Operational impact · Financial exposure
BreachCalc
Loading sector assumptions…
INCIDENT LAB / 01 · CHANGE MANAGEMENT
A new pipe.
An old dependency.
Merrimack Valley, Massachusetts · September 13, 2018
Follow the change that broke a pressure feedback loop.
Loading narration…
Solid line: gas supply · dashed line: sensing connection.
Schematic animation; no measured pressure, exact timing, or geographic scale.
STAGE 1 / 5
The hidden dependency
Evidence, scope & full narration
Historical record: During a main replacement, sensing lines remained on the retired pipe. Depressurizing that pipe caused regulators to open fully, overpressurizing the active network. The NTSB identified management and oversight failures and inadequate overpressure protection. One person died, 22 people were transported to hospitals, and 131 structures were damaged.
Training alternative: The verified-change path assumes a hold point, verified sensing relocation and a review of independent protection. It illustrates a barrier to this failure mechanism; it does not quantify avoided loss or reconstruct an actual successful intervention. Animation timing is compressed. No physical pressure calculations, restoration forecasts or incident cost estimates are used.
Drawings, dependencies, cross-team review and field verification are change-review prompts, not field operating instructions. The financial calculator below remains a separate model.
- NTSB · findings and documented consequences
- NTSB · final report PAR-19/02
- Northeast Gas Association · management-of-change lessons
Research accessed October 12, 2026.
Read all narration
Loading calculator…
Saved scenarios
Saving, sharing and PDF export require an active license. Public calculations remain available offline.