# Rupture of Piney Point Oil Pipeline and Release of Fuel Oil

**Citation:** DCA00MP006  
**Type / status:** incident / current  
**Agency:** National Transportation Safety Board  
**Effective:** 2000-04-07  
**Published:** 2026-01-30

Accident. in Chalk Point, MD, USA. on 2000-04-07. Potomac Electric Power Company. Rupture

## Document text

NTSB investigation DCA00MP006.

Event Type: Accident

Event Date: 2000-04-07

Event City: Chalk Point

Event State Or Region: MD

Event Country: USA

Pipeline Operator: Potomac Electric Power Company

Pipeline Type: Hazardous Liquid - Regulated

Accident Type: Rupture

Completion Status: Completed

Report Number: PAR-02-01

Probable cause: The National Transportation Safety Board determines that the probable cause of the April 7, 2000, Piney Point Oil Pipeline accident at the Potomac Electric Power Company?s Chalk Point, Maryland, generating station was a fracture in a buckle in the pipe that was undiscovered because the data from an in-line inspection tool were interpreted inaccurately as representing a T-piece. Contributing to the magnitude of the fuel oil release were inadequate operating procedures and practices for monitoring the flow of fuel oil through the pipeline to ensure timely leak detection.

Tier1Name: System operating

Tier2Name: Product leak/release

Tier1Name: System operating

Tier2Name: Pipe structural malfunction/failure

Finding Tier1Name: Organizational

Finding Tier2Name: Support/oversight/monitoring

Finding Tier3Name: Oversight

Finding Modifier Name: Federal agency

Finding Report Text: Organizational - Support/oversight/monitoring - Oversight - Federal agency

Finding Tier1Name: Organizational

Finding Tier2Name: Development

Finding Tier3Name: Selection/testing

Finding Modifier Name: Inspection organization

Finding Report Text: Organizational - Development - Selection/testing - Inspection organization

Finding Tier1Name: Pipeline

Finding Tier2Name: Pipline systems/equipment

Finding Tier3Name: (general)

Finding Modifier Name: Inadequate inspection

Finding Report Text: Pipeline - Pipline systems/equipment - (general) - Inadequate inspection

Finding Tier1Name: Pipeline

Finding Tier2Name: Pipeline structure

Finding Tier3Name: Pipe

Finding Modifier Name: Failure

Finding Report Text: Pipeline - Pipeline structure - Pipe - Failure

Official NTSB investigation data. NTSB findings determine probable cause and make safety recommendations; they do not adjudicate civil liability or regulatory violations.

What Happened
On the morning of April 7, 2000, the Piney Point Oil Pipeline system, which was owned by the Potomac Electric Power Company, experienced a pipe failure at the Chalk Point Generating Station in southeastern Prince Georgeís County, Maryland. The release was not discovered and addressed by the contract operating company, Support Terminal Services, Inc., until the late afternoon. Approximately 140,400 gallons of fuel oil were released into the surrounding wetlands and Swanson Creek and, subsequently, the Patuxent River as a result of the accident. No injuries were caused by the accident, which cost approximately $71 million for environmental response and clean-up operations.

What We Found
We determined that the probable cause of the April 7, 2000, Piney Point Oil Pipeline accident at the Potomac Electric Power Companyís Chalk Point, Maryland, generating station was a fracture in a buckle in the pipe that was undiscovered because the data from an in-line inspection tool were interpreted inaccurately as representing a T-piece.
Contributing to the magnitude of the fuel oil release were inadequate operating procedures and practices for monitoring the flow of fuel oil through the pipeline to ensure timely leak detection.
This report discusses the following major safety issues:

The sufficiency of the evaluation procedures for pipe wrinkles;
The efficiency of the leak notification procedures; and,
The effectiveness of the incident command.

In addition to these issues, our investigation addressed the leak detection procedures used on the Piney Point Oil Pipeline and the analysis of the pipeline in-line inspection results.

What We Recommended
As a result of this investigation, we made the following new safety recommendations.
To the Research and Special Programs Administration:

Establish quantitative criteria, based on engineering evaluations, for determining whether a wrinkle may be allowed to remain in a pipeline. (P02-01)
Require pipeline owners and operators to provide follow-up telephone updates to the National Response Center when they discover that the information they initially reported contains significant errors or when they identify significant new information directly related to the reporting criteria. (P-02-02)
To the Environmental Protection Agency: Require all your regions to integrate the principles contained in the National Response Team's Technical Assistance Document Incident Command System/Unified CommandóManaging Responses to Oil Discharges and Hazardous Substance Releases under the National Contingency Plan in their area contingency plans and require the regions to train all personnel who are assigned responsibility to implement the plans according to those principles. (P-02-03)

PAR-02-01
<<<PAGE 1>>>

NTSB/PAR-02/01
PB2002-916501
Pipeline Accident Report
Rupture of Piney Point Oil Pipeline
and Release of Fuel Oil
Near Chalk Point, Maryland
April 7, 2000
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National
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Washington, D.C.

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Pipeline Accident Report
Rupture of Piney Point Oil Pipeline
and Release of Fuel Oil
Near Chalk Point, Maryland
April 7, 2000
NTSB/PAR-02/01
PB2002-916501 National Transportation Safety Board
Notation 7285A 490 LíEnfant Plaza, S.W.
Adopted July 23, 2002 Washington, D.C. 20594

<<<PAGE 4>>>

National Transportation Safety Board. 2002. Rupture of Piney Point Oil Pipeline and Release of Fuel
Oil Near Chalk Point, Maryland, April 7, 2000. Pipeline Accident Report NTSB/PAR-02/01.
Washington, DC.
Abstract: On the morning of April 7, 2000, the Piney Point Oil Pipeline system, which was owned by the
Potomac Electric Power Company, experienced a pipe failure at the Chalk Point Generating Station in
southeastern Prince Georgeís County, Maryland. The release was not discovered and addressed by the
contract operating company, Support Terminal Services, Inc., until the late afternoon. Approximately
140,400 gallons of fuel oil were released into the surrounding wetlands and Swanson Creek and,
subsequently, the Patuxent River as a result of the accident. No injuries were caused by the accident, which
cost approximately $71 million for environmental response and clean-up operations.
The safety issues discussed in this report are the sufficiency of the evaluation procedures for pipe wrinkles;
the efficiency of the leak notification procedures; and the effectiveness of the incident command.
As a result of its investigation, the National Transportation Safety Board issued safety recommendations to
the Research and Special Programs Administration and the Environmental Protection Agency.
The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,
pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board
Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study
transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board
makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and
statistical reviews.
Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also
may be obtained from the Web site or by contacting:
National Transportation Safety Board
Public Inquiries Section, RE-51
490 LíEnfant Plaza, S.W.
Washington, D.C. 20594
(800) 877-6799 or (202) 314-6551
Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To
purchase this publication, order report number PB2002-916501 from:
National Technical Information Service
5285 Port Royal Road
Springfield, Virginia 22161
(800) 553-6847 or (703) 605-6000
The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports
related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

<<<PAGE 5>>>

iii Pipeline Accident Report
Contents
Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Accident Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Actions Taken After Pipeline Shutdown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Response to Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Notifying Authorities and Containing Spill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Response to Escape From Containment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Postaccident Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Piney Point Oil Pipeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Pipeline Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Pipeline Maps and Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Pepco Oil Spill Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Office of Pipeline Safety Postaccident Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Pipeline Safety Actions Since Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Incident Command System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Postaccident Assessments of Chalk Point Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
November 2000 Safety Board Hearing on Pipeline Safety . . . . . . . . . . . . . . . . . . . . . . 35
Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Pipeline In-line Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Evaluation of Pipe Wrinkles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Leak Detection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Leak-related Notifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Inaccurate National Response Center Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Limited Involvement of Local Response Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Incident Command . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

<<<PAGE 6>>>

Contents iv Pipeline Accident Report
Appendixes
A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
B: Initial Incident Timeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
C: Significant Events From Leak Recognition to Loss of Containment . . . . . . . . . . . . . . 53
D: Significant Environmental Response and Clean-up Events . . . . . . . . . . . . . . . . . . . . . . 54

<<<PAGE 7>>>

v Pipeline Accident Report
Acronyms and Abbreviations
API -- American Petroleum Institute
CFR -- Code of Federal Regulations
EPA -- Environmental Protection Agency
Mirant -- Mirant Piney Point, LLP
Pepco -- Potomac Electric Power Company
RSPA -- Research and Special Programs Administration
SCADA -- supervisory control and data acquisition
ST Services -- Support Terminal Services, Inc.

<<<PAGE 8>>>

vi Pipeline Accident Report
Executive Summary
On the morning of April 7, 2000, the Piney Point Oil Pipeline system, which was
owned by the Potomac Electric Power Company, experienced a pipe failure at the Chalk
Point Generating Station in southeastern Prince Georgeís County, Maryland. The release
was not discovered and addressed by the contract operating company, Support Terminal
Services, Inc., until the late afternoon. Approximately 140,400 gallons of fuel oil were
released into the surrounding wetlands and Swanson Creek and, subsequently, the
Patuxent River as a result of the accident. No injuries were caused by the accident, which
cost approximately $71 million for environmental response and clean-up operations.
The National Transportation Safety Board determines that the probable cause of
the April 7, 2000, Piney Point Oil Pipeline accident at the Potomac Electric Power
Companyís Chalk Point, Maryland, generating station was a fracture in a buckle in the
pipe that was undiscovered because the data from an in-line inspection tool were
interpreted inaccurately as representing a T-piece. Contributing to the magnitude of the
fuel oil release were inadequate operating procedures and practices for monitoring the
flow of fuel oil through the pipeline to ensure timely leak detection.
This report discusses the following major safety issues:
ï The sufficiency of the evaluation procedures for pipe wrinkles;
ï The efficiency of the leak notification procedures; and,
ï The effectiveness of the incident command.
In addition to these issues, the Safety Boardís investigation addressed the leak
detection procedures used on the Piney Point Oil Pipeline and the analysis of the pipeline
in-line inspection results.
As a result of its investigation of this accident, the Safety Board makes safety
recommendations to the Research and Special Programs Administration and the
Environmental Protection Agency.

<<<PAGE 9>>>

1 Pipeline Accident Report
Factual Information
Accident Synopsis
On the morning of April 7, 2000, the Piney Point Oil Pipeline system, which was
owned by the Potomac Electric Power Company (Pepco), experienced a pipe failure at the
Chalk Point Generating Station in southeastern Prince Georgeís County, Maryland. (See
figure 1 for a map showing the location of the Chalk Point Generating Station and the spill
site.) The release was not discovered and addressed by the contract operating company,
Support Terminal Services, Inc., (ST Services) until the late afternoon. Approximately
140,400 gallons1 of fuel oil were released into the surrounding wetlands and Swanson
Creek and, subsequently, the Patuxent River as a result of the accident. No injuries were
caused by the accident, which cost approximately $71 million for environmental response
and clean-up operations.
The Accident
At the time of the accident, Pepco was the owner of the Piney Point Oil Pipeline
system. ST Services, a limited partnership of the Kaneb Pipe Line Company, operated the
pipeline and performed certain maintenance functions according to the terms of its
contract with Pepco.2 The pipeline was used to deliver heated No. 6 fuel oil from Piney
Point Terminal, in Maryland, through an intermediate station at Ryceville, Maryland, to
Pepcoís power generating stations at either Chalk Point or Morgantown, Maryland. (See
figure 2.)
On April 7, 2000, a pigging operation was being conducted on the pipeline to
prepare the Chalk Point Station to Ryceville Station segment of the pipeline for an in-line
inspection. The pipeline from the Chalk Point Station to the Ryceville Station was started
in the reverse direction of normal flow with flushing oil3 in the system. (See figure 3 for a
schematic of the pipeline.) Employees calculated the amount of oil in the Chalk Point
flushing oil tank and the Ryceville receiving tank before the operation began. As the
operation proceeded, they obtained tank level data that would typically be used to
determine how much oil had been pumped from Chalk Point and how much had been
received by Ryceville.
1 Pipeline operators typically quantify their product using barrels rather than gallons. There are
42 gallons in a barrel.
2 In December 2000, Pepco sold some of its facilities, including the Piney Point Oil Pipeline and the
Chalk Point Generating Station, to Southern Energy, Inc., of Atlanta, Georgia. Southern Energy later became
Mirant Mid-Atlantic of Atlanta, Georgia. Currently, Mirant Piney Point, LLP, (Mirant) is the pipeline owner
and operator.
3 Flushing oil is a mixture of No. 2 and No. 6 fuel oil. No. 6 fuel oil is a thick, black petroleum liquid
that may become solid at cooler temperatures. No. 2 fuel oil is a light, refined petroleum product similar to
diesel fuel.

<<<PAGE 10>>>

Factual Information 2 Pipeline Accident Report
MARYLAND
Rt 301
PRINCE GEORGE'S
COUNTY
Oil Spill Site
CHARLES
COUNTY
Swanson Creek
PEPCO - Chalk Point
Generating Station
CALVERT
COUNTY
Benedict Route 231
ST. MARY'S
COUNTY
Patuxent
River
N
Major Roads
Figure 1. Map of accident site.

<<<PAGE 11>>>

Factual Information 3 Pipeline Accident Report
Waldorf
Oil
Spill
Site
Chalk Point
Station
5
301
La Plata
4
Hughesville
231
Morgantown
Station Ryceville
Station
5
Mechanicsville
301
234
5
235
Newburg
Patuxent River
4
301
Wicomico River
Potomac River
234
235
Leonardtown
5
PEPCO
Piney Point
Oil Pipeline
Valley Lee
Piney Point
Station
5
Figure 2. Locations of Piney Point Oil Pipeline Stations.
At 0715 eastern daylight time, ST Services employees (see figure 4) at the Chalk
Point Station started pumping and launched a cleaning pig. Before this operation began,
the estimated tank level that would indicate completion of the pigging process was
calculated for Chalk Point. The first pig was initially estimated to arrive at the Ryceville
Station 7 hours after it had been launched. Before launching the cleaning pig, the ST
Services Chalk Point operator walked through the tank and pipe manifold area and
measured the actual level4 of the flushing oil tank. Within 15 to 25 minutes, a sizing pig5
was launched to follow the cleaning pig.
The ST Services Chalk Point operator measured the first tank level at 0910. He
passed this information on to the crew at Ryceville, who had the tank volume conversion
tables that were used to determine the volume in the tank and calculate the oil flow rate.
The first tank gauge was read at Ryceville shortly after the crew arrived, about 0837. The
4 An operator obtains precise tank level measurements by climbing to the top of a tank carrying a
weighted tape, which is used to determine the liquid level in the tank.
5 The sizing pig was constructed to 90 percent of the pipelineís internal diameter to verify that the
pipeline did not have any internal restrictions that could damage or restrict the passage of an ultrasonic
inspection tool.

<<<PAGE 12>>>

PEPCO - Piney Point Oil Pipeline
Flushing
Wicomico River Swanson Creek
Oil
Morgantown Chalk Point
Tank
12" Pipeline 12" Pipeline
Flushing
Oil
Tank
Fuel Oil
Pump
Transfer
Station
Ryceville
Transfer Station
Fuel Oil
Pump
Transfer
Station
Flushing
Oil
Tank
Valve Pit #2
Valve Pit #1
Leak
Site
#6
Oil
Tank
#6
Oil
Tank
16" Pipeline
Legend
Water Crossing-
nitrogen operated valves
Manual isolation Valve
Tank
Piney Point
Transfer
Station
ST Services Terminal
Tank Tank
Piney Point
Figure 3. Piney Point Pipeline schematic.
Factual Information 4 Pipeline Accident Report

<<<PAGE 13>>>

ST Services
Senior Vice President, Mid-Atlantic Region
Director of Operations,
East Coast
Terminal Manager
Administrative
ASSISTANT TERMINAL
MANAGER
Traffic Analyst
MAINTENANCE
FOREMAN
PINEY POINT SHIFT SUPERVISORS
(function as PINEY POINT PIPELINE CONTROLLERS)
Plant Mechanics
(function as CHALK POINT AND
RYCEVILLE OPERATORS) Maintenance Workers-
Relief Operators
Operators (10 positions)
Figure 4. Selective organizational chart for ST Services. Positions cited in accident narrative are in boldface and all capitals. (Note:
This chart was developed by the Safety Board for informational purposes. It is not intended to cover the full range of ST Services
positions.)
Factual Information 5 Pipeline Accident Report

<<<PAGE 14>>>

Factual Information 6 Pipeline Accident Report
ST Services Ryceville operator determined that about 1,500 barrels (63,000 gallons) had
been transferred into the Ryceville tank since the pumping started. The ST Services
Ryceville operator kept some notes during the pumping but did not record the time and
tank level information in the station log.
Tank levels were taken at Chalk Point to be used to check the flow rate from the
facility at about 2-hour intervals for most of the pumping operation. The ST Services
Ryceville operator said he read the tank gauge at Ryceville, the receiving station, about
every 1 1/2 hours to determine the volume of product in the Ryceville tank. The operating
personnel did not provide tank volumes to the ST Services Chalk Point operator, and they
did not calculate the line balance6 periodically during the pigging operation. Further, they
did not communicate the tank level information to the ST Services Piney Point pipeline
controller7 when it was obtained.
At 1119, another tank level measurement was made at Chalk Point, and the ST
Services Chalk Point operator passed the information on to the ST Services Ryceville
operator. A few minutes before 1200, the ST Services Chalk Point operator told Ryceville
that the pumping was going well and that the cleaning pig would arrive early, between
1300 and 1330. At the same time, the ST Services Chalk Point operator asked Ryceville
what it was getting for volume received, as he had not had any confirmation on the
product pumped from his station to Ryceville. Ryceville told him the station was working
on it. As a normal check-in, the ST Services Chalk Point operator also called the ST
Services Piney Point pipeline controller to inform him that he was at the station and that
things were going fine.
The next Chalk Point tank level measurement was taken at 1220 and reported to
Ryceville and Piney Point. The ST Services Chalk Point operator stood by the Chalk Point
pump starting about 1250 and was prepared to shut it down whenever he received a call
from Ryceville stating that the cleaning pig had arrived. The tank gauge was checked at
Ryceville about 1300, but no information on the volume received was calculated or
reported to the ST Services Chalk Point operator or the ST Services Piney Point pipeline
controller. The ST Services Ryceville operator went outside to the Ryceville pipe manifold
about 1300 to await the cleaning pigís arrival. About 1412, the ST Services Chalk Point
operator decided to double-check the Chalk Point tank level because the pig had not
arrived at Ryceville.
About 1430, the Chalk Point pump started cavitating8 due to a low-pressure
condition at the pump inlet, because the level of product in the tank was not providing
sufficient pressure for the pump to run properly. About the same time, the ST Services
Ryceville operator noticed that Rycevilleís meter noise suddenly stopped, indicating no
6 Line balance is the difference between the volume of product pumped at the origin and the volume
received at the destination. It is used for determining whether the pipeline operation is being conducted
within certain limits in order to identify a possible leak.
7 The ST Services Piney Point shift supervisors served as the pipeline controllers.
8 Cavitation is an internal pump condition created by the sudden formation and collapse of bubbles in
a liquid, which makes a characteristic sound.

<<<PAGE 15>>>

Factual Information 7 Pipeline Accident Report
product flow. The ST Services Chalk Point operator kept the pump operating by partially
closing the pump outlet valve in an effort to avoid internal damage to the pump.
The ST Services Chalk Point operator talked to the ST Services maintenance
foreman at Ryceville and was told that the meter noise had stopped and no pig had arrived.
The ST Services Chalk Point operator was then directed to close the valve as much as
possible to maintain product flow. The ST Services Chalk Point operator had not taken a
recent tank level measurement but was now ordered by the ST Services maintenance
foreman to determine the Chalk Point tank level. The ST Services Ryceville operator was
also directed to measure the Ryceville tank level so that the volume pumped could be
compared with the volume received. The ST Services assistant terminal manager was
notified about the situation, and he confirmed the need for an immediate tank level
measurement of the pumping and receiving tanks.
The ST Services Chalk Point operator and the ST Services assistant terminal
manager had a phone conversation about 1440 and reviewed the situation. The ST
Services assistant terminal manager instructed the ST Services Chalk Point operator to
double-check which valves were closed to confirm that the No. 6 fuel system was isolated
from the flushing oil system.
Tank levels were acquired for Chalk Point and Ryceville. The ST Services
Ryceville operator, using the tank volume tables, calculated that enough oil had been
pumped for the pigs to have reached the Ryceville Station. He said he thought that
something was wrong because Ryceville did not receive all the oil pumped from Chalk
Point.
The ST Services assistant terminal manager later said that at the time he believed
that the tank volume discrepancy had been caused by a valve that was improperly aligned
(open to another tank) or leaking (product leaking through a valve to another tank) and
that flushing oil was being transferred to the No. 6 fuel oil tank. He then directed ST
Services employees to make a number of checks to confirm that the correct valves were
open, to obtain a reading of the No. 6 fuel oil meters at Chalk Point, and to measure the
tanks at Piney Point. The ST Services assistant terminal manager had the ST Services
Piney Point pipeline controller perform the line balance calculations, with the result that
3,088.7 barrels (129,725 gallons) could not be accounted for.
By 1534, after receiving the additional information he had requested, the ST
Services assistant terminal manager stated that the discrepancies could not be explained
by tank inventory data. He had ruled out the possibility of the missing oil being anywhere
it should be. During a phone call, the ST Services Chalk Point operator told the ST
Services assistant terminal manager that the requested check had confirmed the isolation
of the flushing oil system from the No. 6 fuel oil. The ST Services assistant terminal
manager told the ST Services Chalk Point operator to shut the Chalk Point pump down. At
1538, the ST Services Chalk Point operator shut down the pump. The ST Services
assistant terminal manager stated that he paged his Pepco pipeline contact, the Pepco
Chalk Point general supervisor for fuel and ash, three times using a ì911 codeî to indicate
the urgent need for a response. (See figure 5 for an organizational chart of Pepco
personnel involved in the accident.)

<<<PAGE 16>>>

PEPCO Generation Organization
Vice President
Environmental
Engineering and
Maintenance Services
Bulk Power
Management
Fuels and Business
Planning
Generation East-
CHALK POINT
GENERATING
STATION MANAGER
Division Manager
ENGINEERING
SUPERVISOR
Environmental Services
Manager
Operations
Fuel and Ash
SENIOR
ENVIRONMENTAL
COORDINATOR
Station
Engineering
Maintenance
and Planning
GENERAL SUPERVISOR
FOR OPERATIONS
GENERAL SUPERVISOR
FOR FUEL AND ASH
ENVIRONMENTAL
COORDINATOR
(also QUALIFIED INDIVIDUAL)
CHALK POINT CONTROL ROOM
OPERATIONS SUPERVISOR
CHALK POINT SHIFT
SUPERVISOR
Figure 5. Selective and simplified organization chart for Pepco Generation Organization, intended only to
show the basic organizational relationships between the major positions cited in the accident narrative. Positions
cited in the narrative are in boldface and all capitals. (Note: This chart was developed by the Safety Board for
informational purposes. It is not intended to cover the full range of Pepco Generation Organization positions.)
Factual Information 8 Pipeline Accident Report

<<<PAGE 17>>>

Factual Information 9 Pipeline Accident Report
Actions Taken After Pipeline Shutdown
The ST Services assistant terminal manager told the ST Services Chalk Point
operator that he had pumped about 8,900 barrels (373,800 gallons) and that Ryceville had
received about 5,900 barrels (247,800 gallons). The ST Services assistant terminal
manager then directed the ST Services Chalk Point operator to check the No. 1 valve pit
area at Swanson Creek for a leak and to look across the creek at the No. 2 valve pit for
signs of a leak. (Valve pit No. 1 is on the north side of Swanson Creek, between the creek
and the Chalk Point Station.) The ST Services Chalk Point operator also obtained the
closing tank level for the Chalk Point flushing oil tank.
The ST Services Chalk Point operator made the visual checks by 1545 and
reported that he saw no sign of an oil leak at the creek. Next, the ST Services Chalk Point
operator was directed to check all roads that the pipeline crossed back to Ryceville for an
oil leak. He called the Chalk Point Operations Center and stated that he was finished
pumping and that the pigs had not been received at Ryceville, indicating there was a
problem with the pipeline. He said he told the Chalk Point Operations Center that he was
checking road crossings and would contact the center if he noticed a leak or some other
problem.
At 1550, the ST Services assistant terminal manager called a Pepco Washington,
D.C., headquarters oil procurement employee who confirmed the pager number for the
Pepco Chalk Point general supervisor for fuel and ash. The contact also provided the
Pepco engineering supervisorís phone number, because the Pepco engineering supervisor
might be able to locate other contacts needed by the ST Services assistant terminal
manager.
The ST Services assistant terminal manager contacted the Pepco engineering
supervisor, who advised him that the Pepco Chalk Point general supervisor for fuel and
ash was on vacation. The ST Services assistant terminal manager told him the details of
the 3,000-barrel line balance discrepancy and was advised to call the Pepco Chalk Point
general supervisor for operations. The ST Services assistant terminal manager also stated
that ST Services personnel were checking the levels of the flushing oil and No. 6 fuel oil
tanks at Chalk Point, Morgantown, and Piney Point to determine the location of a 3,000-
barrel line balance discrepancy. The ST Services assistant terminal manager indicated that
similar discrepancies had occurred in the past due to valve misalignment or valves not
being fully closed, which allowed oil to be inadvertently directed into one of the other oil
storage tanks in the system.
The Pepco engineering supervisor said that about 1620, he called the Pepco Chalk
Point general supervisor for operations and informed him of a 2,000- to 3,000-barrel line
balance discrepancy, which the Pepco Chalk Point general supervisor for operations noted
in his log as a discrepancy of 2,000 barrels. The Pepco Chalk Point general supervisor for
operations also noted in his log that ST Services personnel had initiated a ground
inspection and were checking the pipeline at road crossings. At 1643, the Pepco Chalk
Point general supervisor for operations ordered a patrol flight of the pipeline right-of-way.

<<<PAGE 18>>>

Factual Information 10 Pipeline Accident Report
Response to Accident
Notifying Authorities and Containing Spill
April 7. About 1800 or shortly thereafter, the Pepco Chalk Point general supervisor
for operations called the on-duty Pepco environmental coordinator, who was the
designated Pepco qualified individual,9 at home to discuss the pipeline line balance
shortage. He told the Pepco qualified individual what was being done at the pipeline,
including the tank level measurement discrepancy found when oil had been pumped back
to Ryceville. The Pepco Chalk Point general supervisor for operations also said that he
had ordered a pipeline patrol flight.
At 1802, the ST Services assistant terminal manager learned that during the
pipeline patrol plane flight, an oil release from the Piney Point Oil Pipeline had been
spotted in the Swanson Creek wetlands area. By 1807, the ST Services assistant terminal
manager had put the Chalk Point pipeline emergency response plan into effect by
contacting the Pepco qualified individual and an oil spill clean-up contractor. This plan
listed the criteria for notification of local response agencies as ìfire, explosion, personal
injury or release or significant threat of release off-site.î Local response agencies were not
notified. The ST Services assistant terminal manager called Piney Point to summon ST
Services employees to assist at Chalk Point. (See appendix B for a timeline indicating
significant developments as the leak occurred and was identified.)
The Pepco qualified individual called the Pepco Chalk Point general supervisor for
operations back and reported that the pipeline patrol flight had found an oil spill. The
Pepco Chalk Point general supervisor for operations then notified the Chalk Point control
room of the pipeline release.
The Pepco Chalk Point general supervisor for operations sent the Pepco Chalk
Point shift supervisor to the pipeline crossing at Swanson Creek to assess the situation.
During this period, the Pepco Chalk Point general supervisor for operations reviewed the
three Pepco spill response plans for the area to ensure that all emergency response
requirements were being met.10 Because each plan had a somewhat different purpose and
focus and the general supervisor for operations did not know the exact location of the
(underground) spill, he did not know which plan applied to this accident. Consequently, he
attempted to notify all response personnel identified in all three plans.
9 As indicated under 49 Code of Federal Regulations (CFR) Part 194, the qualified individual is a
company representative available on a 24-hour basis with full authority to: activate personnel and contract
with required oil spill removal organization(s); activate personnel and equipment maintained by the
operator; act as liaison with the on-scene coordinator; and obligate funds needed to carry out all required or
directed oil response activities.
10 The three plans were 1) the Pepco Oil Spill Emergency Response Plan for the Ryceville Pumping
Station and Pipeline, 2) the Pepco Oil Spill Emergency Response Plan for the Chalk Point Generating
Station, and 3) the Pepco Spill Prevention, Control, and Emergency Response Plan for the Chalk Point
Generating Station.

<<<PAGE 19>>>

Factual Information 11 Pipeline Accident Report
About 1817, the Pepco Chalk Point shift supervisor called the Pepco Chalk Point
general supervisor for operations and reported that he would deploy an oil spill boom to
contain the oil in Swanson Creek.
At 1822, the ST Services assistant terminal manager asked the Pepco Chalk Point
control room operations supervisor to notify Federal and State agencies about the release,
as required by the oil spill response plan for the Chalk Point Generating Station. About
1827, the Pepco Chalk Point general supervisor for operations called the headquarters
Pepco senior environmental coordinator at home and discussed the oil spill, so that the
Pepco senior environmental coordinator could notify the National Response Center.11
Between 1830 and 1835, the Pepco qualified individual met the Pepco Chalk Point
shift supervisor (who had been to the leak site) at the Chalk Point plant building and asked
the shift supervisor how much oil had spilled. When the Pepco Chalk Point shift
supervisor responded that he was not sure, the Pepco qualified individual pressed him for
some number because, he said, he believed that he would have to report a spill quantity
when he called the responsible authorities. The Pepco qualified individual stated that,
when pressed, the Pepco Chalk Point shift supervisor said, ì1,000 gallons, 2,000 gallons,
[expletive] mess; tell them what you want.î
They reported together to the office of the Pepco Chalk Point general supervisor
for operations about 1835, during his continuing telephone conversation with the Pepco
senior environmental coordinator. The Pepco qualified individual told the Pepco Chalk
Point general supervisor for operations that the estimated size of the spill was 1,000 to
2,000 gallons. The Pepco senior environmental coordinator later told investigators that
during their phone conversation, he and the Pepco Chalk Point general supervisor for
operations discussed that the ìbest guessî estimate of the release was 1,000 to
2,000 gallons. He stated that he and the Pepco Chalk Point general supervisor for
operations agreed to report a release of 2,000 gallons to the National Response Center.
The Pepco senior environmental coordinator stated that the Pepco Chalk Point general
supervisor for operations did not discuss the ST Services tank level readings with him.
Shortly thereafter, the Pepco senior environmental coordinator called the Pepco
qualified individual for more information about the release. The Pepco qualified
individual confirmed the oil spill location and stated that booms were being placed in the
wetlands. Based on the information they had, the Pepco senior environmental coordinator
and the Pepco qualified individual decided to report the estimated spill volume as
2,000 gallons. They agreed to split the reporting task, with the Pepco senior environmental
coordinator reporting to the National Response Center and the Pepco qualified individual
reporting to the Maryland Department of the Environment.
11 The National Response Center serves as the communications hub of the National Response System,
which is the Federal Governmentís mechanism for providing emergency responses to discharges of oil and
releases of chemicals. The National Response Center receives reports of all reportable oil and hazardous
substance releases anywhere in the United States and its territories. The National Response Center then
distributes incident reports to predetermined Government agencies based on National Response Center
incident classification guidelines.

<<<PAGE 20>>>

Factual Information 12 Pipeline Accident Report
Around 1840, the Pepco Chalk Point general supervisor for operations received a
call from the ST Services assistant terminal manager, who advised him that the ST
Services tank level readings were 3,000 barrels (126,000 gallons) short, that the spill
covered 3 to 4 acres in the wetlands at Swanson Creek, and that he had activated an oil
spill contractor. He also said that ST Services personnel would be arriving in about
15 minutes to close the pipeline valve between Swanson Creek and the Ryceville Station.
The notes made by the Pepco Chalk Point general supervisor for operations at this time
recorded the figure of ì3,000 barrelsî and that a 3- to 4-acre area was affected by the
release.
At 1845, the Pepco qualified individual called the Maryland Department of the
Environment to report the release. At 1850, the Pepco qualified individual called the
Pepco Chalk Point general supervisor for operations and told him that he had reported a
2,000-gallon release to the Maryland Department of the Environment.
About 1850, the Pepco senior environmental coordinator called the National
Response Center and reported a 2,000-gallon No. 2 fuel oil release from a pipeline at the
Pepco Chalk Point Generating Station, on the border of the facility property where the
pipeline crosses Swanson Creek. The Pepco senior environmental coordinator stated that
he understood from people at the plant that most or all of the release was in the creek. The
Pepco senior environmental coordinator also reported that the incident was discovered at
1817 on Friday, April 7, and that a clean up and an investigation into the cause of the
accident were underway. The Pepco senior environmental coordinator indicated that
Pepco had booms in the creek, that materials to absorb oil were being used, and that clean-
up contractors had been activated. He reported that he was not aware of any injuries or
evacuations. The National Response Center watch officer designated the release
notification as Incident Report No. 525411 and, lacking information on the exact source of
the leak, inaccurately classified it as a fixed (power plant) facility incident rather than a
pipeline-type incident. The National Response Center officer sent notifications to the
agencies on the fixed facility distribution list.12 Following the Pepco senior environmental
coordinatorís notification of the National Response Center, the Pepco qualified individual
notified the U.S. Coast Guard Marine Safety Office in Baltimore, Maryland.
By 1850, the Pepco spill response teams had completed the initial deployment of
more than 1 mile of floating boom in the wetland area on the north side of Swanson Creek
and at the mouth of Swanson Creek on the Patuxent River.
About 1911, the National Response Center notified Environmental Protection
Agency (EPA) Region III (Philadelphia) of the accident by fax.13 About 1930, the on-call
EPA Federal On-Scene Coordinator for Region III contacted the Prince Georgeís County
Fire Department requesting directions to the site and was advised that Prince Georgeís
County had not been notified of the spill.
12 The National Response Center maintains a number of distribution lists. The Office of Pipeline Safety
was on the pipeline accident distribution list but not the fixed facility accident distribution list.
13 The EPA responds to spills in the inland areas of the United States, and the Coast Guard responds to
spills in U.S. coastal and inland waterways.

<<<PAGE 21>>>

Factual Information 13 Pipeline Accident Report
The EPA Federal On-Scene Coordinator contacted the Pepco senior environmental
coordinator and advised him to call the Prince Georgeís County Communication Center
and provide the spill information. The Pepco senior environmental coordinator contacted
the Prince Georgeís County Communications Center and advised the center that
ì2,000 gallons of No. 2 fuel oil was released and county fire response was not necessary.î
The communications center informed the countyís hazardous materials coordinator about
the spill, and the hazardous materials coordinator arrived at the accident site within
15 minutes to assess the situation.
About 2015, the Pepco qualified individual stated that when he returned to the
Chalk Point command center, he learned from the information blackboard that the
estimated spill volume was 3,000 barrels (126,000 gallons), rather than 2,000 gallons. The
Pepco qualified individual stated that he advised Maryland Department of the
Environment and Coast Guard representatives, following their arrival on the scene about
2030, that the spill was ìcloser to 3,000 barrels in quantity.î Shortly afterwards, this
information was relayed to the Coast Guard Baltimore office and the State emergency
response duty officer. At 2035, the responders from the Maryland Department of the
Environment called their emergency response duty officer and advised him that the
updated release amount was 3,000 barrels.
Between 2030 and 2100, outside response personnel (including spill response
contractors, key Pepco responders, and State and Federal personnel) began arriving with
additional boom and boom deployment boats to augment those that Pepco already had at
the site. Around 2050, ST Services and other contractors working under Pepcoís direction
began evacuating oil from the pipeline between the closed No. 1 river pit valve and the
Chalk Point Pump Station.
Shortly after 2100, members of Pepcoís engineering and maintenance services
group confirmed a 3,000-barrel release, based on calculations using the tank level
readings that ST Services used. The Pepco senior environmental coordinator stated that,
when he arrived at the Chalk Point command center about 2130, he learned from the
information blackboard that the release volume was estimated to be 3,000 barrels
(126,000 gallons). The Pepco senior environmental coordinator stated that even though he
had notified several agencies earlier of the 2,000-gallon amount, he did not revise the
2,000-gallon notification because he believed representatives of all the agencies he had
notified were on-scene or in contact with each other.
Around 2300, Pepco conducted a command post briefing, during which
participants reviewed the boom placement and the need to augment the boom Pepco had
already deployed to contain the oil. They agreed for the night to place booms to direct the
oil to a point accessible to a vacuum truck. The command post briefing also covered plans
for deploying additional boom at 0600 on April 8, before the anticipated tide change.
During the remainder of the night, Coast Guard Baltimore office representatives and the
Maryland Department of the Environment on-scene coordinator worked with Pepco and
its spill response contractors to contain the spill and prepare collection efforts.

<<<PAGE 22>>>

Factual Information 14 Pipeline Accident Report
April 8. Shortly after 0115, a member of the Prince Georgeís County Hazardous
Materials Team contacted the National Response Center watch officer and advised the
watch officer to update the Coast Guard Baltimore office about the accident status. He
also asked the watch officer whether the Chalk Point event constituted a transportation-
related incident requiring notification of the U.S. Department of Transportationís Office of
Pipeline Safety. Subsequently, the National Response Center determined that the accident
was a pipeline incident rather than a fixed facility incident and distributed the original
incident report, containing the 2,000-gallon spill estimate, to its pipeline notification list,
including the Office of Pipeline Safety and the Safety Board.
Around 0250, the Coast Guard Federal on-scene representative arrived at the
accident site to coordinate Federal, State, and local efforts. The Coast Guard
representative provided Pepco with a copy of the Baltimore Area Contingency Plan and
discussed with Pepco representatives the possibility of pre-staging booms at
environmentally sensitive creeks identified under the area contingency plan. After
assessing the spill location, the Coast Guard representative notified the Coast Guard
Baltimore office that the spill was located above the Benedict Bridge on Highway 231.
According to the Baltimore Area Contingency Plan, Benedict Bridge marks the
jurisdictional dividing line between the Coast Guard Baltimore office and the EPAís
Region III. Had the spill passed under Benedict Bridge, it would have been considered
within the Coast Guardís geographic jurisdiction.
Around 0330, the Coast Guard Baltimore office notified EPA Region III that the
spill was in the EPAís geographic jurisdiction and that Coast Guard personnel were
responding. Several hours later, when the Coast Guard representative on-scene was able to
view the wetlands area in daylight, he updated the Coast Guard Baltimore office. Shortly
after 0530, the Coast Guard Baltimore office advised the EPA Federal On-Scene
Coordinator that although the Coast Guard had personnel on the scene, the EPA should
take the lead for the spill, because the spill was contained in the wetlands and it had
significantly contaminated the wetlands area, including the local wildlife, with oil.
Shortly after 0600, the EPA Federal On-Scene Coordinator deployed from
Philadelphia with an EPA technical support contractor. Around 1015, the EPA Federal On-
Scene Coordinator arrived at the site and assumed responsibility from the Coast Guard for
directing the clean-up activity. Soon afterwards, the EPA Federal On-Scene Coordinator
learned for the first time that the quantity of oil released was actually 3,000 barrels, rather
than 2,000 gallons, of a mixture of No. 2 and No. 6 fuel oil. About 1100, the EPA Federal
On-Scene Coordinator held an organizational meeting with representatives of all the
parties, including Pepco, Pepcoís three spill response contractors,14 the Maryland
Department of the Environment, the Coast Guard, and the U.S. Fish and Wildlife Service.
At the meeting, those attending agreed that:
14 The contractors were A&A Environmental Services, Wood Chuck Enterprise, and Clean Harbors
(standby contactor).

<<<PAGE 23>>>

Factual Information 15 Pipeline Accident Report
ï The Unified Command (the EPA, the Maryland Department of the
Environment, and Pepco) would direct the management of the response
effort.15
ï The responders would continue with the existing boom placement. The
containment and clean-up efforts appeared to be effective, and there was no
apparent threat to public health.
ï Because of the large amount of free product in the wetlands, the primary
emphasis should be on collection of oil in advance of a storm expected by early
evening.
ï With the spill contained in the wetlands, the Unified Command would release
the standby contractor, Clean Harbors.
The weather forecasts changed throughout the afternoon. Earlier forecasts tended
to indicate the approach of a relatively weak storm, but the weather reports became more
threatening as the day progressed. Around 1600, and with the expected approach of severe
winds and heavy rains, the EPA and the Maryland Department of the Environment
surveyed Pepcoís site response activities and revised the storm plan so that additional
collection resources were placed at the secondary containment points and outer booms.
During the early stages of the response, Pepco deployed about 300 of its own
employees and spill response contractors to assist with the oil recovery efforts. (See
figure 6.) Pepco response personnel were on rotating 8-hour shifts. The EPA Federal On-
Scene Coordinator noted that those coming on shift typically were not briefed before or
after arriving at the scene. Little information was shared between shifts of employees.
Pepco response officials stated that they often were not included in the meetings
conducted by the EPA Federal On-Scene Coordinator. In some cases, they could not attend
such meetings because it was physically impossible; the space provided for the meetings
was inadequate to accommodate all those wishing to attend. Pepco indicated that because
of these problems with the meetings, some of the orders of the Unified Command were not
clearly communicated to its personnel.16 At the same time, some meeting attendees were
not essential to the response effort.
15 A Unified Command is an element within the Incident Command System that represents the key
organizations responding to the incident. Under the National Contingency Plan, the Unified Command
typically consists of the Federal On-Scene Coordinator, the State on-scene coordinator, and the incident
commander of the responsible party.
16 From a letter, dated August 3, 2000, from Pepcoís incident commander for the Chalk Point response
to the EPA Federal On-Scene Coordinator for the response concerning lessons learned from the emergency
response to the Chalk Point oil spill.

<<<PAGE 24>>>

Factual Information 16 Pipeline Accident Report
Because Pepcoís qualified individual changed with every 8-hour shift, the Pepco
qualified individual did not provide continuity of response and often had to check with
other Pepco officials before providing assistance requested by the EPA Federal On-Scene
Coordinator. In her postaccident description of events, the EPA Federal On-Scene
Coordinator cited the frequent changing of Pepcoís qualified individual and stated that it
led to ìepisodes of miscommunication and unclear lines of authority during the initial key
dates of the response.î17
Figure 6. Response personnel working on wooden mats in the marsh.
During the first 24 hours of the spill response, three sets of booms had been
deployed, and the oil spill was contained in about 5 acres of wetlands. However, during
the evening of April 8, the weather deteriorated, and conditions included winds in excess
of 50 mph and strong rain showers. Because of the heavy rains and high wind gusts, the
outer booms were breached about 2030, releasing a significant amount of oil into the
Patuxent River. (See figure 7 for an aerial photo of two plumes of oil in Swanson Creek,
moving toward the Patuxent River.) During the night, Pepcoís spill response contractors
attempted to deploy additional personnel and equipment, but the weather made it unsafe
for workers to be in the wetlands area or on the river, so they could not be deployed. (See
appendix C for a listing of the significant events between the recognition of the leak and
the loss of oil containment.)
17 Environmental Protection Agency, After-Action Report for Emergency Response at the Swanson
Creek Oil Spill Site, Aquasco, Maryland, Prince Georgeís, Charles, Calvert, and St. Maryís Counties 7 April
2000 to 16 May 2000, p. 30.

<<<PAGE 25>>>

Factual Information 17 Pipeline Accident Report
Figure 7. Aerial photo of Swanson Creek area taken on April 10, 2000
showing two plumes of oil moving with the creek flow towards the
Patuxent River after containment was lost.
Response to Escape From Containment
After the storm caused the oil to escape containment on the evening of April 8, the
Unified Command attempted, primarily using Pepco contractor resources, to reestablish
control over the spill. The efforts were unsuccessful until the Unified Command 1)
obtained additional personnel to implement an Incident Command System structure on
April 11, and 2) obtained additional marine response equipment for oil recovery. Between
April 8 and 12, the oil plume spread approximately 17 miles (linear) downstream,
affecting approximately 40 miles of shoreline, including several environmentally sensitive
and populated creeks in Calvert and St. Maryís Counties. (See figure 8 for creek boom
locations and spread of spill.) The major events that took place during the response to the
oilís escape from containment are provided below.
April 9. In the early daylight hours of April 9, an oil plume was observed traveling
in a straight line from the mouth of Swanson Creek across the Patuxent River towards
Calvert County. At 0745, the EPA Federal On-Scene Coordinator contacted the Baltimore
office of the Coast Guard to state that the containment had failed and to ask the Coast
Guard to identify potential Federal resources with marine capabilities. The Coast Guard
directed the EPA Federal On-Scene Coordinator to several possible sources of assistance
(Patuxent Naval Air Base, etc.) in the vicinity. Shortly thereafter, Pepco informed the EPA
Federal On-Scene Coordinator that it was having difficulty obtaining the necessary
contractor resources with marine capabilities, particularly the waterborne skimmers and
skimming vessels needed to respond effectively.

<<<PAGE 26>>>

Factual Information 18 Pipeline Accident Report
CHARLES
COUNTY
S
w
a
n
s
o
n
C
r
e
e
k
PRINCE
GEORGE’S
COUNTY
Chalk Point
Spill
Spill
Site
Site
Hunting Creek
I
n
d
i
a
n
C
r
e
e
k
231 2
4
CALVERT COUNTY
5
6
235
Trent Hall
Creek
Washington
Creek Battle Creek
Patuxent River
1 mile
ST. MARY’S
COUNTY
Barrier Booms
Oil Spill
Figure 8. Spill site map showing creek boom placements and range of
oil spill.
As the morning progressed, Pepcoís contractors were deployed in an effort to
corral the moving oil plume on the river with booms before it could affect the Calvert
County shoreline. The effort was unsuccessful.
By mid-afternoon, the EPA Federal On-Scene Coordinator, other EPA officials on
the scene, the Maryland Department of the Environment on-scene coordinator, and a U.S.
Department of the Interior representative had met and agreed that the spill represented a
substantial threat to public health and the environment. As a result, the EPA contracted
with the Marine Spill Response Corporation, an environmental spill response contractor,
to provide on-water response services and personnel.18
At 2100, another meeting was held, during which the protective booming of the
environmentally sensitive Hunting, Indian, and Trent Hall Creeks, all of which fed into the
Patuxent River, was given a high priority. As a result, it was decided to continue contractor
response efforts through the night.
April 10. Around 1200, the EPA Federal On-Scene Coordinator and the Maryland
Department of the Environment on-scene coordinator toured the accident site with the
18 The Marine Spill Response Corporation is a not-for-profit organization that is funded by member
companies. It allows only the Federal Government or member companies to hire it to respond to spills
involving releases greater than 1,200 barrels. Pepco was not a member company.

<<<PAGE 27>>>

Factual Information 19 Pipeline Accident Report
Pepco qualified individual and expressed concern that 1) Pepcoís spill response
contractors had not completed booming the threatened creeks according to plans, 2) the
contractors were making ineffective use of the available response resources, and 3) the
reports being provided to the Unified Command by Pepco about the progress of the
response effort were inaccurate. In recognition of the problems, at 1430, the EPA Federal
On-Scene Coordinator asked Coast Guard on-site personnel to develop an Incident
Command System structure for the response, under her direction. About the same time,
the EPA Federal On-Scene Coordinator strongly advised Pepco that it had to greatly
increase its logistical support for and control over the response contractors and that a spill
management contractor was needed.
At the 2100 staff meeting, the EPA Federal On-Scene Coordinator stressed the
need to deploy protective boom around the creeks. She directed Pepco to immediately
deploy protective booms at Hunting, Indian, and Trent Hall Creeks. At 2200, the EPA
Federal On-Scene Coordinator requested that the Coast Guard provide 25 employees by
0600 on April 11 to staff the Incident Command System structure that was being
developed.
April 11. By 0300, the booming of the creeks had not been completed. The EPA
Federal On-Scene Coordinator again directed Pepco to protectively boom the creeks. At
0715, an overflight of the affected area showed that no boom had been installed to protect
the creeks and that Trent Hall and Indian Creeks both showed evidence of significant oil
contamination.
At the 0900 meeting, Pepco indicated that it was attempting to bring additional
contractor resources to the scene. The EPA Federal On-Scene Coordinator, in recognition
of the ìcontinued failure of the Pepco contractors to carry out direction from the Unified
Command,î19 began preparing to have additional Federal environmental responders
participate in the Incident Command System structure.
The Coast Guard Captain of the Port of Baltimore arrived on the scene about 1100,
with additional personnel to staff the Incident Command System structure that had been
developed since the previous day. Organizational functions were split into four sectionsó
operations, planning, logistics, and financeóand Unified Command officials managed
each section. All field operations were carried out under the direction of the operations
section. The newly arriving Coast Guard personnel were designated to monitor the field
operations being conducted by Pepcoís contractors to ensure that work was completed in a
timely and efficient fashion.
The EPA Federal On-Scene Coordinator again asked Pepco to hire a spill
management team to manage its contractors and the spill response. Pepco subsequently
stated that a firm had been contracted to provide logistic management support and keep
track of the contractor and equipment resources at the site.
19 Environmental Protection Agency, After-Action Report for Emergency Response at the Swanson
Creek Oil Spill Site, Aquasco, Maryland, Prince Georgeís, Charles, Calvert, and St. Maryís Counties,
7 April 2000 to 16 May 2000. Appendix A, Incident Chronology, p. A-9.

<<<PAGE 28>>>

Factual Information 20 Pipeline Accident Report
During the remainder of the day, protective booming was provided for Hunting
Creek, and protective boom was pre-staged for deployment on April 12 for four more
creeks.
April 12 and Afterwards. Once the Incident Command System structure was
implemented, recovery operations were conducted and monitored around the clock with
day and night crews. Protective booms were provided for threatened creeks on April 12
and 13. Eventually, more than 1,000 contract workers were hired to assist with the clean-
up operations.
Restrictions on boating were imposed, and the Maryland Department of the
Environment issued a precautionary advisory on the harvest and consumption of fish and
crabs from the contaminated areas on the Patuxent River. A rehabilitation center for
wildlife was established for oiled animals.
By April 13, Marine Spill Response Corporation skimmers had completed the
collection of free oil in the main body of the Patuxent River. Free oil continued to be
collected through April 16 in several affected creeks in St. Maryís County. During the last
few days of April 2000, the Unified Command developed a long-term site remediation
plan addressing oil removal from the wetlands, soil treatment, site decontamination, and
demobilization. On May 16, 2000, the Unified Command declared the emergency
response phase over. (See appendix D for a timeline of the significant developments in the
environmental response effort.)
Damage
Total environmental clean-up costs were approximately $71 million.
On April 24, 2000, the Maryland Department of the Environment lifted the
advisories it had issued earlier against the harvest and consumption of products from the
Patuxent River. Based on laboratory analyses of crab, fish, and shellfish samples, the
Maryland Department of the Environment determined that eating these river products
would not pose a significant potential for adverse human health effects. In addition, the
Maryland Department of the Environment stated that it had determined that no permanent
damage had been done to fishing resources as a result of the spill.
Personnel Information
The ST Services Chalk Point operator on the day of the accident was a plant
mechanic with over 7 yearsí experience on the Piney Point Oil Pipeline. His duties
included repairing pumps, valves, and construction equipment and being an equipment
and pipeline operator when required. He reported to the ST Services maintenance
foreman.

<<<PAGE 29>>>

Factual Information 21 Pipeline Accident Report
The ST Services Ryceville operator on the day of the accident was a plant
mechanic with 7 yearsí experience on the Piney Point Oil Pipeline. His duties included
repairing pumps, valves, and construction equipment and being an equipment and pipeline
operator when required. He reported to the ST Services maintenance foreman.
The ST Services maintenance foreman had over 3 yearsí experience on the Piney
Point Oil Pipeline. His duties included supervising five employees in terminal and
pipeline operations and maintenance. He reported to the ST Services assistant terminal
manager.
The ST Services assistant terminal manager started working at the Piney Point
Terminal in 1973 in various positions, which included carrying out pipeline operations and
maintenance responsibilities for the previous terminal owner. He had approximately
5 yearsí experience with ST Services as an assistant terminal manager with
responsibilities for the Piney Point Terminal and the Piney Point Oil Pipeline. He reported
to the Piney Point Terminal manager.
Postaccident Examination
The April 7, 2000, pipeline rupture occurred at the Chalk Point Generating Station
in southeastern Prince Georgeís County. At this location, the pipeline was on Pepco
property and passed through wetlands adjacent to Swanson Creek, a tributary to the
Patuxent River. The release point was 127 feet north of valve pit No. 1 on Pepco property.
The pipe at the failure area was 12 3/4-inch-diameter, 0.203-inch wall thickness,
American Petroleum Institute (API) 5L grade X42 electric resistance weld steel pipe,
installed with 1-inch polyurethane thermal insulation and a 170-mill polyethylene jacket
exterior coating. The pipe was insulated and coated before the field bend at this location
was made during the pipelineís installation.
The pipeline was buried about 3 1/2 feet deep at the rupture location. The rupture
area was excavated a few days after the failure. When the pipeline was exposed, the
profile of a buckle could be seen through the pipe coating. (See figure 9.) When the pipe
coating was removed, a crack in the circumferential direction was visible.
In a postaccident communication from Pepco to Safety Board staff, Pepco stated it
had reviewed the recorded pressure information, the size of the pipeline crack, and the
pipeline operating conditions at the time of the accident and determined that, to release the
estimated 129,000 gallons of product spilled, the pipe failure had to have occurred at least
5 hours before the Chalk Point pump began cavitating at 1430 on April 7, 2000. A
subsequent communication from Mirant (current operator of the pipeline)20 to Safety
Board staff noted that the failure had probably occurred during the startup of the Chalk
20 Pepco sold the Piney Point Oil Pipeline and the Chalk Point Generating Station in December 2000.
Mirant subsequently became the pipeline owner and operator.

<<<PAGE 30>>>

Factual Information 22 Pipeline Accident Report
Point pump, about 0715, when pipeline pressure was at its highest. Mirant also indicated
that the final estimated release quantity was about 3,343 barrels (140,400 gallons).
Figure 9. Indication of the buckle (Arrows show buckle location).
Tests and Research
A 53-inch-long section of pipeline taken from the scene was examined at the
Safety Board laboratory. The pipe was bent and contained an outward-protruding buckle
on the inside radius of the bend. The angle of the bend in which the buckle was formed
was determined to be in the 5- to 6-degree range. The buckle extended around 270 degrees
of the pipe circumference, from approximately the 10 oíclock to the 7 oíclock position.
(See figure 10.) The pipe was deformed into a slightly elliptical shape. The buckle area
contained an open crack at the crown of the buckle, which extended from approximately
the 2 oíclock to the 4 oíclock position. The maximum height of the buckle was
approximately 1 inch at the 3 oíclock position on the inside of the bend. The crack was
6 1/2-inches long by 3/8-inch wide at its widest portion. (See figure 11.) No external
corrosion was noted on the pipe section when it was examined under a microscope.
The interior surface of the pipe in the area of the buckle peak contained a number
of shallow secondary cracks. All the cracks were circumferentially oriented, confined to
the permanently deformed area of the pipe (approximately 1/4 inch from the buckle apex),
had blunt tips, and were filled with corrosion products. Some of these cracks exhibited
slight branching. The appearance of these cracks was typical of corrosion fatigue cracking
in low carbon steels, resulting from exposure to high stress amplitudes.

<<<PAGE 31>>>

Factual Information 23 Pipeline Accident Report
Figure 10. Inside view of the buckle in the removed section of pipe.
Figure 11. 6 1/2-inch-long, 3/8-inch-wide crack,
with coating system shown at the left edge of photo.

<<<PAGE 32>>>

Factual Information 24 Pipeline Accident Report
A scanning electron microscope examination revealed five well-defined fracture
zones. Figure 12 illustrates the fracture surface profile of the failure. Bracket ìaî starts at
the interior surface of the pipe, showing a fracture from corrosion fatigue. Brackets ìb,î
ìc,î and ìdî show the crack propagation planes changing from 45 degrees from the
surface of the pipe to roughly perpendicular, showing both tensile overstress and fatigue
propagation, and contain no evidence of corrosion. Bracket ìeî shows the crack
propagation changing to a 45-degree shear plane. The final separation zone adjacent to the
exterior surface of the pipe reveals dimpled features typical of ductile overstress fractures.
Figure 12. Fracture surface profile of failure.
Piney Point Oil Pipeline
Pipeline Information
The Piney Point Oil Pipeline was constructed for the Steuart Petroleum Company
in 1971 and 1972 and put in service in 1973. Pepco purchased the pipeline in 1976. In
1995, ST Services purchased the Piney Point Terminal facility from Steuart Petroleum,
and ST Services operated the pipeline for Pepco with former Steuart Petroleum personnel.
Fuel oil was delivered to the Piney Point Terminal by marine vessels and then
transported from the terminal by the Piney Point Oil Pipeline. The 51.5-mile-long pipeline
system was composed of 12-inch and 16-inch-diameter pipeline segments that were used

<<<PAGE 33>>>

Factual Information 25 Pipeline Accident Report
to transport heated fuel oil from the Piney Point Terminal, via the intermediate Ryceville
Station, to generating stations at Chalk Point and Morgantown. The pipeline segment from
Ryceville to Chalk Point was approximately 11 miles long. The oil was heated to make it
flow more easily, and the system operated up to approximately 160 F.
1995 In-line Inspection. The Ryceville to Chalk Point segment of the Piney Point
Oil Pipeline was internally inspected in November 1995 with a geometry tool and an in-
line magnetic flux leakage tool. After receiving the inspection reports in January 1996,
Pepco exposed the pipeline and examined corrosion anomalies at 29 locations in spring
1996. The data from the magnetic flux inspection did not correlate well with field
measurements for either wall loss data or odometer readings. Pepcoís Pipeline Working
Group recommended that an additional in-line inspection be conducted in 1997 using
ultrasonic inspection tool technology.
1997 Pipetronix In-line Inspection. Pepco contracted with the ultrasonic in-line
inspection contractor Pipetronix21 to conduct a pipeline inspection on August 16, 1997.
Before conducting its ultrasonic inspection tool survey, Pipetronix subcontracted for an in-
line caliper tool22 survey, which was completed on August 11, 1997. Pipetronix had the
caliper tool run to confirm that there were no physical obstructions in the pipeline that
would prevent passage of the ultrasonic inspection tool.
On August 16, 1997, Pipetronix examined the segment of the Piney Point Oil
Pipeline from Ryceville to Chalk Point with an ultrasonic inspection tool. Pepco required
that Pipetronix prepare a final report for the inspection that would include a complete,
written survey report for the pipeline. The report would provide the pipeline operator data,
including all types of corrosion, gouging, pipeline fittings (such as T-pieces,23 valves,
etc.), girth welds, wall thickness changes, special features (such as externally welded
patches, insulating flanges, etc.), and differentiation between internal and external
corrosion (for general surface corrosion, pitting, and channeling).24
According to the contract, Pipetronix was to use a multi-step process to identify
and interpret each feature in the pipeline, as follows:
1. Field check of the data at random locations immediately after the tool run is
2. completed,
Search of the data by automatic computer programs to detect girth welds, pipe
installations, defects (internal and external), markers, and other features,
21 On November 25, 1999, Pipeline Integrity International Ltd. acquired the Pipetronix Group. The
subsidiary PII North America, Inc., now controls those assets that belonged to Pipetronix in the United
States.
22 A caliper tool is an in-line inspection device used to determine the geometrical condition of the pipe,
including the size and location of abnormalities.
23 A T-piece is normally a tee pipe-fitting welded into a pipeline, although alternatively, a T-piece may
be made by welding a pipe stub to a pipeline and drilling a hole into the pipeline.
24 National Association of Corrosion Engineers Standard RP0102-2002, Recommended Practice In-
Line Inspection of Pipelines, table 1, lists the types of in-line inspection tools and inspection purposes.

<<<PAGE 34>>>

Factual Information 26 Pipeline Accident Report
3. 4. Computer generation, with relevant input from the interpreter, of a features list,
Interpretation by the interpreter of each feature found in the search phase.
The completed pipeline features list was to contain all features recorded in the tool
run and present the results of the interpretation in condensed form. The report noted that
data collected during the tool run were systematically evaluated according to criteria
defined in the contract between Pipetronix and Pepco. Pipetronix performed this
evaluation in five phases:
ï Phase 1: Handover of data from the workshop (integration within the
management of the department, handover meeting, familiarizing of the project
leader);
ï Phase 2: Preparation of the interpretation;
ï Phase 3: Main interpretation (automatic interpretation, manual interpretation,
feature list editing, quality check);
ï Phase 4: Summarizing of the results (handover of the features list to the client,
discussion of the results for the final report, documenting of the features,
completion of the final report, quality check);
ï Phase 5: Project completion, including forwarding the final report to Pepco.
After the August 1997 Pipetronix inspection, the pipeline segment from Ryceville
to Chalk Point was excavated and exposed in 12 places in fall 1997. The pipeline was
inspected and repaired at locations indicated by the ultrasonic inspection to have the
deepest and most severe corrosion. At these locations, Pepco determined that the
Pipetronix in-line inspection data correlated relatively well with the field measurements
made of the pipe-wall thickness using an ultrasonic testing instrument. However, Pepco
found that some locations had more severe corrosion than had been indicated by the
ultrasonic inspection.
Pipetronix provided the results of the inspection of the Ryceville to Chalk Point
segment of pipeline to Pepco in a final report dated January 20, 1998. The final report
included general information about the ultrasonic inspection tool used, the ultrasonic
measuring method, the design of the tool, the benefits and limitations of the tool, the
survey procedures, the procedures for evaluating the collected data, and a detailed table of
pipeline features.
Pipetronixís interpretation of the tool data was included in an appendix to the final
report entitled ìFeatures List.î The report identified and located by station number various
pipeline features, including external metal loss, internal metal loss, laminations, flanges,
field bends, weld-o-lets, hot bends, dents, sleeves, markers, girth welds, valves, and T-
pieces. Pepco used Pipetronixís in-line inspection report to establish the baseline
conditions of the pipeline and to conduct its excavation and field inspection program.

<<<PAGE 35>>>

Factual Information 27 Pipeline Accident Report
Excluding various aboveground features at the pig launcher and receiver, the
Pipetronix features list identified three T-pieces in the pipeline. Two T-pieces were
approximately 1,519 feet apart, one on each side of Swanson Creek, at odometer stations
51887.20 and 53406.10. The third identified T-piece, which was actually the buckle that
failed on April 7, 2000, was identified as being located at odometer station 53526.55.
After conducting a postaccident review of the inspection log for the August 1997
in-line inspection, Pipetronix determined that its analyst had inaccurately interpreted the
log indication at odometer station 53526.55 as a T-piece. At the time of the in-line
inspection, Pipetronixís software reference library did not include a standard image of an
outward protruding buckle, such as the one at odometer station 53526.55. Pipetronix
acknowledged that, based on its knowledge at the time, the feature should have been
interpreted as an ìunknown.î25
Before the April 7, 2000, accident, Pepco had authorized another ultrasonic
pipeline inspection to be conducted by Pipetronix in April 2000. At the time of the
accident, Pepco was cleaning the pipeline to prepare it for this upcoming in-line inspection
to take place later in April 2000.
Operations
The pipeline was operated manually for startup and shutdown.26 The Ryceville
Station was normally left unattended after initial system startup when no pump was
operating at Ryceville. Pipeline operating data were not periodically transmitted to the
Piney Point Terminal. The pipeline monitoring system transmitted pipeline pressure,
temperature, and flow rate alarms to Piney Point. The pipeline alarms were displayed on
the computer screen at the Piney Point Terminal, and audible alarms alerted the ST
Services operator on duty to pipeline operating conditions that were outside
predetermined limits. Using his computer terminal, the ST Services shift supervisorís
operating practice while serving as the pipeline controller was to verify the system alarm
status, as well as pressure, temperature, and flow rate information, once each 8-hour shift.
The alarm data were stored at each station for 30 days and could be printed locally at each
station if a data review was desired. The pipeline computer monitoring system provided
the operations data it was designed to gather during No. 6 fuel oil transfers.
Pepcoís Piney Point Oil Pipeline Manual required that during a No. 6 fuel oil
transfer, the ST Services pipeline controller had to conduct a daily recording of meter
readings and to communicate daily with Pepco operations personnel to ascertain the
delivered quantity, flow rate, available tank capacity, and estimated time of operation
completion. The Pepco manual further required that the ST Services pipeline controller
25 A postaccident Office of Pipeline Safety report that evaluated the 1997 Pipetronix survey found that
the ultrasonic inspection tool provided good characterization of the pipelineís physical elements, such as the
valves, tees, bends, fittings, and points of deformation. The report also found that the tool recorded an
indication of a buckle at the location of odometer station 53526.55, but the Pipetronix analyst
mischaracterized the indication as a T-piece.
26 The pipeline was operated on an as-needed basis when a No. 6 fuel oil transfer was required for a
generating station.

<<<PAGE 36>>>

Factual Information 28 Pipeline Accident Report
record the pipeline pressure, temperature, and flow rate at Piney Point at 4-hour intervals
during a No. 6 fuel oil transfer.
The ST Services pipeline controller did not continuously monitor pipeline
operating conditions. The ST Services pipeline controller could receive a call from the
system that a pipeline operating parameter was out of allowable tolerance, and he could
then access the monitoring system to determine the nature of the alarm.
Pipeline flushing was performed at the end of each No. 6 fuel oil transfer.27 Piping
alignments for pigging operations were set up similarly to a flushing operation, although
there were obvious differences in routing the product through the pig traps. The product
did not flow through the meter at the Chalk Point Station during a flushing operation or
during the pigging operation on the day of the accident. In addition, the meters and
pressure-sensing points at the Chalk Point Station were not in the oil flow path, and the
temperature-sensing equipment was not in the direct oil flow path to the Ryceville Station.
The pipeline monitoring system was not capable of monitoring pipeline operating
conditions because of the meter location and the locations of the sensing points. Pipeline
shift supervisors and operators had no predetermined line balance limits to follow to
assess pumped and delivered product volumes during flushing or pigging operations.
Pepcoís Piney Point Oil Pipeline Manual did not require any pipeline operations
personnel to perform periodic line balance calculations during a flushing or pigging
operation, nor did they do so.
The abnormal operating condition procedures described in section 7.4,
paragraph 5.2, of Pepcoís Piney Point Oil Pipeline Manual required the ST Services
terminal duty operator or pipeline operator mechanic to report any abnormal fuel oil
system operating condition that was indicated by 1) an alarm condition on the pipeline
monitoring system, 2) a visual indication of a local pressure or level indication, 3) an
abnormal system operating indication from the Pepco generating station senior power
plant operator, 4) or the One-Call system. Paragraph 5.3 provides an example of an
abnormal system operating condition, which it termed an:
Increase, decrease or an alarm differential in the fuel oil system pressure or flow
rate outside of normal steady state operating conditions as indicated by a
computer monitoring alarm condition or a local pressure instrumentation.
Pipeline Maps and Records
The original Piney Point Oil Pipeline alignment sheets and as-built drawings were
destroyed in a fire before Pepco purchased the pipeline in 1976. Title 49 CFR 195.404
requires operators to have maps and records that include at least the following
information: 1) the location and identification of breakout tanks, pump stations, scraper
and sphere facilities, pipeline valves, cathodically protected facilities, facilities in an
immediate response area not equipped to fail safe, facility rights-of-way, and overpressure
safety devices; 2) all crossings of public roads, railroads, rivers, buried utilities, and
27 Flushing is the process of pumping flushing oil in the reverse direction of normal flow in the pipeline
to displace the No. 6 fuel oil from the pipeline before it cools to the point that it cannot be pumped.

<<<PAGE 37>>>

Factual Information 29 Pipeline Accident Report
foreign pipelines; 3) the maximum operating pressure of each pipeline; and 4) the
diameter, grade, type, and nominal wall thickness of all pipe. During 1993 and 1994,
Pepco had pipeline alignment maps made based on aerial photography and created
drawings for aboveground piping of Piney Point Oil Pipeline facilities.
Meteorological Information
At mid-afternoon, on April 7, 2000, Reagan Washington National Airport (about
40 miles northwest of the accident scene) recorded a maximum wind speed of about
19 mph. The temperature was 77° F, and the sky was overcast. By mid-afternoon on
April 8, 2000, wind gusts of about 50 mph were recorded at the airport. Conditions were
rainy, and the temperature was approximately 57° F. During the evening of April 8, rains
in excess of 1 inch and winds over 50 mph were experienced in the Chalk Point area.
Pepco Oil Spill Preparedness
Under 49 CFR 194.101, pipeline operators are required to submit a spill response
plan to the Research and Special Programs Administration (RSPA) for review and
approval. Pepco had provided such a plan to RSPA. According to the regulation, the plan
must address a response to a worst-case discharge and the threat from such a discharge. It
must also include procedures for conducting drills, including identifying the types of drills
to be conducted and their schedules. Appendix A to Part 194 provides recommendations
concerning the topics that the response plan must address. Under section 7, concerning
drill procedures, it is recommended that drills be conducted on the following topics at the
following frequencies:
ï Quarterly drills on emergency procedures and notifications of qualified
individuals for manned pipelines;
ï Quarterly drills involving emergency actions by assigned operating or
maintenance personnel and notifications of qualified individuals for unmanned
pipelines;
ï Annual tabletop exercises involving the shore-based management team;
ï A drill once every 3 years that exercises the entire response plan for each
response zone of the pipeline system.
In September 1996, a tabletop exercise was conducted at Chalk Point under the
direction of RSPAís Office of Pipeline Safety, with the participation of the Coast Guard.
The response exercise involved a hypothetical spill at the Pepco Morgantown facility of
800 barrels of No. 6 fuel oil into the Wicomico River. This was a coastal inland waterway
release scenario, within the Coast Guardís jurisdiction. (The EPA did not participate in the
drill.) The Office of Pipeline Safety sponsored the tabletop exercise to assess Pepcoís
pipeline emergency preparedness under the National Preparedness for Response Exercise

<<<PAGE 38>>>

Factual Information 30 Pipeline Accident Report
Program and the Oil Pollution Act of 1990. Specifically, the objectives of the tabletop
exercise were to:
Validate the emergency response plans and procedures of Pepco, and to enhance
participantsí knowledge of the appropriate plan and procedures (e.g. Facility
Response Plan, Area Contingency Plan, State Contingency Plan, etc.)[28]
In the review that followed the exercise, Pepco received the following
recommendations addressing incident management:
The Pepco FRP [Facility Response Plan] should be revised to reflect how Pepco
intends to direct response and resolve spill-related issues jointly with local, state,
and federal responders. Additional training on the roles and responsibilities
involved in these assignments should reinforce the policies of the oil spill
contingency plan. The training should include all potential response groups if
possible, to assist each group in clarifying its role in response operations and as a
part of the unified system. The SMT [Spill Management Team] should ensure that
other Pepco personnel potentially involved in response operations are also trained
in their roles. New personnel assignment to perform the functions of the Incident
Command System, revisions of their roles and responsibilities, and a description
of how these will interact with the local, state and federal responders in the unified
system should be reflected in the FRP.[29]
According to Pepco,30 Revision No. 3 (dated March 13, 1997) of the Oil Spill
Emergency Response Plan for the Ryceville Pumping Station and Pipeline incorporated
the above comments. On August 26, 1997, Pepco submitted Revision No. 3 of the plan to
the Office of Pipeline Safety, which, on October 27, 1997, completed review of the
revised plan. The Office of Pipeline Safety stated that the revised plan adequately
addressed the response planning recommendations made by the Office of Pipeline Safety
based on the drill results.
Between January 1999 and April 7, 2000, at least five notification drills were
conducted for the Piney Point Oil Pipeline. Equipment deployment drills were conducted
in July and November 1999.
Postaccident Actions
Office of Pipeline Safety Postaccident Requirements
An April 12, 2000, Office of Pipeline Safety corrective action order stated that
Pepco must not operate the Piney Point Oil Pipeline until the company:
28 Pepco Spill Management Team Tabletop Exercise Report, September 1996, prepared by the
Corporate Response Group, Inc., for RSPAís Office of Pipeline Safety.
29 Pepco Spill Management Team Tabletop Exercise Report.
30 Summary of Changes: Ryceville Facility Response Plan ñRevision 3a, dated May 4, 1998.

<<<PAGE 39>>>

Factual Information 31 Pipeline Accident Report
1. Develops adequate repair procedures,
2. 3. Reviews and addresses procedures for leak detection,
Develops a plan with corrective measures to address leak factors including:
ïReview existing instrumentation and improve manual line balance,
ïDevelop and implement a training program for operations personnel,
ïProvide specific procedures and training for pipeline-system monitoring,
ïReview qualifications of operations personnel, and
ïProvide classroom and practical training exercises for the above training
items.
In an amended corrective action order issued on May 4, 2000, the Office of
Pipeline Safety further required Pepco to:
1. [Conduct] Hydrostatic test[s] for integrity of pipe segment from Swanson
Creek to Chalk Point,
2. Review previous internal inspection, make needed repairs, and plan future
inspections,
3. 4. Implement operations procedures for line monitoring during pigging activities,
Review and update schematic drawings.
Pipeline Safety Actions Since Accident
Since the accident, Pepco began and Mirant continued (after its purchase of the
Piney Point Oil Pipeline) to make improvements to comply with, and in some cases
exceed, the Office of Pipeline Safetyís corrective action orders. Mirant prepared an
integrity study to assess the risks posed by pipe wrinkles,31 to establish acceptance criteria
for pipe wrinkles, and to remove all those wrinkles or defects not satisfying the acceptance
criteria. Mirant also developed additional pipeline repair procedures. After all inspections
and replacements were completed, the entire pipeline system was hydrostatically tested.
The transport temperature for No. 6 fuel oil was reduced temporarily from 160° F to
125° F until the influence of heat on pipeline movement could be studied.
Mirant installed supervisory control and data acquisition (SCADA) systems32 with
software-based leak detection and radar tank gauges with remote reading capability on all
Piney Point Oil Pipeline tanks, and the entire set of operations and maintenance
procedures was rewritten. In support of this pipeline integrity focus, two different smart
31 A wrinkle is a smooth wave deflection of the pipe wall and may have a single inward or outward
deflection or may include a sinusoidal waveform with both inward and outward displacements.
32 Pipeline controllers use SCADA systems to remotely monitor and control movement through
pipelines. With a SCADA system, controllers can monitor flow rates and pressures along the lines and
control valves and pumps to adjust the flow at pump stations and locations throughout the pipeline system.

<<<PAGE 40>>>

Factual Information 32 Pipeline Accident Report
pig technologies (ultrasonic and deformation inertial) were employed to inspect the entire
pipeline system in May 2001. Mirant indicated that the evaluations were intended to
provide a substantial new baseline for maintaining pipeline integrity, in addition to
restoring pipeline activities.
Mirant has put in place a new diversified pipeline management team that has
indicated it intends to continue to use industry-recognized pipeline consultants. This team
intends to prepare and manage a long-term integrity plan for the pipeline, consistent with
the integrity management rule in Federal pipeline safety regulations. Mirant has employed
its own pipeline operating personnel, which, Mirant states, have been trained in the new
procedures and equipment. Mirant has implemented an internal audit process that it says
will provide further assurance that all current regulatory and industry best practices are
maintained.
In accordance with the requirements at 49 CFR 194.101, Mirant submitted to
RSPA in December 2001 a spill response plan dated May 2001. RSPA approved the plan
on April 30, 2002. Mirant developed its facility emergency spill response plans with the
assistance of industry experts. During the first 6 months of 2001, three revisions were
made to the Oil Spill Emergency Response Plan for the Ryceville Pumping Station and
Pipeline. Specifically, these changes addressed ownership and nomenclature adjustments,
as well as additional revisions intended to clarify and simplify the plan. On July 27, 2001,
Mirant published Response Strategies for Southern Maryland. Based on ìoperational
experience gained during the Swanson Creek oil spill response and studies,î the manual
was intended to provide tactical response information for use as a pre-planning document
for response managers and crews. The manual identified key control points along and off
the pipeline corridor where response actions might be taken should a release occur. One of
the main elements in the manual was a site summary sheet for each of the primary control
point locations. The summary sheets were prepared with map and chart references with
global positioning system location data, location and general access instructions, general
release/flow paths, information concerning receiving water bodies and selected sensitive
features, and response protocols and tactics. Shortly after the manual was published,
Mirant personnel met with the members of the Local Emergency Planning Committee,
which represents the local public response agencies of the four surrounding counties, to
familiarize them with the implementation of the manual.
In 2001, Mirant conducted 11 drills concerning spill response (2 deployment drills,
5 tabletop drills, and 4 qualified individual notification drills). As of June 1, 2002, Mirant
had conducted four spill response drills (one deployment, one tabletop, and two qualified
individual notification) in 2002.

<<<PAGE 41>>>

Factual Information 33 Pipeline Accident Report
Other Information
Incident Command System
The Incident Command System concept was developed as a consequence of fires
that destroyed significant environmental assets in 1970 in Southern California. Agencies
recognized that they needed a system that allowed them to work together effectively and
efficiently when conducting responses to the broadest range of emergencies, including
incidents involving threats to lives, property, and the environment. A multi-agency task
force subsequently developed the Incident Command System.
The system consists of procedures for controlling personnel, facilities, equipment,
and communications during an incident response. It is designed to be used from the time
an incident occurs until response operations are completed. The Incident Command
System structure has five major functional areasócommand, operations, planning,
logistics, and financeóbut the structure is flexible and can be accommodated to the
specific needs of each response. Consequently, it can be used for any type or size of
incident. It provides a framework under which agencies may communicate and function
using uniform terminology and operating procedures.
The system is widely used by Federal, State, and local responders. Since the
development of the Incident Command System concept, Incident Command System
structures have been used at hundreds of incidents with general success. In February 1996,
the Coast Guard officially adopted the National Interagency Incident Management System
Incident Command System and has developed various training modules for it.
In an April 24, 2001, letter to the Safety Board, the EPA Federal On-Scene
Coordinator for the Chalk Point accident stated that:
EPA currently has no formal policy on the use of Incident Command
System/Unified Command. The National Response Teamís Technical Assistance
document has been distributed to all EPA on-scene coordinator[s], and EPA
headquarters has encouraged the inclusion of the Incident Command
System/Unified Command into their Area Contingency Plans (ACP). However,
EPAís Regions have been provided the flexibility, consistent with the National
Response Teamís Technical Assistance Document, to adopt response management
structures that use an Incident Command System that may be consistent with
National Interagency Incident Management System [NIIMS]. The Region III
Inland Area Contingency Plan calls for a Unified Incident Command System that
is not based on NIIMS.
EPA has provided no written guidance to its regions on the use of Incident
Command System/Unified Command beyond that provided in the National Response
Team Technical Assistance Document Incident Command System/Unified Commandó
Managing Responses to Oil Discharges and Hazardous Substance Releases under the
National Contingency Plan. The National Response Team, with the Regional Response
Teams, constitutes the Federal component of the National Response System. The National
Response Team and Regional Response Teams are made up of 16 Federal departments and

<<<PAGE 42>>>

Factual Information 34 Pipeline Accident Report
agencies. The EPA chairs the National Response Team, and the Coast Guard serves as
Vice Chair.
The EPAís Office of Emergency and Remedial Response is developing an EPA
policy position on the Incident Command System.
Postaccident Assessments of Chalk Point Response
EPA Federal On-Scene Coordinator. In her postaccident report on the Chalk
Point response,33 the EPA Federal On-Scene Coordinator made numerous findings
concerning a wide range of areas in which the response could have been improved and
made suggestions to improve future responses. She acknowledged that the lack of a
National Interagency Incident Management System-based Incident Command System
structure hindered the establishment of resource tracking and accountability as the Chalk
Point incident progressed. She also stated that because local responders were not included
in the immediate response, their capabilities were not effectively used to disseminate
information to the community or to coordinate response efforts.
Regional Response Team. In its April 5, 2001, report on the Chalk Point
accident response,34 the Regional Response Team review committee found that there
appeared to have been no effective response management system, especially early in the
incident. The committee considered that the task-oriented management structure
originally used was not conducive to managing the rapid expansion of a major oil spill.
The committee added that, although each incident is different, major oil spills have
predictable elements that can be managed more effectively via Incident Command/Unified
Command systems. As a result, the Regional Response Team review committee
recommended that, in future incidents, the Incident Command/Unified Command system
be immediately activated at the spill site to ensure that authority and responsibility are
clearly assigned. Further, the Regional Response Team stated that the EPA should develop
a guidance document on how to set up and run Incident Command/Unified Command
systems, train all Federal On-Scene Coordinators in Incident Command/Unified Command
systems, and consider augmenting the Federal On-Scene Coordinator with an Incident
Command System/Unified Command management team.
Coast Guard. In his August 25, 2001, letter addressing lessons learned from the
Chalk Point accident response, the Chief of Marine Safety for the Fifth Coast Guard
District indicated that the significant delay in establishing an Incident Command System
contributed to a fragmented and ineffective response. He further stated:
The Coast Guard has adopted the Incident Command System (ICS) as its
emergency response process. We have found ICS to be a very effective spill
management tool; particularly as the system is used by most State and Local
response entities as well.
33 Environmental Protection Agency, After-Action Report for Emergency Response at the Swanson
Creek Oil Spill Site, Aquasco, Maryland, Prince Georgeís, Charles, Calvert, and St. Maryís Counties 7 April
2000 to 16 May 2000.
34 Swanson Preparedness and Response Review: Swanson Creek Marsh Oil Spill ñ April 2000, Final
Report, dated April 5, 2001.

<<<PAGE 43>>>

Factual Information 35 Pipeline Accident Report
He noted that, although it appeared that the oil was well-contained in the wetlands
early in the response, other factors were at play (wind, predicted storm, etc.) that might
have led experienced response managers to recognize the precarious nature of the
situation. He indicated that responders conducting overflights or other assessment
activities should have analyzed the gathered information more accurately and realized that
the oil was liable to break out of containment and enter the Patuxent River.
He further found that the limited involvement of the local response community had
a negative effect on the response effort. He indicated that local responders play a major
role in site safety, provide local information needed by responders from other areas, and
can help to establish the Unified Command and Incident Command System structures as
soon as they arrive on the scene.
November 2000 Safety Board Hearing on Pipeline Safety
On November 15 and 16, 2000, the Safety Board held a pipeline safety hearing
that focused on pipeline inspection, integrity verification, and leak detection and response.
Participating in the meeting were representatives of Federal agencies, including the Safety
Board, RSPA, and the Office of Pipeline Safety; the pipeline industry, including pipeline
operators, in-line pipeline inspection services, and integrity assessment consultants; and
academia and research institutes.35
In addition to addressing a wide range of other pipeline safety issues, pipeline
industry representatives stressed the need for pipeline leak detection systems to have
accurate pipeline instrumentation located at sensing sites. During the hearing, the RSPA
Administrator stated that, to increase their efficiency, leak detection systems must be less
dependent on the human pipeline controller. Hearing testimony also indicated that many
leaks could be detected in a matter of minutes with a computational pipeline monitoring
system, which would reduce the reliance of pipeline system operating parameters on
human input.
35 For additional information on the presentations made during the November 2000 pipeline safety
hearing, see the Web link at <http://www.ntsb.gov/events/2000/pipeline_hearing/default.htm>.

<<<PAGE 44>>>

36 Pipeline Accident Report
Analysis
The Accident
About 0715 on April 7, 2000, employees of Pepcoís contractor, ST Services,
launched a cleaning pig in flushing oil from Pepcoís Chalk Point Station toward Ryceville
Station on the Piney Point Oil Pipeline. For the next several hours, periodic tank levels
were taken for the Chalk Point (origin) and the Ryceville (destination) Stationsí flushing
oil tanks, but tank volumes were not calculated from the tank level readings and evaluated
for line balance as the pumping operation proceeded. Because the pumping was
progressing faster than expected, ST Services personnel operating the pipeline expected
the cleaning pig to arrive at the Ryceville Station between about 1300 and 1330, but it did
not. The ST Services Chalk Point operator became concerned and double-checked the
tank level about 1412 because the pig had not arrived at Ryceville, and the Chalk Point
pump began cavitating at 1430. About the same time, the flow of oil stopped at the
Ryceville Station.
By 1440, pipeline personnel had initiated the acquisition of current tank level
measurements for line balance calculations at both stations and the checking of the Chalk
Point manifold for misaligned valves. By 1534, they had calculated that Ryceville had not
received 3,089 barrels (129,738 gallons) of the oil that had been pumped from Chalk
Point. At 1538, pipeline operating personnel shut down the pipeline and initiated surface
inspections at locations where the pipeline crosses roads and Swanson Creek to look for
an oil leak. By 1802, a pipeline aerial patrol, which had been launched earlier at the
direction of the Pepco Chalk Point general supervisor for operations, had reported sighting
a pipeline leak in the wetlands near Swanson Creek, not far from the Chalk Point Station.
Postaccident calculations performed by the Piney Point Oil Pipeline owners, which
were based on review of the recorded pipeline pressure information, the operating
conditions at the time of the accident, the size of the crack, and the amount of product
spilled, indicated that the pipe failure occurred before 0930 on April 7, 2000, probably
when the Chalk Point pump was started, about 0715, and the pipeline pressure was at its
highest level. The Safety Board reviewed this analysis and found it credible.
The pipeline ruptured at a wrinkle in a section of pipe that had been field-bent
during initial construction of the pipeline in 1971 and 1972. The deformation, or wrinkle,
that failed was a single outward deflection of the pipe wall, commonly described as a
buckle. After the pipeline was placed in service, forces imposed on the deformed area of
the bend, including the normal operating pressure and thermal cycles in the pipeline,
caused repeated straining and eventual cracking until the pipe at the deformed area failed.

<<<PAGE 45>>>

Analysis 37 Pipeline Accident Report
Pipeline In-line Inspection
Although in-line inspections were not mandated, Pepco maintained a program
under which it periodically had in-line inspections conducted on the Piney Point Oil
Pipeline to help ensure pipeline integrity. Pipetronix, an ultrasonic in-line inspection
contractor, had conducted the last inspection of the pipeline before the accident on
August 16, 1997. When the April 7, 2000, accident occurred, Pepco was preparing the
Piney Point Oil Pipeline for another in-line inspection.
In accordance with its contract with Pepco for the August 1997 in-line inspection,
Pipetronix examined the segment of the Piney Point Oil Pipeline from Ryceville to Chalk
Point to identify corrosion, gouging, pipeline fittings, girth welds, wall thickness changes,
special features, and differentiation between internal and external corrosion. Pipetronix
interpreted and checked the ultrasonic tool data from the inspection using computer-based
systems and manual review by its technicians. The Pipetronix report to Pepco concerning
the in-line inspection results and Pipetronixís interpretation of the results included an
appendix that identified and located various pipeline features by station number.
Pipetronixís interpretation of the ultrasonic tool data contained a significant
inaccuracy for the feature at odometer station 53526.55. This feature, which was found
after the accident to be a buckle but was inaccurately interpreted by the Pipetronix analyst
as a T-piece, failed and resulted in the leak on April 7, 2000. Based on interpretation of the
data available to Pipetronix at the time of the inspection, the Pipetronix analyst should
have interpreted the feature as an ìunknownî because it did not match the signal
characteristic for a T-piece. Had Pepco been notified that the feature was an unknown, it
might have attempted to determine the featureís true characteristics, through excavation or
other means. Therefore, the Safety Board concludes that because Pipetronix incorrectly
interpreted the results of its ultrasonic tool data for the pipeline feature at odometer station
53526.55, Pepco was not alerted to the need for additional evaluation of the pipe at the
location where it subsequently ruptured. After the accident, Pipetronix updated its
reference library and training materials to include the signal characteristics of the outward
protruding buckle that failed in this accident.
Evaluation of Pipe Wrinkles
After the accident, RSPA required Mirant (which became the pipelineís owner
some months after the accident) to prepare an integrity study of the Piney Point Oil
Pipeline before it would allow the pipeline to be returned to service. Data from the 1997
in-line inspection of the pipeline were compared to the actual geometry of various
wrinkles in pipeline bends, obtained after excavating the most severe wrinkles and
determining the geometry by field measurements. After correlation between the in-line
inspection data and the field measurements was completed, the 1997 in-line inspection
data were used as the basis for the evaluation of wrinkles that had not been excavated and
inspected. An analysis was performed to determine if identified wrinkles needed to be
removed. As a result of this work, Mirant developed quantitative acceptance criteria for

<<<PAGE 46>>>

Analysis 38 Pipeline Accident Report
pipe wrinkles remaining in the pipeline. RSPA accepted the analysis that indicated that
some wrinkles could remain in the pipeline, and RSPA allowed the pipeline to return to
service.
Field bends containing wrinkles were installed in pipelines before the hazardous
liquid pipeline safety regulations went into effect in 1970. Since then, pipeline regulations
have prohibited the installation of pipe containing wrinkle bends during pipeline
construction.36 However, pipe wrinkles that were not discovered during the construction
inspection process or that formed sometime after construction are still periodically found
in pipelines.
According to RSPAís pipeline integrity management rule, when an in-line
inspection tool is selected by a pipeline operator to assess the condition of the pipeline, it
must be ìcapable of detecting corrosion and deformation anomalies including dents,
gouges, and groovesî in high-consequence areas.37 The regulation states that ìan operator
must evaluate all anomalies and repair those anomalies that could reduce a pipelineís
integrity.î38 Although the language in this regulation does not specifically designate
wrinkles as a category of deformation anomaly, when questioned by Safety Board staff,
RSPA officials indicated that the regulation applies to wrinkles.
Wrinkles can sometimes be identified through the use of in-line inspection tools.
However, operators do not have nationally recognized quantitative criteria with which to
assess the effect of a specific wrinkle characteristic on a pipe or to determine whether a
pipeline can be safely operated while it contains some wrinkles. Therefore, the Safety
Board concludes that because pipeline operators have no nationally recognized criteria
with which to evaluate pipe wrinkles, they may not be effectively determining whether
pipe containing wrinkles should be allowed to remain in service. The Safety Board
believes that RSPA should establish quantitative criteria, based on engineering
evaluations, for determining whether a wrinkle may be allowed to remain in a pipeline.
Leak Detection
After the Chalk Point leak began, sometime before 0930 on April 7, 2000, it was
hours before those operating the Piney Point Oil Pipeline recognized that a line balance
shortage, which might indicate a leak, was developing. The leak might have been
recognized much sooner if more systematic leak detection procedures and practices had
been in place and used.
During normal deliveries of No. 6 fuel oil to the Chalk Point Generating Station,
Pepcoís automated pipeline monitoring system was designed to provide alarms for
pressure, temperature, and flow rate to the pipeline controller for operating conditions
36 49 CFR 195.212.
37 49 CFR 195.452(c)(1)(i)(A).
38 49 CFR 195.452(h)(1).

<<<PAGE 47>>>

Analysis 39 Pipeline Accident Report
outside of predetermined limits. During the pigging operation on the day of the accident,
however, the meters and pressure-sensing points at Chalk Point were not in the flushing
oilís flow path, and the temperature-sensing equipment was not in the direct flow path to
Ryceville. Thus, Pepcoís automated pipeline monitoring and leak detection system on the
Piney Point Oil Pipeline did not alert the ST Services personnel to the developing
problem.
With respect to manual monitoring of the pipeline, ST Services did not require its
personnel to perform line balance calculations while conducting either normal pipeline or
pigging operations, nor did the procedures in Pepcoís Piney Point Oil Pipeline Manual
include such requirements. Although ST Services personnel took tank level measurements
at both the Chalk Point and Ryceville Stations throughout the morning of April 7, they did
not use this information to evaluate whether product had been lost from the pipeline.
Based on the speed of the pigging operation and his previous experience, the ST Services
Chalk Point operator updated the estimated cleaning pig arrival time at the Ryceville
Station from about 1415 to between 1300 and 1330. Even when the pig failed to arrive
during this period, ST Services personnel still did not evaluate the tank level information
to check the line balance. It was not until the Chalk Point pump began cavitating and the
flow of oil stopped at the Ryceville Station, about 1430, that ST Services personnel
recognized a problem. Between 1440 and 1534, using tank level measurements for line
balance calculations, they determined that Ryceville had not received 3,089 barrels of the
oil that had been pumped from Chalk Point, and they shut the pipeline down at 1538.
On April 7, 2000, therefore, Pepcoís procedures, as provided in the Piney Point Oil
Pipeline Manual, were inadequate because they did not require ST Services personnel to
conduct line balancing during pigging operations, and ST Servicesí practices were
inadequate because they did not include effective line balancing during the pigging
operation. Although some manual tank levels were obtained throughout the day, they were
not evaluated. Had line balance been determined on a timely basis, the line balance
discrepancy would likely have been discovered within about an hour of its occurrence.
The Safety Board concludes that the absence of effective pipeline monitoring procedures
and practices, including periodic line balancing, delayed the discovery of the fuel oil
shortage on April 7, 2000, which delayed the pipeline shutdown and allowed more oil to
leak from the pipeline.
As a result of a pipeline accident in North Blenheim, New York,39 the Safety Board
issued Safety Recommendation P-91-1 to RSPA. It read:
39 National Transportation Safety Board, Liquid Propane Pipeline Rupture and Fire, Texas Eastern
Products Pipeline Company, North Blenheim, New York, March 13, 1990, Pipeline Accident Report
NTSB/PAR-91/01 (Washington, DC: NTSB, 1991).

<<<PAGE 48>>>

Analysis 40 Pipeline Accident Report
P-91-1
Define the operating parameters that must be monitored by pipeline operators to
detect abnormal operations and establish performance standards that must be met
by pipeline monitoring systems installed to detect and locate leaks.
Safety Recommendation P-91-1 is classified ìOpenóUnacceptable Response.î
RSPA, in its 1991 and 1992 responses to the recommendation, indicated that it
intended to conduct a study of SCADA systems. In response to a 1997 follow-up status
inquiry from the Safety Board, RSPA indicated that it would soon issue rulemaking
concerning leak detection standards.
In 1998, RSPA incorporated parts of an industry standard for leak detection, API
Standard 1130, Computational Pipeline Monitoring, in its hazardous liquid pipeline safety
regulations. In 49 CFR Part 195, computational pipeline monitoring is defined as a
ìsoftware-based monitoring tool that alerts the pipeline dispatcher of a possible pipeline
operating anomaly that may be indicative of a commodity release.î Title 49 CFR 195.134,
which is the safety regulation requiring the use of API Standard 1130 for design, applies
when operators are replacing a component of an existing computational pipeline
monitoring system or installing a new computational pipeline monitoring system on a
pipeline; the regulation does not require that such systems be installed.
Since the April 2000 accident, Pepco initiated, and Mirant completed, the
installation of a new SCADA system that meets API Standard 1130, and a pipeline
controller will continuously monitor it. This system includes additional instrumentation,
sensors, and controls, as well as a computer model that uses current pipeline operating
conditions. The system continuously calculates line balances to enable early detection and
warning, and it allows the pipeline controller to initiate remote shutdown. Mirant now
operates the pipeline with its own employees, and the pipeline controller is engaged in
active analysis and monitoring of pipeline operations. Mirant has revised the operating
procedures so that the pipeline controller initiates an immediate shutdown when a flow
shortage outside of predetermined limits is indicated by its new SCADA-based leak
detection system.
At a Safety Board pipeline safety hearing held in November 2000, panelists
discussed various types of automated monitoring systems that make leak detection
possible within a matter of minutes. In contrast, manual line balancing relies on
acquisition of data by pipeline operators. Manual computation and evaluation are then
required to develop the pipeline operating data. The manual process requires more time to
complete than an automated system, and the input data are more susceptible to human
error than data obtained and used by an automated monitoring system.
On December 1, 2000, RSPA issued a new regulation at 49 CFR 195.452,
requiring hazardous liquid operators with 500 or more miles of pipeline to provide
pipeline integrity management. On January 16, 2002, RSPA amended the regulation to
include operators that own or operate less than 500 miles of regulated hazardous liquid

<<<PAGE 49>>>

Analysis 41 Pipeline Accident Report
pipelines. The regulation requires that operators have a ìmeans to detectî leaks on their
pipeline systems in high-consequence areas, but it does not specify what constitutes
adequate means to detect leaks.
RSPA officials met with Safety Board staff on May 16, 2002. In response to Safety
Board staff questions about how RSPA will enforce the new leak detection requirements,
RSPA officials indicated that they are developing specific criteria for defining adequate
leak detection measures and that the criteria will be posted and enforced.40 The Safety
Board supports this effort and encourages RSPA to expedite the development of the
criteria and, as part of the process, to consider increased system automation to ensure
timely leak detection.
Leak-related Notifications
Once the ST Services pipeline operators confirmed that they had a leak, they began
to initiate an emergency response. The emergency response was affected by several
communications breakdowns. Pepco did not provide accurate information about the
volume of the Chalk Point oil release to public agencies, nor did Pepco ensure that its
internal information exchanges were effectively coordinated. The failures left responders
with inadequate information with which to evaluate the threat posed by the release.
In the case of the Chalk Point accident, the response of deploying booms initially
contained the oil spill, despite failures to effectively notify responders about the scope of
the accident and to inform local response agencies early in the response effort. However,
in future incidents involving pipeline leaks, such notification errors could cause
responders to fail to respond with the resources needed to deal with a release, which could
have negative consequences.
Inaccurate National Response Center Notification
Between 1538, when the pipeline was shut down, and 1850, when the National
Response Center received notification of the Chalk Point spill, miscommunications and
the creation of a release estimate lacking any factual basis took place among the various
Pepco officials managing the release. By the time they shut down the pipeline, ST
Services personnel were aware that they had a line balance discrepancy of about
3,000 barrels (126,000 gallons). Sometime before 1620, the ST Services assistant terminal
manager told the Pepco engineering supervisor that the line balance discrepancy was
about 3,000 barrels. The Pepco engineering supervisor informed the Pepco Chalk Point
general supervisor for operations about the discrepancy at 1620, stating that it was about
2,000 to 3,000 barrels. At this time, the Pepco Chalk Point general supervisor for
operations noted in his log that there was a discrepancy of 2,000 barrels.
40 In addition, RSPA is soliciting research proposals to advance leak detection technologies by
improving leak detection timeliness and accuracy and by developing improved means of detecting small
pipeline leaks.

<<<PAGE 50>>>

Analysis 42 Pipeline Accident Report
About 1827, a still more significant error took place concerning the estimation of
the size of the spill. The Pepco Chalk Point shift supervisor told the Pepco qualified
individual (when pressed to provide an estimate) that the amount of the spill was ì1,000
gallons, 2,000 gallons, [expletive] mess, tell them what you want.î This unfounded
estimate was reported to the Pepco Chalk Point general supervisor for operations, who, in
consultation with the Pepco senior environmental coordinator during a phone
conversation, agreed to report a release of 2,000 gallons to the National Response Center
and the Maryland Department of the Environment. About 1840, ST Services provided
additional confirmation to the Pepco Chalk Point general supervisor that the line balance
shortage was approximately 3,000 barrels (126,000 gallons). About 1850, the Pepco
senior environmental coordinator called the National Response Center and reported a
2,000-gallon No. 2 fuel oil release from a pipeline at Pepcoís Chalk Point Generating
Station, even though the Pepco Chalk Point general supervisor had updated information
that the line balance shortage was actually about 3,000 barrels (126,000 gallons).
By 2015, the estimated release amount of 3,000 barrels (126,000 gallons) had been
posted on the Chalk Point command center information blackboard. Shortly after 2100,
the Pepco engineering group confirmed with line balance calculations that the amount of
flushing oil involved in the release was 3,089 barrels (129,738 gallons).
Pepco officials could have updated the National Response Center when they
learned that the information they had initially reported was inaccurate, but they did not.
The Pepco senior environmental coordinator learned within 2 hours that the 2,000-gallon
release estimate he had given the National Response Center did not approach the true
magnitude of the release, but neither he nor any other Pepco manager updated the report.
When asked why he never updated the National Response Center, the Pepco senior
environmental coordinator said he believed that by 2130 on April 7, representatives of all
the notified agencies were on the scene or were in contact with each other. In fact, the EPA
Federal On-Scene Coordinator was not advised of the revised spill estimate until she
arrived at Chalk Point at 1015 on April 8, about 13 hours after Pepco had confirmation
that the likely size of the spill was 3,089 barrels (129,738 gallons). Thus, those oil spill
responders who received notification from the National Response Center were not
informed of the significant size of the product release and the spillís potential impact on
the environment until they arrived on the scene.
During the May 16, 2002, meeting between RSPA officials and Safety Board staff,
RSPA officials stated that National Response Center notification reports are intended to
provide responders, as quickly as possible, the information they need to activate
appropriate resources to control, mitigate, and/or clean up a product spill. Emergency
responders, as well as accident investigators, rely on the information provided by the
National Response Center when preparing their response efforts. Inaccurate or incomplete
information can hamper these activities. For instance, if the initial information reported
erroneously indicates that the release is minor, some Government responders needed on
the scene to carry out containment or mitigation efforts may decide not to respond to the
accident. And if they do respond, they may not bring sufficient resources to manage the
spill. For those Government agencies that send personnel to the accident, the National

<<<PAGE 51>>>

Analysis 43 Pipeline Accident Report
Response Center report may be the only information that the responders have before
arriving on the scene. The more complete the information is, the better prepared
Government responders will be to react to the particular circumstances of the accident.
In addition to the Chalk Point accident, the Safety Board is aware of other cases in
which pipeline owners or operators reporting an incident to the National Response Center
did not update their initial reports when more comprehensive and accurate information
became available.41 The Safety Board concludes that because pipeline owners and
operators sometimes do not update their initial reports to the National Response Center,
the notifications provided to emergency responders may not always contain the complete
and accurate information needed to develop an effective incident response. Therefore, the
Safety Board believes that RSPA should require pipeline owners and operators to provide
follow-up telephone updates to the National Response Center when they discover that the
information they initially reported contains significant errors or when they identify
significant new information directly related to the reporting criteria.
Limited Involvement of Local Response Agencies
Pepco considered that, under the Chalk Point oil spill response plan, the release did
not meet the criteria for notification of local response agencies, which were ìfire,
explosion, personal injury or release or significant threat of release off-site.î Although the
accident might not have immediately met these specific criteria, Pepco should have
realized that the Chalk Point leak, due to its proximity to Swanson Creek, which fed into
the Patuxent River, had the potential for a significant off-site release. However, Pepco did
not contact local response agencies, including the Prince Georgeís County Fire
Department. As a result, the resources of the local response agencies were not utilized as
soon as possible.
In her postaccident review, the EPA Federal On-Scene Coordinator stated that she
believed the exclusion of local responders from the initial response (having been notified
only once State responders were already on-scene) had a negative impact on the response
operations, particularly with respect to the dissemination of information to the community
and the ability to coordinate response efforts. In addition, the Chief of Marine Safety for
the Fifth Coast Guard District stated, in an August 25, 2000, letter addressing lessons
learned from the Chalk Point accident, that the local responders are needed to ensure the
safety of the site, share local knowledge with the spill management team, and mobilize
essential resources to the scene.
Mirant, the current owner of the Piney Point Oil Pipeline, has significantly revised
the oil spill response procedures for the pipeline. In April 2002, RSPA approved Mirantís
oil spill response plan. After the Chalk Point accident, the Oil Spill Emergency Response
Plan for the Ryceville Pumping Station and Pipeline was revised to improve and clarify it.
41 A March 30, 1998, accident in Sandy Springs, Georgia, that was originally reported to the National
Response Center as a release of 150 gallons of gasoline was later found to be a release of over 15,800
gallons. An August 20, 2001, accident in Jackson County, Oklahoma, that was initially reported to the
National Response Center as a release of 8,400 gallons of crude oil was later found to be a release of about
126,000 gallons.

<<<PAGE 52>>>

Analysis 44 Pipeline Accident Report
Further, on July 27, 2001, Mirant published the manual Response Strategies for Southern
Maryland, which was based on ìoperational experience gained during the Swanson Creek
oil spill response and studies.î42 The Safety Board notes that Mirant personnel met with
the members of the Local Emergency Planning Committee, which represents the local
public response agencies of the four surrounding counties, to familiarize the members
with the implementation of the manual. In the less than 2 years since Mirant became the
owner of the pipeline, it has conducted at least 15 drills concerning elements of effective
spill response, and some of the drills have involved local response agencies. The Safety
Board notes these Mirant efforts to provide prompt involvement of local response
agencies in any future emergencies.
Incident Command
The Safety Board found that the lack of effective incident command had a negative
effect on the emergency response to the Chalk Point release. ST Services, Pepco, and spill
recovery contractors on the scene on April 7 and 8, 2000, were initially successful in
deploying a boom system that contained the leading edge of the spill. On the night of
April 8, however, with the arrival of a severe storm that included heavy rains and 50-mph
winds, the boom containment system was overwhelmed. The spill escaped containment
and ultimately traveled an estimated 17 miles (linear) downstream and oiled 40 miles of
shoreline in Prince Georgeís, Charles, Calvert, and St. Maryís Counties. Responders were
unable to effectively mitigate the environmental impact of the oilís entry into the Patuxent
River, due in part to incident management and oversight deficiencies.
The EPA Federal On-Scene Coordinator arrived on the scene at 1015 on April 8
and began attempting to coordinate the Unified Command without establishing an
Incident Command System. Instead, she relied on a project management structure that
gave the responsible party, Pepco, primary responsibility for directing and monitoring the
activities of response contractors. Throughout April 8, the Unified Commandís efforts
were focused on containing the spill within the Swanson Creek wetlands area. Pepcoís
contractors conducted the booming operation based on the directions they received from
Pepco officials, who received their orders from the Unified Command.
Management problems were evident even at this early stage. The Pepco officials
working with the contractors were on rotating 8-hour shifts, and those personnel going
off-duty sometimes did not fully discuss response developments and necessary tasks with
those coming on-duty. This lack of continuity caused problems with task and status
communication and coordination. Instances of miscommunication and problems with
unclear lines of authority occurred. Important meetings were not attended by all necessary
personnel, and Pepco contractors sometimes did not fully understand the tasks they were
42 The manual is intended to provide tactical information for use as a pre-planning document for
response managers and crews. It identifies key control points along and off the pipeline corridor where
response actions may be taken should a release occur. The manual also includes a summary sheet for each of
the primary control point locations.

<<<PAGE 53>>>

Analysis 45 Pipeline Accident Report
assigned. The EPA Federal On-Scene Coordinator also did not have extensive Federal
response resources to draw upon at this time.
A storm was predicted for that evening, and the Unified Command and the EPA
Federal On-Scene Coordinator ordered, and Pepcoís contractors took, reasonable
precautions to maintain the containment they had achieved in the Swanson Creek
wetlands area. However, the storm was more severe than had been anticipated, and the
outer booms at the Patuxent River were breached about 2030, releasing a significant
amount of oil into the river.
For the next 2 days (April 9 and 10), the Unified Command, under the direction of
the EPA Federal On-Scene Coordinator, attempted to mount an effective response to the
oil spillís escape into the river. Significant resource and organizational problems arose
immediately. Pepco had difficulty obtaining contractor resources that could carry out
marine operations, and the EPA Federal On-Scene Coordinator encountered similar
problems when she attempted to augment the response effort with Federal resources. Even
more importantly, the contractors hired by Pepco were not completing urgent assigned
tasks, and the delays in the response effort were not being promptly and accurately
reported to the Unified Command. The EPA Federal On-Scene Coordinator stated that in
the 2 days following the escape of the oil into the river, the Unified Command repeatedly
directed Pepco to ensure that several environmentally sensitive creeks leading into the
river were protectively boomed. According to the EPA Federal On-scene Coordinator,
Pepco repeatedly indicated that appropriate action was being taken and that the booms
would be placed as soon as possible. As of April 11, no booms had been deployed to
protect the creeks, and two creeks showed evidence of oil contamination.
To address the coordination and communication problems and the contractorsí
inability to complete assigned tasks, the EPA Federal On-Scene Coordinator decided that
an Incident Command System structure had to be implemented. Such a system is designed
to provide more direct Federal control over response activities, a quicker response to spill
developments, greater access to a wider range of resources, and better responder
coordination. Consequently, she requested at 1430 on April 10 that Coast Guard officials
assisting on scene develop such a structure. She also urged Pepco to hire a spill
management contractor to improve the logistics of its contractorsí efforts.
On the morning of April 11, the Coast Guard Captain of the Port of Baltimore
arrived with additional personnel to staff the Incident Command System structure that had
been developed. The new personnel were deployed to monitor the field operations being
conducted by Pepcoís contractors to ensure that work was completed as directed. Almost
immediately, with the marshalling of the additional personnel and equipment, the
effectiveness of the recovery operations improved. Protective booms were provided for
the threatened creeks on April 12 and 13. Within days, marine-specialist responders
finished collecting the free oil in the main body of the Patuxent River, and they were able
to concentrate their efforts on oil collection from the affected creeks and other
environmental mediation projects.

<<<PAGE 54>>>

Analysis 46 Pipeline Accident Report
In their postaccident assessments of the Chalk Point accident, both the Coast
Guard and the Regional Response Team review committee concluded that the response
would have benefited from earlier use of an Incident Command System as the incidentís
coordination and management structure. In fact, the Regional Response Team review
committee recommended that the EPA develop a manual on how to use Incident
Command System/Unified Command structures and train all Federal On-Scene
Coordinators in Incident Command System/Unified Command principles. In her own
assessment of the response, the EPA Federal On-Scene Coordinator acknowledged that the
decision not to implement an Incident Command System structure immediately upon her
arrival at the accident scene ultimately had a detrimental effect on the response effort.
Once the oil escaped from containment in the wetlands and the situation became
more complex and difficult to resolve, the short-term project management approach could
not achieve results with the speed and efficiency needed to avoid a serious environmental
impact. The Incident Command System has proven its effectiveness in incidents covering
a wide range of transportation modes, and it has usually improved the management of a
complex incident response effort, such as the one that evolved from the Chalk Point oil
leak. Once the structure was applied at Chalk Point, response efforts soon became more
efficient and successful. The Safety Board concludes that, because it did not initially put a
fully implemented Incident Command System in place, the Unified Command was for
several days unable to mobilize and control an effective response to the loss of oil
containment that took place on the evening of April 8, 2000.
The Safety Board has previously recognized the benefits an Incident Command
System structure may provide during a pipeline spill response effort. As a result of its
investigation of the October 1994 pipeline failures on the San Jacinto River near Houston,
Texas,43 the Safety Board determined that implementing the Unified/Incident Command
structure and operational principles in the National Response Teamís technical assistance
document addressing Incident Command System/Unified Command enhances the overall
preparedness for responding to oil spills. Consequently, the Safety Board recommended
that the National Response Team:
I-96-2
Motivate National Response Team agencies to integrate into their area
contingency plans the command and control principles contained in Technical
Assistance Document Incident Command System/Unified Command and
encourage them to train all personnel assigned management responsibilities in
those principles.
In a January 17, 2001, response to Safety Recommendation I-96-2, the National
Response Team stated that it was working on methods to ensure that all member agencies
have integrated into their area contingency plans the principles contained in the Technical
43 National Transportation Safety Board, Evaluation of Pipeline Failures During Flooding and of Spill
Response Actions, San Jacinto River Near Houston, Texas, October 1994, Pipeline Special Investigation
Report NTSB/SIR-96/04 (Washington, DC: NTSB, 1996).

<<<PAGE 55>>>

Analysis 47 Pipeline Accident Report
Assistance Document Incident Command System/Unified CommandóManaging
Responses to Oil Discharges and Hazardous Substance Releases under the National
Contingency Plan, as requested. The Safety Board classified Safety Recommendation I-
96-2 ìOpenñAcceptable Response,î pending notification that the action is complete.
The National Response Team is made up of 16 Federal departments and agencies.
The EPA is the permanent Chair of the National Response Team. Since the San Jacinto
accident, the EPA has distributed the Technical Assistance Document Incident Command
System/Unified CommandóManaging Responses to Oil Discharges and Hazardous
Substance Releases under the National Contingency Plan to all EPA on-scene
coordinators, and EPA headquarters has encouraged its regional coordinators to
incorporate the guidance from the document in their area contingency plans. Nevertheless,
an EPA official stated in an April 24, 2001, postaccident letter to the Safety Board that
ìEPA currently has no formal policy on the use of Incident Command System/Unified
Command.î The EPA has not mandated that all its regions use the Incident Command
System. Although the EPAís Office of Emergency and Remedial Response is developing
an EPA policy position on the Incident Command System, the Safety Board is concerned
that no final EPA Incident Command System policy, the development of which began in
1996 in response to lessons learned during the 1994 San Jacinto pipeline accident, has
been completed.
The lack of incident command during the Chalk Point emergency response
indicates that the EPA needs to make a greater commitment to incorporating Incident
Command System principles in its response procedures and to training its people more
effectively about the benefits provided by the use of the system. Therefore, to ensure that
the necessity of an effective Incident Command System is understood by EPA responders,
the Safety Board believes that the EPA should require all its regions to integrate the
principles contained in the National Response Teamís Technical Assistance Document
Incident Command System/Unified CommandóManaging Responses to Oil Discharges
and Hazardous Substance Releases under the National Contingency Plan in their area
contingency plans and require the regions to train all personnel who are assigned
responsibility to implement the plans according to those principles.

<<<PAGE 56>>>

48 Pipeline Accident Report
Conclusions
Findings
1. 2. 3. 4. 5. Because Pipetronix incorrectly interpreted the results of its ultrasonic tool data for the
pipeline feature at odometer station 53526.55, the Potomac Electric Power Company
was not alerted to the need for additional evaluation of the pipe at the location where
it subsequently ruptured.
Because pipeline operators have no nationally recognized criteria with which to
evaluate pipe wrinkles, they may not be effectively determining whether pipe
containing wrinkles should be allowed to remain in service.
The absence of effective pipeline monitoring procedures and practices, including
periodic line balancing, delayed the discovery of the fuel oil shortage on April 7,
2000, which delayed the pipeline shutdown and allowed more oil to leak from the
pipeline.
Because pipeline owners and operators sometimes do not update their initial reports
to the National Response Center, the notifications provided to emergency responders
may not always contain the complete and accurate information needed to develop an
effective incident response.
Because it did not initially put a fully implemented Incident Command System in
place, the Unified Command was for several days unable to mobilize and control an
effective response to the loss of oil containment that took place on the evening of
April 8, 2000.
Probable Cause
The National Transportation Safety Board determines that the probable cause of
the April 7, 2000, Piney Point Oil Pipeline accident at the Potomac Electric Power
Companyís Chalk Point, Maryland, generating station was a fracture in a buckle in the
pipe that was undiscovered because the data from an in-line inspection tool were
interpreted inaccurately as representing a T-piece. Contributing to the magnitude of the
fuel oil release were inadequate operating procedures and practices for monitoring the
flow of fuel oil through the pipeline to ensure timely leak detection.

<<<PAGE 57>>>

49 Pipeline Accident Report
Recommendations
As a result of its investigation, the National Transportation Safety Board makes the
following safety recommendations:
To the Research and Special Programs Administration:
Establish quantitative criteria, based on engineering evaluations, for
determining whether a wrinkle may be allowed to remain in a pipeline. (P-
02-01)
Require pipeline owners and operators to provide follow-up telephone
updates to the National Response Center when they discover that the
information they initially reported contains significant errors or when they
identify significant new information directly related to the reporting
criteria. (P-02-02)
To the Environmental Protection Agency:
Require all your regions to integrate the principles contained in the
National Response Teamís Technical Assistance Document Incident
Command System/Unified CommandóManaging Responses to Oil
Discharges and Hazardous Substance Releases under the National
Contingency Plan in their area contingency plans and require the regions to
train all personnel who are assigned responsibility to implement the plans
according to those principles. (P-02-03)
BY THE NATIONAL TRANSPORTATION SAFETY BOARD
MARION C. BLAKEY
Chairman
CAROL J. CARMODY
Vice Chairman
JOHN A. HAMMERSCHMIDT
Member
JOHN J. GOGLIA
Member
GEORGE W. BLACK, JR.
Member
Adopted: July 23, 2002

<<<PAGE 58>>>

this page intentionally left blank

<<<PAGE 59>>>

51 Pipeline Accident Report
Appendix A
Investigation
The National Transportation Safety Board was informed on April 8, 2000, by the
National Response Center of a fuel oil release from a pipeline that had occurred on
April 7, 2000, at Pepcoís Chalk Point Generating Station near Aquasco, Maryland. The
Safety Board launched an investigative team from Washington, D.C., on April 8, 2000,
that comprised operations and emergency response investigators.
No public hearing took place on the accident, and no formal depositions were
taken.
Parties to the investigation were Pepco; Support Terminal Services, Inc.; Mirant
Piney Point, LLP; and the Office of Pipeline Safety.

<<<PAGE 60>>>

Appendix B
Initial Incident Timeline
Day Time April 7, 2000 0715 0830-1400 1430 1440-1534 1538 1550 1620 1643 1802 1807 52 Pipeline Accident Report
Events
Cleaning pig is launched from Chalk Point Station to Ryceville
Station.
Tank level gauges are taken (but not used to compute line
balance) at Chalk Point and Ryceville.
Chalk Point pump begins cavitating. Meter noise and oil flow stops
at Ryceville Station.
Pepco and ST Services personnel determine that, based on tank
level gauge calculations, Ryceville did not receive all oil pumped
from Chalk Point. Shortfall of 3,089 barrels is estimated.
Chalk Point pump is shut down.
ST Services assistant terminal manager begins trying to report
problems to Pepco officials.
Pepco Chalk Point general supervisor for operations is told of line
balance discrepancy of 2,000 to 3,000 barrels and notes shortfall
quantity as ì2,000 barrels.î
Pepco Chalk Point general supervisor for operations orders flight
to locate leak site.
Report from pipeline patrol plane indicates leak at Swanson
Creek.
Chalk Point emergency plan is put into effect.

<<<PAGE 61>>>

53 Pipeline Accident Report
Appendix C
Significant Events From Leak Recognition
to Loss of Containment
Day Time Events
April 7,
2000
1835 Pepco Chalk Point shift supervisor, when pressed, estimates release size
at 1,000 to 2,000 gallons.
1840 ST Services assistant terminal manager confirms in his conversation with
Pepco Chalk Point general supervisor for operations that line balance
discrepancy is about 3,000 barrels.
1850 Pepco senior environmental coordinator reports 2,000-gallon release to
the National Response Center.
1850 Pepco spill response teams deploy floating boom in Swanson Creek
wetlands area.
2015 Pepco Chalk Point command center information board indicates spill
volume of 3,000 barrels.
2030-2100 State and Coast Guard responders begin arriving at site.
2100 Pepco engineering group confirms 3,000-barrel release figure based on
tank level calculations.
2300 Pepco conducts first command post briefing.
April 8,
2000
0250 Coast Guard Federal on-scene representative arrives.
0330-0530 Coast Guard notifies EPA that incident is in the EPAís geographic
jurisdiction and that it will relinquish lead for incident response to EPA
Federal On-Scene Coordinator.
0600 EPA Federal On-Scene Coordinator leaves Philadelphia.
1015 EPA Federal On-Scene Coordinator arrives at accident site and learns
that spill volume is 3,000 barrels.
1600 Unified Command revises storm plan due to worsening weather
forecasts.
2030 Outer booms at the Patuxent River are breached.

<<<PAGE 62>>>

54 Pipeline Accident Report
Appendix D
Significant Environmental Response and Clean-up Events
Day Time Events
April 9, 2000 Before
0700
Oil plume is seen moving from Swanson Creek across the Patuxent
River.
0745 EPA Federal On-Scene Coordinator contacts the Coast Guard
seeking aid in locating marine response resources.
0800-
2000
Pepco contractors attempt to corral the oil plume in the river; they
are unsuccessful.
2100 EPA Federal On-Scene Coordinator orders Pepco to arrange
protective booming of threatened creeks.
April 10, 2000 1200 EPA Federal On-Scene Coordinator and Maryland Department of the
Environment tell Pepco that the response is not adequate; that the
contractors are not being used successfully; and that Pepcoís
progress reports have not reflected the actual status of the response.
1430 EPA Federal On-Scene Coordinator asks on-scene Coast Guard
personnel to develop an Incident Command System.
2100 EPA Federal On-Scene Coordinator again orders Pepco to boom the
creeks.
April 11, 2000 0300-
0715
EPA Federal On-Scene Coordinator again orders Pepco to boom the
creeks. Contamination is seen at two creeks.
1100 Coast Guard representatives arrive on the scene and establish
Incident Command System.
1100-on Pepco hires contract firm to manage its response. Incident
Command System begins to operate. First creek is boomed; booms
are pre-staged at four more creeks.
April 12-13, 2000--- All creeks are boomed. Free oil collection from the Patuxent River is
completed.
April 16, 2000--- Oil collection from creeks is completed.
May 16, 2000--- Emergency response phase is declared over.

## Provenance

- Official: Yes
- Source: <https://www.ntsb.gov/investigations/Pages/DCA00MP006.aspx>
- Source ID: `ntsb-pipeline`
- SHA-256: `59cd8ad6ac6eb85afea17579de7908e5833d359b13690c41e32edb2ae9458e28`
- Retrieved: 2026-08-20T04:57:25.499Z
- Exported: 2026-08-24T05:09:37.386Z
- Document slug: `ntsb-case-dca00mp006`

### Source metadata

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