February 2026 PSMS Lesson Learned

Incorrect Valve Operation Leads to Supply Interruption

API 1173 aligns closely with the lessons learned from this incident by emphasizing training, communication, record accuracy, and risk-based situational awareness. The misinterpretation of valve data, lack of adequate task-specific training, and failure to follow standards, polices, and administrative controls (SPAC) requirements reflect API 1173’s requirements for competency development, refresher training, and ensuring personnel understand risks and system procedures. These elements correspond to API expectations for maintaining proper training records and fostering communication routines that ensure employees verify information and proactively identify hazards.

The lessons learned regarding incomplete records, missing valve labeling, and the need for safety stops when field conditions conflict with system data map directly to API 1173’s Risk Management, Operational Controls, and Data & Records Management elements. API 1173 stresses accurate documentation, proper asset identification, and ensuring personnel possess the awareness to recognize abnormal conditions and take corrective action. These align with the identified gaps—such as inaccurate service routing information and unmarked valve and reinforce the corrective actions to improve labeling, update records, and strengthen situational awareness expectations.

Description of Event:

An employee arrived at the job location to lock off a curb valve due to lack of access for a service line inspection. While attempting to locate and operate the curb valve, the employee mistakenly operated a main line valve. This action resulted in an unplanned gas supply interruption affecting 19 services on a dead-end.

Key Causal Factors/Root Causes:

• Primary Causal Factor: The employee misinterpreted documented curb valve measurements within the mapping system, resulting in incorrect valve identification and operation.
  • Root Causes: Insufficient training on job specific task, Management System – Standards, Policies, or Admin Controls (SPAC) Not Used – Communication of SPAC Needs Improvement (NI)
• Causal Factor: There was no documentation indicating that the service entered the building through an adjacent address (the building had two storefronts).
  • Root Cause: Management System – SPAC NI – Drawings/Prints NI
• Causal Factor: The main valve that was operated lacked identifying markings.
  • Root Cause: Management System – SPAC NI – Not Strict Enough

Key Corrective Actions:

• Learning & Development (L&D) to revise current valve training provided during new-hire, progression, and Annual Expert Training (AET) to include detailed instruction on interpreting geographic measurements and interpreting mapping records.
• Develop and implement an annual virtual instructor-led training (VILT) on valve identification and mapping system measurements, expanding annual expert training to additional technicians that help distinguish line valve and service valve identification similarities and differences.
• Reinforce the requirement for communication with appropriate personnel prior to operating any valve.
• Reinforce expectations with contractors that all new main installations must include properly installed valve boxes corresponding to associated main valves.
• Update valve inspection procedure to clearly define approved valve labelling and identification methods.
• Correct and update maps & records for the affected address to accurately reflect service routing and entry information.

Key Lessons Learned:

• Verification of documentation and records is essential prior to operating any valve – trust but verify !

• When field conditions do not match system records, employees must initiate a safety stop, notify supervision, and confirm next steps before proceeding.

• Situational awareness and critical thinking are required when system data conflicts with observed field conditions – don’t let complacency creep into what seems to be a routine operation…….. nothing is “routine” when it comes to safety !!!