Honeywell International, Inc.
-From Edward Myszka, Vice President and General Manager: Honeywell1 acknowledges and appreciates the substantial efforts of the National Transportation Safety Board's (the "Board") staff in connection with its response to Incident #DCA 17FP006, its investigation of the causes thereof, and its efforts to address and enhance industry safety. Honeywell's Perfection business has supported and cooperated fully with the Board and its staff throughout this process and commits to continue to do so in the future.
In particular, Perfection commits to work collaboratively with the Board and its staff in regards to Recommendations P-18-3 and P-18-4. Our commitment to health, safety and the environment is an integral aspect of our design of products, processes and services. Honeywell's Health, Safety, Environmental, Product Stewardship and Sustainability (HSEPS) Management practices are managed by a global team of trained professionals with extensive knowledge and hundreds of years of collective experience.
We support the spirit behind the recommendations (i.e ., improving safety) and include herewith revised installation instructions for Perfection Permalock® tapping tees - we've made enhancements in the interest of continuous improvement and refinement; however, we maintain that our instructions were not and have never been inadequate in any way. Further, we believe it beneficial to offer clarification concerning some of the Board's findings and suggestions.
This letter addresses:
1) Federal Regulations and corresponding installer qualification requirements that have come into existence since the installation of the tees in question
2) The fact that the installer appears to have disregarded the written instructions provided with the tees
3) Specific concerns with respect to Recommendations P-18-3 and P-18-4
Updates to Federal Regulations
As acknowledged by the Board, since the 1998 installation of the tee at issue, new federal regulations concerning operator qualification and training were adopted. The Operator Qualification (OQ) rule was adopted into the Code of Federal Regulations under Subpart Nin 49 CFR Part 192 and Subpart Gin 49 CFR Part 195. Under the rule, each pipeline operator is responsible for developing an OQ program, following their written OQ plan, establishing a covered task list applicable to their system, and defining the training and qualification requirements for personnel performing covered tasks on their pipeline facility. It is the operator's responsibility to ensure their contractors and vendors comply with their program requirements.
49 CFR Part 192 was passed in 1999 and amended in 2005. The stated objective of this rule was to reduce the risk of accidents on pipeline facilities attributable to human error. It is intended to provide an additional level of safety by requiring operators of pipelines and natural gas distribution systems to develop qualification programs to evaluate an individual's ability to perform covered tasks. The qualification programs should also ensure that personnel can recognize and react to abnormal operating conditions that may occur while performing covered tasks.
As noted in the report, " ... when the tee assembly involved in the accident was installed in 1998, federal regulations concerning operator qualification training standards for installation of tee assemblies did not exist, and UGI did not have a training program for installing them ... " The Operator Qualification rule, designed to reduce casualty incidents, was not in effect when the Permalock® tee was installed.
Disregard of Written Instructions
In 1998, UGI was relying solely on each of its individual installers to follow the written installation instructions shipped with the tee assembly2• The report states: "NTSB examination of the Permalock® tee assembly involved in the accident has revealed that the tee assembly was incorrectly installed. Although the cutter tool pierced a hole in the main, the locking sleeve did not progress down far enough into the tower to form threads in that hole. As a result, the locking sleeve was not attached to the main." In other words, the installer of the tee in question did not follow the written installation instructions, at a minimum Step 6 of the instructions (set forth below) was omitted. The depth tube was not used, and as a result, the steel locking sleeve never engaged the main. This was evidenced by the lack of formed threads through the entire crosssection of the pipe wall. The punched bore through the exhumed pipe was smooth. During a proper installation, the sleeve always produces a double-lead thread form in the pipe wall. The steel locking sleeve is designed to serve as the primary anchor to the main; preventing radial, lateral and rotational movement. If the instructions were followed, and the depth tube utilized, this incident would not have occurred. Written instructions, no matter how detailed or clearly presented, are only useful if the installer follows them.
Specific Concerns with Respect to Recommendations
The recommendations made by the Board were:
1. Update your Permalock® mechanical tapping tee assembly installation instructions to specify the exact tools that should be used during installation and explain what an installer should sense while using those tools throughout the installation process. (P-18-3)
2. Specify in your Permalock® mechanical tapping tee assembly installation instructions a not-to exceed torque limit for Nylon bolts and have that value checked and adjusted with a torque wrench immediately after installation. (P-18-4)
Prescribing Exact Tool Size
A general description of tool length may provide some benefit. However, using a shorter wrench is subjective rather than objective and does not guarantee or increase the likelihood of a proper installation. Therefore, while we don't think it's necessary, we have added guidance in the updated instructions submitted with this letter.
Installers Should Follow Written Directions and Not Rely on Sense
The use of a depth tube to verify the proper installation of the cutter sleeve is included in both the previous and current installation instructions. This removes the need for subjective sensory input, such as the torque changes between the punching of the main line, and the installation of the cutter sleeve. As mentioned above, the failure of the installer to follow instructions and use the depth tube was the cause of the incorrect installation.
The installation instructions which were reviewed during this investigation were p/n 37575 revision level F, which was the active revision level at the time of installation. These instructions are currently at revision level R. The modifications that have been made to the installation instructions were either made to offer increased clarity to the end user, or to due to design changes to the Permalock® tapping tee which required clarification of the instructions.
The installation instructions (both current and previous revisions) explicitly and objectively state the following:
• Revision F , Step 6: Place DEPTH TUBE on top of the CUTTER ASSEMBLY. Thread CUTTER ASSEMBLY downward using a 5/16" hex wrench. Continue threading the CUTTER ASSEMBLY downward until it becomes snug. The DEPTH TUBE will be flush to 1/8" above the top of the TEE TOWER.
• Revision R4 , Step 1: ... NOTE: A blue colored depth tube is required for 1 1/4 IPS main installation, and a white colored depth tube is required for 2-4 IPS main installation. If you do not have the proper color depth tube, DO NOT install the fitting.
• Revision R, Step 6: Place DEPTH TUBE on top of the CUTTER ASSEMBLY. Thread CUTTER ASSEMBLY downward using a 5/16" hex wrench. Continue threading the CUTTER ASSEMBLY downward until it bottoms in the tower. The DEPTH TUBE is a visual guide and will be approximately flush with the top of the Tee Tower when the cutter is engaged.
As demonstrated by t