NTSB final report on fatal West Reading chocolate factory explosion issued

Yahoo

09-04-2025

Nearly two years after an explosion at a West Reading chocolate factory that claimed the lives of seven workers, the federal agency investigating the blast has issued its final report on the tragedy.
In a report dated March 18 and made public Tuesday, the National Transportation Safety Board confirms the explosion at the R.M. Palmer Co. plant in the first block of South Second Avenue on March 23, 2023, was the result of a natural gas leak.
The final report reiterates the findings of a preliminary report issued in July 2023 as well as during testimony at a public hearing in December.
According to the report, a cracked, out-of-use fitting allowed natural gas to leak into the basement of what was known as Building 2. The gas accumulated there and was ignited by an unknown source, causing an explosion and fire that killed seven workers, injured 10 and destroyed the building.
The plastic fitting, known as a service tee, was installed in 1982. It was retired and capped off by UGI Corp. in 2021 and replaced with a new tee, the report says. However, the old fitting remained connected to the natural gas distribution system.
The old fitting developed cracks due to exposure to high temperatures, largely caused by steam escaping through a nearby pipe, the report says.
The service tee — an Aldyl A service tee with a Delrin insert — was a type commonly used from the late 1960s to the early 1980s. But they were added to the Pipeline and Hazardous Materials Safety Administration's list of materials with 'poor performance histories relative to brittle-like cracking' in September 2007.
The final report lays out a series of safety issues that NTSB officials believe contributed to the fatal blast.
They include the degradation of an out-of-service natural gas service tee, insufficient consideration of threats to pipeline integrity, unmarked private pipelines that crossed public right-of-ways, delayed evacuation of the building, insufficient guidance on gas leak emergency procedures and an absence of natural gas alarms.
The report says Palmer could have done more to prepare employees for a gas leak, and that doing so may have saved lives.
'Although several employees reported smelling the gas in the buildings before the explosion, few evacuated,' the report reads. 'We found that had Palmer implemented natural gas emergency procedures and training before the accident, employees and managers could have responded by immediately evacuating and moving to a safe location.'
The report contains a list of about 20 recommendations directed at various parties ranging from the Pipeline and Hazardous Materials Safety Administration to all 50 states to the Pennsylvania Public Utility Commission to the UGI Corporation to Palmer.
Those recommendations include:
• That the Occupational Safety and Health Administration require employers who use natural gas to implement appropriate safety procedures.
• That all states, Puerto Rico and the District of Columbia require the installation of natural gas alarms in any building in which people congregate that could be affected by a natural gas leak.
• That the Pipeline and Hazardous Materials Safety Administration advise all regulated natural gas distribution pipeline operators to address the risk associated with the fitting that leaked in the Palmer incident.
• That UGI inventory all of its plastic natural gas assets that may be in elevated temperature environments and address the associated risks.
• That Palmer revise its natural gas emergency procedure to direct all employees to immediately evacuate upon smelling natural gas odorant and to specify a safe evacuation location.
In a statement issued Tuesday, officials from Palmer said they are reviewing the NTSB's final report.
'Not a day goes by that we do not remember and reflect on the heartbreaking loss of several colleagues and friends on that tragic day,' it reads. 'We continue to mourn this loss, and our thoughts and prayers are with the families affected by this tragedy.
'R.M. Palmer takes the health, safety and wellness of our employees very seriously and will continue to work tirelessly to ensure the health and safety of our employees and will proactively work with regulators to prevent any similar tragedy in the future.'