NTSB Safety Recommendation P-07-010

NTSB safety recommendation P-07-010.

TO ENTERPRISE PRODUCTS: Provide initial and recurrent training for all controllers that includes simulator or noncomputerized simulations of abnormal operating conditions that indicate pipeline leaks.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2007-06-25

Adopted Date: 2007-06-14

Overall Date Closed: 2010-01-27

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.

Keywords: Training and Education

Ntsbnumber: DCA05MP001

Report Number: PAB-07-02

Addressee Name: Enterprise Products Partners L.P.

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2010-01-27

Addressee Organization Type: P-Private Industry

Communication Date: 2009-10-05

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 10/9/2009 3:14:39 PM MC# 2090632 - From Terry Hurlburt, Senior Vice President, Operations: This letter is in response to the letter from the NTSB, dated August 23,2009, on to the above referenced recommendation issued June 25, 2007 to Enterprise Products Operating LLC. (Enterprise). Enterprise's response to the recommendation is as follows: Enterprise provided non-computerized simulation training of abnormal operating conditions that indicate a possible pipeline leak to all liquid pipeline controllers on 5-Mar-2009, and on 13-Mar-2009. Enterprise implemented and pilot tested a liquid pipeline simulator in December of 2008 and began using the simulator to train controllers in January of2009. To date 61% of our Liquid Controllers have successfully completed the computerized simulator training. Enterprise will require that all liquid controllers take this simulator training initially and annually thereafter not to exceed 18 months. Each Controller will be required to successfully identify an abnormal operating condition, recognize a possible pipeline leak and take appropriate actions.

Addressee Organization Type: P-Private Industry

Communication Date: 2008-08-06

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 8/28/2008 10:33:02 AM MC# 2080499 - From Terry Hurlburt, Senior Vice President, Operations: This letter is in response to the above referenced recommendation issued June 25,2007 to Enterprise Products Operating LLC. (EPOLLC). EPOLLC’s response to the recommendation is as follows: EPOLLC provided non-computerized simulation training of abnormal operating conditions that indicate a possible pipeline leak to all liquid pipeline controllers on 10-Nov-2004, and on 29-Nov-2006, and we plan to conduct this training again in 2008. EPOLLC is in the final phases of developing and implementing a computerized liquid pipeline simulator for the purpose of training liquid pipeline controllers to identify abnormal operating conditions that indicate a possible pipeline leak. EPOLLC expects this simulator to be in operation by the end of 2008. EPOLLC will require that all liquid controllers take this simulated training initially, and on an annual calendar year basis and successfully identify abnormal operating conditions that indicate a possible pipeline leak. Should a liquid pipeline controller not be able to successfully identify the abnormal operating condition, that individual will receive additional training until they are able to successfully complete the computer simulated abnormal operating conditions that indicate a possible pipeline leak. Please contact us if you have any questions. Terry Hurlburt, Sr. V.P. Operations, Enterprise Products Operating L.L.C. P.O. Box 4324 Houston, Texas 77210-4324, 713-880-6500; 2727 North Loop West Houston, Texas 77008-1044 www.epplp.com

Addressee Organization Type: P-Private Industry

Communication Date: 2010-01-27

Communication Type: Official Correspondence

Communication Contents: Enterprise held a pilot test of its newly implemented liquid pipeline simulator in December 2008. The following month, it began using the simulator to train controllers, and, on March 5 and 13, 2009, Enterprise provided non-computerized simulation training of abnormal operating conditions that indicate a possible pipeline leak. To date, 61 percent of the liquid controllers have successfully completed the computerized simulator training; all liquid controllers will be required to take this simulator training initially and will receive refresher training every 12 to 18 months. In addition, each controller will be required to successfully identify an abnormal operating condition, recognize a possible pipeline leak, and take appropriate actions. These actions by Enterprise fully satisfy Safety Recommendation P-07-10; accordingly, the recommendation is classified CLOSED -- ACCEPTABLE ACTION.

Addressee Organization Type: P-Private Industry

Communication Date: 2009-01-05

Communication Type: Official Correspondence

Communication Contents: The Safety Board notes that Enterprise provided non-computerized simulation training of abnormal operating conditions that indicate a possible pipeline leak to all liquid pipeline controllers on November 10, 2004, and again on November 29, 2006, and planned to conduct this training again in 2008. The Board further notes that Enterprise is in the final phases of developing and implementing a computerized liquid pipeline simulator for the purpose of training liquid pipeline controllers to identify abnormal operating conditions that indicate a possible pipeline leak. Mr. Hurlburt advised the Board that Enterprise expects this simulator to be in operation by the end of 2008 and that the company will require all liquid controllers to take this simulated training initially and annually thereafter; following training, any controller who is unable to identify conditions that could indicate a leak will be retrained. The Safety Board is pleased that Enterprise is taking action to implement the recurrent controller training. Pending notification that the planned computerized liquid pipeline simulator training proram has been implemented, Safety Recommendation P-07-10 is classified OPEN -- ACCEPTABLE RESPONSE.