Incident details
Operator, cause, commodity and consequences with raw source fields.
GD incident on 2023-07-03 — CA
Operator
Pacific Gas & Electric Co
Cause
Incorrect Operation
Commodity
Natural Gas
Program
GD
Damage and Injuries
0 fatalities
1 injury
Property damage (nominal)
$4,538
Incident datetime
2023-07-03 00:00 UTC
Report number
Location
CA, SANTA CLARA
Narrative
On thursday, june 8, 2023, pg&e incident on-duty personnel confirmed that a release of gas from a pipeline resulted in an injury necessitating in-patient hospitalization. The pg&e employee was admitted to the hospital, was under observation after suffering facial injuries, and is in stable position. The injuries occurred while working on a 4-inch steel distribution main and involved the dislodgment of a plug during a scheduled leak repair. Local fire and police department personnel responded, and the employee was transported for treatment in an ambulance. This incident was reported to the DOT and cpuc due to a release of gas resulting in an injury requiring hospital admission and at least one overnight stay. Per the investigation report the direct cause for this incident is inadequate thread engagement due to debris. A lack of proficiency combined with the failure to identify an aoc led to the dislodgement of the plug. The ce team completed a hazard barrier analysis of the expected controls around the work task, as well as utilized the human factors analysis and classification system to determine human performance precursors that may have contributed to the event. On june 7, 2023, pg&e crews responded to a grade 3 leak at 15630 alum rock ave. In san jose. As part of the leak repair process, two 4" mueller line stopper fittings were successfully installed, and leak repairs were performed. Upon completion of the leak repairs, workers were in the process of installing and tightening two completion plugs with a wrench when a failure of the pressure boundary was experienced. At approximately 0300am on june 8th, the final completion plug had been installed and was being tightened with a wrench when it inadvertently blew out of the fitting and exposed two coworkers to a direct stream of gas at distribution pressure. This resulted in an uncontrolled release of gas without ignition causing injuries to one coworker in the form of metal shavings lodged in their face and eyes. The injured coworker was also potentially struck in the head with either a tightening wrench and or the completion plug when the completion plug became dislodged. Two coworkers working in the trench were evacuated and the crews were moved a safe distance from the gas stream. Emergency responders arrived and injured coworker was transported to a local hospital for treatment. The cause evaluation (ce) team conducted interviews with the injured coworker (icw) along with other coworkers (cw1, cw2) who were at the work site at the time of incident. The ce team completed a hazard barrier analysis of the expected controls around the work task to determine human performance precursors that may have contributed to the event. After reviewing the collected information, documentation and related factors, the direct cause for this incident is inadequate thread engagement due to debris. This is based on the sme evaluation of the equipment post incident where minimal thread damage is present, and the equipment performed as designed. The first apparent cause (ac1) is workers were qualified but not proficient with the mueller line stopper process contained in utility procedure. The second apparent cause (ac2) is less than adequate (lta) job preparation provided to workers. A lack of proficiency combined with the failure to identify an aoc led them to further tighten the completion plug, which dislodged. Additional details and results of the causal analysis are documented in the cause evaluation report that has previously been submitted to PHMSA and cpuc.
Detailed record list
Report Received Date
2023-07-03 00:00:00
Iyear
2023.0
Report Number
20230032.0
Supplemental Number
38962.0
Report Type
Supplemental Final
Operator Id
15007
Name
Pacific Gas & Electric Co
Operator Street Address
6121 Bollinger Canyon Rd.
Operator City Name
San Ramon
Operator State Abbreviation
CA
Operator Postal Code
94583.0
Time Zone
Pacific
Daylight Savings Ind
Yes
Location Street Address
15630 Alum Rock Avenue
Location City Name
San Jose
Location County Name
Santa Clara
Location State Abbreviation
CA
Location Postal Code
95127.0
Location Latitude
37.3859178
Location Longitude
-121.81463
Flow Cont Key Crit Ind
Yes
Flow Cont Main Valve Ind
Yes
Nrc Rpt Num
1369527.0
Additional Nrc Report Numbers
1369698.0
Commodity Released Type
Natural Gas
Unintentional Release
716.0
Intentional Release
0.0
Fatality Ind
No
Fatal
0
Injury Ind
Yes
Num Emp Injuries
1
Num Contr Injuries
0
Num Er Injuries
0
Num Worker Injuries
0
Num Gp Injuries
0
Injure
1
Ignite Ind
No
Num Pub Evacuated
0.0
Communication State Fed Ind
Yes
Party Initiated Communication
Operator
Federal
No
Location Type
Public Property
Incident Area Type
Underground
Incident Area Subtype
Under Soil
Depth Of Cover
40.0
Other Underground Facilities
No
Crossing
No
Pipe Facility Type
Investor Owned
System Part Involved
Main
Installation Year
1925.0
Pipe Diameter
4.0
Pipe Specification
Unknown
Pipe Manufacturer
Unknown
Material Involved
Steel
Steel Seam Type
Other
Steel Seam Type Details
Unknown
Release Type
Leak
Leak Type
Other
Leak Type Other
Dislodgment Of Plug
Class Location Type
Class 3 Location
Est Cost Oper Paid
0.0
Est Cost Prop Damage
4538.0
Est Cost Emergency
4050.0
Est Cost Other
0.0
Est Cost Other Details
No Facilities Were Damaged Due To This Incident, Nor Was Restoration Required.
Gas Cost In Mcf
9.2
Est Cost Unintentional Release
6587.0
Est Cost Intentional Release
0.0
Prpty
15175.0
Commercial Affected
0.0
Industrial Affected
0.0
Residences Affected
0.0
Num Persons Hosp Not Ovnght
0.0
Num Injured Treated By Emt
0.0
Num Resident Building Affctd
0.0
Num Business Building Affctd
0.0
Accident Psig
54.0
Normal Psig
54.0
Mop Psig
60.0
Mop Cfr Section
192.619(A)(3)
Maop Established Date
1966-01-01 00:00:00
Accident Pressure
Pressure Did Not Exceed Maop
Gas Odorized System Type
Odorized By Others
Gas Odorized Lvl Not Msrd Ind
Yes
Scada In Place Ind
No
Accident Identifier
Local Operating Personnel, Including Contractors
Operator Type
Operator Employee
Investigation Status
No, the facility was not monitored by a controller(s) at the time of the incident
Employee Drug Test Ind
Yes
Num Employees Tested
1
Num Employees Failed
0
Contractor Drug Test Ind
No
Cause
Incorrect Operation
Cause Details
Equipment Not Installed Properly
Operation Type
Equipment Not Installed Properly
Related Failure Follow Ind
Yes
Category Type
Other Maintenance
Operator Qualification Ind
Yes
Qualified Individuals
Yes, They Were Qualified For The Task(S)
Preparer Name
R*** D*****
Preparer Title
Program Manager
Preparer Email
R***@p**.com
Authorizer Name
S**** R*******
Authorizer Title
Gas Regulatory Compliance Manager
Authorizer Telephone
925-786-0267
Authorizer Email
G***@p**.com
Narrative
On thursday, june 8, 2023, pg&e incident on-duty personnel confirmed that a release of gas from a pipeline resulted in an injury necessitating in-patient hospitalization. The pg&e employee was admitted to the hospital, was under observation after suffering facial injuries, and is in stable position. The injuries occurred while working on a 4-inch steel distribution main and involved the dislodgment of a plug during a scheduled leak repair. Local fire and police department personnel responded, and the employee was transported for treatment in an ambulance. This incident was reported to the DOT and cpuc due to a release of gas resulting in an injury requiring hospital admission and at least one overnight stay. Per the investigation report the direct cause for this incident is inadequate thread engagement due to debris. A lack of proficiency combined with the failure to identify an aoc led to the dislodgement of the plug. The ce team completed a hazard barrier analysis of the expected controls around the work task, as well as utilized the human factors analysis and classification system to determine human performance precursors that may have contributed to the event. On june 7, 2023, pg&e crews responded to a grade 3 leak at 15630 alum rock ave. In san jose. As part of the leak repair process, two 4" mueller line stopper fittings were successfully installed, and leak repairs were performed. Upon completion of the leak repairs, workers were in the process of installing and tightening two completion plugs with a wrench when a failure of the pressure boundary was experienced. At approximately 0300am on june 8th, the final completion plug had been installed and was being tightened with a wrench when it inadvertently blew out of the fitting and exposed two coworkers to a direct stream of gas at distribution pressure. This resulted in an uncontrolled release of gas without ignition causing injuries to one coworker in the form of metal shavings lodged in their face and eyes. The injured coworker was also potentially struck in the head with either a tightening wrench and or the completion plug when the completion plug became dislodged. Two coworkers working in the trench were evacuated and the crews were moved a safe distance from the gas stream. Emergency responders arrived and injured coworker was transported to a local hospital for treatment. The cause evaluation (ce) team conducted interviews with the injured coworker (icw) along with other coworkers (cw1, cw2) who were at the work site at the time of incident. The ce team completed a hazard barrier analysis of the expected controls around the work task to determine human performance precursors that may have contributed to the event. After reviewing the collected information, documentation and related factors, the direct cause for this incident is inadequate thread engagement due to debris. This is based on the sme evaluation of the equipment post incident where minimal thread damage is present, and the equipment performed as designed. The first apparent cause (ac1) is workers were qualified but not proficient with the mueller line stopper process contained in utility procedure. The second apparent cause (ac2) is less than adequate (lta) job preparation provided to workers. A lack of proficiency combined with the failure to identify an aoc led them to further tighten the completion plug, which dislodged. Additional details and results of the causal analysis are documented in the cause evaluation report that has previously been submitted to PHMSA and cpuc.
| Report Received Date | 2023-07-03 00:00:00 |
|---|---|
| Iyear | 2023.0 |
| Report Number | 20230032.0 |
| Supplemental Number | 38962.0 |
| Report Type | Supplemental Final |
| Operator Id | 15007 PHMSA Enforcement |
| Name | Pacific Gas & Electric Co |
| Operator Street Address | 6121 Bollinger Canyon Rd. |
| Operator City Name | San Ramon |
| Operator State Abbreviation | CA |
| Operator Postal Code | 94583.0 |
| Time Zone | Pacific |
| Daylight Savings Ind | Yes |
| Location Street Address | 15630 Alum Rock Avenue |
| Location City Name | San Jose |
| Location County Name | Santa Clara |
| Location State Abbreviation | CA |
| Location Postal Code | 95127.0 |
| Location Latitude | 37.3859178 Google Maps OpenStreetMap |
| Location Longitude | -121.81463 Google Maps OpenStreetMap |
| Flow Cont Key Crit Ind | Yes |
| Flow Cont Main Valve Ind | Yes |
| Nrc Rpt Num | 1369527.0 NRC Report How to search |
| Additional Nrc Report Numbers | 1369698.0 |
| Commodity Released Type | Natural Gas |
| Unintentional Release | 716.0 |
| Intentional Release | 0.0 |
| Fatality Ind | No |
| Fatal | 0 |
| Injury Ind | Yes |
| Num Emp Injuries | 1 |
| Num Contr Injuries | 0 |
| Num Er Injuries | 0 |
| Num Worker Injuries | 0 |
| Num Gp Injuries | 0 |
| Injure | 1 |
| Ignite Ind | No |
| Num Pub Evacuated | 0.0 |
| Communication State Fed Ind | Yes |
| Party Initiated Communication | Operator |
| Federal | No |
| Location Type | Public Property |
| Incident Area Type | Underground |
| Incident Area Subtype | Under Soil |
| Depth Of Cover | 40.0 |
| Other Underground Facilities | No |
| Crossing | No |
| Pipe Facility Type | Investor Owned |
| System Part Involved | Main |
| Installation Year | 1925.0 |
| Pipe Diameter | 4.0 |
| Pipe Specification | Unknown |
| Pipe Manufacturer | Unknown |
| Material Involved | Steel |
| Steel Seam Type | Other |
| Steel Seam Type Details | Unknown |
| Release Type | Leak |
| Leak Type | Other |
| Leak Type Other | Dislodgment Of Plug |
| Class Location Type | Class 3 Location |
| Est Cost Oper Paid | 0.0 |
| Est Cost Prop Damage | 4538.0 |
| Est Cost Emergency | 4050.0 |
| Est Cost Other | 0.0 |
| Est Cost Other Details | No Facilities Were Damaged Due To This Incident, Nor Was Restoration Required. |
| Gas Cost In Mcf | 9.2 |
| Est Cost Unintentional Release | 6587.0 |
| Est Cost Intentional Release | 0.0 |
| Prpty | 15175.0 |
| Commercial Affected | 0.0 |
| Industrial Affected | 0.0 |
| Residences Affected | 0.0 |
| Num Persons Hosp Not Ovnght | 0.0 |
| Num Injured Treated By Emt | 0.0 |
| Num Resident Building Affctd | 0.0 |
| Num Business Building Affctd | 0.0 |
| Accident Psig | 54.0 |
| Normal Psig | 54.0 |
| Mop Psig | 60.0 |
| Mop Cfr Section | 192.619(A)(3) View CFR 49 §192 |
| Maop Established Date | 1966-01-01 00:00:00 |
| Accident Pressure | Pressure Did Not Exceed Maop |
| Gas Odorized System Type | Odorized By Others |
| Gas Odorized Lvl Not Msrd Ind | Yes |
| Scada In Place Ind | No |
| Accident Identifier | Local Operating Personnel, Including Contractors |
| Operator Type | Operator Employee |
| Investigation Status | No, the facility was not monitored by a controller(s) at the time of the incident |
| Employee Drug Test Ind | Yes |
| Num Employees Tested | 1 |
| Num Employees Failed | 0 |
| Contractor Drug Test Ind | No |
| Cause | Incorrect Operation |
| Cause Details | Equipment Not Installed Properly |
| Operation Type | Equipment Not Installed Properly |
| Related Failure Follow Ind | Yes |
| Category Type | Other Maintenance |
| Operator Qualification Ind | Yes |
| Qualified Individuals | Yes, They Were Qualified For The Task(S) |
| Preparer Name | R*** D***** |
| Preparer Title | Program Manager |
| Preparer Email | R***@p**.com |
| Authorizer Name | S**** R******* |
| Authorizer Title | Gas Regulatory Compliance Manager |
| Authorizer Telephone | 925-786-0267 |
| Authorizer Email | G***@p**.com |
| Narrative | On thursday, june 8, 2023, pg&e incident on-duty personnel confirmed that a release of gas from a pipeline resulted in an injury necessitating in-patient hospitalization. The pg&e employee was admitted to the hospital, was under observation after suffering facial injuries, and is in stable position. The injuries occurred while working on a 4-inch steel distribution main and involved the dislodgment of a plug during a scheduled leak repair. Local fire and police department personnel responded, and the employee was transported for treatment in an ambulance. This incident was reported to the DOT and cpuc due to a release of gas resulting in an injury requiring hospital admission and at least one overnight stay. Per the investigation report the direct cause for this incident is inadequate thread engagement due to debris. A lack of proficiency combined with the failure to identify an aoc led to the dislodgement of the plug. The ce team completed a hazard barrier analysis of the expected controls around the work task, as well as utilized the human factors analysis and classification system to determine human performance precursors that may have contributed to the event. On june 7, 2023, pg&e crews responded to a grade 3 leak at 15630 alum rock ave. In san jose. As part of the leak repair process, two 4" mueller line stopper fittings were successfully installed, and leak repairs were performed. Upon completion of the leak repairs, workers were in the process of installing and tightening two completion plugs with a wrench when a failure of the pressure boundary was experienced. At approximately 0300am on june 8th, the final completion plug had been installed and was being tightened with a wrench when it inadvertently blew out of the fitting and exposed two coworkers to a direct stream of gas at distribution pressure. This resulted in an uncontrolled release of gas without ignition causing injuries to one coworker in the form of metal shavings lodged in their face and eyes. The injured coworker was also potentially struck in the head with either a tightening wrench and or the completion plug when the completion plug became dislodged. Two coworkers working in the trench were evacuated and the crews were moved a safe distance from the gas stream. Emergency responders arrived and injured coworker was transported to a local hospital for treatment. The cause evaluation (ce) team conducted interviews with the injured coworker (icw) along with other coworkers (cw1, cw2) who were at the work site at the time of incident. The ce team completed a hazard barrier analysis of the expected controls around the work task to determine human performance precursors that may have contributed to the event. After reviewing the collected information, documentation and related factors, the direct cause for this incident is inadequate thread engagement due to debris. This is based on the sme evaluation of the equipment post incident where minimal thread damage is present, and the equipment performed as designed. The first apparent cause (ac1) is workers were qualified but not proficient with the mueller line stopper process contained in utility procedure. The second apparent cause (ac2) is less than adequate (lta) job preparation provided to workers. A lack of proficiency combined with the failure to identify an aoc led them to further tighten the completion plug, which dislodged. Additional details and results of the causal analysis are documented in the cause evaluation report that has previously been submitted to PHMSA and cpuc. |
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