U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD 

INVESTIGATION REPORT 

REPORT NO. 2007-04-I-WV 

SEPTEMBER 2008

LITTLE GENERAL STORE – PROPANE EXPLOSION

(Four Killed, Six Injured) 

Photo courtesy of West Virginia State Fire Marshal 

LITTLE GENERAL STORE, INC. 

GHENT, WEST VIRGINIA

KEY ISSUES: JANUARY 30, 2007 

• EMERGENCY EVACUATION

• HAZARDOUS MATERIALS INCIDENT TRAINING FOR FIREFIGHTERS

• 911 CALL CENTER RESOURCES

• PROPANE COMPANY PROCEDURES

• PROPANE SERVICE TECHNICIAN TRAINING
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Contents 

EXECUTIVE SUMMARY.......................................................................................................................... 1

KEY FINDINGS .......................................................................................................................................... 3

1.0 INTRODUCTION........................................................................................................................... 4

1.1 Summary ......................................................................................................................................... 4

1.2 Investigative Process ....................................................................................................................... 7

1.3 Little General Store, Inc. ................................................................................................................. 8

1.4 Little General Store Propane Suppliers ........................................................................................... 8

1.5 West Virginia Emergency Service Organizations........................................................................... 9

1.6 Professional and Industry Organizations....................................................................................... 12

2.0 INCIDENT DESCRIPTION ......................................................................................................... 13

2.1 Events Preceding January 30, 2007 Explosion.............................................................................. 13

2.2 Day of the Incident ........................................................................................................................ 14

2.3 Response to the Propane Release .................................................................................................. 17

3.0 PROPANE INCIDENT FREQUENCY ........................................................................................ 20

3.1 United States Hazardous Materials Incidents 2001 – 2006........................................................... 20

3.2 Recent Propane Incidents .............................................................................................................. 21

4.0 PROPANE SYSTEM FUNDAMENTALS .................................................................................. 22

4.1 Propane Properties......................................................................................................................... 22

4.2 System Features............................................................................................................................. 22

4.3 Propane Standards ......................................................................................................................... 24

4.4 Propane Emergency Guidance ...................................................................................................... 25

5.0 INCIDENT AND EMERGENCY RESPONSE ANALYSIS ....................................................... 27
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5.1 Liquid Withdrawal Valve.............................................................................................................. 27

5.2 Propane Tank Placement ............................................................................................................... 30

5.3 Propane Service Technician Training and Response .................................................................... 36

5.4 Fire Department Response ............................................................................................................ 41

5.5 911 Emergency Call Center Response .......................................................................................... 44

6.0 REGULATORY ANALYSIS ....................................................................................................... 46

6.1 Occupational Safety and Health Administration........................................................................... 46

6.2 Environmental Protection Agency ................................................................................................ 46

6.3 West Virginia Fire Commission.................................................................................................... 47

7.0 FINDINGS .................................................................................................................................... 51

8.0 CAUSES........................................................................................................................................ 53

9.0 RECOMMENDATIONS .............................................................................................................. 54

Governor and Legislature of the State of West Virginia ............................................................................ 54

West Virginia Fire Commission................................................................................................................. 54

West Virginia Office of Emergency Medical Services .............................................................................. 54

National Fire Protection Association.......................................................................................................... 55

Association of Public-Safety Communications Officials........................................................................... 55

Propane Education and Research Council.................................................................................................. 55

National Propane Gas Association ............................................................................................................. 56

West Virginia E911 Council ...................................................................................................................... 56

Ferrellgas .................................................................................................................................................... 57

REFERENCES........................................................................................................................................... 58

APPENDIX A FERRELLGAS INSTALLATION REVIEWS OF THE INCIDENT TANK.................. 60

APPENDIX B 911 CALL AND INITIAL FIRE DEPARTMENT DISPATCH ...................................... 63
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APPENDIX C RECENT PROPANE INCIDENTS.................................................................................. 66

RECENT PROPANE INCIDENTS ........................................................................................................... 67

1.0 PROPANE RELEASE INCIDENTS ............................................................................................ 67

1.1 Aberdeen, Washington .................................................................................................................. 67

1.2 Lynchburg, Virginia ...................................................................................................................... 68

1.3 Bristow, Virginia........................................................................................................................... 70

2.0 PROPANE RELEASE AND FIRE INCIDENTS......................................................................... 72

2.1 Sallis, Mississippi.......................................................................................................................... 72

2.2 Danville, Alabama......................................................................................................................... 73

APPENDIX D TABLE OF STATE REQUIREMENTS FOR PROPANE SERVICE TECHNICIANS . 75

APPENDIX E UNITED STATES EPA - 40 CFR 311 ............................................................................. 77
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List of Figures 

Figure 1. Aerial photograph of Little General store and surrounding plot. .................................................4

Figure 2. Site plan of Little General Store. ..................................................................................................6

Figure 3. Liquid withdrawal valve.............................................................................................................15

Figure 4. Timeline of initial events............................................................................................................17

Figure 5. Timeline of incident response.....................................................................................................19

Figure 6. Typical ASME propane tank. .....................................................................................................23

Figure 7. Incident valve plug (Telltale circled)...........................................................................................27

Figure 8. Crack in valve seal.......................................................................................................................29

Figure 9. Pre-incident photograph of the Ferrellgas tank. .........................................................................30

List of Tables 

Table 1. U.S. hazardous materials incidents 2001-2006............................................................................20
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List of Acronyms and Abbreviations 

ASME American Society of Mechanical Engineers 

APCO Association of Public-Safety Communications Officials 

CETP Certified Employee Training Program 

CFR Code of Federal Regulations 

CSB U.S. Chemical Safety and Hazard Investigation Board 

DOT U.S. Department of Transportation 

EMS Emergency Medical Services 

EMT Emergency Medical Technician 

EOC Emergency Operations Center 

EPA U.S. Environmental Protection Agency 

FIR Ferrellgas Installation Review 

HAZWOPER Hazardous Waste Operations and Emergency Response 

HVAC Heating, Ventilation, and Air Conditioning 

IC Incident Commander 

LP Gas Liquefied Petroleum Gas 

MSDS Material Safety Data Sheet 

NENA National Emergency Number Association 

NFIRS National Fire Incident Reporting System 

NFPA National Fire Protection Association 

NIMS National Incident Management System 

NPGA National Propane Gas Association 

OES Raleigh County Office of Emergency Services 

OSHA U.S. Occupational Safety and Health Administration 

PERC Propane Education and Research Council 

RESA Regional Education Service Agency 

SCGM Service Center General Manager 

STARS Safety and Training Administrative Records System 

WVC West Virginia Code 

WVCSR West Virginia Code of State Rules 
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Executive Summary 

On January 30, 2007, a propane explosion at the Little General Store in Ghent, West Virginia, killed two 

emergency responders and two propane service technicians, and injured six others. The explosion leveled 

the store, destroyed a responding ambulance, and damaged other nearby vehicles. 

On the day of the incident, a junior propane service technician employed by Appalachian Heating was 

preparing to transfer liquid propane from an existing tank, owned by Ferrellgas, to a newly installed 

replacement tank. The existing tank was installed in 1994 directly next to the store’s exterior back wall in 

violation of West Virginia and U.S. Occupational Safety and Health Administration regulations. 

When the technician removed a plug from the existing tank’s liquid withdrawal valve, liquid propane 

unexpectedly released. For guidance, he called his supervisor, a lead technician, who was offsite 

delivering propane. During this time propane continued releasing, forming a vapor cloud behind the 

store. The tank’s placement next to the exterior wall and beneath the open roof overhang provided a 

direct path for the propane to enter the store. 

About 15 minutes after the release began, the junior technician called 911. A captain from the Ghent 

Volunteer Fire Department subsequently arrived and ordered the business to close. Little General 

employees closed the store but remained inside. Additional emergency responders and the lead 

technician also arrived at the scene. Witnesses reported seeing two responders and the two technicians in 

the area of the tank, likely inside the propane vapor cloud, minutes before the explosion. 

Minutes after the emergency responders and lead technician arrived, the propane inside the building 

ignited. The resulting explosion killed the propane service technicians and two emergency responders 

who were near the tank. The blast also injured four store employees inside the building as well as two 

other emergency responders outside the store. 
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The CSB identified the following causes: 

1. The Ferrellgas inspection and audit program did not identify the tank location as a hazard. 

Consequently, the tank remained against the building for more than 10 years. 

2. Appalachian Heating did not formally train the junior technician, and on the day of incident he was 

working alone. 

3. Emergency responders were not trained to recognize the need for immediate evacuation during liquid 

propane releases. 

The CSB makes recommendations to the governor and legislature of the State of West Virginia, the West 

Virginia Fire Commission, the West Virginia Office of Emergency Medical Services, the National Fire 

Protection Association, the Association of Public-Safety Communications Officials, the Propane 

Education and Research Council, the National Propane Gas Association, the West Virginia E911 Council, 

and Ferrellgas. 
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Key Findings 

1. The propane service technicians, emergency responders, and store employees did not evacuate the 

area as recommended by nationally accepted guidance for propane emergencies. 

2. A defect in the existing tank’s liquid withdrawal valve caused it to malfunction and remain in an open 

position. 

3. The junior propane service technician who was servicing the tank on the day of the incident had no 

formal training and did not recognize the defect in the withdrawal valve. He was also working 

unsupervised, even though he had been on the job for only one and a half months. 

4. The placement of the 500-gallon propane tank against the building’s exterior back wall provided 

releasing propane a direct path into the store’s interior. 

5. The Occupational Safety and Health Administration’s and National Fire Protection Association’s 

propane standards require training but do not include curricula, practical exercises, or knowledge 

evaluation. 

6. 911 operators in the United States lack propane emergency guidance to help them collect important 

information from callers, offer life-saving advice, and convey relevant information to first responders. 

7. Firefighters in West Virginia are required to attend a minimum of four hours of hazardous materials 

emergency response training as part of their initial training sequence, but refresher training is not 

required. The responding Ghent Volunteer Fire Department captain last attended a hazardous 

materials response course in 1998. 

8. Propane safety and emergency training is voluntary for fire department personnel in West Virginia. 

None of the responders from the Ghent Volunteer Fire Department had specific propane emergency 

training. 
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1.0 Introduction 

1.1 Summary 

At 10:53 am on January 30, 2007, a propane explosion leveled the Flat Top Little General Store (Little 

General) in Ghent, Raleigh County, West Virginia (Figure 1). The explosion killed four and injured six. 

The dead included two emergency responders (a fire department captain and an emergency medical 

technician, both from the Ghent Volunteer Fire Department) and two Appalachian Heating propane 

service technicians. The injured included the four Little General employees who remained inside the 

store, and two other Ghent Volunteer Fire Department emergency responders. 

Figure 1. Aerial photograph of Little General store and surrounding plot. 
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The morning of the explosion, a junior propane service technician1

 (junior technician) from Appalachian 

Heating was preparing to transfer liquid propane from an existing tank owned by Ferrellgas to a newly 

installed tank2

 owned by Thompson Gas and Electric Services (Thompson). The Ferrellgas propane tank 

was installed in 1994 directly against the store’s exterior back wall (Figure 2). At about 10:25 am, the 

junior technician, working alone, removed a threaded plug from the liquid withdrawal valve3

 on the 

Ferrellgas tank and liquid propane began flowing uncontrollably. Liquid propane sprayed upward, 

against the roof overhang, and dense propane gas accumulated at ground level around the tank and the 

foundation of the building. Over the next 25 minutes, the escaping propane entered the Little General 

store through openings in the roof overhang. 

Shortly after the release began, the junior technician called the lead technician to report the release and 

seek guidance. At 10:40 am, the junior technician called 911 to report the emergency and summon help. 

A captain and two emergency medical technicians from the Ghent Volunteer Fire Department were the 

first to arrive, followed by the lead technician and two other emergency responders. Shortly after their 

arrival, the propane in the store ignited, leveling it and killing two emergency responders (the fire captain 

and one of the emergency medical technicians) and the two Appalachian Heating propane service 

technicians. 

 

1

 The report discusses the activities of two propane service technicians: a junior technician, who had been 

performing propane duties for one and a half months, and a lead technician, who had been performing propane 

duties for one and a half years. “Junior” and “lead” are used in this report to differentiate the technicians’ relative 

experience in propane service. 

2

 While commonly referred to as tanks, both of these were 500-gallon pressure vessels. The American Society of 

Mechanical Engineers (ASME) publishes the Boiler and Pressure Vessel code; generally, stationary propane tanks 

are considered unfired pressure vessels and manufactured in accordance with Section VIII of the code. 

3

 The liquid withdrawal valve was a RegO Chek-Lok valve model number 7572FC, which is no longer 

manufactured. Although the RegO name is still used on propane equipment, the company that manufactured this 

valve is no longer in business. 
Little General Store September 2008 

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Fire departments from the neighboring communities of Beckley, Beaver, and Princeton responded to the 

explosion. Later that day a team from the West Virginia Office of the State Fire Marshal arrived to 

investigate, assisted by an agent from the U.S. Bureau of Alcohol, Tobacco, Firearms, and Explosives 

(ATF). 

 Figure 2. Site plan of Little General Store. 
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1.2 Investigative Process 

The CSB investigation team arrived at the incident scene on January 31. They joined the Incident 

Command structure, in accordance with the National Incident Management System (NIMS),4

 and began 

on-scene investigation activities. On February 2, 2007, Incident Command demobilized after the State 

Fire Marshal concluded that the incident was not a criminal act. The CSB investigation team remained, 

and with the help of Little General management, protected and preserved evidence, moving it to a secure 

storage locker. 

The team interviewed employees of the companies involved, emergency responders, and officials from 

the West Virginia Office of the State Fire Marshal; The West Virginia Division of Labor; the Raleigh 

County Building Department; Regional Education Service Agency (RESA)5

 Region I; the United States 

Fire Academy; the ATF; the Beckley and Beaver, West Virginia Fire Departments; the Occupational 

Safety and Health Administration (OSHA); the National Fire Protection Association (NFPA); the 

National Propane Gas Association (NPGA); and the Propane Education and Research Council (PERC). 

In addition, the CSB tested and examined the valve that released the propane from the Ferrellgas tank. 

The test protocol included in situ examination and flow testing; removal of the liquid withdrawal valve 

assembly (valve, tank nozzle, and dip tube); photography and examination of the valve and dip tube, 

including removal of the dip tube; and dismantling and examination of the valve. 

 

4

 NIMS is a comprehensive approach to incident response management that provides a consistent, nationwide 

template to enable all response entities to work in concert during incidents. Implementation of NIMS is required 

by the US Department of Homeland Security in accordance with its authority in Homeland Security Presidential 

Directive 5 “Management of Domestic Incidents.” The State Fire Marshal reestablished an incident command 

system following the explosion. 

5

 Enacted by the West Virginia Legislature in 1972, RESA provides educational services to schools, including 

technical, professional, operational, and programmatic services. In addition to school-based programs, RESA 

coordinates much of West Virginia’s professional firefighter training program. 
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1.3 Little General Store, Inc. 

Little General Store, Inc. operates 48 convenience stores throughout southern and central West Virginia 

and western Virginia. The Ghent store was a combination gasoline station and convenience market. At 

the time of the incident, the Ghent store and three others included pizzerias, which used propane for 

cooking. 

1.4 Little General Store Propane Suppliers 

1.4.1 Southern Sun 

Southern Sun supplied propane to Little General beginning in late 1994. Southern Sun was a familyowned propane, heating oil, and ice supplier located in south central West Virginia. In 1996 Southern 

Sun sold its propane operations to Ferrellgas, which became the supplier to Little General. 

1.4.2 Ferrellgas 

Ferrellgas, headquartered in Overland Park, Kansas, is the second-largest propane marketer in the United 

States, with offices and customers in all 50 states. One of Ferrellgas’ business strategies is to “expand 

operations through disciplined acquisitions and internal growth.” Since 1986 Ferrellgas has acquired 166 

propane distributors throughout the United States. 

Late in 2006, Little General initiated a change in propane suppliers from Ferrellgas to ThompsonGas 

Propane Partners. 

1.4.3 Thompson Gas and Electric Service, Inc. 

Thompson is a privately held company that installs commercial and residential propane systems and 

delivers propane in the eastern and southeastern United States. 
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1.4.4 Appalachian Heating 

Appalachian Heating is a family-owned heating, ventilation, air conditioning (HVAC), and plumbing 

company. Appalachian installs appliances, installs and maintains heating and cooling systems, and 

installs and repairs plumbing. Appalachian entered into a contract with Thompson in August 2005 to 

extend its business to include propane supply. 

1.4.5 ThompsonGas Propane Partners, LLC 

ThompsonGas Propane Partners is the limited liability company (LLC) formed between Thompson of 

Hagerstown, Maryland, and Appalachian Heating of Bradley, West Virginia. Under the agreement 

forming ThompsonGas Propane Partners, LLC, Appalachian Heating provides personnel to install 

propane systems and deliver propane; Thompson provides equipment, bulk propane, and technical 

support. The LLC has no employees. 

1.5 West Virginia Emergency Service Organizations 

1.5.1 West Virginia State Fire Commission 

The West Virginia Fire Prevention and Control Act6 of 1975 established the West Virginia State Fire 

Commission and granted the commission authority to promulgate and establish a state fire code.7

 The 

commission established the National Fire Codes8

 as the minimum fire prevention and protection 

requirements for the state. 

 

6

 West Virginia Code Chapter 29, Article 3 “The Fire Prevention and Control Act.” 

7

 West Virginia Legislative Rule Title 87, Series 1, “State Fire Code.” 

8

 NFPA publishes the National Fire Codes annually. The National Fire Codes are a collection of all NFPA’s 

standards. 
Little General Store September 2008 

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1.5.2 West Virginia State Fire Marshal 

The West Virginia State Fire Marshal’s Office, overseen by the State Fire Commission, has four divisions 

providing fire protection and regulatory services: regulation and licensing, public education, fire 

investigation, and regional response. The Fire Marshal enforces the rules of the State Fire Commission 

throughout West Virginia. Currently, the Fire Marshal’s Office employs 12 code inspectors and 11 fire 

investigators. 

1.5.3 Raleigh County Emergency Services 

An executive group is responsible for emergency services management in Raleigh County, West Virginia. 

Group membership includes county commissioners; the district attorney; mayors of municipalities; the 

county sheriff; the Office of Emergency Services (OES); and the county public information officer. 

Raleigh County emergency services encompass mutual aid management among municipal fire 

departments (career and volunteer); police; emergency medical transport services; and community-based 

support agencies. Services are coordinated under a unified command system at the Emergency 

Operations Center (EOC) located in Beckley. 

Local municipalities are responsible primarily for emergency response activities within their areas. 

County resources are available from the OES and coordinated through the EOC when emergencies exceed 

local response capabilities. The OES develops and maintains the Raleigh County Emergency Plan and 

manages the county’s 911 emergency call center. 

1.5.4 Ghent Volunteer Fire Department 

The Ghent Volunteer Fire Department was incorporated in 1973 and has 28 members providing fire 

fighting, life protection, and ambulance service to residents in the Ghent area. Salaried Emergency 
Little General Store September 2008 

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Medical Technicians (EMTs) are on duty at the fire station 24 hours a day, seven days a week.9

 All 

Ghent area emergency 911 calls are routed to the Raleigh County EOC where operators dispatch the 

appropriate fire or emergency medical service. 

1.5.5 West Virginia E911 Council 

West Virginia established the E911 Council in 1986 to organize and implement the universal 911 

emergency telephone number system. The council promotes, researches, plans, educates, develops 

funding streams, and proposes state legislation to ensure reliable 911 call service operations. 

Representatives from West Virginia’s 55 counties serve on the council, which meets monthly. 

The council works closely with emergency response industry organizations including the National 

Emergency Number Association (NENA) and the Association of Public-Safety Communicators Officials 

(APCO). In addition, the council is involved in activities to promote and fund 911 systems statewide. 

1.5.6 West Virginia Office of Emergency Medical Services 

The West Virginia Office of Emergency Medical Services (EMS) is a division of the West Virginia State 

Trauma and Emergency Care System, administered by the West Virginia Department of Health and 

Human Resources. The Office of EMS was legislatively mandated in 1975 and tasked with operating a 

comprehensive statewide EMS program. It oversees licensing for EMS agencies and training and 

certification for responders. 

 

9

 The Ghent fire department comprises trained volunteer firefighters and paid emergency medical technicians. 

Many of the emergency medical technicians, including those who responded to the Little General propane release, 

also serve as volunteer firefighters. 
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1.6 Professional and Industry Organizations 

1.6.1 National Fire Protection Association 

The NFPA publishes consensus standards applicable to specific industries and activities, including the 

propane industry and hazardous materials incident response. These standards, while voluntary unless 

incorporated into state laws or regulations, provide safe practice guidelines for operations in the processes 

they address. West Virginia adopted the National Fire Codes into the State Fire Code.10 

1.6.2 Propane Education and Research Council 

Congress created the Propane Education and Research Council (PERC) in the Propane Education and 

Research Act of 1996. PERC’s purpose is to promote the safe use of propane energy in the United States. 

Each gallon of odorized propane sold in the United States is assessed one-half of one cent to fund PERC. 

PERC estimates revenue of $45,300,000 for the 2009 fiscal year. 

PERC develops the curriculum for the Certified Employee Training Program (CETP), which is the 

propane industry’s primary training method for service technicians, bulk plant operators, delivery truck 

drivers, and customer service representatives. 

1.6.3 National Propane Gas Association 

Founded in 1931, the National Propane Gas Association (NPGA) is the trade association representing all 

propane industry segments. It is located in Washington, D.C., and affiliated with 38 state and regional 

associations, including the West Virginia Propane Gas Association. 

The NPGA administers CETP throughout the United States. 

 

10 The CSB determined that the National Fire Codes were adopted by the West Virginia State Fire Marshal prior to 

1967, although the exact date is unknown. 
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2.0 Incident Description 

2.1 Events Preceding January 30, 2007 Explosion 

Significant events preceding the January 30, 2007, explosion at the Ghent Little General Store include 

1. 1988 - Southern Sun buys the incident tank and places it in propane service. 

2. Late 1994 - Southern Sun relocates the incident tank from its original installation to the Little General 

Store in Ghent and installs it against the store’s exterior back wall.11

3. 1996 - Ferrellgas buys the Southern Sun propane business and performs a pre-acquisition review of 

the business and operations, including an inspection of some of Southern Sun’s propane systems. 

4. 1996 to 2007 - Ferrellgas drivers fill the incident tank about 14 times per year conducting about 140 

pre-fill inspections. 

5. April and June 2000 – Ferrellgas employees perform two Installation Reviews (Appendix A) on the 

propane system at Little General. 

6. August 2005 – Thompson Gas and Electric Service, Inc. and Appalachian Heating form the business 

ThompsonGas Propane Partners, LLC. 

 

11 At the time of the installation, West Virginia and OSHA required 500-gallon propane tanks to be at least 10 feet 

from buildings; however, Raleigh County had no code enforcement mechanism at that time. 
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7. September 2006 – Appalachian Heating’s only propane service technician (the lead technician at the 

scene of the incident) completes training and becomes fully qualified (in accordance with CETP) to 

install propane tank systems.12

8. Fall 2006 – Little General Store, Inc., begins changing propane suppliers from Ferrellgas to 

ThompsonGas Propane Partners. 

9. December 2006 – Appalachian Heating reassigns an HVAC technician to the propane business (the 

junior technician at the scene of the incident). 

10. January 2007 – The two propane service technicians from Appalachian Heating began installing a 

new Thompson Gas tank and associated equipment at Little General. 

2.2 Day of the Incident 

On the morning of Tuesday, January 30, the two propane service technicians traveled separately to the 

Little General Store. At around 9:15 am, witnesses observed both of their trucks at the store. According 

to Appalachian Heating, the day’s work plan was to transfer the propane from the existing Ferrellgas tank 

to the newly installed Thompson tank and place the new propane system in service. 

By 9:30 am the lead technician had left the store to make a delivery 31 miles northwest of Little General; 

the junior technician remained alone at the store. For the next hour, the junior technician worked alone 

while he prepared to transfer propane from the Ferrellgas tank to the Thompson tank. 

 

12 Thompson trained the lead technician on sections 1, 2, and 4 of CETP. The lead technician also spent nearly a full 

year working with experienced personnel from multiple Thompson offices. 
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Around 10:25 am, the junior technician removed a plug13 from the liquid withdrawal valve (Figure 3) on 

the Ferrellgas tank. When he removed the plug, liquid propane unexpectedly began spraying from the 

valve. 

Figure 3. Liquid withdrawal valve. 

At 10:28 am, the junior technician called14 the lead technician, who was still offsite, to report the problem. 

In response, at 10:31 am, the lead technician called Thompson technical support for guidance. After the 

call to technical support, the lead technician called the junior technician twice, most likely to relay the 

guidance from technical support and to encourage him to call 911. 

 

13 The valve plug has two functions: to prevent a propane leak if the valve seat leaks and to prevent foreign 

materials’ entering the valve mechanism. The withdrawal valve itself is spring-loaded and self-closing and should 

not leak; however, if it does, a telltale hole drilled through the threaded portion of the plug sprays a small amount 

of propane giving an early warning of a malfunction prior to completely removing the plug. 

14 All telephone calls discussed throughout this report were from cellular phones. 

Plug 

Valve Body 

Valve sealing disk and washer 
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A deliveryman in the store at about 10:30 am told the CSB that he smelled a strong odor and that the store 

employees’ eyes were watering. The Little General cashier, concerned about the odor, went outside to 

check on the junior technician. The cashier told the CSB that she saw him standing between the tank and 

his service truck within a dense vapor cloud,15 but that he told her he was “okay.” 

At 10:40 am, the junior technician called 911 to summon help from emergency services (see transcript in 

Appendix B). He reported to the 911 operator that he had a leaking propane tank at the Little General in 

Ghent and needed the fire department’s assistance to secure the area. The 911 operator collected this 

information, clarified the location, and ended the call. 

After the 911 call, the junior technician called the lead technician again. The cashier checked on the 

junior technician a second time, finding him in the same location between the tank and truck. Figure 4 is 

an event timeline prior to the lead technician’s return. 

 

15 Propane is a colorless gas. A liquid release from a tank forms a dense white cloud of visible propane liquid 

droplets that then evaporate. 
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Figure 4. Timeline of initial events 

2.3 Response to the Propane Release 

After the junior technician’s call, Raleigh County Emergency Services dispatched the Ghent Volunteer 

Fire Department to the Little General (Appendix B). 

The first to arrive, at about 10:47 am,16 was a captain from the Ghent Volunteer Fire Department. The 

captain assumed the role of incident commander (IC) in accordance with Ghent Volunteer Fire 

Department guidelines.17

 

16 As no record of precisely what time the captain arrived at the scene exists, the CSB estimated it from other known 

events. 

17 Although functioning in accordance with the Ghent Volunteer Fire Department guidelines, the captain had no 

formal incident command training and did not establish command in accordance with NIMS. 
Little General Store September 2008 

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Shortly thereafter, two EMTs arrived in an ambulance. The surviving EMT told investigators that he saw 

the IC at the store’s front door when he arrived. According to the Little General store manager, the IC 

had ordered the business to close.18

The IC asked the EMTs to follow him behind the building to treat the junior technician for a burn on his 

forearm. The EMTs examined the junior technician and determined that the burn was frostbite likely 

from the releasing liquid propane. 

Following the medical examination, the IC sent the EMTs to the front of the store to ensure that the 

business had closed, gasoline was not being pumped, and no one was smoking. One EMT walked to the 

store entrance and found it locked; however, he was able to speak to the Little General employees inside 

to confirm that the business was closed. The Little General employees had hung a small sign on the door 

to inform customers that the store was closed due to a gas leak. The EMT positioned himself in the 

parking lot and proceeded to direct traffic and customers away from the property. 

Just after 10:50 am, the lead technician returned to the store. He parked in front of the building and 

walked to the area of the tanks. 

A firefighter arrived in his personal vehicle to assist with the emergency and checked in with the IC. The 

firefighter saw the IC and the two technicians working around the leaking tank; he could hear the 

escaping propane. The IC ordered him to “make sure everybody’s out, okay?” However, as the 

firefighter began walking to the front of the store, the propane ignited and exploded. 

 

18 When ordered to close, the Little General employees turned off the gasoline pumps, locked the doors, and 

remained in the building. 
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The explosion killed four near the tanks (the two technicians, the IC, and one EMT). The four workers 

inside the building and the firefighter survived but sustained serious injuries. The EMT, who was 

directing traffic and customers, suffered an arm injury. 

The explosion leveled the building, destroyed a Ghent Volunteer Fire Department ambulance (cover 

photograph), and damaged many parked vehicles. The force of the blast threw the Ferrellgas tank about 

80 feet and the Thompson tank about 50 feet. Figure 5 is an event timeline of the initial emergency 

response. 

Figure 5. Timeline of incident response. 
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3.0 Propane Incident Frequency 

3.1 United States Hazardous Materials Incidents 2001 – 2006 

The National Fire Incident Reporting System (NFIRS) is the United States Fire Administration’s database 

of fire and emergency incidents. The CSB reviewed the NFIRS database for the years 2001 to 2006 to 

determine the frequency with which United States fire departments responded to propane incidents. 

In this six-year period, the NFIRS database includes 36,744 hazardous materials responses in the United 

States.19 Of these responses, 35.3 percent were responses to releases of gasoline, natural gas, or propane. 

Incidents involving propane occur nearly once per day. 

Table 1. U.S. hazardous materials incidents 2001-2006. 

 Gasoline

Natural 

Gas Propane

Total 

hazardous 

materials 

incidents 

2001 658 468 157 4154 

2002 817 627 210 4661 

2003 1084 830 263 5904 

2004 1149 863 234 6307 

2005 1423 1151 301 8301 

2006 1406 997 317 7417 

Total 6537 4936 1482 36,744 

 

19 As not all states require participation in NFIRS data collection, the total number of hazardous materials responses 

may not be exhaustive; however, the CSB and the U.S. Fire Administration consider the types of responses 

representative of the United States as a whole. 
Little General Store September 2008 

21

3.2 Recent Propane Incidents 

Since the explosion in Ghent, several similar propane release incidents have occurred in the United States. 

The CSB researched five incidents similar to the Little General incident (see Appendix C). 

Three incidents involved only propane releases and two involved releases and flash fires. In the three 

release-only incidents, both firefighters and propane service technicians responded. A propane service 

technician secured one of the incident tanks, and firefighters trained in hazardous materials response 

secured the other two. No injuries occurred in these incidents. 

The two incidents involving releases and flash fires both occurred at sites where propane service 

technicians were involved in tank-to-tank transfers of liquid propane. In these cases, fire departments 

responded, and in both incidents destroyed the structures located nearest the propane tanks. One flash fire 

injured a person onsite. The other killed one propane service technician and severely injured two others. 

Firefighters, propane service technicians, or both regularly respond to propane release incidents. The 

successful mitigation of a release depends on the training and experience of both groups. 

Additionally, shortly before the Ghent incident, a liquid propane release and explosion occurred at the 

Falk Corporation facility in Milwaukee, Wisconsin on December 6, 2006. Employees discovered a pool 

of liquid propane near a propane pipeline. Most employees began evacuating; three remained to attempt 

to repair the leak. About 10 minutes after the pool of propane had been discovered, it ignited, killing the 

three employees and injuring over 40 others. OSHA cited Falk and its piping contractor for failing to 

prepare employees for emergencies involving liquid propane. 
Little General Store September 2008 

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4.0 Propane System Fundamentals 

4.1 Propane Properties 

Propane is used extensively as a fuel for cooking and heating in residential, retail, and commercial 

applications.20 It is a gas at ambient temperature and pressure but is transported and stored as a liquid. 

Propane-air mixtures can be explosive when the atmospheric concentration of propane is between 2.4 and 

9.5 percent by volume. Because propane is odorless and colorless, small quantities of an odorizing 

chemical (ethyl mercaptan) are added so leaks can be detected by smell. 

Unlike natural gas, propane is heavier than air. Consequently, propane releases tend to accumulate at 

ground level or in other low points such as pits and basements. 

4.2 System Features 

The propane system at Little General consisted of a stationary 500-gallon storage tank (Figure 6) and two 

supply regulators to reduce the pressure of the propane for pizza ovens used in the store. The storage tank 

had five connections: 

1. A fill connection fitted with an internal check valve; 

2. A liquid level gage to measure the quantity of propane in the tank; 

3. A relief valve (safety device) to prevent over-pressurization of the tank; 

4. A service valve to supply gaseous propane to the regulators; and 
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5. A liquid withdrawal valve fitted to an internal dip tube for removing liquid propane when necessary. 

Figure 6. Typical ASME propane tank. 

The liquid withdrawal valve incorporated several safety features: 

1. A threaded valve plug to protect the valve from foreign material and provide a secondary seal if the 

primary valve were to leak. 

2. A telltale in the threaded area on the valve plug. The telltale is exposed before the plug is completely 

removed. The telltale releases propane if the primary valve leaks allowing a propane service 

technician to check for valve leaks before completely removing the plug. 

3. A special connector that, when screwed on, opens the valve. 

 

20 According to PERC, about 17.5 million U.S. households use propane as a heating or cooking fuel, excluding 

grills. About 3,500 companies market propane around the country. 
Little General Store September 2008 

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4. An excess flow disk in the valve to limit flow should flow exceed a preset limit, such as during a hose 

rupture. 

4.3 Propane Standards 

4.3.1 Occupational Safety and Health Administration 

The OSHA standard Storage and Handling of Liquefied Petroleum Gases21 establishes specific 

requirements for most workplaces22 storing and handling liquefied petroleum gases (LP gases)23, 

including propane. 

The standard’s requirements include, but are not limited to, design, operation, technician training, safety 

devices, and tank placement. A 500-gallon tank, like the one at Little General, must be located at least 10 

feet from buildings. 

4.3.2 NFPA Propane Standards 

Two NFPA standards address propane: the National Fuel Gas Code (NFPA 54), which applies to fixed 

gas-consuming (including propane) equipment attached to piping, and the Liquefied Petroleum Gas Code

(NFPA 58), which applies to the storage, handling, transportation, and use of LP gas. NFPA 58 Chapter 6 

addresses installing LP gas systems, including requirements for tank locations. NFPA 58 also requires a 

500-gallon tank to be at least 10 feet from commercial and residential buildings. 

 

21 29 CFR 1910.110. 

22 Little General is covered by OSHA’s occupational safety and health standards. 

23 Liquefied petroleum gas is the general term for mixtures of hydrocarbon gases liquefied by pressure and used for 

cooking, heating, and vehicle fuel. Liquefied petroleum gas can be propane, butane, propylene, butylene or any 

mixture of these compounds. 
Little General Store September 2008 

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4.4 Propane Emergency Guidance 

4.4.1 Guidance for Consumers 

Propane companies (including Ferrellgas and Thompson), NPGA, and PERC distribute literature and 

publish information on their websites guiding consumers on actions to take during propane emergencies 

such as leaks and releases. If consumers detect a propane leak, this guidance recommends that they: 

• Extinguish smoking materials and discontinue the use of lights, appliances, phones, or any electrical or 

spark producing device. 

• Evacuate the area or building immediately. 

• If possible, turn off the gas supply at the tank or cylinder. 

• Go to a neighbor’s house and call the propane company or 911. 

• Stay out of the area or building where the leak was detected. 

4.4.2 Guidance for Emergency Responders 

Propane Emergencies, published for the NPGA and PERC, is the primary text for training emergency 

responders to handle propane emergencies. The textbook outlines a process wherein the IC should 

perform a series of actions prior to attempting remediation of the propane emergency. The first step the 

textbook specifies is site control; it states that the IC must keep all responders and members of the public 

clear of the hazard until the scene and the hazard are fully understood. 

The US DOT Emergency Response Guidebook recommends an immediate evacuation to at least 330 feet 

in all directions and 1⁄2-mile downwind for large spills. Responders are cautioned to keep all members of 
Little General Store September 2008 

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the public away from the area surrounding the point of the release. In addition, the Guidebook states that 

propane gas is heavier than air and may settle in low or confined areas. 
Little General Store September 2008 

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5.0 Incident and Emergency Response Analysis 

5.1 Liquid Withdrawal Valve 

Liquid withdrawal valves are rarely used. Technicians only open them when tanks must be completely 

emptied of liquid. The liquid withdrawal valves on most propane tanks may never be used. At Little 

General, the day of the incident was either the first or the second time that the plug had been removed 

from the liquid withdrawal valve in the tank’s 19 years of propane service. 

When the junior technician removed the plug from the liquid withdrawal valve, liquid propane released 

uncontrollably. The plug, though, has a telltale drilled through the threaded portion (Figure 7) which 

should have released a small stream of propane once the plug was partially backed out. This should have 

alerted the technician that the valve was leaking. 

Figure 7. Incident valve plug (Telltale circled). 
Little General Store September 2008 

28

The CSB determined that the junior technician likely was unaware of the existence and function of the 

telltale due to inexperience and lack of training and removed the plug completely. Although the CSB 

determined that it is highly unlikely the telltale hole was obstructed at the time of the incident, CETP 

training could have made the junior technician aware of and prepared for the possibility of an obstruction 

of the telltale. The CETP section on liquid withdrawal valves states: 

In some cases, a damaged seat may allow an excessive amount of liquid to be discharged when 

the closing cap [plug]24 is loosened. A bleed hole [telltale] in the closing cap has been provided 

to vent the liquid before the cap is completely unscrewed. If a significant amount of liquid 

continues to be blown from under the closing cap for more than 30 seconds, it can be assumed 

that the internal seat will not prevent a dangerous amount of gas from escaping. IF IN DOUBT, 

DO NOT REMOVE THE CLOSING CAP. [CETP 2.2.13] 

In addition to the information on the valve above, the CETP procedure for transferring liquid propane 

from a tank to a truck states:25

While removing the plug, if an excessive volume of propane leaks from the valve, reinstall the 

plug and follow manufacturer’s instructions. [CETP 2.2.13] 

The CSB initially tested and examined the tank and valve in its “as-found” condition. The CSB 

determined that the liquid withdrawal valve leaked when the tank was pressurized.26 Following this 

examination and test, the CSB removed the valve from the tank, performed additional examinations and 

 

24 Plug (external threads) closures are no longer used with liquid withdrawal valves; therefore CETP refers only to 

cap (internal threads) closures. 

25 CETP contains step-by-step procedures for liquid propane transfer from a stationary tank to a tank truck. Liquid 

propane transfer from a stationary tank to a second stationary tank is not described in CETP. 

26 Nitrogen was used to pressurize the tank since it is inert and allowed this test to be conducted safely. 
Little General Store September 2008 

29

tests, and partially disassembled the valve. The CSB found the valve jammed, likely because of a 

manufacturing defect,27 and the valve seal cracked (Figure 8). With the valve jammed in an open 

position, only the plug stopped the liquid propane from escaping. When the junior technician removed 

the plug, propane began uncontrollably releasing. Cracks in the seal material likely prevented the excess 

flow feature from limiting the release. 

Figure 8. Crack in valve seal. 

 

27 A hole bored through the center of the lower guide through which the valve stem moves was determined to be too 

small for the valve stem to move freely. 
Little General Store September 2008 

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5.2 Propane Tank Placement 

In 1994, Southern Sun installed the 500-gallon propane tank directly against the Little General store’s 

exterior back wall. The tank remained in this position and in operation until the day of the incident. The 

position of the tank was contrary to both the West Virginia Fire Code and the OSHA LP gas standard. 

Figure 9 shows a 2003 photograph of the building with the propane tank visible behind a wooden fence. 

Photo courtesy of Little General Store, Inc. 

Figure 9. Pre-incident photograph of the Ferrellgas tank. 

Multiple witnesses told the CSB that Southern Sun placed the tank against the back wall. Paint patterns 

on the tank corroborate this: the outward facing side of the tank was painted with the Ferrellgas color and 

logo, while the side of the tank facing the building was painted with the Southern Sun name and logo 

(Figure 10). This suggests that Ferrellgas painted only the side of the tank that was accessible. 
Little General Store September 2008 

31

Figure 10. Incident tank side facing building. 

During the release, witnesses described seeing billowing white clouds striking the building and roof 

overhang and cascading toward the ground, which is consistent with the known behavior of propane 

vapor following a liquid release. The peaked roof of the store overhung the exterior walls. The overhang 

was open to allow ventilation in the store’s attic space; restroom exhaust ducts terminated inside the 

overhang directly above the incident tank. The open overhang and restroom exhaust ducts provided a 

direct pathway for propane to enter the building. The CSB found that if the tank were placed at least 10 

feet from the store, propane likely would not have entered the store in large quantities. 

5.2.1 Southern Sun Acquisition 

Ferrellgas’ acquisition of Southern Sun included a pre-acquisition review of Southern Sun’s business and 

operations, which included inspections of propane systems at select Southern Sun customer locations. In 

addition, Ferrellgas was allowed to identify and request correction of any deficiencies discovered in the 

year following the acquisition. According to Southern Sun, only two propane tanks were returned, both 
Little General Store September 2008 

32

because of illegible or missing tank nameplates. Ferrellgas first filled the tank at the Little General soon 

after the acquisition, and did not identify the tank placement as deficient.28

5.2.2 Ferrellgas Inspection and Quality Review Program 

5.2.2.1 Ferrellgas Inspections 

The Ferrellgas inspection program for propane systems at customer locations consists of two separate 

activities: the driver’s pre-fill inspection, where delivery personnel visually inspect the system and the 

Ferrellgas Installation Review (FIR), where an experienced service technician visually inspects the 

system and records the findings. 

1) Drivers’ Pre-Fill Inspection 

Drivers perform pre-fill inspections prior to each propane delivery at a customer location. This visual 

inspection includes the tank, visible piping, regulators, and the area around the tank. Ferrellgas trains 

drivers to inspect the installation for potential deficiencies such as tank damage or corrosion, 

accumulations of combustible materials near the tank, fitness of piping and regulators, tank placement and 

new structures near the tank, and tank labeling. The driver does not record the results of the pre-fill 

inspection, but does have the authority to remove the system from service upon finding unsafe conditions. 

The driver must also report unsafe conditions to management so that a service technician can fix any 

noted problems. Ferrellgas training materials for delivery drivers discuss tank placement and clearly state 

that 500-gallon propane tanks must be at least 10 feet from buildings. 

 

28 The week prior to the incident, Appalachian Heating had also replaced another Ferrellgas tank that was placed less 

than 10 feet from a different Little General Store location. 
Little General Store September 2008 

33

Ferrellgas filled the tank at Little General Store about 14 times per year; in the 10 years that Ferrellgas 

owned the tank, drivers would have performed more than 100 pre-fill inspections. The CSB interviewed 

several drivers who filled the Little General tank and performed the required inspections. All drivers 

stated that they believed the tank was permitted to be directly against the building’s exterior back wall 

either because it was “grandfathered,”29 the installer had received a variance from local authorities,30 or 

there was no other place to install the tank. 

2) Ferrellgas Installation Review 

The Ferrellgas Installation Review (FIR)31 is a visual inspection of the installation at a customer’s site. 

The FIR includes the same topics as the driver’s pre-fill inspection; however, the inspector records the 

results either on a form or handheld computer. The service center receives the results of the FIR, records 

deficiencies, and dispatches service technicians to repair noted problems. 

Ferrellgas performed two FIRs on the Little General Store installation in 2000, four years after acquiring 

the tank (Appendix A). These inspections were two months apart; neither inspector noted the placement 

of the tank on the form.32 Both inspectors told CSB that they could remember neither the inspections nor 

the reasons for not reporting the tank’s placement in the FIR. 

 

29 They believed that the tank installation predated the 10-foot clearance requirement, and was permitted to remain 

next to the building under some previous set of rules. 

30 Local authorities issue formal waivers from code requirements such as the tank placement distances, which are 

known as variances. Ferrellgas training materials reference the possibility of obtaining a variance from local 

authorities; however, a variance was not issued for the placement of the tank at Little General. 

31 Ferrellgas called this inspection program the FIR during the time it owned the incident tank. The review has been 

renamed and is now called the Product Installation Review. The methodology for inspection has not changed. 

32 Checking the location of an installed tank is step one in the FIR procedures, which states that tanks that do not 

meet the 10-foot placement requirement must have a written variance from local authorities. 
Little General Store September 2008 

34

5.2.2.2 Ferrellgas Quality Review Program 

Ferrellgas’s Quality Review program33 comprises two annual internal audits; each reviews safety and 

quality at a Ferrellgas service center location. Each service center’s general manager (SCGM) conducts 

one audit (the SCGM audit), and a regional technical analyst conducts the other (the regional technical 

analyst audit). 

1. Service Center General Manager’s Audit 

Since 2005, Ferrellgas has required its SCGM to perform quarterly audits of his service center. Each 

SCGM uses a standard checklist-based procedure to audit specific segments of the business according to 

the following schedule: 

• First Quarter: Administration, including delivery, installation, and training documentation, operating 

procedures, and inspection results; 

• Second Quarter: Plant operations, including piping, tanks, system and container integrity, and operator 

proficiency; 

• Third Quarter: Delivery operations, including delivery trucks’ integrity and roadworthiness, and driver 

proficiency; and 

• Fourth Quarter: Customer installations, including inspection of 10 old and 10 new systems.34 

 

33 The Quality Review program is independent of the FIR and the driver’s pre-fill inspection. Neither audit is 

scheduled to coincide with a system installation or propane delivery. 

34 New installations might be placed by Ferrellgas during the year or be acquired by buying other preexisting 

propane systems. 
Little General Store September 2008 

35

The CSB requested all SCGM audits from the Princeton and Beckley, West Virginia, service centers for 

the 10 years preceding the incident. Ferrellgas provided SCGM audits from 2005 and 2006 but provided 

no documentation of any customer installation audits. 

2. Regional Technical Analyst Audit 

At least once annually, regional technical analysts (known as operations managers prior to 2005) conduct 

compliance and safety audits at Ferrellgas service centers in their respective regions. The audit is similar 

to the SCGM quarterly audit in that the technical analyst examines delivery operations, administration, 

plant operations, and customer installations, using a checklist to guide the audit and record the results. 

The only apparent difference is that the technical analyst performs all four segments of the audit within 

one to two days and the SCGM examines one segment per quarter. 

5.2.3 Ferrellgas Inspection and Quality Review Program Analysis 

At least six Ferrellgas delivery drivers and service technicians were in a position to identify and report the 

incorrect placement of the tank behind Little General; none did. Although Ferrellgas training materials 

discuss correct tank placement and list tank placement as an inspection criterion for which drivers and 

technicians may remove tanks from service, the employees who filled and inspected the tank believed that 

its location was approved.35 

The SCGM customer installation audits for the Beckley and Princeton offices were likely not conducted.36 

Had managers performed these audits, it is still possible that because of the sampling methods used they 

 

35 All Ferrellgas drivers and technicians reported to the CSB that they had received training in accordance with 

Ferrellgas procedures. 

36 Ferrellgas was unable to provide any documentation of customer installation audits for the ten years preceding the 

incident. 
Little General Store September 2008 

36

would not have detected the improper installation at Little General. Ferrellgas’ instructions on 

conducting audits merely recommend SCGMs inspect customer installations that were filled on the day 

prior to the review or inspect those that the manager is driving past. These methods of sampling provide 

no way to systematically review all installations over time. 

SCGMs’ and regional technical analysts’ audits focus primarily on identifying and correcting deficiencies 

at facilities and customer locations. Only those installations that are spot-checked during the quality 

review are corrected; therefore broader systemic problems may remain undetected. In contrast, generally 

recognized and accepted practices for auditing safety management systems focus on assessing and 

verifying system effectiveness.37 These practices include using statistical sampling, trend analysis, 

management system review, and corrective action to detect systemic problems and ensure ongoing hazard 

control throughout the organization.38 

5.3 Propane Service Technician Training and Response 

5.3.1 Propane Service Technician Training 

5.3.1.1 Federal and State Training Requirements 

The United States Department of Transportation (DOT) and OSHA regulations have limited propane 

service technician training requirements. DOT requires training only for propane personnel who engage 

in transportation activities. OSHA requires training for propane service technicians but does not elaborate 

on this requirement (Section 6.1). 

 

37 Standard safety texts describe audits as systematic, independent reviews that determine conformance to company 

and industry standards whereas inspections are physical inspection of installations and facilities. 

38 CCPS, 1993; Petersen, D., 1996; Weinstein, M.B., 1997 
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37

Some form of state-mandated training and/or testing requirement for propane service technicians exists in 

14 states, and 10 of those have specific training requirements; however, the depth of training required 

varies broadly. No states require emergency response training for propane service technicians. 

Three states require licensing for propane service technicians. States use licensing to establish and 

enforce minimum competency standards for technicians; collect funds for inspection, compliance, and 

training programs; and communicate technician qualifications to consumers. In the states that license 

propane service technicians, CETP is an accepted training program. Additionally, at least 10 states have 

licensing programs applicable to propane and natural gas appliance installers. Recurrent licensing 

requirements, based on state-established standards of training, testing, and/or experience, aim to ensure 

that only qualified personnel work on indoor propane and natural gas systems. 

West Virginia does not require propane service technicians to be trained, certified, or licensed. Appendix 

D contains a table of the state requirements.39

5.3.1.2 NFPA 58 Training Recommendations 

NFPA 58 recommends training for propane industry employees who perform activities within its scope, 

which includes those who transport and transfer LP gas. The standard states that these employees “shall 

be trained in proper handling procedures. Refresher training must occur at least every 3 years. The 

training shall be documented.”40 An appendix note states that refresher training may be less intensive 

than original training. However, NFPA 58 does not elaborate on what constitutes initial training. It 

includes no guidance suggesting a scope, timeframe, or testing component for facilitating an enforceable 

training standard for states that have adopted NFPA 58, including West Virginia. 

 

39 Information on state training requirements was provided to the CSB by PERC. 

40 NFPA 58 – 2008 Section 4.4 “Qualifications of Personnel.” 
Little General Store September 2008 

38

5.3.1.3 Propane Industry Training Program 

PERC and the NPGA developed its comprehensive training curriculum for propane industry employees, 

CETP, in 1988. Although CETP is voluntary in most states, many employers in the propane industry use 

it to train and certify employees. PERC offers the task-based modular curriculum both in instructor-led 

settings and as a computerized self-teaching program, and sells course materials to employers for inhouse training and preparation for CETP certification tests. 

CETP consists of eight modules. Applicable training modules include 

• Propane “basics,” including properties of propane, industry standards and organizations, bulk 

plant and delivery vehicle identification, safe work practices, and reacting to interruptions of 

customer gas service; 

• Propane delivery, including equipment and operating procedures, loading and unloading, 

inspecting delivery trucks and installed propane systems, responding to customer calls, and 

evacuating propane tanks; and 

• Propane vapor distribution system installation, including transporting tanks and cylinders, 

installing aboveground and underground tanks, installing regulators and piping, performing leak 

checks, documenting installations, and communicating safety information to customers. 

Employers may select topics as appropriate to address job tasks for individual employees, who may then 

take certification exams in those areas for which they have completed training. For example, customer 

service representatives often complete the propane basics module, and delivery drivers complete the 
Little General Store September 2008 

39

propane basics and propane delivery modules. Companies may also augment the curriculum to include 

company-specific policies and information.41 

An important part of the CETP curriculum is its skills testing component. The training program itemizes 

basic propane procedures; within 12 months of passing the CETP certification exam, certification 

candidates must demonstrate these procedures and be evaluated. The CETP curriculum includes skills 

assessment forms; a trainer or other supervisor with sufficient experience must observe a certification 

candidate perform or simulate procedures correctly, document performance evaluations for each set of 

procedures, and forward the documentation to PERC before the candidate is certified to work alone. 

The junior technician at Little General was preparing for a tank-to-tank transfer of liquid propane. 

Although a CETP module provides step-by-step procedures for liquid transfers to and from bulk delivery 

trucks, such procedures do not exist for tank-to-tank transfers. While some propane companies may 

develop their own instructions for this task, the junior technician had no written procedure for his 

activities on the day of the incident. 

5.3.1.4 Propane Service Technician Emergency Response Training 

A propane incident involving fire department response occurs nearly once per day in the United States 

(see Table 1). The CSB found that propane service technicians routinely respond to these emergencies. 

When the lead technician returned to the Little General store in response to the emergency, he was 

functioning as a specialist responder, with expertise in propane and propane systems. By the time he 

arrived, a hazardous materials release had been underway for at least 20 minutes. However, his training 

had not included an emergency response component. 

 

41 PERC offers the Safety and Training Administrative Records System (STARS), a computer-based program for 

record keeping and training management, which also allows employers to add their own policies to modules. 
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40

The CSB found a number of other incidents in which propane service technicians assisted first responders 

in emergencies involving their companies’ equipment and product. First responders consider propane 

service technicians to be “product and container specialists” who have more experience dealing with 

propane and its systems than firefighters, police, paramedics, and EMTs.42 Although propane service 

technicians are not trained to take action to mitigate a hazardous materials emergency without specific 

training,43 emergency responders often seek their advice and assistance. 

PERC and the NPGA provide a Propane Emergencies training curriculum for first responders that 

addresses the role of propane service technicians in the incident command structure (see Section 5.3). 

However, CETP only briefly addresses emergencies at bulk plants and traffic accidents involving delivery 

vehicles. No CETP module specifically addresses the potential emergencies service technicians 

encounter or the basics of hazardous materials incident response. 

5.3.2 Thompson Gas/Appalachian Heating Employee Training 

Thompson Gas Propane Partners, LLC required all propane service technicians to be CETP-trained to the 

appropriate level for their jobs. The 2005 contract with Appalachian Heating defines responsibilities, 

including employee training: Appalachian is responsible for ensuring that all employees working with 

propane are qualified “as defined in NFPA 54 and 58” and CETP-trained for their particular jobs. The 

specific requirements include completion of CETP 1.0, Basic Principles and Practices, within 30 calendar 

days of first working for Appalachian/Thompson, and completion of other applicable modules within one 

year. Additionally, Appalachian Heating must maintain all training records and certifications, provide 

ongoing training, and update the staff list for Thompson Gas before any new employees begin working. 

 

42 Propane Emergencies, PERC and NPGA, 3rd edition, page 44. 

43 HAZWOPER Standard, 29 CFR 1910.120(q). 
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41

Thompson provided CETP training for Appalachian’s lead technician in 2006, including the basic 

principles, delivery, and vapor distribution system installation modules. Experienced Thompson trainers 

directly supervised his performance of propane service and delivery tasks for nearly a year. This was 

combined with the CETP classroom training to ensure that he was able to demonstrate proficiency and 

pass certification examinations prior to working unsupervised. 

The junior technician began working in the propane business in mid-December, about 45 days prior to the 

incident. However, Appalachian did not inform Thompson of the new employee. At the time of the 

incident the junior technician had not trained with CETP and had not received any other formal propane 

service training. 

Had Appalachian Heating implemented the training procedures required by the contract, the junior 

technician would have, via CETP, become familiar with a range of procedures and situations that might 

occur in the course of working with propane including operation of the liquid withdrawal valve. 

5.4 Fire Department Response 

The IC arrived at the Little General store shortly after the initial dispatch call. In the approximately five 

minutes from his arrival until the explosion at 10:53 am, the IC took several actions. He: 

• Assessed the frostbite injury to the junior technician; 

• Ordered the business to close; 

• Directed the EMTs to the rear of the building to treat the junior technician’s frostbite; 

• Ordered the EMTs to ensure that the business was closed, that no one was smoking, and that no 

gasoline was being pumped; and 

• Ordered the firefighter to ensure that everyone was out of the building. 
Little General Store September 2008 

42

Guidance for emergency responders in hazardous materials emergencies recommends evacuating and 

evaluating the situation from a safe distance as the first task. However, the IC’s final direction, to ensure 

that everyone was out of the building, came too late. Within about 30 seconds of the order, the propane 

ignited and the building exploded. 

Based on witness statements and the IC’s known actions, the CSB determined that the IC allowed the 

propane service technician to try to correct the propane release while the IC managed the scene. 

However, the IC was likely unaware of two critical facts: 

• The junior technician, upon whom the IC was relying to correct the release, was neither trained 

nor experienced in propane transfer operations and propane emergencies (Section 5.3). 

• The building was filling with a flammable mixture of propane and air. While the IC was 

concerned with ignition sources outside such as cigarettes and vehicles, ignition sources inside 

the building remained uncontrolled during the release. 

Without knowledge of these facts, the IC was likely unable to fully understand the severity of the 

emergency at Little General, even though he was fully trained in accordance with the rules of the West 

Virginia Fire Commission. 

5.4.1 Hazardous Materials Incident Training for Firefighters 

West Virginia requires all firefighters to receive basic training in hazardous materials incident response. 

This training is required prior to working as a firefighter and therefore is generally conducted only once, 
Little General Store September 2008 

43

early in a firefighter’s career. In contrast, chemical facilities and refineries in the United States that 

maintain hazardous materials response teams are required to train team members annually.44

The required hazardous materials incident response training teaches firefighters to identify hazardous 

materials and incidents involving hazardous materials, use DOT’s Emergency Response Guidebook, and 

recognize when additional resources are necessary. The training instructs firefighters to take only 

defensive actions when encountering a hazardous materials incident; it does not give firefighters the 

knowledge or skills to enter the area of the release and attempt to stop the release. This action is reserved 

for organized hazardous materials response teams. 

The IC at Little General attended a hazardous materials incident response course in 1998. This was a 

higher-level course than required (see Section 6.3 for requirements), and included topics such as incident 

risk assessment, selection of personal protective equipment, and control techniques, and a practical 

exercise. However, this training occurred nine years before the Little General incident, and the CSB 

found no documentation that the IC had attended refresher training or practical exercises. Unrehearsed 

knowledge decays over time; hazardous materials incident response skills acquired in training are more 

difficult to retain without regular refresher training or practice.45 

5.4.2 Propane Industry Training for Emergency Responders 

The Propane Emergencies training program offered by PERC and the NPGA is free to fire departments 

around the United States. The program trains first responders to recognize the specific hazards of a 

 

44 29 CFR 1910.120 requires industrial hazardous materials incident responders to attend eight hours of refresher 

training annually. 

45 For a full discussion of skill loss, see Arthur Jr., W., Bennett Jr., W., Stanush, P., & McNelly, T. (1998). “Factors 

That Influence Skill Decay and Retention: A Quantitative Review and Analysis,” Human Performance, Vol. 11, 

pp. 57-101. 
Little General Store September 2008 

44

propane release and treat it as a hazardous materials incident. It emphasizes the importance of evacuating 

the incident area and evaluating the hazards from a safe distance prior to taking other actions. 

Additionally, it addresses incident command structure implementation and the advisory role of propane 

service technicians. None of the Ghent Volunteer Firefighters had participated in this program. 

5.5 911 Emergency Call Center Response 

At many 911 call centers around the United States, operators use quick-reference guide cards to help them 

evaluate caller emergencies, gather pertinent incident details, and convey life-saving information to 

callers. Several organizations in the United States produce pre-written guide cards for 911 centers to 

purchase.46 These guide cards provide easy-to-access information for operators, including questions 

relevant to the emergency and instructions to be given to the caller prior to emergency services’ arrival. 

Specific sets of guide cards exist for health and injury, fire service, and police response emergencies. 

Raleigh County 911 uses guide cards for health emergencies and injuries only. 

At 10:40 am on the day of the incident, the propane service technician called Raleigh County 911 to 

report the release and summon emergency services. The operator who received the call did not have a 

guide card or protocol to help evaluate the situation, collect pertinent information, and provide guidance 

to the caller. 

 

46 Guide cards are available as printed or electronic references and kept at each operator’s station. 
Little General Store September 2008 

45

The propane industry developed a model questionnaire and script to use in situations where customers 

report propane emergencies such as leaks or releases. The questionnaire prompts personnel answering 

calls to ask questions such as 

• Where is the leak? 

• Do you hear gas escaping? 

• Is the leak near any building? 

• Is there an odor of gas in the building? 

An affirmative answer to these and other questions prompts the gas company operator to read a script that 

instructs the caller to eliminate ignition sources, evacuate the building to a safe distance, and wait for gas 

professionals or fire service personnel. 

Equipping 911 operators with such a prewritten guide can potentially improve safety by initiating 

important first response actions such as evacuation. 
Little General Store September 2008 

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6.0 Regulatory Analysis 

6.1 Occupational Safety and Health Administration 

The OSHA standard regulating propane systems requires that all personnel “performing installation, 

removal, operation, and maintenance of propane equipment shall be properly trained in such function.”47 

However, neither the standard, its preamble, nor letters of interpretation define or interpret “properly 

trained,” nor does it provide for specific training standards, requirements for recurrent training, written 

testing, or skills testing. OSHA only requires employers to develop training programs they deem 

appropriate without providing any performance criteria such as those under the industry’s program. 

Additionally, the OSHA standard requires that owners of propane tank(s) be notified prior to work being 

done on their tank(s) by others.48 Although Appalachian Heating employees removed the liquid 

withdrawal valve plug from the Ferrellgas tank, Appalachian Heating did not notify Ferrellgas. 

6.2 Environmental Protection Agency 

Firefighters and emergency medical personnel are typically the first responders to hazardous materials 

spills and releases, like the incident at Little General. However, in 26 states (including West Virginia), 

state and municipal employees are not covered by the OSHA health and safety regulations that require 

first responder hazardous materials training.49 In an attempt to close the gap, the U.S. Environmental 

Protection Agency (EPA) promulgated the Worker Protection standard (Appendix E)50 for municipal and 

state emergency responders. 

 

47 29 CFR 1910.110(b)(16). 

48 29 CFR 1910.110(b)(14)(ii). 

49 See CSB Report No. 2006-03-I-FL “Bethune Point Wastewater Treatment Plant” for a full discussion. 

5040 CFR 311. 
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The Worker Protection standard requires states and municipalities to prepare employees for hazardous 

materials emergencies in accordance with OSHA’s Hazardous Waste Operations and Emergency 

Response standard.51 The standard’s requirements apply to career and volunteer fire companies, and 

public emergency medical response agencies. The United States Fire Administration and PERC52 both 

cite the Worker Protection standard in their incident response training courses for firefighters. The rules 

for firefighters and emergency medical personnel in West Virginia, however, do not specifically 

incorporate the EPA requirements under the Worker Protection standard. 

6.3 West Virginia Fire Commission 

The primary role of the Fire Commission in West Virginia is the promulgation of the state fire code and 

certification requirements for fire departments. 

6.3.1 Requirements for Fire Departments53

The West Virginia Fire Commission certifies fire departments every five years based on 

• location, size and boundaries of the fire protection district; 

• number of active and available personnel and their level of training; 

• quantity and type of equipment; 

• administrative procedures and policies including chain-of-command; 

 

51 29 CFR 1910.120 – Hazardous Waste Operations and Emergency Response generally requires employers to 

develop emergency response and health and safety plans that address worker training, preparedness, and health 

monitoring. The regulation applies to both long-term hazardous waste clean-up operations in addition to 

emergency response for incidents involving any hazardous material (not limited to hazardous wastes). The 

standard requires initial training and annual refresher training. 

52 Propane Emergencies, 3rd ed., p. 41. 

53WVC 29-3-2. 
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• 911 service and mutual aid agreements for the area served; 

• the department’s record of response to emergency calls; and 

• recordkeeping and NFIRS reporting.54

On April 1, 2005, the Fire Commission published an administrative policy to assist it in its evaluation of 

fire departments.55 The policy addresses certifying and training active personnel in fire departments, 

requiring them to attend Firefighter Level I, first aid, cardio-pulmonary resuscitation (CPR), and 

hazardous materials response training. 

The Fire Commission’s policy specifically requires the following for hazardous materials response: 

Fire department members and officers shall be trained in NFPA Standard No. 472, Professional 

Competence of Responders to Hazardous Materials Incidents.

56 All Fire Department personnel 

shall be certified at the Awareness level. Fire Department personnel that operate at hazardous 

materials incidents must minimally meet U.S. Environmental Protection Agency and U.S. 

Occupational Safety and Health Administration requirements for response at the Operations level. 

Additional training should be at the discretion of the fire chief based on possible involvement 

with hazardous materials incidents unless otherwise directed by federal or state statutes, rules 

and/or regulations. [WVC 29-3-9(i)] 

Unlike requirements for industrial hazardous materials incident responders, this Fire Commission 

requirement does not specifically address recurrent training. All active industrial hazardous materials 

 

54 The criteria are located in WVR 87-6-5. 

55 The administrative policy is found at WVC 29-3-9(i). 

56 NFPA 472 was renamed the Standard for Competence of Responders to Hazardous Materials/Weapons of Mass 

Destruction Incidents in the 2008 revision. 
Little General Store September 2008 

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responders in the United States are required to undergo an annual refresher course. Yet firefighters, who 

are likely to respond to many incidents involving gasoline, natural gas, or propane—all hazardous 

materials—in any given year, are not specifically required by the West Virginia Code to complete an 

annual refresher course or perform regular response drills. As discussed in Section 5.4, the IC in the 

Ghent incident had not trained for or practiced hazardous materials emergency response in almost 10 

years. 

6.3.2 West Virginia Fire Code 

West Virginia has a comprehensive statewide fire code.57 The fire code incorporates, by reference, the 

majority of the NFPA’s standards and guides. Incorporated standards include NFPA 472, which addresses 

response to hazardous materials incidents. NFPA 472 defines the levels of response to hazardous 

materials incidents—awareness, operations, technician, incident commander, and specialist employee—

and outlines basic expectations for responders at each level. 

The NFPA’s definition of awareness level personnel is consistent with OSHA’s definition:58 awareness 

level personnel are those who, during the course of their normal job functions, could encounter 

emergencies involving hazardous materials. These persons must be able to recognize hazardous materials 

emergencies, protect themselves, call for trained assistance, and secure the area.59 Awareness level would 

apply to propane service technicians like the junior technician at Little General when the release began, 

since they may encounter propane emergencies during the course of their duties. 

Operations level personnel respond to already-discovered hazardous materials incidents, taking actions to 

protect people, the environment, and property from the effects of the release. They are qualified to take 

 

57 West Virginia Rule Title 87 Series 1 Fire Code. 

58 29 CFR 1910.120 

59 NFPA 472 Chapter 4 
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defensive actions to mitigate the damage caused by a hazardous materials incident, but not to actively 

handle or attempt to contain the hazardous material(s). This type of action might include assessing the 

scene and planning a response, establishing evacuation perimeters, setting up communications, and 

initiating the incident command system. The operations level designation applies to anyone arriving at 

the scene in response to a hazardous materials emergency; in Ghent, the lead technician, the EMTs, and 

the fire department personnel acted at an operations level by arriving at the Little General in response to 

the junior technician’s phone call. 

Hazardous materials technicians, in contrast, are those qualified to take defensive and offensive actions in 

response to an incident. Offensive actions entail entering the incident “hot zone” to attempt to control a 

release, and require additional training beyond the operations level.60 Additionally, hazardous materials 

responders may seek the help of specialists: industry employees familiar with and trained in the hazards 

and systems of a given material, like propane. Specialist employees must also meet specific NFPA 472 

competencies to be qualified to perform release control actions. Propane service employees who assist 

emergency responders physically secure releases must meet at least these competencies. Although the 

evidence and witness statements indicate that the Appalachian Heating employees and Ghent Volunteer 

Fire Department personnel were standing in the vapor cloud and attempting stop the release, none were 

trained to the technician or specialist level.

 

60 Technician level training corresponds to 29 CFR 1910.120 40-hour HAZWOPER training. 
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7.0 Findings 

1. The propane service technicians, emergency responders, and store employees did not evacuate the 

area as recommended by nationally accepted guidance for propane emergencies. In fact, emergency 

responders and the propane service technicians were observed standing in the propane vapor cloud. 

2. Propane companies, the National Propane Gas Association, and the U.S. Department of 

Transportation recommend evacuation to a safe distance as the first action in response to a propane 

release. 

3. The fire department captain, the propane service technicians, and the Little General Store employees 

were unaware of the dangerous propane accumulation inside the building. 

4. A defect in the existing tank’s liquid withdrawal valve caused it to malfunction and remain in an open 

position. 

5. About 25 minutes elapsed from the time the release began until the explosion. 

6. Both the U.S. Occupational Safety and Health Administration’s and the West Virginia Fire 

Commission’s propane standards require a distance of at least 10 feet between 500-gallon propane 

tanks and buildings such as the Little General Store. However, when the Southern Sun propane 

company installed the propane tank in 1994 it was placed directly against the Little General Store’s 

exterior back wall. 

7. Ferrellgas, which acquired Southern Sun in 1996, allowed the tank to remain against the building’s 

exterior wall for more than 10 years. 

8. The placement of the 500-gallon propane tank against the building’s exterior wall provided propane a 

direct pathway into the store’s interior during the release. 

9. Ferrellgas management’s quality review program functions as a basic safety inspection rather than a 

management systems audit. 
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10. The junior propane service technician who was servicing to the tank on the day of the incident had no 

formal training and did not recognize the defect in the withdrawal valve. He was also working alone 

even though he had been on the job for only one and a half months. 

11. Propane service technicians commonly do not receive emergency response training. 

12. The propane industry’s primary training curriculum (the Certified Employee Training Program) 

consists of procedures and materials for performing routine (non-emergency) tasks only. 

13. The Occupational Safety and Health Administration’s and National Fire Protection Association’s 

propane standards require training but do not include curricula, practical exercises, emergency 

actions, or knowledge evaluation tools. 

14. A propane emergency significant enough for fire department response is reported nearly everyday in 

the United States. Only gasoline and natural gas are involved in more hazardous materials 

emergencies. 

15. 911 operators in the United States lack propane emergency guidance to help them collect important 

information from callers, offer life-saving advice, and convey relevant information to first responders. 

16. Minimal information on the nature of the incident was exchanged between the propane service 

technician and the 911 operator. Therefore, the only information the 911 operator provided the Ghent 

Volunteer Fire Department responders was the incident location and the “report of a propane leak.” 

17. Firefighters in West Virginia are required to attend a minimum of four hours of hazardous materials 

emergency response training as part of their initial training sequence but refresher training is not 

required. The responding Ghent Volunteer Fire Department captain last attended a hazardous 

materials response course in 1998. 

18. Propane safety and emergency training is voluntary for fire department personnel in West Virginia. 

None of the responders from the Ghent Volunteer Fire Department had specific training relating to 

propane emergencies. 
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8.0 Causes 

1. The Ferrellgas inspection and audit program did not identify the tank location as a hazard. 

Consequently, the tank remained against the building for more than 10 years. 

2. Appalachian Heating did not formally train the junior technician, and on the day of the incident he 

was working alone. 

3. Emergency responders were not trained to recognize the need for immediate evacuation during liquid 

propane releases. 
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9.0 Recommendations 

Governor and Legislature of the State of West Virginia 

2007-04-I-WV-R1 

Require training and qualification of individuals who operate bulk propane plants, dispense and deliver 

propane, install and service propane systems, and install propane appliances. The training and 

qualification requirements should be comparable to those of existing propane industry programs such as 

the Certified Employee Training Program. 

West Virginia Fire Commission 

2007-04-I-WV-R2 

Revise the Fire Commission rules and codes to require annual hazardous materials response refresher 

training for all firefighters in West Virginia. 

2007-04-I-WV-R3 

Revise the Fire Commission rules and codes to require that all West Virginia fire departments perform at 

least one hazardous material response drill annually. 

West Virginia Office of Emergency Medical Services 

2007-04-I-WV-R4 

Revise the Office of Emergency Medical Services rules and codes to require annual hazardous materials 

response refresher training for all emergency medical personnel in West Virginia. 
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National Fire Protection Association 

2007-04-I-WV-R5

In the Liquefied Petroleum Gas Code (NFPA 58) “Qualifications for Personnel” section, specify training 

requirements (including supervised on-the-job training), training curricula, competencies, and testing 

through written examination and performance evaluation, or reference a nationally recognized curriculum 

for these requirements. 

Association of Public-Safety Communications Officials 

2007-04-I-WV-R6

Develop a guide card for propane emergencies to assist 911 operators in the collection of pertinent 

information on propane emergencies. The questionnaire in Section 1.9.1 in the Propane Education and 

Research Council’s Certified Employee Training Program may be used as a model. 

Propane Education and Research Council 

2007-04-I-WV-R7

Revise the Certified Employee Training Program to include 

• Procedures for transfer of liquid propane from tank to tank, or 

• The prohibition of the transfer of liquid propane from tank to tank.

2007-04-I-WV-R8

Revise the Certified Employee Training Program to include emergency response guidance for propane 

service technicians who respond to propane emergencies similar to guidance provided to emergency 

responders in the Propane Emergencies program. 
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56

National Propane Gas Association 

2007-04-I-WV-R9

Submit a request to the United States Occupational Safety and Health Administration for a letter of 

interpretation to determine if the Certified Employee Training Program curriculum meets the training 

requirements in 29 CFR 1910.110. 

2007-04-I-WV-R10

Work with the West Virginia E911 Council with development of propane emergency guidance by 

providing the Council with the customer leak questionnaire located in Section 1.9.1 of the Certified 

Employee Training Program and technical assistance. 

West Virginia E911 Council 

2007-04-I-WV-R11

Work with the National Propane Gas Association to develop and distribute propane emergency guidance 

for use by all county and municipal 911 communication centers in West Virginia. 
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Ferrellgas 

2007-04-I-WV-R12

Establish and implement a comprehensive safety management system that includes at a minimum: 

• An auditing program developed in accordance with generally accepted methodologies to 

monitor the performance and effectiveness of safety management systems and personnel 

at all levels,

• An inspection program that uses NFPA 58 as a guide to systematically inspect all 

customer propane systems and identify all deficiencies,

• A means of tracking audits and inspections and identified deficiencies,

• A means of tracking corrective actions,

• A means of collecting and using audit and inspection data for trend analysis and 

organizational learning,

• A means of periodically reporting audit and inspection trends to the Board of Directors 

and Managing Board, and

• A provision for periodic safety management system audits conducted by a third party 

competent in the requirements of NFPA 58.
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By the 

U.S. Chemical Safety and Hazard Investigation Board 

John S. Bresland 

Chair 

Gary Visscher 

Member 

William Wark 

Member 

William Wright 

Member 

Date of Board Approval 
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References 

Center for Chemical Process Safety (CCPS), 1993. Guidelines for Auditing Process Safety Management 

Systems, American Institute of Chemical Engineers (AIChE). 

Ferrellgas Partners, L.P., 2006. US SEC Form 10-K – Annual Report Pursuant to Section 13 or 15(d) of 

the Securities Exchange Act of 1934. 

Hildebrand, M.S., and G. G. Noll, 2007. Propane Emergencies,3rd ed., National Propane Gas Association 

(NPGA) and Propane Education & Research Council (PERC). 

Lemoff, T. C., ed., 1998. LP-Gas Code Handbook (5th edition), National Fire Protection Association 

(NFPA). 

National Fire Protection Association (NFPA), 2008a. Liquefied Petroleum Gas Code, NFPA 58. 

NFPA, 2008b. National Fuel Gas Code, NFPA 54. 

NFPA, 2008c. Standard for Competence of Responders to Hazardous Materials/Weapons of Mass 

Destruction Incidents, NFPA 472. 

Occupational Safety and Health Administration (OSHA), 2007. Storage and Handling of Liquefied 

Petroleum Gases, 29 CFR 1910.110, OSHA. 

Petersen, D., 1996. Analyzing Safety System Effectiveness, Third Edition, John Wiley & Sons, Inc. 

Raleigh County Emergency Services Agency, 2006. Raleigh County Emergency Operations Plan (EOP). 

West Virginia Fire Commission, 2004. State Fire Code, Title 87 Series 1 (87CSR1), West Virginia 

Legislative Rules. 

Weinstein, M.B., 1997. Total Quality Safety Management and Auditing, Lewis Publishers. 

West Virginia Legislature, 2007. Fire Prevention and Control Act, Chapter 29 Article 3 (WVR 29-3), 

West Virginia Code. 
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Appendix A 

Ferrellgas Installation Reviews of the Incident Tank
Little General Store September 2008 

61
Little General Store September 2008 

62
Little General Store September 2008 

63

Appendix B 

911 Call and Initial Fire Department Dispatch 
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Emergency 911 Call – Report of Release 

AUTOMATED VOICE: Conversation recorded on January 30th, 2007, at 10:40, on Channel 7. 

DISPATCHER: 9-1-1, where is your emergency? 

CALLER: Yes, ma'am. I need to -- I need a fire department down at the Little General Store in Ghent. I 

need a -- I got a propane leak -- I need their help to secure the area. 

DISPATCHER: A propane leak? 

CALLER: Yes, ma'am. 

DISPATCHER: What's the address? Is that the one on Odd Road? 

CALLER: No, ma'am. It's the one actually on, uh -- the one going towards Shady Springs. With the 

Godfather's Pizza. 

DISPATCHER: Do you know the address? 

CALLER: No, I don't, ma'am. Right in front of Flat Top Lake. 

DISPATCHER: Flat Top Lake. 

CALLER: Yes, ma'am. 

DISPATCHER: And this is Little General, right? 

CALLER: Yes, ma'am. 

DISPATCHER: And this is a propane leak? What is your name? 
Little General Store September 2008 

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CALLER: XXXXXXXXXXXXX;1

 I work for Appalachian Heating; we've had a dysfunction in the 

tanks, and I have a leaky tank. 

DISPATCHER: Okay. All right, I'll get the fire department out there for you. 

CALLER: Thank you. Bye-bye. 

DISPATCHER: Thank you. 

Emergency Dispatch – Initial Dispatch Notification to Ghent 

Volunteer Fire Department 

AUTOMATED VOICE: Conversation recorded on January 30th, 2007, at 10:43, on Channel 21. (Fire 

tones.) 

DISPATCHER: Raleigh Control, Station 110 -- Station 110 -- you need to respond to Flat Top Road in 

Ghent, the Little General, across from Flat Top Lake; report of a propane leak. Repeating, Station 110, 

need units to respond to Flat Top Road at the Little General, report of a propane leak. WGC808, 10:44. 

 

1

 Name removed. 
Little General Store September 2008 

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Appendix C 

Recent Propane Incidents 
Little General Store September 2008 

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Recent Propane Incidents 

CSB identified the following incidents for further research based on their similarity to the Little General 

incident. The CSB interviewed the propane companies, emergency responders, and local investigators 

involved in these incidents to collect relevant information. The CSB did not conduct an independent 

investigation. 

1.0 Propane Release Incidents 

1.1 Aberdeen, Washington 

1.1.1 Incident Description 

On October 23, 2007, the Southshore Mall in Aberdeen, Washington, was evacuated due to a vapor 

release from a 1,150-gallon propane tank. The tank was located in a utility yard approximately 25 feet 

from the mall restaurants for which it supplied heat and fuel. Shortly after 2:00 pm, a mall employee 

heard a “pop” and, upon going outside to investigate, discovered the leaking tank. The fire department 

responded, evacuated the mall, and isolated the scene. 

The fire department called the propane company that owned the tank for incident support. The company 

sent one service technician to assist the fire department. The responding technician found the release was 

from the tank’s fill valve, which had become stuck partially open. The technician installed a doublecheck valve on the leaking fill valve to stop the release. The fire department lifted the evacuation order 

by 2:45 pm. 

1.1.2 Incident Responders 

The propane company involved in this incident reported having a preexisting working relationship with 

the fire department. All the propane company’s employees train on job procedures with CETP and 
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practice emergency response scenarios. The service technician who was sent to assist the fire department 

had both CETP training on all propane service and delivery procedures and on-the-job experience as a 

service technician and a delivery driver. 

In emergency response cases like this one, the fire department is in charge of the scene, with the gas 

company employees on the scene to assist and advise the fire department as necessary. Occasionally, 

propane service technicians responding at the request of a fire department take offensive steps to stop a 

release—in this case, by installing a valve. The fire department’s decision to allow the propane service 

technician to repair the tank was different from the Ghent incident in several important ways: 

• The fire department had evacuated and secured the scene prior to the technician’s entry. 

• The vapor release from the leaking fill valve was much less severe than the liquid propane release 

in Ghent, requiring only a small repair for the tank to remain in service safely. 

• The technician was CETP-certified and experienced, had drilled on emergency response 

scenarios, and had previously worked with the fire department on propane incidents. 

When emergency responders and service technicians have clearly established and rehearsed roles in an 

incident command structure, both groups are better equipped to implement their training. 

1.2 Lynchburg, Virginia 

1.2.1 Incident Description 

At about 1:00 pm on November 26, 2007, a traffic accident caused a vehicle to crash into a 1,000-gallon 

propane tank used for filling cylinders, located outside of a True Value Hardware store in Lynchburg, 

Virginia. When the vehicle struck the tank, the inch-and-a-half liquid line connecting a pump and the 

tank was severed. The tank settled on top of the severed pipe, which in turn prevented the excess-flow 

valve from seating, resulting in a liquid propane release. Hardware store employees called 911 and the 
Little General Store September 2008 

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propane company that owned the tank. Although the 911 operator dispatched the hazardous materials 

response team to the incident as a gas leak, a citizen driving past called the team to clarify that it was a 

propane release. 

The team arrived and secured the area, evacuating shoppers from the rear of the hardware store on foot. 

Since the valve could not be repaired, the response team used water spray to disperse the vapor cloud 

formed by the liquid release, while keeping the area evacuated. Once most of the propane in the tank had 

been released, the response team approached the tank and used a strap to completely seal it. They then 

loaded the sealed tank onto a truck for removal from the area. The release lasted two hours. 

Propane service technicians from the company that owned the tank also responded. They arrived after the 

hazardous materials response team, and attempted to approach the tank. Response team members 

removed the technicians to the incident command post, outside of the release area. 

1.2.2 Incident Responders 

The responding hazardous materials team is an all-career unit, with all members trained to technician 

level (40-hour) training, which qualifies them to take offensive action in response to releases. According 

to responders, propane incidents occur frequently in the area; although most involve residential propane 

cylinders, the hazmat team has responded to several major incidents. As a result of the prevalence of 

propane in the area, its hazards are a focus in training sessions. With this training, responders were able 

to quickly assess the uncontrolled release and evacuate the area. 

All propane service technicians at the company that owned the tank, a small locally owned business, 

receive CETP training. Additionally, the company has trained with the fire department in CETP 

procedures to help emergency responders understand propane systems. However, the CETP program has 

no emergency response component, and propane service technicians do not train with responders the 

incident command system or other aspects of hazmat response. As in Ghent, propane service technicians 
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attempted to take an active role in release mitigation without hazardous materials or emergency response 

training. However, unlike Ghent, fire department responders in this incident were trained and 

experienced in the hazards of propane releases, and evacuated everyone, including technicians, from the 

area. 

1.3 Bristow, Virginia 

1.3.1 Incident Description 

On May 19, 2008, the Linton Hall School in Bristow, Virginia, was evacuated due to a vapor release from 

a 500-gallon propane tank. The tank was located 15 to 20 feet from the school, near the cafeteria kitchen. 

At about 11:20 am, a trash truck backed into a chain connecting the tank to a light pole,

1

 overturning the tank and shearing off its service valve, causing a propane vapor release. School 

administrators called 911 and the propane company that owned the tank, and evacuated the 205 students 

and 30 faculty members according to routine fire drill procedures. 

The 911 operator who received the call dispatched the county fire department to the incident as an outside 

gas leak. The first responding fire engine company arrived on scene, assessed the situation, and revised 

the call to an inside gas leak due to the tank’s proximity to the school kitchen and water heater, 

dispatching the hazardous materials response team.2

 When the team arrived, it sprayed water in a fog 

pattern to push released vapor down and away from the school, then used a wooden dowel and a towel to 

plug the leak. Propane service technicians from the company that owns the tank arrived after the team 

had secured the release and moved the tank to a large open parking lot away from the school to repair the 

 

1

 A “No Parking” sign hung from the chain. 

2

 The dispatching system in this county requires the hazardous materials unit to respond to all interior gas leaks. 
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valve. No one was injured. Students remained at a church across the street until parents arrived to take 

them home. 

1.3.2 Incident Responders 

The hazardous materials team involved in this incident has responded to several propane incidents in the 

last year, all of which have been vapor releases. They receive technical information from propane service 

technicians, but take release mitigation actions themselves. To protect propane service technicians from 

entering the release area, the team uses methods including 

• taking digital photographs of tank damage so that technicians can see and assess the damage on a 

remote laptop computer, 

• bringing similar tanks or other equipment to the scene so that technicians can point out features 

the team will find on the incident tank, and 

• escorting technicians to the edge of the secured release area to point out potential leak sources for 

team members. 

Additionally, the hazardous materials response team trains local 911 operators to use follow-up questions 

to elicit needed information from callers reporting hazardous materials incidents. In this incident, as in 

Ghent, the 911 operator conveyed little information to the fire department. However, unlike Ghent 

responders, the first fire engine company to arrive immediately recognized the danger posed by the 

release’s proximity to a building and called for hazardous materials backup. 

The propane service technicians responding to this incident were branch employees of a national propane 

company that uses CETP. In the event of a propane emergency, whichever technicians are working 

nearest the incident stop work immediately and respond. Since these responders are all trained with 

CETP, they are familiar with what types of incidents they can mitigate using normal propane procedures. 
Little General Store September 2008 

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In this case, propane service technicians attempted to repair the tank only after the fire department had 

secured it and removed it from nearby buildings. 

2.0 Propane Release and Fire Incidents 

2.1 Sallis, Mississippi 

2.1.1 Incident Description 

On May 13, 2007, a propane explosion occurred at the Longhorn’s Steak House in Sallis, Mississippi, 

while the restaurant was closed and two propane service technicians were transferring propane from an 

old 500-gallon tank into a new 500-gallon tank behind the building. The transfer procedure had been 

completed and the new tank was leak-tested and placed in service. The technicians next planned to 

remove the old tank (which still contained some propane) from the premises, but were unable to load it 

onto the service truck. They left and returned later in the day with a trailer. As the technicians were 

loading the old tank onto the trailer, it slid to one side, severing a valve at the bottom of the tank. The 

technicians heard a loud noise and saw liquid propane releasing from the bottom of the tank and forming 

a vapor cloud along the ground. They immediately ran toward the front of the building; the propane 

reached an unknown ignition source and a flash fire occurred seconds later. Another person who was 

near the front door of the restaurant at the time was badly burned in the flash fire. The building and a 

pickup truck parked in front were destroyed. Local volunteer fire departments responded, and the 

Mississippi State Fire Marshal’s office investigated. 

2.1.2 Incident Responders 

The propane service technicians were from a local propane company. Although they had already 

completed a tank-to-tank transfer without incident, they immediately realized the danger of a liquid 

propane release from the damaged tank. Since the propane reached an ignition source only seconds after 
Little General Store September 2008 

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the release began, the technicians were unable to evacuate the person in front of the restaurant before the 

flash fire. Both reported to investigators that they had attempted to do so. 

Local firefighters responded and reported the incident as a structure fire. The county sheriff’s department 

informed the State Fire Marshal’s Office that propane was involved, and LP Gas Division investigators 

completed the state’s report. 

2.2 Danville, Alabama 

2.2.1 Incident Description 

On May 20, 2008, three propane service technicians were attempting to perform a tank-to-tank transfer of 

liquid propane at a farm in Danville, Alabama, when a propane vapor release caused a flash fire. A 

1,000-gallon propane tank at a chicken house was reported by property owners to be leaking around the 

pressure relief valve. Technicians were to replace the half-full tank with a new tank and transfer the 

remaining propane. 

The technicians removed the leaking tank from its installed location and placed it to the side, then set the 

new tank in its place. Employees next used the service truck boom to suspend the leaking tank upside 

down and at an angle, near the new tank. They planned to use the filler valve to evacuate the old tank, 

hooking it to a hose with a filler valve adaptor. However, damage to the filler valve caused it to stick in 

an open position and release propane vapor. The vapor reached the service truck, idling near the transfer 

location, and ignited setting fire to the chicken house. 

The town’s volunteer fire department was dispatched to a structure fire. When firefighters arrived, they 

discovered that the fire was due to a propane release. The firefighters then moved the three injured 

technicians away from the fire, used water to cool the propane tank, and approached the tank in full 

protective equipment to attempt to close the valve. They discovered that the valve had been sheared off 

entirely and withdrew, continuing to contain the fire to prevent it from reaching other propane tanks 
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located 25 to 30 feet away. The firefighters called for the nearest hazardous materials response team to 

assist them in using thermal imaging to determine how much propane remained in the tanks. The incident 

tank was empty; no other tanks released. The chicken house was destroyed. All three propane service 

technicians were severely burned; one died in hospital. 

2.2.2 Incident Responders 

The volunteer firefighters in Danville are all trained using the Propane Emergencies curriculum, which is 

offered through the state fire college as a two-day program. The fire chief requires that they complete the 

program twice before responding to propane incidents. This training includes practice on controlled 

propane releases and fires, and allows the fire department to mitigate propane emergencies without 

relying on propane companies. If firefighters cannot contain a release, they may let propane service 

technicians work on the tank, but only if no fire is involved and the area has been secured. 
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Appendix D 

Table of State Training, Testing, and Licensing Requirements 

for Propane Service Technicians 
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For Propane Service Technicians, this state 

Arkansas 

Alabama 

Colorado 

Florida 

Iowa 

Maine 

Maryland 

Michigan 

Missouri 

Nebraska 

New Jersey 

Requires training x x x x x x x x x Requires testing x x x x x x Requires recurrent training x* x x x x Accepts CETP x x x x x x Requires CETP† x† x x† x x Requires License x x x 

* Only safety training required on a recurrent basis † CETP or equivalent training required
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Appendix E 

United States EPA - 40 CFR 311 
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311.1 Scope and application. 

The substantive provisions found at 29 CFR 1910.120 on and after March 6, 1990, and before March 6, 

1990, found at 54 FR 9317 (March 6, 1989), apply to State and local government employees engaged in 

hazardous waste operations, as defined in 29 CFR 1910.120(a), in States that do not have a State plan 

approved under section 18 of the Occupational Safety and Health Act of 1970. 

311.2 Definition of employee. 

Employee in Sec. 311.1 is defined as a compensated or noncompensated worker who is controlled 

directly by a State or local government, as contrasted to an independent contractor.