NTSB Safety Recommendation P-11-007

NTSB safety recommendation P-11-007.

TO THE UNITED STATES DEPARTMENT OF TRANSPORTATION: Ensure that the Pipeline and Hazardous Materials Safety Administration amends the certification program, as appropriate, to comply with the findings of the audit recommended in Safety Recommendation P-11-6.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2011-09-26

Adopted Date: 2011-09-12

Overall Date Closed: 2015-11-02

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: DOT

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2015-11-02

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2015-02-10

Communication Type: Recommendation Reiteration

Communication Contents: -From the Safety Study "Integrity Management of Gas Transmission Pipelines in High Consequence Areas" (SS-15-01, Notation 8565A, adopted January 27, 2015) The NTSB reiterated Safety Recommendation P-11-7. In 2011, as a result of the San Bruno, California, incident investigation (NTSB 2011), the NTSB concluded that oversight of state public utility commissions needed improvement and recommended59 that USDOT conduct an audit of PHMSA’s state pipeline safety program certification program. The DOT Inspector General (DOT IG) completed this audit in May 2014, analyzing all aspects of the state pipeline safety program (not only IM) and finding deficiencies in the following areas: PHMSA’s formula for calculating staffing levels, qualifications for leading inspections, guidelines for scheduling and conducting inspections, reviews of grant expenditures, evaluation of states’ compliance with program requirements, and the use of grant funds for fiscally challenged states (USDOT 2014). The NTSB also issued a companion safety recommendation,60 which recommended that USDOT make certain that the state pipeline safety program certification program is modified to incorporate the results of this audit. The NTSB reiterates Safety Recommendation P-11-7 to USDOT to ensure that PHMSA amends the certification program, as appropriate, to comply with the findings of the audit recommended in Safety Recommendation P-11-6.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2013-09-30

Communication Type: Official Correspondence

Communication Contents: This letter concerns 22 open safety recommendations that the National Transportation Safety Board (NTSB) issued to the US Department of Transportation (USDOT) between 1997 and 2013. Enclosure 1 is a list of these recommendations; Enclosure 2 is a copy of the correspondence history regarding them. The NTSB is currently reviewing a July 24, 2013, update from the Pipeline and Hazardous Materials Safety Administration regarding Safety Recommendations I-02-1 and -2, which will be addressed in separate correspondence. We recently corresponded with the Federal Aviation Administration regarding Safety Recommendation A-06-43; Enclosure 3 provides a more detailed history of correspondence regarding this recommendation. The NTSB is interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. We are concerned because we have not received updates regarding action either taken or planned to address the remaining 19 open recommendations for some time—in some cases, over 10 years. We would like to point out that, when we issue a safety recommendation directly to the USDOT rather than to an individual modal agency, we do so because the scope of the recommendation falls outside the authority of the modal agency, or for some other specific reason. Failure to address these important safety issues places the public at risk.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2012-01-31

Communication Type: Official Correspondence

Communication Contents: The NTSB notes that the DOT will conduct an audit of the effectiveness of PHMSA’s oversight of performance-based pipeline safety programs to address Safety Recommendation P-11-4 and will review its enforcement policies and procedures as recommended in Safety Recommendation P-11-5. We also note that, to address Safety Recommendation P-11-6, the DOT Inspector General has been scheduled to audit PHMSA’s State pipeline safety certification program. In addition, the PHMSA Administrator has been directed to ensure that the certification program is amended, as appropriate, to comply with the findings of the audit. Pending completion of these efforts, Safety Recommendations P-11-4 through -7 are classified OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2014-07-29

Communication Type: Official Correspondence

Communication Contents: We have reviewed the audit report that the Office of Inspector General issued on May 7, 2014, PHMSA’s State Pipeline Safety Program Lacks Effective Management and Oversight, Pipeline and Hazardous Materials Safety Administration, Report Number: AV-2014-041. The report satisfies Safety Recommendations P-11-4 through -6; accordingly, these recommendations are classified "Closed--Acceptable Action." We look forward to receiving information regarding action you are taking to address Safety Recommendation P-11-7. In the meantime, this recommendation is classified OPEN--ACCEPTABLE RESPONSE.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2015-07-15

Communication Type: Official Correspondence

Communication Contents: On January 31, 2012, because the DOT Inspector General (DOT IG) planned to audit PHMSA’s state pipeline safety certification program and PHMSA had been directed to ensure that the certification program was amended, as appropriate, to address any deficiencies that the auditors identified, we classified Safety Recommendations P-11-6 and -7 “Open—Acceptable Response” pending completion of those actions. On June 29, 2014, upon review of the DOT IG’s May 2014 report, PHMSA’s State Pipeline Safety Program Lacks Effective Management and Oversight, PHMSA Report Number AV 2014 041, we classified Safety Recommendation P-11-6 “Closed—Acceptable Action.” Safety Recommendation P 11 7 remained classified “Open?Acceptable Response” pending completion of PHMSA’s actions in response to the DOT IG’s recommendations. We understand that you have implemented six of the DOT IG’s seven recommendations, numbers 2 through 7, and that your proposed plan, which the DOT IG has approved, is to revise the Staffing Formula for States by July 31, 2015, thus addressing DOT IG recommendation 1. Pending our receipt and review of the revised staffing formula, Safety Recommendation P-11-7 remains classified OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2015-11-02

Communication Type: Official Correspondence

Communication Contents: We understand that PHMSA collaborated with the National Association of Pipeline Safety Representatives Grant Allocation and Strategic Planning Committee to revise the existing staffing formula so that it accounts for risk and non-standard inspections, and that these changes were circulated to the state pipeline authorities on June 9, 2015. These actions satisfy Safety Recommendation P-11-7, which is classified CLOSED—ACCEPTABLE ACTION.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2011-01-03

Communication Type: Official Correspondence

Communication Contents: -From Ray LaHood, Secretary of Transportation: This letter responds to the National Transportation Safety Board's (NTSB) safety recommendations P-11-4 through -7, which were issued on September 26, 2011, following NTSB's investigation of the tragic September 9, 2010, natural gas pipeline rupture in the city of San Bruno, California. The U.S. Department of Transportation (DOT) takes NTSB's safety recommendations seriously and is focused on appropriately addressing all of the pipeline safety recommendations in your report. The Department will conduct an audit of the effectiveness of the Pipeline and Hazardous Materials Safety Administration's (PHMSA) oversight of performance based pipeline safety programs (P-11-4), as well as a review of its enforcement policies and procedures (P-11-5). In addition, the DOT Inspector General is already scheduled to conduct an audit of PHMSA's State pipeline safety certification program which will fulfill the final recommendation (P-11-6). I have directed the PHMSA Administrator to ensure that the certification program is amended, as appropriate, to comply with the findings of this audit (P-11-7). If I can provide further information or assistance please feel free to call me.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2012-01-03

Communication Type: Official Correspondence

Communication Contents: -From Ray LaHood, Secretary, United States Department of Transportation: This letter responds to the National Transportation Safety Board's (NTSB) safety recommendations P-11-4 through -7, which were issued on September 26,2011, following NTSB's investigation of the tragic September 9, 2010, natural gas pipeline rupture in the city of San Bruno, California. The U.S. Department of Transportation (DOT) takes NTSB's safety recommendations seriously and is focused on appropriately addressing all of the pipeline safety recommendations in your report. The Department will conduct an audit of the effectiveness of the Pipeline and Hazardous Materials Safety Administration's (PHMSA) oversight of performance-based pipeline safety programs (P-11-4), as well as a review of its enforcement policies and procedures (P-11-5). In addition, the DOT Inspector General is already scheduled to conduct an audit of PHMSA's State pipeline safety certification program which will fulfill the final recommendation (P-11 6). I have directed the PHMSA Administrator to ensure that the certification program is amended, as appropriate, to comply with the findings of this audit (P-11-7).

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2015-06-19

Communication Type: Official Correspondence

Communication Contents: -From Stacy Cummings: Interim Executive Director: PHMSA has taken actions to amend its certification program, resulting in the OIG closing six of the seven recommendations. Our response to all seven of the OIG recommendations is provided below. PHMSA proposed an Action Plan, which was approved by the OIG, to address the remaining OIG open recommendation. The Action Plan specifies that PHMSA will revise the Staffing Formula for States by July 31, 2015. PHMSA expects to meet this deadline. OIG Recommendation 1: Revise the staffing formula so that it accounts for risk and nonstandard inspections, and periodically analyze State-provided inspection unit data to validate staffing formula results. Status: In 2010 PHMSA evaluated the merits of the existing staffing formula with a team of State pipeline safety program representatives. The team determined that the existing formula was appropriate for setting a baseline inspector corps. PHMSA is working with the National Association of Pipeline Safety Representatives (NAPSR) to review the current staffing formula again. We will consider including factors for addressing non-standard inspections, such as integrity management, and high-risk pipe such as cast iron. PHMSA believes that material composition, which can impose a higher risk to safety than the age of pipe, is a better indicator of risk to safety. Therefore, material composition will be considered as a factor instead of pipe age as suggested by the OIG, which notes that pipelines composed of materials such as cast iron or bare steel are "at a higher risk for failure than newer pipelines made of more resilient materials." We will also look to improve our guidance in support of this issue. We expect this review to be complete by the end of July 2015 in accordance with the timeframe approved by the OIG. OIG Recommendation 2: Develop and include in PHMSA's State Program Guidelines: a. Minimum training standards for State inspector qualifications for leading inspections (i .e., classroom and/or on-the-job training). b. A system that tracks revisions to Federal inspection forms and actively notifies States when these new forms are available. c. Standards for time allowed between inspections for all inspection types. Status: The OIG has closed this recommendation based on the following actions taken. PHMSA worked with NAPSR to develop and publish minimum training requirements for State inspectors' qualifications to lead inspections. These requirements were published by PHMSA in the "2015 Guidelines for States Participating in the Pipeline Safety Program" issued on February 23, 2015. On July 6, 2014, PHMSA submitted documents to the OIG showing evidence that PHMSA alerted States to the locations of the most recent inspection forms, as well as a copy of the revised State guidance establishing maximum time intervals for all inspections. PHMSA also established a 5-year maximum inspection interval for non-standard inspections. These guidelines were also published in the "2015 Guidelines for States Participating in the Pipeline Safety Program," issued on February 23, 2015. PHMSA's "2015 Guidelines for States Participating in the Pipeline Safety Program" also formally notified States that the PHMSA inspection forms will be updated when regulations change and the forms will be posted on FedStar. PHMSA actively notifies States when new forms are available and will continue to do so. Guidance material has been developed for State Program Evaluators to determine if the State is implementing its inspection procedures in accordance with PHMSA guidance. OIG Recommendation 3: Develop and implement procedures to review the adequacy of inspection procedures as part of the annual program evaluation. Status: The OIG has closed this recommendation based on the following actions taken. PHMSA established key elements for inspection procedures and included them in our "2015 Guidelines for States Participating in the Pipeline Safety Program," issued on February 23, 2015. The inspection procedure's key elements encompass pre-inspection planning, conducting the inspection, and exiting the inspection. OIG Recommendation 4: Provide States with comprehensive guidance to ensure States effectively implement PHMSA's risk analysis methods for scheduling inspections. Status: The OIG has closed this recommendation based on the following actions taken. On July 6, 2014, PHMSA submitted to the OIG a copy of the web-based training (WBT) discussed in our response to the draft OIG report. PHMSA developed and incorporated Appendix S, "Examples of State Pipeline Safety Program Plan, Procedures, and Risk Based Inspection Model," into the "20 15 Guidelines for States Participating in the Pipeline Safety Program," issued on February 23, 2015. Appendix S provides guidance and examples for a risk-based approach to inspections. Section 5.1.2 of the 2015 State Program Guidelines specifies that each State must develop risk-based procedures for determining when an inspection unit is to be evaluated. OIG Recommendation 5: Document the procedures for conducting triennial grant reviews to ensure consistency of oversight. Status: On July 6, 2014, PHMSA submitted its procedures for conducting triennial grant reviews to the OIG. In response, the OIG closed Recommendation 5. OIG Recommendation 6: Develop a training program that ensures PHMSA evaluators can successfully conduct the following program evaluation procedures: a. Determine and verify whether States have complied with all Program Evaluation requirements according to its procedures. b. Accurately notify States of non-compliance with Program Evaluation requirements to ensure States take correct action to achieve compliance. Status: The OIG has closed this recommendation based on the following actions taken. On July 6, 2014, PHMSA sent to the OIG PHMSA's policy to separate grant funding from program evaluation scoring and an example Program Evaluation Letter. This policy was instituted with the FY2013 grant cycle. PHMSA communicated this policy to the NAPSR Grant Allocation Committee during their August 5-8, 2013, meeting in Washington, D.C. Additionally, PHMSA has begun to alert State Senior Personnel with responsibility for pipeline safety that they will lose grant funding if an identified issue is not corrected. This notice is issued as part of our Program Evaluation Letters. Furthermore, PHMSA is annually reviewing the Program Evaluation Guidance Criteria with the State Program Evaluators. PHMSA conducted this review during our January 12-16, 2015, State Programs All Hands Meeting and will continue to conduct the review and training each year. Additionally, each Evaluator/State Liaison has been instructed to contact the Director of State Programs if during a State Program Evaluation they have any questions regarding how to score or review a question. OIG Recommendation 7: Develop and implement a plan for auditing States' use of suspension funds, and work with State Program Managers to identify current suspension fund administration challenges requiring additional guidance. Status: The OIG has closed this recommendation based on the following actions taken. On July 6, 2014, PHMSA sent to the OIG a copy of PHMSA's Suspension Funding Audit Plan, which was communicated to State Program Evaluators in an email dated February 28, 2014, from the Director of State Programs. The State Program Evaluators are currently implementing the plan. On November 4-6, 2014, PHMSA met with State Program Managers to identify administrative challenges and develop additional guidance with regard to Suspension funds. This guidance was included in the 2015 Guidelines for States Participating in the Pipeline Safety Program issued on February 23, 2015.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2015-09-16

Communication Type: Official Correspondence

Communication Contents: -From Marie Therese Dominguez, Administrator: You also state that P-11-7 remains classified Open- Acceptable Response pending completion of PHMSA's action in response to the DOT IG's recommendations. P-11-7 reads as follows: Ensure that the Pipeline and Hazardous Materials Saf ety Administration amends the certification program, as appropriate, to comply with the findings of the audit recommended in Safety Recommendation P-11-6. At the time of your July 15, 2015, letter, PHMSA had closed six of the seven open recommendations. The remaining open recommendation was to revise the Staffing Formula for States, which was due to be completed by July 31, 2015. PHMSA collaborated with the National Association of Pipeline Safety Representatives (NAPSR) Grant Allocation and Strategic Planning Committee to revise the existing Staffing Formula so that it accounts for risk and non-standard inspections. Changes were circulated to the States on June 9, 2015. A description of the changes is below: • The new Inspection Activity Analysis provides for the State's considerations of risk factors unique to each pipeline operator/unit while accounting for the inspection time necessary to address all types of inspections (standard and non-standard) within established guidelines. The Inspection Activity Analysis allows each State, based on their local knowledge and experience of the pipeline system, to submit the additional time necessary to address the specific risk factors for a given operator/unit during an inspection. Examples of operator types are Local Distribution Companies, Municipal Gas Operators, Master Meter Operators, Liquid Propane (LPG) Operators, Gas Transmission Operators, LNG Operators, Hazardous Liquid Operators, Gathering Operators, and All other jurisdictional operators- (Anhydrous, Carbon Dioxide, Ammonia, etc.). Section 4.1.3 of the 2015 Guidelines for States Participating in the Pipeline Safety Program was amended to reflect this change. • A peer review process will be initiated to review State minimum required inspection days resulting from the Inspection Activity Analysis. This peer review will be conducted by PHMSA in consultation with the NAPSR Grant Allocation Committee. If the minimum required inspection days is found not to be appropriate for an individual State by the peer review group, PHMSA will open a dialogue with the State to discuss the issue and make necessary changes as appropriate. Section 4.1.2 of the State Guidelines was amended to address the new peer review process. Based on these actions, on July 13, 2015, the OIG informed PHMSA that this recommendation is closed. Therefore, we respectfully request closure of recommendation P-11-7. As a safety organization we take our responsibility to address all recommendations seriously and will continue to work aggressively to close all open recommendations.