Incident details
Operator, cause, commodity and consequences with raw source fields.
GTG incident on 2024-08-09 — CA
Operator
Pacific Gas & Electric Co
Cause
Incorrect Operation
Commodity
Natural Gas
Program
GTG
Damage and Injuries
0 fatalities
1 injury
Property damage (nominal)
$1,572,059
Incident datetime
2024-08-09 00:00 UTC
Report number
Location
CA
Narrative
On wednesday, july 10, 2024, at approximately 21:04 hours, pg&e incident on-duty personnel confirmed a release of gas at kettleman compressor station resulted in an injury necessitating in-patient hospitalization. Following completion of construction, clearance activities to re-introduce gas and purge air from the system, initiated: - the approved clearance required v-56 to be "checked open" for purging, however, it had been closed for stem seal replacement work on july 8, 2024, and only partially opened prior to the purge - operations that had not been documented nor approved as part of the sequence of operations in the clearance. - gas was re-introduced to the system from a 34'' control valve (v-90), a clearance point with 618 psi. There are two ways to operate v-90, manual hydraulic and manual pneumatic. - when attempting to manually operate v-90 hydraulically, oil unexpectedly discharged from the actuator's manual hydraulic override system relief valve and the valve failed to operate. - v-90 was then partially opened using the manual pneumatic controls. This method is not effective for fine throttling as required for purging in design standard a-38. Gas from v-90 began to displace air at multiple vent locations per the established clearance plan. It is suspected that as a result of the partial open position of v-56, a greater amount of gas flow was directed toward v-78. Instead of gas exiting the 1/2'' vertical vent valve downstream of v-78 as approved in the clearance, gas exited the full 6'' pipe opening horizontally where the blind flange had been removed on july 9. Gas flowed directly into an opposing blind flange roughly 20'' away at v-79. This resulted in deflection in all directions, including into the excavation below. A hazardous air-gas plume developed. At approximately 18:42 hours, the air-gas plume ignited, resulting in serious burns to one coworker and minor injuries to others. Cws in the area immediately responded, attending to the injured cw and extinguishing various spot fires using pre-staged fire extinguishers. A cw closed v-90 to shut in the gas before ignition, allowing the flame to extinguish in about one minute. Procedure use & adherence was the apparent cause of this incident. Configuration control was not applied when clearance work was executed. Prior to purging into service, cws failed to recognize a high energy essential control had been disabled during the purge out of service. Procedures involving purging gas facilities, installation and operation of air movers, and temporary vent stacks provide a barrier in the form of requirements to calculate and monitor purge drive pressure, properly size air movers and fresh air sources, and install temporary vent stacks to safely disperse gas to atmosphere. Procedure involving new clearances for gt facilities provides a barrier in the form of change management for the clearance process and endorsement requirements, which failed as the clearance team did not follow them. The precise ignition source and location could not be determined to a certainty; however, the following potential ignition sources were assessed and could not be ruled out. An electrostatic discharge from the generated dust cloud. An electrostatic discharge from either the pipeline itself (due to charging from the venting gas) or an electrostatic discharge from an employee in the vicinity of the venting gas (due to electrostatic accumulation on their person). A mechanical spark from debris exiting the pipeline at high velocity or kicked up by the venting gas. Electrical equipment in the vicinity of the venting gas was locked out and tagged out and was ruled out as a potential ignition source. The injured employee was transferred by ambulance to a local hospital and then medevacked to a fresno area hospital to receive care. This incident was reported to the DOT and cpuc due to a release of gas resulting in an injury requiring hospital admission for overnight stay.
Detailed record list
Report Received Date
2024-08-09 00:00:00
Iyear
2024
Report Number
20240099
Supplemental Number
41190
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
Time Zone
Pacific
Daylight Savings Ind
Yes
Location Latitude
36.04356
Location Longitude
-120.1114
Nrc Rpt Num
1404348
Additional Nrc Report Numbers
1404493
Commodity Released Type
Natural Gas
Unintentional Release
31.83
Intentional Release
0
Accompanying Liquid
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
Status When Identified
Normal Operation, Includes Pauses During Maintenance
Shutdown Due Accident Ind
No
Shutdown Explain
Injury Did Not Occur Due To Shut Down.
Communication State Fed Ind
Yes
Party Initiated Communication
Operator
Ignite Ind
Yes
How Extinguished
Operator/contractor
Gas Consumed By Fire In Mcf
31.83
Explode Ind
No
Upstream Action Taken
Valve Closure
Downstream Action Taken
Operational Control
Downstream Oprtnl Cntrl Detail
No Downstream Valve Existed Due To One Way Feed.
Num Pub Evacuated
0
On Off Shore
Onshore
Onshore State Abbreviation
Ca
Onshore Postal Code
93239
Onshore City Name
Avenal
Onshore County Name
Kings
Designated Location
Not Applicable
Pipe Fac Name
Kettleman Compressor Station
Segment Name
L-300a
Federal
No
Location Type
Operator-Controlled Property
Incident Area Type
Aboveground
Incident Area Subtype
Typical Aboveground Facility Piping Or Appurtenance
Crossing
No
Pipe Facility Type
Intrastate
System Part Involved
Onshore Pipeline, Including Valve Sites
Item Involved
Pipe
Pipe Type
Pipe Body
Pipe Diameter
6
Puddle Weld Ind
No
Pipe Wall Thickness
0.28
Pipe Smys
35000
Pipe Specification
5l
Pipe Seam Type
Seamless
Pipe Manufacturer
Unknown
Pipe Coating Type
Paint
Coating Applied Ind
Unknown
Installation Year
2001
Manufactured Year
Unknown
Material Involved
Carbon Steel
Release Type
Other
Release Type Details
Downstream Purging
Class Location Type
Class 1 Location
Could Be Hca
No
Pir Radius
135
Heat Damage Ind
No
Non Heat Damage Ind
No
Hca Fatalities Ind
No
Did Occur In Mca Ind
No
Est Cost Oper Paid
0
Est Cost Unintentional Release
191
Est Cost Intentional Release
0
Est Cost Prop Damage
1572059
Est Cost Emergency
6350
Est Cost Other
0
Gas Cost In Mcf
6
Prpty
1578600
Num Persons Hosp Not Ovnght
0
Num Injured Treated By Emt
1
Num Resident Building Affctd
0
Num Business Building Affctd
0
Wildlife Impact Ind
No
Accident Psig
619
Gas Flow In Pipe In Mcf
0
Mop Psig
840
Mop Cfr Section
192.619(A)(2)
Maop Established Date
2001-05-01 00:00:00
Maop Reversal Flow Ind
No
Accident Pressure
Pressure Did Not Exceed Maop
Pressure Restriction Ind
No
Gas Required Odorized Ind
No
Gas Odorized Ind
Yes
Upstream Valve Type Ind
Manual
Length Segment Isolated
1
Internal Inspection Ind
No
Other Inspection Ind
Yes
Internal Inspection Details
Piping Was Part Of A Flanged Above Ground System.
Operation Complications Ind
Yes
Other Complications Ind
Yes
Inspect Comp Details
Part Of A Flanged Above Ground System.
Pipeline Function
Transmission System
Scada In Place Ind
Yes
Scada Operating Ind
Yes
Scada Functional Ind
Yes
Scada Detection Ind
No
Scada Conf Ind
No
Accident Identifier
Local Operating Personnel, Including Contractors
Operator Type
Operator Employee
Investigation Status
No, the operator did not find that an investigation of the controller(s) actions or control room issues was necessary due to: (provide an explanation for why the operator did not investigate)
Investigation Status Details
Valve involved in the incident was manually operated.
Employee Drug Test Ind
Yes
Contractor Drug Test Ind
No
Num Employees Tested
2
Num Employees Failed
0
Cause
Incorrect Operation
Cause Details
Other Incorrect Operation
Operation Type
Other Incorrect Operation
Operation Details
Failure To Achieve Effective Change In Safe Behaviors And The Implementation Of Essential Controls To Mitigate High-Energy Hazards.
Related Other Ind
Yes
Operation Related Details
Gas Coworker Fundamental Knowledge And Proficiency Challenges.
Category Type
Routine Maintenance
Operator Qualification Ind
Yes
Qualified Individuals
Yes, They Were Qualified For The Task(S)
Io Follow Procedure Ind
Yes
Preparer Name
R*** D*****
Preparer Title
Program Manager
Preparer Email
R**********@p**.com
Preparer Telephone
510-298-7063
Authorizer Name
F****** Y**
Authorizer Title
Gas Regulatory Compliance Senior Manager
Authorizer Telephone
925-200-4736
Authorizer Email
F**********@p**.com
Narrative
On wednesday, july 10, 2024, at approximately 21:04 hours, pg&e incident on-duty personnel confirmed a release of gas at kettleman compressor station resulted in an injury necessitating in-patient hospitalization. Following completion of construction, clearance activities to re-introduce gas and purge air from the system, initiated: - the approved clearance required v-56 to be "checked open" for purging, however, it had been closed for stem seal replacement work on july 8, 2024, and only partially opened prior to the purge - operations that had not been documented nor approved as part of the sequence of operations in the clearance. - gas was re-introduced to the system from a 34'' control valve (v-90), a clearance point with 618 psi. There are two ways to operate v-90, manual hydraulic and manual pneumatic. - when attempting to manually operate v-90 hydraulically, oil unexpectedly discharged from the actuator's manual hydraulic override system relief valve and the valve failed to operate. - v-90 was then partially opened using the manual pneumatic controls. This method is not effective for fine throttling as required for purging in design standard a-38. Gas from v-90 began to displace air at multiple vent locations per the established clearance plan. It is suspected that as a result of the partial open position of v-56, a greater amount of gas flow was directed toward v-78. Instead of gas exiting the 1/2'' vertical vent valve downstream of v-78 as approved in the clearance, gas exited the full 6'' pipe opening horizontally where the blind flange had been removed on july 9. Gas flowed directly into an opposing blind flange roughly 20'' away at v-79. This resulted in deflection in all directions, including into the excavation below. A hazardous air-gas plume developed. At approximately 18:42 hours, the air-gas plume ignited, resulting in serious burns to one coworker and minor injuries to others. Cws in the area immediately responded, attending to the injured cw and extinguishing various spot fires using pre-staged fire extinguishers. A cw closed v-90 to shut in the gas before ignition, allowing the flame to extinguish in about one minute. Procedure use & adherence was the apparent cause of this incident. Configuration control was not applied when clearance work was executed. Prior to purging into service, cws failed to recognize a high energy essential control had been disabled during the purge out of service. Procedures involving purging gas facilities, installation and operation of air movers, and temporary vent stacks provide a barrier in the form of requirements to calculate and monitor purge drive pressure, properly size air movers and fresh air sources, and install temporary vent stacks to safely disperse gas to atmosphere. Procedure involving new clearances for gt facilities provides a barrier in the form of change management for the clearance process and endorsement requirements, which failed as the clearance team did not follow them. The precise ignition source and location could not be determined to a certainty; however, the following potential ignition sources were assessed and could not be ruled out. An electrostatic discharge from the generated dust cloud. An electrostatic discharge from either the pipeline itself (due to charging from the venting gas) or an electrostatic discharge from an employee in the vicinity of the venting gas (due to electrostatic accumulation on their person). A mechanical spark from debris exiting the pipeline at high velocity or kicked up by the venting gas. Electrical equipment in the vicinity of the venting gas was locked out and tagged out and was ruled out as a potential ignition source. The injured employee was transferred by ambulance to a local hospital and then medevacked to a fresno area hospital to receive care. This incident was reported to the DOT and cpuc due to a release of gas resulting in an injury requiring hospital admission for overnight stay.
| Report Received Date | 2024-08-09 00:00:00 |
|---|---|
| Iyear | 2024 |
| Report Number | 20240099 |
| Supplemental Number | 41190 |
| 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 |
| Time Zone | Pacific |
| Daylight Savings Ind | Yes |
| Location Latitude | 36.04356 Google Maps OpenStreetMap |
| Location Longitude | -120.1114 Google Maps OpenStreetMap |
| Nrc Rpt Num | 1404348 NRC Report How to search |
| Additional Nrc Report Numbers | 1404493 |
| Commodity Released Type | Natural Gas |
| Unintentional Release | 31.83 |
| Intentional Release | 0 |
| Accompanying Liquid | 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 |
| Status When Identified | Normal Operation, Includes Pauses During Maintenance |
| Shutdown Due Accident Ind | No |
| Shutdown Explain | Injury Did Not Occur Due To Shut Down. |
| Communication State Fed Ind | Yes |
| Party Initiated Communication | Operator |
| Ignite Ind | Yes |
| How Extinguished | Operator/contractor |
| Gas Consumed By Fire In Mcf | 31.83 |
| Explode Ind | No |
| Upstream Action Taken | Valve Closure |
| Downstream Action Taken | Operational Control |
| Downstream Oprtnl Cntrl Detail | No Downstream Valve Existed Due To One Way Feed. |
| Num Pub Evacuated | 0 |
| On Off Shore | Onshore |
| Onshore State Abbreviation | Ca |
| Onshore Postal Code | 93239 |
| Onshore City Name | Avenal |
| Onshore County Name | Kings |
| Designated Location | Not Applicable |
| Pipe Fac Name | Kettleman Compressor Station |
| Segment Name | L-300a |
| Federal | No |
| Location Type | Operator-Controlled Property |
| Incident Area Type | Aboveground |
| Incident Area Subtype | Typical Aboveground Facility Piping Or Appurtenance |
| Crossing | No |
| Pipe Facility Type | Intrastate |
| System Part Involved | Onshore Pipeline, Including Valve Sites |
| Item Involved | Pipe |
| Pipe Type | Pipe Body |
| Pipe Diameter | 6 |
| Puddle Weld Ind | No |
| Pipe Wall Thickness | 0.28 |
| Pipe Smys | 35000 |
| Pipe Specification | 5l |
| Pipe Seam Type | Seamless |
| Pipe Manufacturer | Unknown |
| Pipe Coating Type | Paint |
| Coating Applied Ind | Unknown |
| Installation Year | 2001 |
| Manufactured Year | Unknown |
| Material Involved | Carbon Steel |
| Release Type | Other |
| Release Type Details | Downstream Purging |
| Class Location Type | Class 1 Location |
| Could Be Hca | No |
| Pir Radius | 135 |
| Heat Damage Ind | No |
| Non Heat Damage Ind | No |
| Hca Fatalities Ind | No |
| Did Occur In Mca Ind | No |
| Est Cost Oper Paid | 0 |
| Est Cost Unintentional Release | 191 |
| Est Cost Intentional Release | 0 |
| Est Cost Prop Damage | 1572059 |
| Est Cost Emergency | 6350 |
| Est Cost Other | 0 |
| Gas Cost In Mcf | 6 |
| Prpty | 1578600 |
| Num Persons Hosp Not Ovnght | 0 |
| Num Injured Treated By Emt | 1 |
| Num Resident Building Affctd | 0 |
| Num Business Building Affctd | 0 |
| Wildlife Impact Ind | No |
| Accident Psig | 619 |
| Gas Flow In Pipe In Mcf | 0 |
| Mop Psig | 840 |
| Mop Cfr Section | 192.619(A)(2) View CFR 49 §192 |
| Maop Established Date | 2001-05-01 00:00:00 |
| Maop Reversal Flow Ind | No |
| Accident Pressure | Pressure Did Not Exceed Maop |
| Pressure Restriction Ind | No |
| Gas Required Odorized Ind | No |
| Gas Odorized Ind | Yes |
| Upstream Valve Type Ind | Manual |
| Length Segment Isolated | 1 |
| Internal Inspection Ind | No |
| Other Inspection Ind | Yes |
| Internal Inspection Details | Piping Was Part Of A Flanged Above Ground System. |
| Operation Complications Ind | Yes |
| Other Complications Ind | Yes |
| Inspect Comp Details | Part Of A Flanged Above Ground System. |
| Pipeline Function | Transmission System |
| Scada In Place Ind | Yes |
| Scada Operating Ind | Yes |
| Scada Functional Ind | Yes |
| Scada Detection Ind | No |
| Scada Conf Ind | No |
| Accident Identifier | Local Operating Personnel, Including Contractors |
| Operator Type | Operator Employee |
| Investigation Status | No, the operator did not find that an investigation of the controller(s) actions or control room issues was necessary due to: (provide an explanation for why the operator did not investigate) |
| Investigation Status Details | Valve involved in the incident was manually operated. |
| Employee Drug Test Ind | Yes |
| Contractor Drug Test Ind | No |
| Num Employees Tested | 2 |
| Num Employees Failed | 0 |
| Cause | Incorrect Operation |
| Cause Details | Other Incorrect Operation |
| Operation Type | Other Incorrect Operation |
| Operation Details | Failure To Achieve Effective Change In Safe Behaviors And The Implementation Of Essential Controls To Mitigate High-Energy Hazards. |
| Related Other Ind | Yes |
| Operation Related Details | Gas Coworker Fundamental Knowledge And Proficiency Challenges. |
| Category Type | Routine Maintenance |
| Operator Qualification Ind | Yes |
| Qualified Individuals | Yes, They Were Qualified For The Task(S) |
| Io Follow Procedure Ind | Yes |
| Preparer Name | R*** D***** |
| Preparer Title | Program Manager |
| Preparer Email | R**********@p**.com |
| Preparer Telephone | 510-298-7063 |
| Authorizer Name | F****** Y** |
| Authorizer Title | Gas Regulatory Compliance Senior Manager |
| Authorizer Telephone | 925-200-4736 |
| Authorizer Email | F**********@p**.com |
| Narrative | On wednesday, july 10, 2024, at approximately 21:04 hours, pg&e incident on-duty personnel confirmed a release of gas at kettleman compressor station resulted in an injury necessitating in-patient hospitalization. Following completion of construction, clearance activities to re-introduce gas and purge air from the system, initiated: - the approved clearance required v-56 to be "checked open" for purging, however, it had been closed for stem seal replacement work on july 8, 2024, and only partially opened prior to the purge - operations that had not been documented nor approved as part of the sequence of operations in the clearance. - gas was re-introduced to the system from a 34'' control valve (v-90), a clearance point with 618 psi. There are two ways to operate v-90, manual hydraulic and manual pneumatic. - when attempting to manually operate v-90 hydraulically, oil unexpectedly discharged from the actuator's manual hydraulic override system relief valve and the valve failed to operate. - v-90 was then partially opened using the manual pneumatic controls. This method is not effective for fine throttling as required for purging in design standard a-38. Gas from v-90 began to displace air at multiple vent locations per the established clearance plan. It is suspected that as a result of the partial open position of v-56, a greater amount of gas flow was directed toward v-78. Instead of gas exiting the 1/2'' vertical vent valve downstream of v-78 as approved in the clearance, gas exited the full 6'' pipe opening horizontally where the blind flange had been removed on july 9. Gas flowed directly into an opposing blind flange roughly 20'' away at v-79. This resulted in deflection in all directions, including into the excavation below. A hazardous air-gas plume developed. At approximately 18:42 hours, the air-gas plume ignited, resulting in serious burns to one coworker and minor injuries to others. Cws in the area immediately responded, attending to the injured cw and extinguishing various spot fires using pre-staged fire extinguishers. A cw closed v-90 to shut in the gas before ignition, allowing the flame to extinguish in about one minute. Procedure use & adherence was the apparent cause of this incident. Configuration control was not applied when clearance work was executed. Prior to purging into service, cws failed to recognize a high energy essential control had been disabled during the purge out of service. Procedures involving purging gas facilities, installation and operation of air movers, and temporary vent stacks provide a barrier in the form of requirements to calculate and monitor purge drive pressure, properly size air movers and fresh air sources, and install temporary vent stacks to safely disperse gas to atmosphere. Procedure involving new clearances for gt facilities provides a barrier in the form of change management for the clearance process and endorsement requirements, which failed as the clearance team did not follow them. The precise ignition source and location could not be determined to a certainty; however, the following potential ignition sources were assessed and could not be ruled out. An electrostatic discharge from the generated dust cloud. An electrostatic discharge from either the pipeline itself (due to charging from the venting gas) or an electrostatic discharge from an employee in the vicinity of the venting gas (due to electrostatic accumulation on their person). A mechanical spark from debris exiting the pipeline at high velocity or kicked up by the venting gas. Electrical equipment in the vicinity of the venting gas was locked out and tagged out and was ruled out as a potential ignition source. The injured employee was transferred by ambulance to a local hospital and then medevacked to a fresno area hospital to receive care. This incident was reported to the DOT and cpuc due to a release of gas resulting in an injury requiring hospital admission for overnight stay. |
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