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Safety Recommendation Details

Safety Recommendation P-97-007
Details
Synopsis: ABOUT 8:30 A.M. ON 11/21/96, AN EXPLOSION OCCURRED IN THE HUMBERTO VIDAL SHOE STORE AND OFFICE BUILDING AT 100 JOSE DE DIEGO CALLE IN RIO PIEDRAS, PUERTO RICO. LOCAL EMERGENCY AGENCIES RESPONDED AND INITIATED SEARCH AND RESCUE OPERATIONS, BY 12/5/96 30 FATALITIES HAD BEEN CONFIRMED, AND 5 PEOPLE, BELIEVED TO STILL BE IN THE BUILDING RUINS, WERE MISSING. LOCAL AUTHORITIES HAVE SUSPENDED SEARCH EFFORTS UNTIL THE BUILDING CAN BE MADE SAFE FOR RESCUE WORKERS.
Recommendation: THE NTSB RECOMMENDS THAT THE RSPA: COMPLETE A FINAL RULE ON EMPLOYEE QUALIFICATION TRAINING, AND TESTING STANDARDS WITHIN ONE YEAR. REQUIRE OPERATORS TO TEST EMPLOYEES ON THE SAFETY PROCEDURES THEY ARE EXPECTED TO FOLLOW AND TO DEMONSTRATE THAT THEY CAN CORRECTLY PERFORM THE WORK.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Pipeline
Location: San Juan, PR, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA97MP004
Accident Reports:
San Juan Gas Company, Inc./Enron Corp. Propane Gas Explosion
Report #: PAR-97-01
Accident Date: 11/21/1996
Issue Date: 1/6/1998
Date Closed: 4/18/2001
Addressee(s) and Addressee Status: RSPA (Closed - Unacceptable Action)
Keyword(s): Rulemaking, Training and Education

Safety Recommendation History
From: NTSB
To: RSPA
Date: 4/18/2001
Response: The Safety Board notes that RSPA's final rule on operator personnel qualification was published on August 27, 1999 (64 FR 46853). However, RSPA's final regulations do not require operators to test employees on the safety procedures they are expected to follow and to demonstrate that they can correctly perform the work, as requested. Accordingly, Safety Recommendation P-97-7 is classified "Closed--Unacceptable Action," and despite RSPA's request for a change in status, P-87-2 remains classified "Closed--Unacceptable Action."

From: NTSB
To: RSPA
Date: 7/13/2000
Response: ON 2/19/99, BASED ON INFORMATION PROVIDED IN THE RSPA LETTER OF 7/8/98, P-97-7 WAS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE." COPIES OF RECOMMENDATIONS P-87-34, P-90-21, P-95-4, P-96-1, P-97-6, P-97-7, P-97-8, P-98-1, P-98-2, P-98-3, P-98-4, P-98-5, AND P-98-25 AND ASSOCIATED CORRESPONDENCE ARE ENCLOSED. THE SAFETY BOARD WOULD APPRECIATE LEARNING OF ANY ACTION TAKEN OR PLANNED TO COMPLY WITH THESE RECOMMENDATIONS, ESPECIALLY P-97-7 AND -8, WHICH MAY BE DISCUSSED AT A BOARD MEETING.

From: RSPA
To: NTSB
Date: 4/24/2000
Response: As you know, RSPA published a final rule on operator personnel qualification on August 27, 1999 (64 FR 46853). The rule requires operators to develop and maintain a written qualification program for individuals performing covered tasks on pipeline facilities. NTSB Safety Recommendation P-87-3 called for training and testing requirements. In 1997 NTSB issued Safety Recommendation P-97-7, which urged RSPA to complete the final rule on pipeline employee qualification, and that the rule include requirements for testing. On July 27, 1998, NTSB classified Safety Recommendation P-87-2 as "Closed--Unacceptable Response," because of the extensive time taken to issue the final rule and because RSPA indicated that testing was not prescribed. The Accountable Pipeline Safety and Partnership Act of 1996 revised the language in the congressional mandate regarding qualification requirements by removing the requirement for testing and certification. The revised mandate focused on ensuring qualification of those performing safety related activities on pipeline systems. Therefore, the final rule does not specify training, testing, or certification as the only method of qualifying individuals performing covered tasks on pipeline facilities. It does, however, specify that all persons performing covered operations and maintenance tasks will be evaluated against the qualification plan to ensure that they can safely and effectively perform their safety-related functions. RSPA expects that qualification will include, but not be limited to, training and testing of personnel, on-the-job training, observation during performance of a task, simulations, and other means of ensuring personnel qualification. RSPA is working with government agencies, pipeline industry groups, and training organizations to facilitate implementation of the operator qualification rule. The Pipeline Employee Performance Group was established so that industry and regulatory training and technical personnel could communicate and coordinate a unified effort to provide training on the pipeline safety regulations. The initial effort of this group is to provide industry with guidance on the operator qualification rule. Efforts are also underway to ensure that small operators are aware of rule and are developing a plan to comply with the rule. RSPA's Guidance Manual for Operators of Small Natural Gas Systems is being revised to provide detailed guidance on compliance with the operator qualification rule. RSPA is also working to ensure that compliance and enforcement of this rule will be consistent throughout the nation. In the year 2000, efforts are being made to educate and train RSPA and State pipeline inspection staff about the requirements of rule. This includes regional seminars, training at the Transportation Safety Institute, and guidance documents. In addition, pipeline safety inspectors have begun to question operators on their initial operator qualification rule implementation efforts. I believe further discussion between the staffs will help clarify the issues. This discussion should allow NTSB to fully understand our response to NTSB Safety Recommendation P-97-7, and should form the basis for NTSB to re-evaluate the classification of Safety Recommendation P-87-2.

From: NTSB
To: RSPA
Date: 2/19/1999
Response: THE SAFETY BOARD NOTES THAT AN NPRM WAS ISSUED ON 10/27/98, AND REQUESTED COMMENTS BY 12/28/98. THE SAFETY BOARD HAS PROVIDED COMMENTS TO THE DOCKET. IN THAT REGARD, THE BOARD DOES NOT BELIEVE THAT THE NPRM ADEQUATELY ADDRESSES TRAINING AND DOES NOT REQUIRE OPERATORS TO TEST EMPLOYEES AS REQUESTED IN P-97-7. PENDING ISSUANCE OF A FINAL RULE THAT ADEQUATELY ADDRESSES TRAINING ISSUES, P-97-7 IS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

From: NTSB
To: RSPA
Date: 1/26/1999
Response: Notation 7106: The National Transportation Safety Board has reviewed the Notice of Proposed Rulemaking (NPRM) concerning the qualification of pipeline personnel (Docket No. RSPA-983783; Notice 1). The Safety Board has long been concerned about training in all transportation modes, including pipelines. In a report adopted on February 18, 1987, concerning pipeline accidents in Kentucky during 1985 and 1986, the Safety Board recommended that Research and Special Program Administration (RSPA): Amend 49 Code of Federal Regulations (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 carrying out each assigned responsibility which is necessary for complying with 49 CFR Parts 192 or 195 as appropriate. (P-87-2) Because over ten years had passed since the recommendation was issued, the Safety Board classified Safety Recommendation P-87-2 "Closed-Unacceptable Action" on July 27, 1998. In support of the recommendation, the Safety Board noted that it had issued more than 100 recommendations about the training of pipeline workers. The Board had issued the recommendations as a result of various pipeline accidents that took place between 1975 and 1986, and the recommendations covered a wide variety of training deficiencies that applied to a broad segment of pipeline activities. As a result of its investigation of a pipeline accident in San Juan, Puerto Rico, on November 21, 1996,' that resulted in 33 fatalities, the Safety Board made the following safety recommendation to RSPA: Complete a final rule on employee qualification, training, and testing standards within 1 year. Require [pipeline] operators to test employees on the safety procedures they are expected to follow and to demonstrate that they can correctly perform the work. (P-97-7) On July 8, 1998, RSPA advised that it expected to issue a final rule by November 1998 on an employee qualification program. The Safety Board is evaluating this response. In the San Juan report, the Safety Board reached several conclusions related to training. In this accident, the gas company employee who received telephoned reports of gas odors failed to provide effective instruction to callers about the dangers of propane and the steps they should take to protect themselves because neither employee training nor supervision was adequate. The gas company's employees were not adequately trained in surveying and pinpointing leaks. Furthermore, the gas company's employees were not properly trained in testing for leaks; they did not locate and repair the leak in the week before the accident. In addition, the leak detection training given to the gas company's employees was inadequate partly because neither the gas company, nor its consultant, identified the tasks for which the employees needed to be trained or tested the employees to make sure the training had been effective. Further, following the Safety Board's investigation of a pipeline accident near Fork Shoals, South Carolina, on June 26,1996,' which resulted in the release of about 957,000 gallons of fuel oil, the Board addressed the lack of adequate training for pipeline controllers. According to the pipeline operator, before the accident, controllers learned to recognize and handle normal conditions or emergency situations by reading a training guide and having discussions with other controllers. Actual experience with such an event would only occur coincidentally, if a controller happened to be working on the involved line at the time of the event. However, the job descriptions for both regular and relief controllers at the company required that the controller monitor pressures and respond to alarms caused by abnormal situations, as well as know the correct response and quickly execute it to prevent emergency situations. In this accident, the controller mistakenly shut down a pump station, then attempted to keep the line running even while high pressures were being recorded at many locations, relief valves were opening, and numerous alarms were being reported by the supervisory control and data acquisition system. The Board concluded that the training provided to the pipeline operator's controllers was inadequate to prepare them to respond properly to abnormal conditions. Ensuring that controllers and supervisors respond appropriately in such a high-stress environment requires adequate training. Because the company's controller training program did not include such training, the Safety Board concluded that the training provided by the company to its shift supervisors and pipeline controllers before the accident was inadequate to prepare them to respond properly and in a timely fashion to abnormal conditions and pipeline emergencies. The subject NPRM provides for the identification of relevant operations and maintenance area tasks; an evaluation procedure to determine whether individuals performing such tasks are qualified to perform them, as well as to respond to abnormal operating conditions; and the maintenance of records of each individual's tasks and evaluations. However, the NPRM does not actually require that operating and maintenance personnel be trained. The approach taken by the NPRM is rather to evaluate each individual's ability to perform the required tasks. The NPRM proposes that this evaluation could be performed by methods such as written or oral examination, or observation during on-the-job perfom1ance. Observation during job performance is a routine supervisory function. Tests must be administered in conjunction with training so that an objective assessment can be made as to the success of the training. The Safety Board believes that strong training and testing requirements are needed to ensure that employees can properly perform their tasks. The NPRM includes provisions to re-evaluate individuals as their tasks change or if there are indications that an individual may no longer be qualified. A provision also allows operators to determine whether periodic re-evaluation is needed and what the time interval should be between evaluations. The Safety Board believes that requirements are needed for retraining and re-testing. The Board is disappointed that, although RSPA has been aware of the prevalence of accidents in the pipeline industry associated with deficient personnel training for a number of years, the proposed NPRM does not require training and associated testing for qualification. Therefore, the Safety Board urges RSPA to amend the final rule to require that individuals be trained, that they be tested to assess the success of the training, and that they be periodically retrained and re-tested. The Safety Board appreciates being provided the opportunity to comment on this rulemaking action. Should you require additional infom1ation or clarification, please advise.

From: RSPA
To: NTSB
Date: 7/8/1998
Response: Letter Mail Controlled 7/14/98 3:05:56 PM MC# 980875 THIS NEW RECOMMENDATION ON QUALIFICATION OF PIPELINE OPERATOR PERSONNEL IS SIMILAR TO NTSB RECOMMENDATION P-87-2. RSPA ESTABLISHED A NEGOTIATED RULEMAKING COMMITTEE TO DEVELOP A NEW NPRM ON OPERATOR PERSONNEL QUALIFICATION. THE COMMITTEE IS COMPOSED OF PERSONS WHO REPRESENT THE INTERESTS AFFECTED BY A QUALIFICATION RULE, SUCH AS GAS PIPELINE OPERATORS, HAZARDOUS LIQUID AND CARBON DIOXIDE PIPELINE OPERATORS, MEMBERS OF STATE AND FEDERAL GOVERNMENTS, LABOR UNIONS, AND OTHER INTERESTED PARTIES. SPECIFICALLY, THE COMMITTEE IS MADE UP OF: AMERICAN GAS ASSOCIATION; AMERICAN PETROLEUM INSTITUTE; INTERSTATE NATURAL GAS ASSOCIATION OF AMERICA; AMERICAN PUBLIC GAS ASSOCIATION; NATIONAL PROPANE GAS ASSOCIATION; ASSOCIATION OF TEXAS INTRASTATE NATURAL GAS PIPELINES; MIDWEST GAS ASSOCIATION; NATIONAL ASSOCIATION OF CORROSION ENGINEERS; NATIONAL ASSOCIATION OF PIPELINE SAFETY REPRESENTATIVES; NATIONAL ASSOCIATION OF REGULATORY UTILITY COMMISSIONERS; NATIONAL ASSOCIATION OF FIRE MARSHALS; INTERNATIONAL UNION OF OPERATING ENGINEERS; INTERNATIONAL BROTHERHOOD OF ELECTRICAL WORKERS; AND RSPA'S OFFICE OF PIPELINE SAFETY. WE WILL SOON ISSUE AN NPRM THAT WAS PRODUCED BY THE COMMITTEE, AND WE HOPE TO PUBLISH A FINAL RULE BY NOVEMBER 1998. UNDER THE PROPOSAL, PIPELINE OPERATORS ARE REQUIRED TO PREPARE A WRITTEN QUALIFICATION PLAN, TO IDENTIFY COVERED OPERATIONS AND MAINTENANCE TASKS, AND TO ENSURE THAT ALL INDIVIDUALS, WHETHER EMPLOYEES OR CONTRACT PERSONNEL, ARE FULLY QUALIFIED TO PERFORM SAFETY-RELATED ACTIVITIES ON GAS AND HAZARDOUS LIQUID PIPELINES. RSPA BELIEVES THAT FINAL RULE WILL FULLY ADDRESS P-97-7.