liad identified in 1995. The Safety Board concludes that the lack of written guidance for PSC inspectors on documenting probable violations, on formally notifying tlie SJGC, on doing timely followups to 1#

Page 33 determine whether violations have been corrected, and on telling the PSC commissioners when there is a need for formal action to enforce coinpliance contributed to poor coininunications among PSC staff, its commissioners, and SJGC management. The lack of effective program management likely contributed to tlie ineffective use of PSC. enforcement capabilities and may have contributed to the failure of Enron and the SJGC to correct deficiencies. The Safety Board believes that tlie PSC must develop written procedures to guide its staffs actions if it is to ensure that monitoring will be effective, that the SJGC will be iiolilied of its probable violations, and that the comniissioners will rake pionipt. aggressive enforcement steps if the S.JGC fails to make timely corrections in its operations. Another factor in this accident was the SJGC’s method of handling abandoned gas lines. The Humberto Vidal building was on the coriier of .lost de Diego and Camelia Soto. Before the accident, more than 10 pipes and conduits ‘iveie beneath Camelia Soto. some meant for future use, some being used, and others that had been abandoned. The investigators found that many of the 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 more of the active and abandoned pipes and coiiduits under Camelia Soto until it reached the HV building. During tlie investigation, investigators found several buried facilities for which the maps and related records were nonesistent. out of date, or incomplete. For 1 days, the S.1GC was unable to find its drawings of the plastic gas line under Camelia Soto, and some records it produced of gas service lines i n the area were not fully desciiptive. Additionally, no one was able to locate ariy records that showed the purpose or ownership of tlie 2-inch-diameter plastic conduit found i n contact with the gas sei,vice line under tlie street that was parallel to Jost de Diego. Therefore, the National Transportation Safety Board issues the following recommendations to tlie Puerto Rico Public Senrice Commission: Develop written procedures to guide pipeline inspectors i n assessing the coinpliance of gas pipeline operators with pipeline safety i,equirenients, in documenting probable violations. i n notifying gas pipeline opelators of probable violations, and in recommending to the commissioners any formal action that may be required to obtain prompt compliance. (P-97-9), Require that San Juan Gas Company, Inc , take action necessary to ensure that abandoned pipelines ale propeily disconnected, purged of propane, and adequately secured to prevent tlie t~ansmission of llaiiimable vapors and gases, and to ensure that abandoned pipelines are ploperly identified 011 maps (P-97-10) Also, the Safety Board issued Safety Reco~ii~nendations P-97-5 to the US. Secretary of Transportation, P-97-6 through -8 to the Research and Special Programs Administration, P-97-11 and -12 to Ewon Corp , and P-97- I3 to Heath Consultants, Inc. The National Transportation Safety Board is an independent Federal agency with the statutory responsibility “to promote transportation safety by conducting independent accident#

Page 44 investigations and by formulating safety improvement iecommeiidations” (Public Law 93-633)., The Safety Board is vitally interested i n any action taken as a result of its safety recommendations. ‘Therefore. it would appreciate a iesponse fIom you regarding action taken or contemplated with respect to the recommendation in this letter Please refer to Safety Recoininendations P-97-9 and -10 in youI reply If you need additional information, you may call (202) 3 14-6468. Chairman HALL. Vice Chairman I; RANCIS, and Members HAMMERSCHMIDT, GOGLIA, and BLACK concurred i n these recommendations. Cliaii man (#