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Material factor
- natural gas is forced through the piping at a high pressure and volume to remove debris.

2. People factor
-the workers did not receive and review the natural gas blow procedure
-workers used natural gas at a pressure of approximately 650 pounds per square inch gauge
-On the day of the incident, the pipe cleaning crew did not have a safety meeting that specifically
discussed the hazards of natural gas blows

3. Recommendation
-short term recovery to run the long term
-lines used to convey the natural gas and flue gas must be absolutely free of any debris resulting
from construction
-pipe cleaning before start-up
-prohibit the release of flammable gas to the atmosphere for the purpose of cleaning fuel gas
-prohibit any work in areas where the concentration of flammable gas exceeds a specified level
as determined by appropriate combustible gas monitoring
-require the companyto develop flammable gas safety procedures and training that involves
contractors, workers and their representatives in decision making.