On September 13, 2018 at approximately 4:00 pm EDT a series of emergency calls were received by 911 operators working the Lawrence and North Andover region of Massachusetts. The calls ranged from smells of “natural gas” to actual fires to actual explosions (at least five recorded). A low-pressure natural gas supply system (0.5 psig 14 in. water column) “overpressurized” by at least one order of magnitude. Approximately 8600 customers were affected. Of these, 131 customers had some type of “extended over pressure event” such as a release of natural gas within their basement. This is a 1.5% failure rate on systems that should have been in place when over pressure occur. Unfortunately, this 1.5% failure rate translated into a multimillion dollar loss for the gas company, and the disruption of quality of life for 8600 residents, hundreds of whom were displaced for over 6 months as their homes were rebuilt. One year later, full recovery is still in progress for the area. The root cause traces back to a failed “management of change” system. With proper a hazard analysis/safety review and communication, this event could have been prevented or at least mitigated.

中文翻译：

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对哥伦比亚天然气爆炸劳伦斯和马萨诸塞州北安多佛的见解2018年9月13日

在2018年9月13日在4:00左右 日下午美国东部时间（EDT），工作在马萨诸塞州劳伦斯和北安多佛地区的911名操作员接到了一系列紧急电话。通话范围从“天然气”的气味到实际的大火再到实际的爆炸（至少记录了五次）。低压天然气供应系统（0.5 psig 14英寸水柱）“超压”至少一个数量级。大约有8600个客户受到影响。在这些客户中，有131位客户发生了某种“压力过大事件”，例如地下室中的天然气释放。在发生超压时应该已经就位的系统上，这是1.5％的故障率。不幸的是，这1.5％的失败率给煤气公司造成了数百万美元的损失，并破坏了8600名居民的生活质量，数百人因重建房屋而流离失所超过6个月。一年后，该地区仍在全面恢复。根本原因可追溯到失败的“变更管理”系统。通过适当的危害分析/安全审查和沟通，可以避免或至少缓解此事件。