On September 13, 2018 at approximately 4:00 PM EDT a series of emergency calls were received by 911 operators working the Lawrence and North Andover region of Massachusetts. The calls ranged from smells of "natural gas" to actual fires to actual explosions (at least five recorded). A low pressure natural gas supply system (0.5 psig) "over-pressurized" by at least one order of magnitude. Approximately 8,600 customers were affected. Of these, 131 customers had some type of "extended over pressure event" such as a release of natural gas within their basement. This is a 1.5% failure rate on systems that should have been in place when over pressure occur. Unfortunately, this 1.5% failure rate translated into multi-million dollar loss for the gas company, and the disruption of quality of life for 8600 residents, 100's of whom were displaced over six months as their homes were rebuilt. One year later, full recovery is still in progress for the area. The root cause traces back to a failed "management of change" system. With proper a hazard analysis/safety review and communication, this event could have been prevented or even mitigated.
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