NTSB Safety Recommendation P-07-009

NTSB safety recommendation P-07-009.

TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Require an operator to revise its pipeline risk assessment plan whenever it has failed to consider one or more risk factors that can affect pipeline integrity.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2007-06-25

Adopted Date: 2007-06-14

Overall Date Closed: 2009-09-18

Synopsis: About 11:15 a.m. central daylight time on October 27, 2004, an 8-inch-diameter pipeline owned by Magellan Midstream Partners, L.P., (Magellan) and operated by Enterprise Products Operating L.P. (Enterprise) ruptured near Kingman, Kansas, and released approximately 4,858 barrels (204,000 gallons) of anhydrous ammonia. Nobody was killed or injured due to the release. The anhydrous ammonia leaked into a creek and killed more than 25,000 fish including some from threatened species. Enterprise reported that the cost of the accident was $680,715, including $459,415 for environmental remediation.

Probable Cause: The National Transportation Safety Board determines that the probable cause of the pipeline rupture near Kingman, Kansas, on October 27, 2004, was a pipe gouge created by heavy equipment damage to the pipeline during construction in 1973 or subsequent excavation activity at an unknown time that initiated metal fatigue cracking and led to the eventual rupture of the pipeline. Contributing to the severity of the accident was the pipeline controller’s failure to accurately evaluate available operating data and initiate a timely shutdown of the pipeline.

Ntsbnumber: DCA05MP001

Report Number: PAB-07-02

Addressee Name: PHMSA

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2009-09-18

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2009-09-18

Communication Type: Official Correspondence

Communication Contents: The NTSB notes that PHMSA reviewed its inspection protocols and process for adequacy. PHMSA reports that its inspections provide a comprehensive and systematic approach to evaluating operator compliance with all integrity management program requirements in 49 Code of Federal Regulations (CFR) 195.452 and that it believes its inspection protocols explicitly address the completeness of an operator’s risk analysis. To support the inspection protocols, PHMSA developed comprehensive enforcement guidance to assist its inspectors in evaluating integrity management programs, which detail the explicit steps that must be followed to select the appropriate enforcement action and to determine the relative severity of the issues identified in the inspection. This guidance provides additional information to help inspectors ensure that an operator has complied with all requirements and draws on the risk factors listed in 49 CFR 195.452, Appendix C to Part 195, and the API (American Petroleum Institute) Standard 1160, Managing System Integrity for Hazardous Liquid Pipelines. When operators fail to consider one or more risk factors, PHMSA will address deficiencies through enforcement actions. PHMSA’s integrity management enforcement guidance has been revised to include the following explicit direction to inspectors and regional directors who prepare enforcement cases: If one or more of the probable violations or inadequate procedures deals with the incomplete consideration of risk factors, then the proposed compliance order or Notice of Amendment must explicitly direct the operator to consider all risk factors in revising its information/risk analysis, periodic evaluations, assessment plans, and determining necessary preventive and mitigative measures. Because PHMSA revised its integrity management enforcement guidance to ensure that operators revise their pipeline risk assessment plans when it is found that they have failed to consider one or more risk factors that affect pipeline integrity, Safety Recommendation P-07-9 is classified Closed Acceptable Action.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2008-01-22

Communication Type: Official Correspondence

Communication Contents: The Safety Board notes PHMSA’s willingness to review the regulations that require operators to develop a comprehensive risk analysis process and to consider all relevant risk factors. The Board also notes that PHMSA has found that 37 percent of hazardous liquid operators have failed to comply with the regulations and has taken appropriate enforcement action to address deficiencies. Although PHMSA believes its current regulations contain explicit risk analysis criteria, the Board is pleased that PHMSA will consider modifying the language in its enforcement actions to explicitly require the operator to ensure that it addresses all risk factors. Therefore, pending further information from PHMSA regarding this issue, Safety Recommendation P-07-009 is classified Open Acceptable Response.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2007-10-29

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 10/29/2007 12:02:52 PM MC# 2070611: : Regarding NTSB Safety Recommendation P-07-09, PHMSA reviewed its current regulations to ensure that they are adequate. The Federal pipeline safety regulations require operators to develop a comprehensive risk analysis process and consider all relevant risk factors (49 CFR § 195.452(e)). During our integrity management inspections for hazardous liquid operators, we found that 37 percent of the operators failed to adequately develop a comprehensive risk analysis, and where appropriate, we have addressed deficiencies through enforcement actions. PHMSA also reviewed its inspection protocols for adequacy, and found that they contain explicit risk analysis criteria. Based on the NTSB recommendation, however, PHMSA is considering modifying the language in its enforcement actions to explicitly require the operator to ensure that it addresses all risk factors. We will update you on the status of these initiatives this fall.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2008-10-02

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 10/9/2008 1:34:43 PM MC# 2080615: 10-2-08: PHMSA reviewed its regulations and finds that we do require consideration of all relevant risk factors. The Federal pipeline safety regulations (195.452 (g)) specify that the operator’s risk analysis process must consider all available information concerning the likelihood and consequences of pipeline failures. The application of the risk analysis in assessment schedule development (195.452(e)(1)), evaluation of preventive and mitigative measures (195.452(i)(2)). and periodic evaluations (195.452(i)(2)) requires consideration of all important risk factors. Furthermore, Frequently Asked Questions (FAQs) on PHMSA’s Implementing Integrity Management web site (https://primis.phmsa.dot.gov/iim/index.htm) further reinforce the need for a complete consideration of risk factors and a comprehensive risk analysis. The following FAQs all relate to risk factor consideration in integrity management programs: 3.3, 3.21, 4.7, 5.10, 8.11, 8.14, 8.15, 9.2, 9.4, and 9.8. PHMSA has also reviewed its inspection protocols and process for adequacy. PHMSA’s inspections provide a comprehensive and systematic approach to evaluating operator compliance with all integrity management program requirements in 195.452. PHMSA’s inspection protocols explicitly address the completeness of an operator’s risk analysis. Specifically Protocol 5.1 requires the inspector to: Verify that the operator’s process for evaluating risk requires consideration of all relevant risk categories and operating' conditions when evaluating pipeline segment risk. To support use of the protocols, PHMSA has developed a comprehensive set of inspection enforcement guidance to assist inspectors in evaluating operator integrity management programs. This guidance is an internal document used following each inspection to guide regional personnel in the preparation of enforcement cases following an integrity management inspection. It details the explicit steps that must be followed to select the appropriate enforcement action and to determine the relative severity of the issues identified in the inspection. This guidance provides additional information to help inspectors assure an operator has complied with the above-referenced requirements, and draws on the risk factors listed in 195.452, Appendix C to Part 195, and the API Standard 1160, Managing System Integrity for Hazardous Liquid Pipelines.” When operators failed to consider one or more risk factors, PHMSA has for years now, where appropriate, addressed these deficiencies through enforcement actions. Based on the NTSB recommendation, however, PHMSA has decided to modify our integrity management enforcement guidance to add the following explicit direction to inspectors and regional directors who prepare enforcement cases: If one or more of the probable violations or inadequate procedures deals with the incomplete consideration of risk factors, then the proposed compliance order or Notice of Amendment must explicitly direct the operator to consider all risk factors in revising its information/risk analysis, periodic evaluations, assessment plans, and determining necessary preventive and mitigative measures. Based on the above PHMSA action, this letter requests closure of Safety Recommendation P-07-9 and requests it is classified as Closed--Acceptable Action. If you have questions, please feel free to contact me at 202-366-4433. Respectfully, Rick Kowalewski, Acting Assistant Administrator/Chief Safety Officer