NTSB Safety Recommendation P-02-005

NTSB safety recommendation P-02-005.

The National Transportation Safety Board therefore makes the following safety recommendations to the Research and Special Programs Administration: Issue an advisory bulletin to all pipeline operators who use supervisory control and data acquisition (SCADA) systems advising them to implement an off-line workstation that can be used modify their SCADA system database or to perform developmental and testing work independent of their on-line systems. Advise operators to use the off-line system before any modifications are implemented to ensure that those modifications are error-free and that they create no ancillary problems for controllers responsible for operating the pipeline.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2002-10-11

Adopted Date: 2002-10-08

Overall Date Closed: 2004-03-03

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: 2004-03-03

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 on July 16, 1999, RSPA issued an advisory bulletin to operators of gas and hazardous liquid pipeline systems on the need to review the capacities of their SCADA systems to operate under abnormal situations. RSPA indicates that it will prepare and issue an additional advisory bulletin to all pipeline operators who use SCADA systems. The notice will address systems development and operations coordination and will advise pipeline operators to establish thorough testing regimes for their SCADA systems for application when modifications or enhancements are being designed and implemented. It will recommend that changes be developed and tested first on off-line workstations, then deployed on-line under close monitoring at times when there are a minimum number of operational changes expected on the pipeline. The Safety Board also notes that 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 draw on the results of the Safety Board's SCADA survey and report. By the end of 2003, RSPA will review how SCADA systems are referenced, directly or indirectly, in the pipeline safety regulations. In early 2004, RSPA will revise SCADA inspection protocols. Later in 2004, RSPA will begin development of a multi-tier SCADA inspection approach. The Safety Board further notes that RSPA has also initiated a study of controller certification, and that Section 13(b) of the Pipeline Safety Improvement Act of 2002 directs the Secretary of Transportation to develop tests and other requirements for certifying the qualifications of individuals who operate computer-based systems for controlling the operations of pipelines. The Safety Board appreciates RSPA's providing these details. Safety Recommendation P-02-5 is classified "Open--Acceptable Response" pending completion of the recommended advisory bulletin.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2004-03-03

Communication Type: Official Correspondence

Communication Contents: The Safety Board notes that on December 23, 2003, RSPA issued an advisory bulletin to all pipeline operators who use SCADA systems, as requested. Accordingly, Safety Recommendation P-02-5 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: 2003-12-23

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 12/30/2003 2:43:28 PM MC# 2030613 RSPA issued an advisory bulletin as requested.