# NTSB Safety Recommendation P-10-002 - **operation:** document - **citation:** P-10-002 - **title:** NTSB Safety Recommendation P-10-002 - **source type:** guidance - **agency:** National Transportation Safety Board - **status:** guidance - **official:** true - **published on:** 2011-01-03 - **effective on:** 2011-01-03 - **summary:** TO THE PACIFIC GAS AND ELECTRIC COMPANY: Aggressively and diligently search for all as-built drawings, alignment sheets, and specifications, and all design, construction, inspection, testing, maintenance, and other related records, including those records in locations controlled by personnel or firms other than Pacific Gas and Electric Company, relating to pipeline system components, such as pipe segments, valves, fi - **machine formats:** - **json:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-10-002.json - **markdown:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-10-002.md - **app url:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-10-002 - **source url:** https://data.ntsb.gov/carol-main-public/sr-details/P-10-002 **body:** NTSB safety recommendation P-10-002. TO THE PACIFIC GAS AND ELECTRIC COMPANY: Aggressively and diligently search for all as-built drawings, alignment sheets, and specifications, and all design, construction, inspection, testing, maintenance, and other related records, including those records in locations controlled by personnel or firms other than Pacific Gas and Electric Company, relating to pipeline system components, such as pipe segments, valves, fittings, and weld seams for Pacific Gas and Electric Company natural gas transmission lines in class 3 and class 44 locations and class 1 and class 25 high consequence areas6 that have not had a maximum allowable operating pressure established through prior hydrostatic testing. These records should be traceable, verifiable, and complete. (Urgent) Priority: CLASS I Overall Status: Closed - Acceptable Action Issued Date: 2011-01-03 Adopted Date: 2010-12-30 Overall Date Closed: 2012-03-13 Synopsis: On September 9, 2010, about 6:11 p.m. Pacific daylight time,1 a 30-inch-diameter natural gas transmission pipeline (Line 132) owned and operated by Pacific Gas and Electric Company (PG&E) ruptured in a residential area in the city of San Bruno, California. The accident killed eight people, injured many more, and caused substantial property damage. The rupture on Line 132 occurred near milepost 39.33, at the intersection of Earl Avenue and Glenview Drive in San Bruno. About 47.6 million standard cubic feet of natural gas were released as a result of the rupture. The rupture created a crater about 72 feet long by 26 feet wide. A ruptured pipe segment about 28 feet long was found about 100 feet away from the crater. The released natural gas was ignited sometime after the rupture; the resulting fire destroyed 37 homes and damaged 18. Probable Cause: The National Transportation Safety Board determines that the probable cause of the accident was the Pacific Gas and Electric Company's (PG&E) (1) inadequate quality assurance and quality control in 1956 during its Line 132 relocation project, which allowed the installation of a substandard and poorly welded pipe section with a visible seam weld flaw that, over time grew to a critical size, causing the pipeline to rupture during a pressure increase stemming from poorly planned electrical work at the Milpitas Terminal; and (2) inadequate pipeline integrity management program, which failed to detect and repair or remove the defective pipe section. Ntsbnumber: DCA10MP008 Report Number: PAR-11-01 Addressee Name: Pacific Gas and Electric Company Addressee Status: Closed - Acceptable Action Addressee Date Closed: 2012-03-13 Addressee Acronym: PG&E Addressee Organization Type: P-Private Industry Communication Date: 2012-03-13 Communication Type: Official Correspondence Communication Contents: The NTSB notes that PG&E completed the requested search for as-built drawings, alignment sheets, and specifications, and for design, construction, inspection, testing, maintenance, and other related records, for 2,000 miles of pipelines located in HCAs. These efforts included searching for records related to pipeline system components outside PG&E (such as pipe segments, valves, fittings, and weld seams for PG&E natural gas transmission lines in class 3 and class 4 locations and in class 1 and class 2 HCAs) for which no MAOP has been established through prior hydrostatic testing. These actions satisfy Safety Recommendation P-10-2, which is classified CLOSED—ACCEPTABLE ACTION. Addressee Acronym: PG&E Addressee Organization Type: P-Private Industry Communication Date: 2011-11-23 Communication Type: Official Correspondence Communication Contents: -From NTSB. –To: Christina Sames, Vice President Operations and Engineering, American Gas Association. NOT TO THE ADDRESSEE. NOT TO PGE. Thank you for your June 14, 2011, letter, regarding Safety Recommendations P-10-01 through -04, which the National Transportation Safety Board (NTSB) issued on January 3, 2011, regarding the San Bruno, California, pipeline accident. Safety Recommendation P-10-01 was issued to the Pipeline and Hazardous Materials Safety Administration (PHMSA), and Safety Recommendations P-10-02 through -04 were issued to the Pacific Gas and Electric Company (PG&E); all were urgent recommendations. The San Bruno pipeline accident report and the related safety recommendation issuance letters are posted on the NTSB’s website at http://www.ntsb.gov/doclib/reports/2011/PAR1101.pdf and http://www.ntsb.gov/recsletters/ DisplayLetters.aspx?FolderYR=2011, respectively. Your interpretations of our intent in issuing these recommendations, stated in your letter, are correct. To address another of your concerns, the NTSB does not intend for Federal or state agencies to codify the language from our safety recommendations directly into state and Federal rules and regulations. We believe that each agency should develop appropriate language for its own rules and regulations, to address and accomplish the intent of our safety recommendations. Of particular concern to you and your organization is the requirement for a postconstruction hydrostatic pressure test. For pipelines constructed before 1970 that were not required to be hydrostatically tested, 49 Code of Federal Regulations (CFR) 192.619(a)(3), commonly referred to as the “grandfather clause,” allows the maximum allowable operating pressure (MAOP) to be based on “the highest actual operating pressure to which the segment was subjected during the 5 years preceding … July 1, 1970.” In contrast to MAOP based on hydrostatic pressure testing, the grandfather clause does not specify a minimum amount of time that the historical pressure must have been held to be used as the basis for the MAOP. Studies have shown that hydrostatic pressure testing is most effective when it incorporates a spike test in which the pipeline is initially pressurized to a higher level for a short time. Accordingly, the NTSB recommended that PHMSA amend 49 CFR 192.619 to delete the grandfather clause and to require that all gas transmission pipelines constructed before 1970 be subjected to a hydrostatic pressure test that incorporates a spike test. Additional information regarding this safety recommendation can be obtained in our San Bruno pipeline accident report, at the address cited above. The NTSB considers the San Bruno accident report and the safety recommendations issued as a result of our findings, to be of the utmost importance to the gas pipeline industry and to the American people. We encourage all involved interests, including the AGA, to ensure that pipelines are maintained properly and are operated safely. Thank you for your interest in these very important pipeline safety issues. Should you require any additional information or clarification, please contact us. Addressee Acronym: PG&E Addressee Organization Type: P-Private Industry Communication Date: 2011-03-14 Communication Type: Official Correspondence Communication Contents: The NTSB is pleased with the following actions that PG&E is taking to implement these recommendations: • PG&E’s business lead for this records verification project reports directly to the Senior Vice President, Engineering and Operations. • PG&E has retained numerous leading external partners to lend specialized expertise and significant additional resources to this process in the areas of document management, process controls, engineering, pipeline pressure calculations, and auditing. • PG&E has leased new space to house the record verification operations and has built out space in its existing facilities to accommodate this activity. • PG&E has collected hundreds or boxes of original records from over 20 field office and other locations across the service territory, and document scanning and indexing operations are proceeding 24 hours a day, 7 days a week. PG&E further reports it is using the scanned and indexed records to verify the completeness of pressure test records and other applicable records used to establish each line’s maximum allowable operating pressure (MAOP) per industry standards and Federal code compliance. Over the next 6 weeks, PG&E will determine the total number of miles for which it has complete, verifiable, and traceable records of prior pressure tests, and will start the process of using all available verified records identified in the collection, scanning, and indexing process to compile a segment-by-segment pipeline features list. Where necessary, PG&E will perform excavations to verify pipeline features. In the end, as directed by the California Public Service Commission, the MAOP will be validated based on the weakest segment in the transmission pipeline sections of these Class 3 and 4 locations and Class 1 and 2 high consequence areas. In addition, PG&E reports it is taking all steps to ensure the safety and integrity of its gas pipeline systems, including verifying the underlying records of over 1,800 miles of pipeline by March 15, 2011. Because these actions, when completed, should satisfy Safety Recommendations P-10-2 through -4, the recommendations are classified OPEN – ACCEPTABLE RESPONSE. Addressee Acronym: PG&E Addressee Organization Type: P-Private Industry Communication Date: 2011-02-02 Communication Type: Official Correspondence Communication Contents: CC# 201100045: - From Christopher P. Johnson, President: On January 3, 2011, the National Transportation Safety Board (NTSB) issued several Safety Recommendations to PG&E and others arising out of its ongoing investigation into the tragic accident in San Bruno, California, on September 9, 2010. In your January 3 letter, you requested that PG&E respond within thirty days with the actions we have taken or intend to take to implement your recommendations. PG&E is fully committed to working expeditiously and cooperatively with the NTSB, the California Public Utilities Commission (CPUC) and other stakeholders to restore public confidence in the safety and integrity of our natural gas transmission system. Ensuring the completeness and the accuracy of PG&E's system records is absolutely fundamental to this effort. As you know, the same day that the NTSB issued these Safety Recommendations to PG&E and sent related Safety Recommendations P-10-5 through P-10-7 to the CPUC, the CPUC's Executive Director sent PG&E a directive to implement the NTSB's Safety Recommendations. The Executive Director's letter was subsequently ratified by CPUC Resolution L-410. On January 7, 2011, PG&E responded to the CPUC's letter, with a description of the scope of the task and the efforts already underway. Yesterday we provided the CPUC with a more detailed update on the work and the plan going forward. A copy of each of our letters is enclosed. PG&E is dedicated to taking all steps to ensure the safety and integrity of our gas pipeline systems, including the monumental effort of verifying the underlying records of over 1,800 miles of pipeline by March 15th. In the meantime, however, if you have any questions, please do not hesitate to contact me. A January 7, 2011 letters from Pacific Gas and Electric to the California Public Utilities Commission: PG&E is fully committed to working expeditiously and cooperatively with the Commission to restore public confidence in the safety and integrity of our natural gas transmission system. Ensuring the completeness and the accuracy of PG&E's system records is absolutely fundamental to this effort. Accordingly, our customers and the Commission have PG&E's pledge that verifying its gas system records is among PG&E's most immediate and highest priorities. As you know, following the San Bruno accident, we discovered a discrepancy in OUI' records. A discrepancy of this nature is not acceptable to us, We initiated a comprehensive records review for the approximately 150 miles of transmission pipeline on the San Francisco Peninsula, Your directive following this week's National Transportation Safety Board (NTSB) recommendations calls on us to extend this type of review to approximately 1,800 miles of transmission pipelines in class 3 and class 4 locations and class I and class 2 high consequence areas throughout our service area. Your January 3, 2011, letter directed PO&E to undertake specific actions in response to the NTSB recommendations and requested that we confirm by today whether this work could be completed by February 1, 2011. PG&E recognizes and supports the urgency surrounding this work and is moving forward aggressively. Our first step, already under way, is to gather all hydrostatic and other pressure test information to verify which pipeline segments have had their maximum allowable operating pressure established through pressure testing. Although we maintain a centralized data base that indicates that the majority of the 1,800 miles of pipeline have been pressure tested, we understand that your directive requires us to review and verify the original paper records, which currently are kept in local offices and records storage facilities. As pal1 of this process, we will also be collecting images of the original records in a centralized system, which is consistent with our understanding of your request. A February 1, 2011 letters from Pacific Gas and Electric to the California Public Utilities Commission: In our January 7, 2011, letter to you we committed to provide the California Public Utilities Commission (Commission) with an update of our progress in fulfilling the directives in your January 3, 2011 letter, ratified by the Commission through Resolution 1.,-410 on January 13, 2011. PG&E is aggressively and diligently working to meet the expectations of the Commission to perform our records review and verification work by March 15, 2011. This letter provides an update on PG&E's work and plan going forward. The Commission's directive applies to over 1,800 miles of gas transmission pipelines in Class 3 and Class 4 locations, and Class I and 2 high consequence areas throughout PG&E's service territory. Consistent with federal regulations, not all of these lines require a pressure test-established maximum allowable operating pressure (MAOP); nevertheless, we are in the process of verifying the number of these pipeline miles for we have records of pressure tests, containing the information required by 49 C.F.R. § 192.517(a). The foundational step and PG&E's initial focus have been collecting, scanning and indexing an estimated 1.25 million individual records associated with approximately 2,750 "job numbers" from PG&E's hard copy records into its electronic database. It is critical to the remainder of this records verification and validation effort that tbis first step provide comprehensive, high quality electronic documentation of PG&E's gas transmission system. Toward that end, the entire process is being subjected to detailed quality assurance oversight, as described in more detail below. As part of the first phase of this records verification project, PG&E has taken the following actions: • PG&E's business lead for this records verification project reports directly to the Senior Vice President, Engineering & Operations. The business lead oversees an internal team of over 50 engineers, estimators, mappers, information technology specialists and managers dedicated exclusively to the project; this team will continue to grow. • PG&E has retained numerous leading external partners to lend specialized expertise and significant additional resources to this process in the areas of document management, process controls, engineering, pipeline pressure calculations, and auditing. For example, Iron Mountain, Inc., a leading global document management company, is dedicating over 230 staff to assist PG&E in timely completing the document collection, scanning and indexing operation. • PG&E has leased new space to house the record verification operations as well as built out space in its existing facilities to accommodate this activity. Progress to date on this project includes: • Document scanning and indexing operations are proceeding 24 hours-a-day, seven days-a-week. • PG&E has collected hundreds or boxes of original records from over 20 field office and other locations across the service territory. • At this stage, PG&E is scanning and indexing tens of thousands of these documents each day. PG&E is using the scanned and indexed records to verify the completeness of pressure test records and other applicable records used to establish each line's MAOP per industry standards and federal code compliance. Over the next six weeks, PG&E will determine the total number of miles for which it has complete, verifiable and traceable records of prior pressure tests. At the same time, PG&E will start the process of using all available verified records identified in the collection, scanning and indexing process to compile a segment-bysegment pipeline features list (PFL). Where necessary, PG&E will perform excavations to verify pipeline features. In the end, as directed by the Commission, MAOP will be validated based on the weakest segment in these Class 3 and 4, and Class I and 2 HCA transmission pipeline sections. PG&E is dedicated to taking all steps to ensure the safety and integrity of our gas pipeline systems, including Addressee Acronym: PG&E Addressee Organization Type: P-Private Industry Communication Date: 2011-06-14 Communication Type: Official Correspondence Communication Contents: From The American Gas Association, NOT FROM THE ADDRESSEEE. NOT FROM PGE. –From Christina Sames, Vice President, Operations and Engineering, American Gas Association: The American Gas Association (AGA) has reviewed the safety recommendations issued by the National Transportation Safety Board (NTSB) on January 3, 2011 (P-10-1 through P-10-7). As is our practice, AGA forwarded the recommendations to its member companies. AGA has received a number of questions from its members regarding the' NTSB recommendations and is therefore seeking clarification. Our members, who operate approximately 50,000 miles of transmission pipeline, have been actively engaged in following the developments of the investigation and have been considering how that information should be used to reduce the probability of similar incidents on their system. To that end, the NTSB's recommendations serve as prudent guidance regarding potential safety problems that operators may need to act on if it addresses a relevant factor on their system. Given these recommendations have not gone through the cost-benefit analysis, public notice and comment due process or analysis for potential adverse consequences, which are all normal steps in the rulemaking process, it is assumed these recommendations should not be considered a regulatory mandate nor should they be followed verbatim if the circumstances are not applicable for their system. To ensure appropriate response, AGA is seeking clarification from the NTSB that it did not intend for federal or state regulators to codify the exact language in the safety recommendations into state and federal pipeline safety codes which are applicable to all operators. In many cases, the safety recommendations appear to conflict with existing language, in other instances, the recommendations omit key provisions of the pipeline safety regulations. The clarification of the intended scope and applicability of the safety recommendations will allow operators nationwide to focus finite resources on appropriate areas that will provide real improvement in pipeline safety rather than diluting efforts in as that were never intended by the NTSB. Specific NTSB safety: recommendations that AGA believes should be clarified to achieve a consistent interpretation across the natural gas industry include P-10-1 to P-:-10-4 as follows. P-10-001: Please clarify the NTSB's intent relative to recommendation P-10-1. AGA believes the NTSB intended that PHMSA should inform pipeline operators of the circumstances and consequences surrounding the pipeline rupture in San Bruno and that, based on this information, operators should take appropriate action, if necessary, to conduct additional records searches based on the unique circumstances of their individual systems. AGA believes that the NTSB did not intend all natural gas transmission pipeline operators to implement an exhaustive records search or the other provisions detailed in recommendations P-10-2 to P-10-4 (below). P-10-002: Please clarify the NTSB's intent related to recommendation P-10-2. AGA believes that the NTSB intended that the recommendation to "aggressively and diligently search for all as-built drawings, alignment sheets, and specifications, and all design, construction, inspection, testing, maintenance, and other related records" applied exclusively to Pacific Gas and Electric Company or other operators who in individually determine the need to conduct a detailed records search for their natural gas transmission lines in class 3 and class 4 locations and class 1 and class 2 high consequence areas that have not had a maximum allowable operating pressure (MAOP) established through prior hydrostatic or pressure testing. AGA also requests that the NTSB clarify its use of the term "hydrostatic testing." AGA believes the intent of the recommendation was to focus the record search on pipelines where MAOP has not been previously established through "pressure testing" in accordance with 49 CFR Part 192, Subpart J add 192.619 (see the request for clarification to P-10-4 below). AGA also requests clarification for transmission pipelines installed prior to the enactment of Subpart J. AGA believes the phrase "established through prior hydrostatic pressure testing" is meant to address the stability of transmission pipeline longitudinal seams through a post construction pressure test and no a requirement to have all pipelines be tested to Subpart J standards. Finally, AGA requests that the NTSB provide clarification to the phrase "traceable, verifiable and complete". AGA believes that the recommendation was intended to direct Pacific Gas and Electric to identify records confirming the strength of the line pipe and related components from the time of construction. In the event that the appropriate records are unavailable for any reason, AGA believes the N SB intended PG&E, or other operator who individually determines the need to conduct a detailed records search, to make a conservative default assumption relative to the strength of the respective pipe or components. P-10-003: Please clarify the NTSB's intent related to recommendation P-10-3. AGA believes that the NTSB intended the recommendation to use traceable, verifiable, and complete records located by implementation of P-0-2 to determine the valid MAOP of natural gas transmission lines in class 3 and class 4 locations and class 1 and class 2 high consequence areas that have not had an MAOP established through prior hydrostatic or pressure testing to apply exclusively to Pacific Gas and Electric Company or those operators who individually determine the need to re-establish the MAOP of natural gas transmission lines based on the information contained in the PHMSA Advisory. As noted in the response to P-10-2 (above) and P-10-4 (below), please clarify NTSB's intent that the MAOP could have been previously established using "pressure testing" as defined by the provisions of 49 CFR Part 192, Subpart J and 1 2.619. P-10-004: Please clarify the NTSB's intent related to recommendation P-10-4. AGA believes that the NTSB intended for recommendation P-10-4, requiring natural gas transmission pipelines in class 3 and class 4 locations and class 1 and class 2 high consequence areas that have not had a maximum allowable operating pressure established through "prior pressure testing" to have the MAOP determined by a spike test followed by a hydrostatic pressure test, to apply exclusively to Pacific Gas and Electric Company. AS the NTSB noted in the safety recommendations, an operator may not be able to comply with safety recommendations P-10-2 and P-10-3. Operators have stated before the California Public Utility Commission (CPUC) that "traceable, verifiable and complete records for pipelines installed over 50 years ago was a very difficult, if not infeasible threshold to achieve." The phrase is not used in applicable regulations. As the NTSB noted, "Although hydrostatic testing is recognized to be a direct and effective methodology for validating an MAOP, its implementation requires that operating lines be shut down, which may adversely affect customers dependent on the natural gas supplied by the pipeline, particularly if the pipe fails during the test, which could necessitate a protracted shutdown." In addition, AGA notes that by placing water, a corrosive fluid, in a pipeline there is a very real possibility of introducing an unintended consequence of internal corrosion to the pipeline if the water is not eliminated completely after the hydro-test. Complete dehydration is extremely difficult for a pipeline that has already been placed into se ice and lines that include certain valves and laterals. Since the pipeline safety code, 49 CFR Part 192 -Transportation of Natural Gas by Pipeline: Minimum Federal Safety Standards, was established in 1970, operators and regulators have been very clear on the regulatory requirements for establishing the MAOP of new, r Addressee Acronym: PG&E Addressee Organization Type: P-Private Industry Communication Date: 2011-12-22 Communication Type: Official Correspondence Communication Contents: -From Christopher P. Johns, President: Pacific Gas and Electric Company (PG&E) has fully embraced the safety recommendations outlined by the National Transportation Safety Board (NTSB) as part of the agency's review of the September 2010 San Bruno pipeline accident. We at PG&E recognize the importance of preventing a tragedy like this from ever happening again, and we are grateful for the NTSB's guidance toward that goal. As requested in your September 26, 2011 letter, we are providing an update on the actions PG&E is taking, and the plans that are in place to implement the NTSB's thoughtful and thorough recommendations. These recommendations have prompted PG&E to take significant actions on many fronts, including pipeline leak and break identification, emergency response, integrity management, threat assessments, public awareness of pipeline safety measures, and recordkeeping. The NTSB's recommendations have helped propel PG&E to make fundamental changes to our operations and management-all intended to underscore our commitment to putting public and employee safety first. For example, we've completed Maximum Allowable Operating Pressure validation of more than 1,600 miles of high consequence area pipelines, with plans to complete all 2,000 miles by the end of January 2012. We are implementing a new data management system intended to address the NTSB's recommendations for traceable, verifiable and complete records. Additionally, PG&E has automated 11 shutoff valves in 2011. As part of the company's Pipeline Safety Enhancement Plan, which was presented for approval to the California Public Utilities Commission this year, PG&E has proposed automating a total of 228 valves through 2014. We've also updated our emergency response plans to reflect industry best practices and have begun training employees, public officials and first responders. In an effort to improve public gas safety awareness, we've mailed more than two million safety information letters to customers who live within 2,000 feet of a transmission pipeline. We realize we still have much to learn and do in the wake of the tragic San Bruno accident. As you'll see in the attachment, we have completed several of the recommendations and are in mid-stream on the remainder. We're working with urgency to complete all of the recommendations and we remain steadfast in our commitment to safety and to regaining the trust of the public and our regulators. The attachment to this letter provides a more detailed summary of each NTSB recommendation and the steps we are taking to act upon them. If you have any questions, please contact me directly. • PG&E has completed an aggressive and diligent search for as-built drawings, alignment sheets, and specifications, and design, construction, inspection, testing, maintenance, and other related records for 2,000 miles of pipelines located in high consequence areas. o This also includes searching for records in locations outside of PG&E. related to pipeline system components, such as pipe segments, valves, fittings, and weld seams for Pacific Gas and Electric Company natural gas transmission lines in class 3 and class 4 locations and class 1 and class 2 HCAs that have not had an MAOP established through prior hydrostatic testing. Addressee Acronym: PG&E Addressee Organization Type: P-Private Industry Communication Date: 2013-09-09 Communication Type: Official Correspondence Addressee Acronym: PG&E Addressee Organization Type: P-Private Industry Communication Date: 2013-09-04 Communication Type: Official Correspondence - **truncated:** false - **body characters:** 29230