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Merrimack Valley Gas Explosions Case Study

(REDACTED)

Executive Summary

On September 13, 2018, excessive pressure in natural gas lines owned by Columbia Gas

caused a series of explosions and fires in Massachusetts's Merrimack Valley region. The system

over-pressure ultimately damaged 131 structures, hospitalized 21 individuals, and killed one

person. (National Transportation Safety Board, 2019) Columbia Gas of Massachusetts did not

offer any advisories, and police and firefighters were doing a better job evacuating people from

their homes. It ultimately left thousands of households displaced without heat or the ability to

cook for months and bankrupted Columbia Gas of Massachusetts.

Although the accident can be attributed – on face value – to technical errors, these errors

shine a light on more profound organizational complacency within Columbia Gas, not the least

of which involve a gap in good project management practice and responsibility. A thorough

investigation conducted by the NTSB provided many technical recommendations to Columbia

Gas. To protect against future disasters, however, changes must be made from the project

management perspective. The three top identified top issues are cost-cutting in safety efforts,

lack of coordination internally and with local governments, and a culture of complacency.

I will discuss how these three major issues led to the subsequent disaster, solutions, pros

and cons, and these two overall recommendations: adding safety to the performance criterion

for project managers and developing a precise emergency plan with routine drills.

Background

On September 13, 2018, excessive pressure in natural gas lines owned by Columbia Gas

caused a series of explosions and fires in Massachusetts's Merrimack Valley region. The system

over-pressure ultimately damaged 131 structures, hospitalized 21 individuals, and killed one

person. (National Transportation Safety Board, 2019) Columbia Gas of Massachusetts failed to

proactively communicate with the local population. The people of Merrimack Valley were

getting their news instead from the local law enforcement agencies. This disaster ultimately left

thousands of households displaced without heat or the ability to cook for months and bankrupted

Columbia Gas of Massachusetts.

The disaster's technical causes could be traced back to replacing aging cast iron gas pipes

with polyethylene pipes. Contractors followed the work package that Columbia gas developed

and approved. The contractors removed a length of pipe without the very important step of

disconnecting a pressure sensor that was still attached to the removed pipe section. The pressure

sensor began reading a pressure drop that opened valves in the gas network until they were open

completely. Alarms were triggered at NiSource, Columbia's parent company, in Ohio. However,

they had no remote control of the valves and could only respond in person, and by the time the

valves were shut and brought back in control, the damage had already been done. (Maltzman,

2020)

Although seemingly technical in nature, this disaster points to multiple systemic issues

linked to project managers' failures and top management at Columbia Gas. The three issues

discussed in this paper are cost-cutting in safety efforts, lack of coordination internally and

with local governments, and a culture of complacency.

Issues Identification

Issue 1 – Cost Cutting in Safety Efforts

Ironically, the modernization project that set off the disaster was to replace the old pipes

with newer, safer, polyethylene pipes. However, the mitigation of risk through this

modernization created a secondary risk that revealed cost-cutting measures that made the process

unsafe. As it is cheaper to hire a contractor to replace the pipes, Columbia Gas outsourced labor

on this project. (Penn, 2019) By engaging a third party, Columbia Gas would have less oversight

over the project with contractors working on an unfamiliar system. Furthermore, Columbia Gas

typically had a technician from the Meter and Regulation Department assigned to the site to

manage the pressure readings. This practice was ended four years ago. (Penn, 2019) Columbia

Gas did not provide any reasons for ending the procedure, but it seems evident that it is a cost-

cutting measure, undertaken (in the author’s opinion) without proper consideration of the

downside.

However, even if Columbia Gas were directly working on the project, the accident may

have still happened. The NTSB investigation revealed the work package was signed off by an

engineer-in-training, not a licensed professional engineer. The office working on the project only

had two licensed engineers, and they only dealt with signing off on more extensive projects,

which this pipeline replacement was not (National Transportation Safety Board, 2019). This

seems to be a workflow process problem – something a project manager should consider.

Finally, there was a lack of documentation of the sensors resulting in them being

excluded from the work package. Had the engineers had the resources to review and provide that

information to the construction workers diligently, they would have accounted for the regulator

sensing lines.

Issue 2 – lack of coordination

Had the significant increase in gas pressure been detected and promptly acted upon, the

damage would have been significantly reduced. The first alarm that warned of high pressure

went off at 3:57 pm. It was not until 4:30 pm that technicians arrived at the first regulator station

to cut off the high-pressure gas flow – and not until 7 pm later that evening that the high gas

pressure was brought back in control. The NTSB investigation showed that Columbia Gas was

not prepared to respond to the emergency. Their emergency documents did not provide clear and

actionable steps for responding to this large-scale emergency event. (National Transportation

Safety Board, 2019). Although not per se related to this particular project, the project manager

could ‘step up’ and question why a particular project does not have these emergency steps.

Furthermore, information was not provided to municipal governments and emergency

first responders. The NiSource Emergency Manual states that when an over-pressurization of the

system occurs, there "may be a need" to communicate with local government officials and

emergency management agencies as well as fire and police departments. Had firefighters and

police been given the actionable information in a timely fashion, evacuations and precautions

could have begun. This communication could have potentially prevented multiple injuries and

the single death that occurred. Further, better communications could have prevented the

embarrassing situation of leaving the Twitter feed posting the company receiving a safety award

rather than providing the local population with vital, urgent information about the disaster as it

unfolded.

Issue 3 – lack of safety culture

Massachusetts Department of Public Utilities provided documentation on enforcement

action against Columbia gas for the preceding five years. Many of the incidents show a history of

improper maintenance, documentation, and inspection of their gas lines.

In Columbia Gas' pursuit of higher profit, minimum resources were placed into making

sure the gas lines they operated could be as safe as possible. A lack of safety culture also reveals

a culture of complacency. This culture can be seen in their lack of thorough risk assessment and

planning for emergency events. Investment into classes and exercises for their on-site engineers

would have also made the response less hectic and more unified.

Furthermore, had safety been a higher priority, the planning process would have included

a thorough check for safety issues. At the time, Massachusetts' state did not require a

professional engineer to sign off on the project plans. Columbia gas, therefore, did the bare

minimum to be following regulatory guidelines. Had also safety been taken into account during

their review and planning process for modernizing their gas lines, the potentially deadly issue of

over-pressure would have come up and been a more significant part of the review process for the

construction plans. Again, although this is not the specific role of the PM, the PM can and

should be the person to highlight these issues to management.

Proposed Solutions Table

Issues # – Solution # Solution

1-1 Re-invest in safety heavily. Create an executive-level office to

advocate for safety across the entire company's operation. Use this new

people's power to conduct a thorough review of engineering and

planning processes to refocus on safety.

1-2 Add safety as a performance target criterion to protect against

sacrificing quality over budget and time constraints.

1-3 Modify company policy concerning project planning and review so that

it goes above and beyond the regulatory requirements set forth by the

government.

2-1 Develop a precise and thorough emergency action plan that includes

Columbia Gas, local governments, and emergency first responders.

Make sure different monitoring stations are adequately staffed so that

no one person is entirely swamped when an emergency incident occurs.

2-2 Plan routine drills that practice potential emergencies. Make sure that

emergency first responders are included. Conduct reviews of these

drills to see if there are any improvements to be made

2-3 Conduct a review of how different departments and regional offices

communicate with each other. Create a communications plan that

allows information, especially in an emergency, to be communicated

timely.

3-1 Create a company-wide safety program that educates people on safety

practices and standards that must be respected. Also, put in place a

mechanism to make sure violations are dealt with transparently and

timely.

3-2 Make training classes for new hires, especially in the technical

department, mandatory.

3-3 Bring in new board members, executive-level hires with extensive

experience working in organizations that focus on safety. Such as the

NTSB or OSHA.

Pros and Cons Matrix

Solution Pros Cons

1-1: Create

executive-level

office overseeing

safety

 Does not add to current

employee's responsibilities.

 Dedicated teams can dig deeper

and provide more unbiased

recommendations.

 It will take time to set

up.

 Without strong

backing from board

members, may not

have enough influence

to provide long-

lasting change

1-2: Add safety as a

performance

criterion

 Limit the pressure for project

managers to meet budget and

time constraints at the cost of

safety

 Quality over cost constraints

 There is a subjectivity

to how safety factors

in and can be

confusing for project

managers

1-3: Modify

company policy to

exceed regulatory

requirements

 Columbia Gas becomes a leader

over a follower regarding safety

regulations.

 Reduces the possibility that

Columbia Gas will be fined.

 Increased margins

required may turn the

company to be less

competitive with other

companies that follow

the bare minimum

 Takes increased time

before project start

2-1: develop a

precise emergency

plan

 Reduces the need for the on-site

managers to make high-pressure

decisions in the moment

 The plan could be too

rigid, leading to

secondary risks

2-2: Conduct

routine drills  Make sure employees practice

the emergency plan.

 Practice coordination with local

emergency first responders

 Expensive and time-

consuming

 May inadvertently

create more

complacency by

allowing people to

feel too comfortable

2-3: Review how

departments

communicate

within the company

 Create pathways for company-

wide improvement that will

have long-term benefits for

safety and productivity

 Would require drastic

changes to

communications

systems that could be

expensive or time-

consuming to

implement

3-1: Create a

safety-program  Invests in future profits by

reducing costs for disaster

events

 Will take time to

translate into

employees' attitude

3-2: Create training

classes for new

hires

 Improve technical qualifications

within the team

 Provide another perk for

employment

 Costly and time

consuming to create

and complete

3-3: Bring on board

safety-oriented

board members and

executives

 Enables new exchange of

information and practices

 Changes may take

time to trickle down

to the whole company

Solutions Ranking Table (Top Solutions in green)

Solution Likelihood of

Success

Difficulty

Implementing

Solution

Score

Solution

Rank 1-5, 5 highest 1-5, 5 least difficult Likelihood of

success times

difficulty

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Adfadfaafadfdfafadsfadsfasdf 5 5 25 1

Adfadsfasdfadfa 3 4 12 2

Adfafddfadfaf adfadsfadf asfasdf 5 5 25 1

Asdfafdadfadsfadf 5 5 25 1

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Adffdaasdfaddadfaasdfadsfadsfasdf 5 1 5 5

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Recommendations

From the solutions ranking table above, we can see two stand-out solutions. They have a

high likelihood of success with low difficulty: adding safety to the performance criterion for

project managers and developing a precise emergency plan with routine drills. These are

incredibly urgent as there is no good emergency plan currently in place, and Columbia Gas

cannot sustain another mismanaged emergency, and of course the people of the Merrimack

Valley have had enough in terms of fires and explosions in and around their homes.

These aren’t the only changes – there are also more long-term changes, these changes

will be useful but will require significant resources and time before positive results appear. These

changes are necessary to reinstate their customers' trust in the company as one that safely

manages their natural gas. These changes include creating long term safety programs, more

comprehensive technical training, and making an executive-level office overseeing safety within

the company.

Lastly, a review of the company's communication and corporate culture will shed light on

where Columbia Gas has become complacent. This review is a massive undertaking but will

reveal safety downfalls and inefficient and redundant parts of the company to reorganize to bring

this ancient company forward into the more competitive landscape. These changes, prioritized

and implemented immediately, will significantly reduce any potential future disasters and

mismanagement.

References

Maltzman, R. (2020). Columbia Gas of Massachusetts – Project Issue Analysis – AD642

Individual Assignment 2. Boston.

National Transportation Safety Board. (2019). Overpressurization of Natural Gas Distribution

System, Explosions, and Fires in Merrimack Valley, Massachusetts, September 13, 2018.

Washington, DC: Pipeline Accident Report NTSB/PAR-19/02.

NiSource Inc. (2020, December 1). Home – NiSource. Retrieved from Nisource:

https://www.nisource.com/home

Penn, N. (2019, June 3). The Day the Town Blew Up – Andover Masssachusetts Gass Explosion.

Retrieved from Popular Mechanics:

https://www.popularmechanics.com/technology/infrastructure/a27309627/andover-gas-

explosion/

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Columbia Gas of Massachusetts – Project Issue Analysis – AD642 Individual Assignment 2 ©2020 Richard Maltzman, Master Lecturer, Boston University Metropolitan College It was late in the afternoon of September 13, 2018. Professor Rich Maltzman looked up, startled, as three sharp raps on his car window interrupted the online course he was teaching from his car. Why from his car? Everyone in the town of Andover (Massachusetts, USA) had already been told to get out of their their homes, and they awaited word from the police – should they leave the town altogether? Yes! The three raps were from the Professor’s wife, and she was animatedly and urgently conveying the message: “we have to LEAVE TOWN. NOW!” The urgency was coming from the breaking story so well-summarized by the podcast series, “Fire in the Valley”. Fires and explosions were occurring in over 100 structures in the Merrimack Valley region of Massachusetts, north of Boston, in particular in the City of Lawrence and the towns of North Andover and Andover, Massachusetts, where the Professor and his family reside.

It was hard for residents to get the important details. Local news stations were covering the story, but the information was scattered and hard to decipher meaningfully. The Twitter feed from Columbia Gas of Massachusetts, the utility that operates the natural gas lines that were involved had this post on their web page for hours during the incident:

This was of little help – and if it wasn’t so sad, it would actually be funny. The local police were doing a better job posting advice and making announcements and sending out reverse 911 calls to residents. This is what triggered the raps on the windows and yielded the decision for Professor Maltzman to prematurely end his class, which ironically was about qualitative decision making. This tweet from the authorities made things much more clear:

So, the Professor and his family headed to Cape Cod to stay with relatives – they were very lucky to have this option available. Others were not so lucky. See this video from Rabbi Howard Mandell who tells his story, which starts with a 6- foot flame emanating from his boiler’s gas supply.

What happened here?

A tremendous write-up of the story comes from an article from the June, 2019 issue of Popular Mechanics – an article entitled, “The Day the Town Blew Up”.

Here the key extract:

…On the Salem Street side of the O’Connell South Common (in Lawrence, Massachusetts), a public park, a contractor removes a length of cast-iron pipe, caps it, and sets it aside.

Feeney Brothers Utility Services (“Providing Underground Utility Services since 1988”) has a permit to open up a two-foot-wide, 340-foot-long stretch of Salem Street, for the purpose of “completing gas main tie-ins and retirement of dual cast-iron gas mains.” Feeney Brothers is a family-owned operation with seven hundred employees. They’ve worked extensively not only for Columbia Gas but also for the region’s other major natural-gas supplier, Eversource. In recent years, gas utilities in Massachusetts have increasingly relied on contractors to carry out projects like this.

It’s usually cheaper.

The job today is to install new polyethylene pipeline and tie it into a new distribution main, also plastic. The Feeney Brothers contractor may or may not be aware that a regulator sensing line— a gauge that measures gas pressure—is attached to the pipe he had discarded. But it’s important to note that he and his crew are performing their duties as directed, under Columbia Gas supervision, and correctly following the steps in the work package Columbia Gas developed and approved. Columbia Gas’s work order doesn’t mention the sensor and was not prepared by a professional engineer. Until four years ago, a technician from the Meter and Regulation Department would have been assigned to the site to monitor pressure readings on the affected section of gas main, but Columbia Gas, for undisclosed reasons, has ended this practice.

The sensor on the discarded length of pipe thinks it’s still measuring the gas pressure in a vast underground network. In fact, it is measuring nothing: The pipe has been disconnected from the network. The sensor might as well be attached to a hot dog. But the sensor doesn’t know any of that, and there is no other sensor in this segment of the network to contradict it.

The sensor sends a message to the regulator valves in this segment of the network: Boost the pressure! Which they do. But the sensor, because it’s still attached to the dead piece of pipe,

doesn’t detect any of that. Instead, it registers a pressure drop, all the way down to 0.01 psi. More pressure, it tells the valves, until they have opened completely, and two distribution systems that were supposed to be segregated, cordoned off from each other, are instead tied directly into each other for twenty-six minutes.

A wave of high-pressure gas rushes into the regional gas-main system that serves Lawrence, Andover, and North Andover. In the older cast-iron segments of the network, the pressure rises to at least 6 psi, twelve times what the pipes are capable of handling.

At 4:04 p.m., the first high-pressure alarm is received by the NiSource monitoring station—in Columbus, Ohio. A second alarm is received at 4:05 p.m.

In the control room in Ohio, the NiSource employees have no capacity to control, let alone shut down, the gas flow. They can only contact the Meters and Regulations Group at Columbia Gas, which at 4:06 p.m. dispatches its entire team of inspectors to investigate—a total of two people, or approximately one per 2,494.75 miles of pipe.

The result of this over-pressurization: 141 fires, 5 explosions, 21 serious injuries, 1 death, many people displaced and/or without heat or the ability to cook – for months, and the bankruptcy of Columbia Gas of Massachusetts.

This was the incident. How about the cause?

The NTSB incident report summarized the case in the following way:

NTSB investigators learned that, until about 4 years ago, Columbia Gas required that a technician monitor any gas main revision work which required depressurizing the main. The technician—typically from the Meter and Regulation department—would use a gauge to monitor the pressure readings on the impacted main and would communicate directly with the crew making the change. If a pressure anomaly occurred, the technician could quickly act to prevent an overpressurization action. Columbia Gas offered no explanation as to why this procedure was phased out.

Although the Columbia Gas monitoring center in Columbus, Ohio, received high-pressure alarms and reported the event to the Meters and Regulations department two minutes after receiving the first alarm, there were no technicians prestaged or positioned to immediately close valves when the overpressurization occurred. Had Columbia Gas adequately performed MOC (Management of Change) and placed personnel at critical points along the system, Columbia Gas could have immediately addressed the issue and mitigated the consequences of the event. Therefore, the NTSB recommends that NiSource apply MOC processes to all changes to adequately identify system threats that could result in a common mode failure. Additionally, the NTSB recommends that NiSource develop and implement control procedures during modifications to gas mains to mitigate the risks identified during MOC operations. Gas main pressures should be continually monitored during these modifications and assets should be placed at critical locations to immediately shut down the system if abnormal operations are detected.

NTSB Recommendations In November 2018, the NTSB issued a series of “urgent” safety recommendations. The report contained four recommendations for NiSource, the parent company of Columbia Gas, and one for the state, seeking elimination of the professional engineer licensure exemption for public utility work and a requirement for a professional engineer’s seal on public utility engineering drawings.

The NTSB report recommends NiSource do the following:

• revise the engineering plan and constructibility review process across all subsidiaries; • review

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