CSB Safety Recommendations from Ghent, West Virginia Propane Explosion Largely Adopted, Effecting Life-Saving Change

January 27, 2012
CSB Safety Recommendations from Ghent, West Virginia Propane Explosion Largely Adopted, Effecting Life-Saving Change   
Statement by Chairman Rafael Moure-Eraso Marks Five-Year Anniversary of the Convenience Store Tragedy that Claimed Lives of Two Emergency Responders and Two Propane Technicians
Monday, January 30, marks the fifth anniversary of a terrible tragedy that occurred in Ghent, West Virginia – a propane explosion that took the lives of four people and injured six others at a Little General convenience store. The accident occurred as an inexperienced worker attempted to transfer propane from a tank located against an outside wall of the store. 
I am pleased to report today satisfactory progress in the adoption of a number of important CSB recommendations made in our final report of September 2008, aimed at improving training requirements for propane technicians, and at improving emergency response actions by on-scene technicians and 911 operators. The recommendations have largely been adopted and will result in lives saved. 
We recall with sadness that the explosion killed two emergency responders and two propane technicians and injured four clerks inside the store and two other emergency technicians standing by outside the store, which had not been evacuated. The store was leveled.
The CSB’s final report found that a junior propane service technician was preparing to transfer propane, unsupervised, to a new tank from an old tank located near an outside wall of the store – a location that violated state and federal regulations. The technician removed a plug from the liquid withdrawal valve on the old tank, but the valve evidently malfunctioned, causing an uncontrollable release of propane. Propane entered the store through the restroom ventilation system.  The technician had only 45 days of limited on-the-job training with his supervisor.
We issued twelve recommendations to a total of nine recipients and most have resulted in what the Board determined to be “Acceptable” action, or are being held as “Open Acceptable” because they are on the brink of completion. 
It’s particularly gratifying to note that our recommendation to the National Fire Protection Association (NFPA) resulted in the issuing of a temporary standard providing guidance for personnel who work with liquefied petroleum gas. This includes training with a defined curriculum and testing, actions which resulted in an “Open Acceptable” status determination in April 2011. I encourage the NFPA to permanently adopt the training and testing requirements for individuals who work with propane, helping reduce the loss of life and injury among propane workers and potential dangers to members of the public.
Our recommendation to the governor and legislature of West Virginia – dealing with training and qualification requirements of propane workers – was closed as “Acceptable” in August 2010 when the State Fire Marshal’s Office reported that the state fire code was updated earlier that year. This kind of action serves as an example for other states. 
The Board had recommended that the Association of Public Safety Communications Officials develop a guide card for propane emergencies to assist 911 operators. The association moved promptly and within a year we determined this action to be “Acceptable.”
The National Propane Gas Association adopted our recommendation, and we closed it as “Acceptable Action” in 2010, as a result of NPGA’s communication with OSHA and its work with the West Virginia 911 Council to develop emergency propane guidance for 911 operators. The West Virginia 911 Council on a similar recommendation received the same satisfactory determination from the Board following the council’s action.
The Board voted just last month, in December 2011, to close as “Acceptable” the response by Ferrellgas to our recommendation to establish and implement a comprehensive safety management system, as the company has improved its inspection and auditing program to detect and correct safety deficiencies. For many years, Ferrellgas owned and serviced the existing tank, which had been installed in 1994 by another company directly next to the store’s exterior back wall, in violation of West Virginia and U.S. Occupational Safety and Health Administration regulations.
The CSB called on the Propane Education and Research Council – which has the critical mission of determining procedures and certifying propane technicians – to revise its Certified Employee Training Program. This would include, among other things, guidance to emergency responders, and procedures for, or a prohibition on, transferring liquid propane from tank to tank. 

While we were pleased with PERC’s statement in 2009 that they would act on the recommendation, we had hoped for more expeditious action. However, we are retaining its status as “Open-Acceptable Response,” because PERC has indicated it will submit its revised guidance documents by the end of this month. 
Finally, I must note a disappointment resulting from our recommendations:
The Board was compelled to vote as “Unacceptable” action not taken by the West Virginia Office of Emergency Medical Services. We urged the agency to require annual hazardous materials response refresher training for all emergency medical personnel in West Virginia. To date, training occurs only once every two years. The CSB believes recurrent annual training is critical for responders who must deal with hazardous materials emergencies such as with propane.
We made a similar recommendation to the West Virginia Fire Commission. Though this has not been acted upon, we are keeping this status “Open” because we are informed that revised evaluation forms requiring annual training have been completed. We look forward to receiving the materials so we can determine this “Closed-Acceptable.”
To view the CSB’s Little General Store Investigation Information Page (and associated recommendations),
click here.
To View the CSBs Safety Video on the accident, “Half an Hour to Tragedy,” click here.
The CSB is an independent federal agency charged with investigating serious chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov.    
For more information, contact Communications Manager Hillary Cohen, 202-446-8094, or Sandy Gilmour, cell 202-251-5496.
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