NTSB Safety Recommendation P-11-003

NTSB safety recommendation P-11-003.

TO THE PACIFIC GAS AND ELECTRIC COMPANY: 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.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2011-06-08

Adopted Date: 2011-05-27

Overall Date Closed: 2012-08-29

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: Pacific Gas and Electric Company

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2012-08-29

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 has made significant progress to address the emergency response issue; however, we point out that Safety Recommendation P-11-3 was classified “Open—Unacceptable Response” (see enclosures) on December 16, 2011, because the process outlined in PG&E’s August 26, 2011, letter lacked sufficient detail and guidance to ensure prompt and immediate notification to 911 emergency call center(s). Specifically, the supervisory control and data acquisition (SCADA) operating data and alarms should be the basis for all 911 notifications. To satisfy Safety Recommendation P-11-3, PG&E needs to do the following: • Establish 911 notification criteria based on the SCADA alarms received, such as loss of pressure, the magnitude and time rate of pressure loss, and changes in flow rates. • Whenever the parameters exceed designated thresholds, gas control room operators should first contact 911, then focus on handling the event (a rupture, valve failure, venting gas, etc.), and, finally, contact corporate management. The NTSB awaits a further response to Safety Recommendation P-11-3 regarding 911 notifications. However, because PG&E has initiated action to address the other issues identified in Safety Recommendation P-11-25, it is classified “Open—Acceptable Response.”

Addressee Acronym: PG&E

Addressee Organization Type: P-Private Industry

Communication Date: 2012-08-29

Communication Type: Official Correspondence

Communication Contents: The NTSB notes that PG&E’s supervisory control and data acquisition (SCADA) operating data and alarms are now the basis for all 911 notifications to ensure prompt and immediate notification to 911 emergency call centers. PG&E established 911 notification criteria based on the SCADA alarms received, such as loss of pressure, the magnitude and time rate of pressure loss, and changes in flow rates. Whenever the parameters exceed designated thresholds, gas control room operators are first, to contact 911; then, to focus on handling the event (for example, a rupture, valve failure, or venting gas); and, finally, to contact corporate management. This revised policy satisfies Safety Recommendation P-11-3, which is classified CLOSED—ACCEPTABLE ACTION.

Addressee Acronym: PG&E

Addressee Organization Type: P-Private Industry

Communication Date: 2011-12-16

Communication Type: Official Correspondence

Communication Contents: The NTSB notes that PG&E implemented a Gas Control Room Process (911 notification process) for its employees to follow whenever an incident has the potential of becoming an emergency that could affect the safety of the public, property, or the environment. However, the process outlined by PG&E lacks sufficient detail and guidance to ensure prompt and immediate notification to the 911 emergency call center(s). Specifically, the NTSB believes that the supervisory control and data acquisition (SCADA) operating data and alarms should be the basis for all 911 notifications. PG&E needs to establish 911 notification criteria based on the SCADA alarms received, such as loss of pressure, the magnitude and time rate of pressure loss, and changes in flow rates. Whenever the parameters exceed designated thresholds, gas control room operators should first contact 911, then focus on handling the event (a rupture, valve failure, venting gas, etc.), and, finally, contact corporate management. Accordingly, we request that PG&E revise its Gas Control Room Process to address the shortcomings identified above. Pending a further response, Safety Recommendation P-11-3 is classified OPEN—UNACCEPTABLE RESPONSE.

Addressee Acronym: PG&E

Addressee Organization Type: P-Private Industry

Communication Date: 2011-08-26

Communication Type: Official Correspondence

Communication Contents: CC# 201100322: - From Christopher P. Johns, President: In your June 8 letter, you requested that PG&E respond within ninety days with the actions we have taken or intend to take to implement the recommendation. PG&E is fully committed to working expeditiously and cooperatively with the National Transportation Safety Board, the California Public Utilities Commission and other stakeholders to restore public confidence in the safety and integrity of our natural gas transmission system. Ensuring effective and timely emergency response to both potential and actual emergency gas events is critical to protecting public safety and restoring that confidence. To that end, PG&E established and has put into place the attached Gas Control Room Process (911 Notification Process) pursuant to which PG&E Gas Control will notify the appropriate 911 agency whenever an incident has the potential of becoming an emergency operating condition that may affect the safety of the public, property or the environment. PG&E will also be evaluating industry best practices in this area and will incorporate such practices as appropriate into its procedures. PG&E is dedicated to taking all of the steps necessary to ensure public safety and the integrity of our gas pipeline systems. PG&E's actions in response to the NTSB's Safety Recommendation are an important step in that process.

Addressee Acronym: PG&E

Addressee Organization Type: P-Private Industry

Communication Date: 2012-05-23

Communication Type: Official Correspondence

Communication Contents: -From Christopher P. Johns, President: Pacific Gas and Electric Company (PG&E) is making substantial progress to implement the safety recommendations outlined by the National\ Transportation Safety Board's (NTSB) investigation of the September 2010 San Bruno pipeline accident. This status report details the actions PG&E has taken and will continue to take to assure public safety remains the company's highest priority in the operation of our natural gas transmission system. We have made many fundamental changes to the operations and management practices throughout our gas organization. Some of the more critical actions include: completion of the Maximum Allowable Operating Pressure validation of all 2,088 miles of high consequence area (HCA) pipelines; validation of 1,032 miles of non -HCA pipelines through April 2012; and automation of 36 valves. In 2011, PG&E conducted strength tests and verified strength test pressure records for a total of approximately 214.5 miles of pipeline. Additionally, from January through April 2012, an additional 37.6 miles have been tested or verified. PG&E's Pipeline Safety Enhancement Plan (PSEP), currently before the CPUC for approval in R.11-02-019, outlines our plan for testing or verifying records of 547 miles in 2012 -2014. PG&E has modified its 911 Notification Process to respond to the NTSB's suggestion that SCADA real time operating data and alarms serve as triggers for 911 notifications. We have developed a comprehensive emergency response procedure for large-scale emergencies on transmission lines, which identifies a single person in charge, outlines specific protocols and provides for drills and training. PG&E has also incorporated performance measures and guidelines to assure continuous improvement in our public awareness program. PG&E has initiated a complete assessment of every aspect of our transmission integrity management program including threat identification and assessment. Much more work lays ahead, but the progress to date gives us confidence that PG&E is on track to achieving the goal of regaining the trust of the public and our regulators by demonstrating our steadfast commitment to safety. The attachment to this letter provides a more detailed summary of each NTSB recommendation and the steps we have taken and continue to take to act upon them. If you have any questions, please contact me directly. PG&E has modified its initial 911 Notification Process based on the feedback received from the NTSB that SCADA real time operating data and alarms should be used to make 911 notifications. The modification of the process requires PG&E's control room operators to make the 911 Notification immediately based on the following SCADA alarm conditions: • relief valve open alarm venting gas to atmosphere • automatic shut off valve closed alarm indicating isolation of a section of pipeline • activation of a pressure drop -rate high alarm indicating a high differential across one of the newly installed remote control isolation valves • activation of a La-La pressure alarm indicating possible pipeline rupture (confirmed valid by verification of upstream and downstream pressure sites and correlated supply source metered flow increase) "In the event of an emergency operating condition that is known to be or has the possibility of impacting the public, property, or the environment, Gas Control is required to immediately notify the responsible 911 Emergency Response Center(s) to establish 'situational awareness'''. The 911 Notification Procedure details the communication protocol required to ensure the establishment of situational awareness of the emergency operating condition: 1. The Senior Transmission Coordinator will make the required immediate notification to the responsible 911 Emergency Response Center(s) using the Gas Control Contact Number Matrix, located in Section 2.4 of the Control Room Management Operations Manual. 2. The Senior Transmission Coordinator will provide a detailed description of the incident to the 911 dispatcher providing the following: Name of Senior Transmission Coordinator making the call Trigger indicator prompting 911 Notification Location or approximate location of incident Contact number to notify Gas Control if any additional updates are received ETA of PG&E First Responders if they are not yet on the scene. 3. The Senior Transmission Coordinator will also obtain the follOWing information from the dispatcher at the responsible 911 Emergency Response Center(s). Name of dispatcher Any information the 911 Emergency Response Center(s) have regarding the nature of the incident, its location or pipeline marker. Are Emergency Response Agencies on Site? Additional contact number to reach 911 Emergency Response Center(s) for any additional information.