Safety Recommendations

The NTSB issues safety recommendations to address specific safety concerns uncovered during investigations and to specify actions to help prevent similar accidents from occurring in the future. Safety recommendations are our most important product because they alert government, industry, and the public to the critical changes that are needed to prevent transportation accidents and crashes, reduce injuries, and save lives. We:

issue recommendations to the organizations best able to take corrective action, such as the US DOT and its modal administrations, the Coast Guard, other federal and state agencies, manufacturers, operators, labor unions, and industry and trade organizations.
issue safety recommendations at any point during the investigation of transportation accidents and in connection with safety studies.
monitor the progress of action to implement each recommendation until it is closed, which usually takes several years.

Find Our Recommendations

CAROL   (Case Analysis and Reporting Online) is our search tool for investigations and safety recommendations across all modes. CAROL includes all NTSB recommendations. See the Field Descriptions page for specific information about safety recommendations data fields.

Recommendation Spotlight

Each month, we shine the spotlight on a few recommendations that have been successfully implemented (closed acceptable action) and are helping to further safety. These recommendations span all modes of transportation and recommendation recipients. Visit the Recommendation Spotlight Archive to see previous safety wins.

We urge recommendation recipients to keep us informed of the progress on implementing recommendations. If you do, you may see your recommendation spotlighted here. Read more about responding to our safety recommendations.

West Reading Recommendations Lead to Pipeline Safety Improvements

The March 24, 2023, natural gas-fueled explosion and fire at the R.M. Palmer Co. candy factory in West Reading, Pennsylvania, showed the devastating consequences of hidden underground hazards.

Natural gas escaped from a vintage plastic pipeline fitting under the street and migrated underground into the Palmer factory buildings. Once inside, the gas accumulated and ignited, causing an explosion that killed seven Palmer employees, injured 10 people, destroyed one Palmer building, severely damaged another, and displaced three families from a neighboring apartment building.

Our investigators found that the fitting degraded after exposure to elevated ground temperatures caused by steam escaping from a nearby corroded, cracked underground steam pipe. Because the steam pipe was not marked through the state’s one-call system, and because UGI Corp., the natural gas pipeline operator, was not aware of the steam line, the company did not fully consider the heat-related threat to its natural gas system.

The Board recently closed three West Reading safety recommendations after finding that actions taken by the Pipeline and Hazardous Materials Safety Administration (PHMSA) and the Common Ground Alliance (CGA) addressed key risks identified in the investigation.

PHMSA Actions

PHMSA, the federal agency that regulates pipeline safety, issued an advisory bulletin to natural gas distribution operators nationwide. The bulletin encourages operators to identify plastic pipeline assets near heat sources, evaluate the risks, and take steps to reduce them. It also encourages operators to address risks associated with certain older plastic pipeline fittings, including replacement or repair as needed.

The Board recently found that PHMSA’s advisory bulletin met the intent of Safety Recommendations P-25-1 and P-25-2 by addressing the risks posed by nearby heat sources and older plastic pipeline fittings and classified them as Closed, Acceptable Action.

CGA Actions

CGA develops best practices for preventing damage to underground facilities, including guidance for 811 centers, the “call before you dig” notification systems used to identify and mark buried utilities. In West Reading, however, Palmer’s privately owned steam pipe ran underground beneath a public street but was not registered with PA One Call, Pennsylvania’s 811 program, because state law did not require it. CGA revised its guidance to clarify who should participate in 811 programs, helping make more buried lines and pipes known before they pose risks to nearby infrastructure.

The Board recently found that CGA’s actions met the intent of Safety Recommendation P-25-12 by clarifying who should participate in state 811 call-before-you-dig systems. Greater participation will help make more buried lines and pipes known before they pose risks to nearby infrastructure. The Board recently classified the response to our recommendation as Closed, Acceptable Action.

Together, these actions help operators and damage-prevention partners better identify hidden underground hazards, evaluate risks, and act before those risks lead to another tragedy.