CSB Releases Draft Report on Little General Store Propane Explosion
In a draft final report released Sept. 25, investigators from the U.S. Chemical Safety Board (CSB) concluded that inadequate propane technician and emergency responder training and unsafe propane tank placement were the primary causes of a fatal 2007 accident at the Little General convenience store in Ghent, W.Va.
The propane explosion on January 30, 2007, killed two emergency responders and two propane technicians. Six others were injured. All of the victims had remained in the immediate vicinity of a propane release from a storage tank behind the store and did not evacuate the area. The store, which was leveled in the explosion, was located in rural West Virginia about 70 miles south of Charleston.
The report calls on West Virginia to provide annual hazardous materials training and drills for all firefighters and recommends improved training for propane service technicians throughout the country. All findings, causes, and recommendations in the draft report remain preliminary pending approval by CSB.
Deadly Errors
The accident occurred as a junior propane technician, who had not been formally trained and had been on the job only 1 and a half months, prepared to transfer about 350 gallons of propane from an old 500-gallon tank to a new tank.
Propane was released from the old tank's liquid withdrawal valve after the technician removed a safety plug from the valve. CSB later determined the valve had a manufacturing defect that caused it to be stuck in an open position. CSB also determined that, probably because of a lack of training, the technician likely did not observe a telltale sign that the valve was defective: the safety plug has a small hole through which propane may be seen leaking if the valve is stuck open, before the plug is fully removed.
CSB estimated the leak began at about 10:25 a.m. and that the building exploded just after 10:53 a.m.
"We investigated this accident because of the tragic, unnecessary loss of life," said John Bresland, CSB chairman and CEO. "Nearly 30 minutes elapsed between the release and the explosion. If there'd been an evacuation during those 30 minutes, all of the lives would have been saved."
CSB’s investigation found that a propane tank had been installed against the back wall of the store in 1994 by propane supplier Southern Sun, in violation of OSHA regulations and the West Virginia state fire code, which require 500-gallon tanks to be placed at least ten feet away from buildings. Southern Sun was later acquired by Ferrellgas in 1996, but the tank remained where it was against the back wall.
CSB Lead Investigator Jeffrey Wanko said, "Had the tank been ten feet away from the building – as required by OSHA standards and the state fire code – it is unlikely that an explosive concentration of propane would have built up inside the store."
Insufficient Training
According to the draft report, emergency responders did not have sufficient training to recognize the need for an immediate evacuation. West Virginia only requires initial hazardous materials training for firefighters, generally a 4-hour course when firefighters begin their careers, but refresher training is not required. The Ghent volunteer fire captain had received hazardous materials training only once, in 1998. CSB also found West Virginia and 35 other states have no requirements for training or qualification of propane technicians.
“Emergency responders often need to call on propane technicians for assistance during propane-related emergencies,” said Bresland. “There is a need for training of both firefighters and technicians so they may work together to safely deal with propane releases that threaten the lives of residents, workers, and responders.”
Training should include appropriate emergency measures including the need for immediate evacuation in the case of a significant propane release, CSB said.
"There are about 17.5 million propane installations in the United States,” Wanko said. “Firefighters respond to propane emergencies nearly every day. Propane technicians, firefighters, and 911 operators have to be prepared for these emergencies."
Mr. Wanko added that 911 operators typically use a set of guide cards to acquire pertinent information from callers and give appropriate instructions while dispatching responders to calls for help. However, there is no card specific to propane emergencies.
"Such a guide card would prompt operators to ask about the size and nature of propane leaks and potential dangers, and increase the likelihood of timely evacuations while firefighters determine the extent of the threat," Mr. Wanko said.
Recommendations
The draft report recommends that the governor and legislature of West Virginia require training and qualification for all propane technicians. To improve training across the United States, the report recommends the National Fire Protection Association amend the national fire codes to call for specific training and testing for all personnel who handle propane.
To assure propane technicians are knowledgeable in handling emergencies, the draft report recommends that the Propane Education and Research Council, established by Congress to promote the safe use of propane, revise its training program to include emergency response guidance. Investigators said this training should emphasize the need to evacuate the scene of a release until all the hazards are known.
The report also calls on West Virginia to require annual hazardous materials training for all firefighters and emergency medical technicians in the state. In addition, the report recommends that the West Virginia State Fire Commission require all fire departments to perform at least one hazardous materials response drill each year.
Following approval of the draft report, the CSB plans to release a 23-minute video, "Half an Hour to Tragedy," containing the 3-D computer animation of the events in Ghent and a description of the causes, consequences, and lessons of the accident. The video will feature West Virginia State Fire Marshal Sterling Lewis, Jr., CSB investigators and CSB Chairman John Bresland.