# NTSB Safety Recommendation P-11-002

- **operation:** document
- **citation:** P-11-002
- **title:** NTSB Safety Recommendation P-11-002
- **source type:** guidance
- **agency:** National Transportation Safety Board
- **status:** guidance
- **official:** true
- **published on:** 2011-06-08
- **effective on:** 2011-06-08
- **summary:** TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Issue guidance to operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines regarding the importance of control room operators immediately and directly notifying the 911 emergency call center(s) for the communities and jurisdictions in which those pipelines are located when a possible rupture of any pipeline is indica
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- **source url:** https://data.ntsb.gov/carol-main-public/sr-details/P-11-002
**body:**

NTSB safety recommendation P-11-002.

TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Issue guidance to operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines regarding the importance of control room operators immediately and directly notifying the 911 emergency call center(s) for the communities and jurisdictions in which those pipelines are located when a possible rupture of any pipeline is indicated. (Superseded by P-11-9)

Priority: CLASS II

Overall Status: Closed - Superseded

Issued Date: 2011-06-08

Adopted Date: 2011-05-27

Overall Date Closed: 2011-09-26

Synopsis: On September 9, 2010, about 6:11 p.m. Pacific daylight time,1 a 30-inch-diameter underground natural gas transmission pipeline (which is identified by the company as Line 132), owned and operated by Pacific Gas and Electric Company (PG&E), ruptured in a residential area in San Bruno, California. The accident killed eight people, injured many more, and caused substantial property damage. The rupture on Line 132 occurred near mile point 39.28, 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 released natural gas was ignited after the rupture; the subsequent explosion created a crater about 72 feet long by 26 feet wide, and the resulting fire destroyed 38 homes and damaged 70. A ruptured pipe segment about 28 feet long was found about 100 feet away from the crater.

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: PHMSA

Addressee Status: Closed - Superseded

Addressee Date Closed: 2011-09-26

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2011-09-26

Communication Type: Official Correspondence

Communication Contents: From the greensheet issuing recommendations P-11-8 through P-11-20 to the Pipeline and Hazardous Materials Administration as a result of the September 9, 2010 pipeline rupture in San Bruno, California: The NTSB noted that PG&E did not notify emergency officials that the accident involved the rupture of one of PG&E’s pipelines, even after they had deduced this to be the case. On June 8, 2011, the NTSB made the following recommendations to address these issues. Specifically, the NTSB recommended that the Pipeline and Hazardous Materials Safety Administration (PHMSA) do the following: Issue guidance to operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines regarding the importance of sharing system-specific information, including pipe diameter, operating pressure, product transported, and potential impact radius, about their pipeline systems with the emergency response agencies of the communities and jurisdictions in which those pipelines are located. (P-11-1) Issue guidance to operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines regarding the importance of control room operators immediately and directly notifying the 911 emergency call center(s) for the communities and jurisdictions in which those pipelines are located when a possible rupture of any pipeline is indicated. (P-11-2) To PG&E, NTSB recommended the following: Require your control room operators to notify, immediately and directly, the 911 emergency call center(s) for the communities and jurisdictions in which your transmission and/or distribution pipelines are located, when a possible rupture of any pipeline is indicated. (P-11-3) Because of emergency response awareness issues discovered in the Carmichael, Mississippi, and San Bruno investigations, the NTSB is concerned that similar problems may exist with other pipeline operators and believes that the guidance recommended in Safety Recommendations P-11-1 and -2 should be codified as requirements. To address these concerns, the NTSB recommends that PHMSA require operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines to provide system-specific information about their pipeline systems to the emergency response agencies of the communities and jurisdictions in which those pipelines are located. This information should include pipe diameter, operating pressure, product transported, and potential impact radius. As a result of this new recommendation to PHMSA, Safety Recommendation P-11-1 is classified “Closed—Superseded.” Further, the NTSB recommends that PHMSA require operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines to ensure that their control room operators immediately and directly notify the 911 emergency call center(s) for the communities and jurisdictions in which those pipelines are located when a possible rupture of any pipeline is indicated. As a result of this new recommendation to PHMSA, Safety Recommendation P-11-2 is classified CLOSED—SUPERSEDED.
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