NTSB Safety Recommendation P-02-004

NTSB safety recommendation P-02-004.

The National Transportation Safety Board therefore makes the following safety recommendation to the Pipeline and Hazardous Materials Safety Administration (Originally issued to RSPA): Develop and issue guidance to pipeline operators on specific testing procedures that can (1) be used to approximate actual operations during the commissioning of a new pumping station or the installation of a new relief valve, and (2) be used to determine, during annual tests, whether a relief valve is functioning properly.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2002-10-11

Adopted Date: 2002-10-08

Overall Date Closed: 2006-05-03

Synopsis: About 3:28 p.m. on June 10, 1999, a 16-inch-diameter steel pipeline owned by Olympic Pipe Line Company ruptured and released about 237,000 gallons of gasoline into a creek that flowed through Whatcom Falls Park in Bellingham, Washington. About 1 1/2 hours after the rupture, the gasoline ignited and burned approximately 1 1/2 miles along the creek. Two 10-year-old boys and an 18-year-old young man died as a result of the accident. Eight additional injuries were documented. A single-family residence and the city of Bellingham's water treatment plant were severely damaged. As of January 2002, Olympic estimated that total property damages were at least $45 million.

Probable Cause: The National Transportation Safety Board determined that the probable cause of the June 10, 1999, rupture of the Olympic pipeline in Bellingham, Washington, was (1) damage done to the pipe by IMCO General Construction, Inc., during the 1994 Dakin-Yew water treatment plant modification project and Olympic Pipe Line Company’s inadequate inspection of IMCO’s work during the project; (2) Olympic Pipe Line Company’s inaccurate evaluation of in-line pipeline inspection results, which led to the company’s decision not to excavate and examine the damaged section of pipe; (3) Olympic Pipe Line Company’s failure to test, under approximate operating conditions, all safety devices associated with the Bayview products facility before activating the facility; (4) Olympic Pipe Line Company’s failure to investigate and correct the conditions leading to the repeated unintended closing of the Bayview inlet block valve; and (5) Olympic Pipe Line Company’s practice of performing database development work on the supervisory control and data acquisition (SCADA) system while the system was being used to operate the pipeline, which led to the system’s becoming non-responsive at a critical time during pipeline operations.

Ntsbnumber: DCA99MP008

Report Number: PAR-02-02

Addressee Name: RSPA

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2006-05-03

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2003-11-21

Communication Type: Official Correspondence

Communication Contents: The Safety Board notes that RSPA will issue an advisory bulletin by December 2003 to provide guidance to pipeline operators on testing procedures for control and relief valves. The guidance will address the issue of testing a control valve that can operate as a pressure-reducing valve, a flow controller, or a relief valve. Pending issuance of an advisory bulletin as described above, Safety Recommendation P-02-4 is classified "Open--Acceptable Response."

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2004-11-24

Communication Type: Official Correspondence

Communication Contents: Update requested

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2006-05-03

Communication Type: Official Correspondence

Communication Contents: The Safety Board notes that on August 10, 2005, PHMSA issued Advisory Bulletin ADB 05-5, which provides guidance to pipeline operators on inspecting and testing procedures for pilot-operated relief valves. The guidance applies to used, new, replaced, or relocated pilot-operated relief valves, and is also used during periodic inspection and testing of these valves. ADB 05-5 provides specific steps that operators' valve inspection and testing procedures should include to determine whether these valves function properly. The issuance of ADB 05-5 completes the recommended action; accordingly, Safety Recommendation P 02-4 is classified "Closed-Acceptable Action."

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2003-08-28

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 9/3/2003 9:47:07 AM MC# 2030442 This is the Research and Special Programs Administration's (RSPA) response to the National Transportation Safety Board (NTSB) Safety Recommendations P-02-04 and P-02-05, resulting from the hazardous liquid pipeline accident in Bellingham, Washington. RSPA requests that these recommendations be classified as "OPEN - Acceptable Action" based on proposed advisory bulletins on 1) testing protocols for control/relief valves and 2) modification procedures for Supervisory Control and Data Acquisition (SCADA) systems to address systems development and operations issues. Although Recommendation P-02-05 calls only for an advisory bulletin, RSPA has taken additional actions to improve SCADA and controller operations and our inspection process. RSPA has initiated a SCADA study to establish a national and uniform perspective on the safety evaluation of pipeline SCADA technology. In addition to developing inspection and guidance criteria, the project will also draw on the results of the NTSB's ongoing SCADA survey and report. RSPA has also initiated a study of Controller Certification in compliance with Section 13(b) of the Pipeline Safety Improvement Act of 2002 to develop tests and other requirements for certifying the qualifications of individuals who operate computer-based systems for controlling the operations of pipelines.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2005-11-10

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 11/28/2005 2:28:39 PM MC# 2050545 This letter explains how our August 10 Advisory Bulletin on pilot-operated relief valves (copy enclosed) relates to the safety and reliability of these valves. We recently met with members of your staff, Rod Dyck, Associate Director, Pipeline Division, and Robert Trainor, Associate Director, Hazardous Materials Division, and they suggested an explanation would be a helpful addition to our August 23 letter which requested closure of Recommendation P-02-04 based on publication of the Advisory Bulletin. Recommendation P-02-04 resulted from a 1999 gasoline pipeline accident in Bellingham, Washington which the National Transportation Safety Board (NTSB) attributed, in part, to improper configuration of a pilot-operated relief valve. A key finding in the NTSB's report was the operator's testing procedure was inadequate to reveal the pilot had been reconfigured improperly and would not work reliably. Based on this finding and the recommendation, the Advisory Bulletin provides six steps that operators' valve inspection and testing procedures should include. The steps help guide compliance with relevant rules (49 CFR 195.262(c) and 195.428) and ensure the valves will work properly after installation and pilot reconfiguration. The first step includes quality assurance and control measures for proper valve installation. Operators are to review relevant information and make sure the valve is compatible with particular pipeline characteristics and conditions. Also, they are to make sure the valve conforms to the purchase order and manufacturer's model, service, and configuration specifications. Lastly, they are to ensure that activation of the pilot valve at the set pressure opens the in-line valve. Opening the in-line valve confirms correct configuration of the pilot and ensures the test approximates actual operation of the relief valve. The second step concerns reconfiguration or repair of the pilot assembly on previously installed valves. For this work, our personnel qualification rules (49 CFR Part 195, Subpart G) require operators to employ personnel with appropriate training, knowledge, skills, and abilities. The Advisory Bulletin adds that operators are to do the work according to the valve manufacturer's specifications. More important, they are to ensure that activation of the pilot valve at the set pressure opens the in-line valve. However, triggering a relief valve could be risky if the valve's vent piping is not connected to a holding tank, as may be the case on a few older pipelines. The Advisory Bulletin provides that if venting would be unsafe or environmentally harmful, operators are to test the pilot at least twice and make sure it activates consistently at the set pressure. The third and fourth steps help operators discover design and installation flaws that a single set pressure test might not reveal. In the third step, operators are to make sure the set pressure is consistent with the design and configuration of the pilot and in-line valve. In this step, they also make sure the set pressure is consistent with use of the relief valve for primary overpressure protection or for backup protection. The fourth step advises operators to test the pilot at least twice and make sure it activates consistently at the set pressure. Both steps apply during installation testing and annual testing. The fifth step will help operators find maintenance errors that could affect valve reliability. During annual testing, operators are to review the valve installation to see if it has changed since the last inspection. If it has changed, operators are to make sure the pilot sensor and inlet and vent piping are consistent with the intended design. Finally, the sixth step supports accountability and enables trend analyses. This step advises operators to document the other steps. It also advises them to sign, date, and keep all documentation for the life of the valve. During development of the Advisory Bulletin, we sought the opinion of our pipeline safety advisory committees and the American Petroleum Institute. We believe the information they gave us helped make the Advisory Bulletin's guidance useful and meet the objectives of Recommendation P-02-04, By following the guidance, operators can prevent repetition of events that caused the valve failure in the Bellingham accident. Sincerely, Stacey L. Gerard, Acting Assistant Administrator/Chief Safety Officer

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2005-08-23

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 8/30/2005 8:56:30 AM MC# 2050395 This recommendation resulted from a pipeline rupture and release of gasoline into a creek near Whatcom Falls Park in Bellingham, Washington. The NTSB listed several items as probable cause. Among them was the failure by the pipeline operator to ensure the proper working condition of relief valves associated with a new pumping station. In response to P-02-04, PHMSA issued advisory bulletin ADB-05-05 (70 FR 46569; August 10, 2005) about pilot-operated pressure relief valves installed in hazardous liquid pipelines. The bulletin provides pipeline operators guidance on whether their inspection and test procedures are adequate to decide if these valves work properly. In the bulletin, PHMSA advises operators of hazardous liquid pipelines to review their in-service inspection and test procedures on their used, new, replaced, or relocated pilot-operated pressure relief valves during periodic inspection and testing of these valves. Before publication, PHMSA obtained advice on the matter from its technical advisory committee at a May 2005 meeting. A copy of the advisory bulletin is enclosed.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2005-02-28

Communication Type: Official Correspondence

Communication Contents: In its 2/28/2005 report to Congress, "Open Statutory Mandates Regarding Pipeline and Hazardous Materials Safety," the DOT wrote: RSPA expects to publish bulletin and request closure in early February 2005.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2006-04-14

Communication Type: Official Correspondence

Communication Contents: In its 4/14/2006 report to Congress, "National Transportation Safety Board (NTSB) and DOT Office of Inspector General (OIG): On August 10,2005, PHMSA published an advisory bulletin that provides pipelme operators guidance on whether their inspection and test procedures are adequate to determine if these valves function properly. On August 23,2005, PHMSA submitted B letter to NTSB requesting closure. In September, PHMSA met with NTSB representatives and at their request provided supplemental background information on our request for elosure. The supplemental information was sent to the NTSB on November 10, 2005.