ILLINOIS POWER CO — Gas distribution — incident on 2009-08-15

Gas distribution incident in UTICA, LASALLE County, IL. Reported cause: 23. Reported consequences: 0 fatalities, 1 injuries, $0 reported property damage. Operator-reported incident data submitted to PHMSA, generally within 30 days. Records may be supplemented or corrected and do not represent final agency causal findings.

Report number: 20090131.

Operator ID: 8040.

Reported incident date: 8/15/2009.

Cause detail: INCORRECT OPERATION

Cause detail: THE GAS CONSTRUCTION CREW WAS SCHEDULED TO REBUILD A METER SET REPLACING TWO AL 5000 DIAPHRAGM METERS WITH ROATARY METERS. THE PROJECT WAS SCHEDULED FOR SATURDAY, AUGUST 15TH TO MINIMIZE CUSTOMER IMPACT DUE TO THE OUTAGE REQUIRED TO COMPLETE THIS REBUILD. A WALK THROUGH WAS CONDUCTED ON FRIDAY, AUGUST 14TH TO EVALUATE THE SCOPE OF THE PROJECT AND TO COMMUNICATE THE EXTENT OF THE OUTAGE WITH THE CUSTOMER. THE CONSTRUCTION CREW WOULD DISCONNECT THE FACILITIES FROM THE SOURCE OF SUPPLY AND REBUILD THE METER SET. THE FOLLOWING MONDAY, A REGULATOR TECHNICIAN WAS SCHEDULED TO REESTABLISH GAS TO THE CUSTOMER. THE CREW MET AT THEIR WORK HEADQUARTERS AT 6:30 A.M., LOADED THE MATERIALS AND HEADED FOR THE JOB SITE. ONCE ON SITE, THE CREW CONDUCTED A JOB BRIEFING THAT FOCUSED ON: ENERGY SOURCES - CONTROLLING THE SOURCE OF GAS WITH VALVES WORK PROCEDURES SPECIFICALLY WELDING SPECIAL PRECAUTIONS FIRE EXTINGUISHER, PROPER TOLS, WORK AREA CONDITIONS PPE REQUIREMEMNTS - GLOVES, SAFETY GLASSES, HIGH VIS VESTS, WELDING APPAREL STRAIN HAZARDS ASSOCIATED WITH REMOVING THE AL 5000 GAS METERS THE EXISTING FACILITIES WERE CONSTRUCTED WITH TWO RISERS PROVIDING 90 PSIG GAS TO PARALLEL AL 5000 GAS METERS WITH A SINGLE DOWNSTREAM 461 REGULATOR DELIVERING 55 PSIG GAS TO THE CUSTOMER. THE CREW CLOSED TWO INLET RISER VALVES ISOLATING THE METER SET FROM THE DISTRIBUTION SUPPLY. THE CREW BROKE THE UNIONS DOWNSTREAM OF EACH AL 5000 GAS METER TO BLEED OFF THE GAS. THE RISER VALVES WERE WELD-BY FLANGED GATE VALVES WITH 2" 150 CLASS FLANGE CONNECTIONS DOWNSTREAM OF THE GATE. THE CREW CUT THE PIPING DOWNSTREAM OF THE FLANGE AND REMOVED THE AL 5000 GAS METERS TO HAVE BETTER ACCESS TO REMOVE THE FLANGE BOLTS. THE CREW ORIGINALLY PLANNED TO USE AN IMPACT WRENCH TO REMOVE THE FLANGE BOLTS; HOWEVER, THEY COULD NOT LOCATED A 3/4" X 1/2" IMPACT WRENCH ADAPTER, SO DECIDED TO USE AN OXY-ACETYLENE TORCH TO CUT THE FLANGE BOLTS. THE CREW CHECKED FOR GAS BLEED BY AT THE INLET GATE VALVES TO ENSURE THAT THEY WERE WORKING IN A GAS FREE ENVIRONMENT WITH THE TORCH AND THEN PROCEEDED TO CUT THE EIGHT FLANGE BOLTS. SEVEN OF THE EIGHT FLANGE BOLTS WERE REMOVED WHEN THE FINAL BOLT REQUIRED ADDITIONAL CUTTING TO REMOVE A BURR THAT INHIBITED THE REMOVAL OF THE BOLT. THERE WAS APPROXIMATELY 6 FEET OF SEPARATION BETWEEN THE RISER VALVES AND UNIONS. THIS PIPING DOWNSTREAM OF THE UNIONS HAD BEEN OPEN TO THE ATMOSPHERE FOR APPROXIMATELY 15 MINUTES WHEN THE RESTRICTING ELEMENT ON THE DOWNSTREAM 461 DIRECT OPERATED REGULATOR OPENED ALLOWING THE RELEASE OF CUSTOMER LINE PACK TO THE ATMOSPHERE. THIS LINE PACK CAME INTO CONTACT WITH THE TORCH AND IGNITED, RESULTING IN INJURIES TO AN EMPLOYEE. MEDICAL TREATMENT FOR THE BURN INJURIES WAS PROVIDED AT A LOCAL HOSPITAL. LATER THAT AFTERNOON OR EARLY EVENING, THE EMPLOYEE MADE THE DECISION TO GET ADDITIONAL TREATMENT AT A HOSPITAL IN NORTHERN ILLINOIS WHERE HE WAS ADMITTED OVERNIGHT FOR OBSERVATION AND RELEASED THE FOLLOWING DAY. THE EXTENT OF HIS INJURIES INCLUDED FIRST DEGREE BURNS TO THE SIDE OF HIS FACE AND SECOND DEGREE BURNS TO HIS WRIST BETWEEN HIS GLOVES AND WELDING JACKET. THE APPARENT CAUSE OF THIS INCIDENT IS RELATED TO THE RELEASE OF CUSTOMER LINE PACK DOWNSTREAM OF THE 461 REGULATOR. THE CREW THOUGHT THAT THE GAS DOWNSTREAM OF THE INLET RISER VALVE WAS COMPLETELY BLED OFF WHEN THE TWO UNIONS WERE BROKE AND THE GAS METERS REMOVED. THE GAS IGNITION WAS NOT ORIGINALLY IDENTIFIED AS A REPORTABLE INCIDENT BECAUSE THE SOURCE OF GAS RELEASED WAS CUSTOMER LINE PACK DOWNSTREAM OF THE GAS METERS AND REGULATOR. AMEREN IP DID PROVIDE NOTIFICATION TO THE ILLINOIS COMMERCE COMMISSION (ICC) OF THE IGNITION AND SUBSEQUENT MEDICAL TREATMENT THE FOLLOWING MONDAY, AUGUST 17TH. THE ICC STAFF, IN CONSULTATION WITH PHMSA CENTRAL REGION, STATED THAT THIS GAS IGNITION SHOULD BE REPORTED AS A DISTRIBUTION INCIDENT BECAUSE THE GAS WAS RELEASED THROUGH COMPANY PIPELINE FACILITIES WHEN THE 461 REGULATOR OPENED ALLOWING THE CUSTOMER LI NE PACK TO BLEED OFF TO THE ATMOSPHERE. FOLLOWING THIS DISCUSSION THE INCIDENT WAS REPORTED TO PHMSA AT 11:30 A.M. ON AUGUST 17, 2009. POST INCIDENT ALCOHOL AND DRUG TESTING WAS NOT PERFORMED DUE TO THE 32 HOUR TIME LAPSE.

PHMSA trend classification: significant incident, serious incident, not fire-first.

PHMSA standardized cause: INCORRECT OPERATION — OTHER INCORRECT OPERATION.

PHMSA indexed costs: $0 reported total cost, $0 in 1984 dollars, $0 in current-year dollars.

PHMSA trend flags, standardized causes, and indexed costs are analytical fields added to operator-reported incident data. They do not represent final agency causal findings.