PACIFIC GAS & ELECTRIC CO

Incident 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.