NTSB Safety Recommendation P-11-016

NTSB safety recommendation P-11-016.

TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Assist the California Public Utilities Commission in conducting the comprehensive audit recommended in Safety Recommendation P-11-22.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2011-09-26

Adopted Date: 2011-09-12

Overall Date Closed: 2015-04-08

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 - Acceptable Action

Addressee Date Closed: 2015-04-08

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2011-12-07

Communication Type: NPRM Response

Communication Contents: Notation 8360: The National Transportation Safety Board (NTSB) has reviewed the Pipeline and Hazardous Materials Safety Administration (PHMSA) Advance Notice of Proposed Rulemaking (ANPRM), “Pipeline Safety: Safety of Gas Transmission Pipelines,” that was published in the Federal Register on August 25, 2011. PHMSA is considering whether changes to the regulations governing the safety of gas transmission pipelines are needed, and is inviting comments on 14 specific topic areas in 2 broad categories—integrity management-related requirements and nonintegrity management requirements. In the area of integrity management, PHMSA is seeking comments and information about revising the definition of high consequence areas (HCA), including more prescriptive language, and placing additional restrictions on the use of specific pipeline assessment methods. In the nonintegrity management area, PHMSA is seeking information and comments about strengthening or expanding requirements for the spacing of mainline valves; installation of remotely operated or automatically operated valves; and corrosion control of steel pipelines, gas gathering lines, and underground gas storage facilities. The NTSB believes that the regulations for gas transmission pipelines can and should be improved and supports the overall intent of the ANPRM. However, the publication of the ANPRM 5 days before the NTSB public meeting on the Pacific Gas and Electric Company (PG&E) natural gas transmission pipeline rupture in San Bruno, California, precluded any mention in the ANPRM of the safety recommendations the NTSB adopted at the public meeting held on August 30, 2011, and issued on September 26, 2011. As a result of the Board Meeting, the NTSB issued 13 safety recommendations (P-11-8 through P-11-20) to PHMSA to improve the safety of natural gas transmission pipelines. The NTSB believes PHMSA should seek comments and information related to its safety recommendations to PHMSA issued as a result of the San Bruno investigation to take certain regulatory actions. In the ANPRM, PHMSA is also seeking information that would be relevant to Safety Recommendation P-93-9 the NTSB issued as a result of its accident investigation of an explosion and fire of a natural gas pipeline from a salt dome storage cavern in Brenham, Texas, on April 7, 1992. The accident resulted in 3 fatalities and 21 injuries. Safety Recommendation P-93-9 was classified “Closed—Unacceptable Action” on July 27, 1998, after a rulemaking proceeding to regulate underground gas storage was terminated in 1997. The NTSB supports PHMSA’s intention to reconsider regulating underground gas storage and is pleased PHMSA is revisiting this issue by seeking information and comment in this ANPRM. In support of our position, the NTSB is providing the following table listing the NTSB’s responses (that is, previously issued safety recommendations) to certain specific questions posed by PHMSA in the ANPRM: PHMSA’s ANPRM Questions NTSB’s Responses (Safety Recommendations) K.1. Should PHMSA develop Federal standards governing the safety of underground gas storage facilities? If so, should they be voluntary? If so, what portions of the facilities should be addressed in these standards? Develop safety requirements for storage of highly volatile liquids and natural gas in underground facilities, including a requirement that all pipeline operators perform safety analyses of new and existing underground geologic storage systems to identify potential failures, determine the likelihood that each failure will occur, and assess the feasibility of reducing the risk; require that operators incorporate all feasible improvements. (P-93-9) K.6. What standards are used for emergency shutdowns, emergency shutdown stations, gas monitors, local emergency response communications, public communications, and O&M Procedures? 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. (P-11-8) L.1. Are there standards used by the pipeline industry to guide management processes including management of change? Do standards governing the management of change process include requirements for IM procedures, O&M manuals, facility drawings, emergency response plans and procedures, and documents required to be maintained for the life of the pipeline? 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. (P-11-9) PHMSA’s ANPRM Questions NTSB’s Responses (Safety Recommendations) B.4. What measures, if any, should operators be required explicitly to implement? Should they apply to all HCAs, or is there some reasonable basis for tailoring explicit mandates to particular HCAs? Should additional preventative and mitigative measures include any or all of the following: Additional line markers (line-of-sight); depth of cover surveys; close interval surveys for cathodic protection (CP) verification; coating surveys and recoating to help maintain CP current to pipe; additional right-of-way patrols; shorter ILI run intervals; additional gas quality monitoring, sampling, and in-line inspection tool runs; and improved standards for marking pipelines for operator construction and maintenance and one-calls? Require that all operators of natural gas transmission and distribution pipelines equip their supervisory control and data acquisition systems with tools to assist in recognizing and pinpointing the location of leaks, including line breaks; such tools could include a real-time leak detection system and appropriately spaced flow and pressure transmitters along covered transmission lines. (P-11-10) Amend Title 49 Code of Federal Regulations 192.935(c) to directly require that automatic shutoff valves or remote control valves in high consequence areas and in class 3 and 4 locations be installed and spaced at intervals that consider the factors listed in that regulation. (P-11-11) M.4. Are there any standards that exist that PHMSA could adopt or from which PHMSA could adapt concepts for Quality Management System (QMS)? Amend Title 49 Code of Federal Regulations 199.105 and 49 Code of Federal Regulations 199.225 to eliminate operator discretion with regard to testing of covered employees. The revised language should require drug and alcohol testing of each employee whose performance either contributed to the accident or cannot be completely discounted as a contributing factor to the accident. (P-11-12) Issue immediate guidance clarifying the need to conduct postaccident drug and alcohol testing of all potentially involved personnel despite uncertainty about the circumstances of the accident. (P-11-13) N.2. Should PHMSA repeal the MAOP exemption for pre-1970 pipelines? Should pre-1970 pipelines that operate above 72% SMYS be allowed to continue to be operated at these levels without increased safety evaluations such as periodic pressure tests, in-line inspections, coating examination, CP surveys, and expanded requirements on interference currents and depth of cover maintenance? N.3. Should PHMSA take any other actions with respect to exempt pipelines? Amend Title 49 Code of Federal Regulations 192.619 to delete the grandfather clause and require that all gas transmission pipelines constructed before 1970 be subjected to a hydrostatic pressure test that incorporates a spike test. (P-

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2014-01-03

Communication Type: Official Correspondence

Communication Contents: We understand that PHMSA assisted CPUC in conducting comprehensive audits of all aspects of PG&E’s operations, including control room operations, emergency planning, record keeping, performance-based risk and integrity management programs, and public awareness programs. In a June 3, 2013, update on Safety Recommendation P-11-22 (issued to CPUC), CPUC advised us that it has worked with PHMSA and PG&E, as requested, to complete audits of numerous operations, plans, and programs from November 2011 through April 2013, and that it continues this cooperative effort. Emphasizing the findings of the NTSB’s San Bruno accident investigation during these audits, CPUC noted several deficiencies and stated that it plans to work with PG&E to correct them. As a result, Safety Recommendation P 11-22 was classified “Open—Acceptable Response” pending completion of these efforts in conjunction with PHMSA and PG&E. Accordingly, Safety Recommendation P-11-16 remains classified OPEN-ACCEPTABLE RESPONSE, pending the continued participation of PHMSA in the completion of these efforts.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2015-04-08

Communication Type: Official Correspondence

Communication Contents: On September 19, 2014, we classified Safety Recommendation P-11-22 (a companion recommendation to Safety Recommendation P-11-16 that we had issued to CPUC) “Closed?Acceptable Action” because CPUC had worked with you as requested to complete the recommended audit. Accordingly, Safety Recommendation P 11-16 is classified CLOSED—ACCEPTABLE ACTION.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2012-04-24

Communication Type: Official Correspondence

Communication Contents: Because PHMSA is assisting the CPUC as requested, Safety Recommendation P-11-16 is classified OPEN—ACCEPTABLE RESPONSE, pending completion of the CPUC’s audit.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2013-08-29

Communication Type: Official Correspondence

Communication Contents: -From Cynthia L. Quarterman, Administrator: PHMSA proposes to close this recommendation. PHMSA assisted the California Public Utilities Commission (CA PUC) with conducting seven comprehensive audits of all aspects of PG&E’s operations, including control room operations, emergency planning, record-keeping, performance-based risk and integrity management programs, and public awareness programs. The audits are as follows: • Public Awareness Effectiveness - November 1-3, 2011; • Operation, Maintenance, and Emergency Response Plans - February 13-17, 2012; • Operator Qualification - July 30 - August 3, 2012; • Transmission Integrity Management - August 27-31, 2012 and September 10-14, 2012; • Control Room Management - October 22-26, 2012; • Distribution Integrity Management Inspection - December 10-14, 2012; and • Standard Inspection North Bay Operations - April 8-12, 2013.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2015-01-22

Communication Type: Official Correspondence

Communication Contents: -From Timothy P. Butters, Acting Administrator: PHMSA proposes to close this recommendation. PHMSA assisted the California Public Utilities Commission (CA PUC) in conducting a series of comprehensive audits of all aspects of Pacific Gas & Electric's operations, including control room operations, emergency planning, record-keeping, performance-based risk and integrity management programs, and public awareness programs. The dates the audits were conducted are as follows: • Public Awareness Plan- November 1-3, 2011; • Operation, Maintenance, and Emergency Response Plans- February 13-17, 2012; • Transmission Integrity Management- August 27-31,2012 and September 10-14, 2012; • Operation Qualification Program Inspection- October 22- 26, 2012; • Control Room Management- October 29-November 2, 2012; • Distribution Integrity Management Inspection- December 10-14, 2012; and • Standard Inspection North Bay Operations- April8-12, 2013. The CA PUC has confirmed the completion of these audits and the dates in their August 27, 2014, NTSB Status Report, http://www.cpuc.ca.gov/NR/rdonlyres/28318F8D-F574-459EAB40-40C4DB5CABAA/O/NTSB Status Report August 2014FINAL 2.pdf.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2011-12-14

Communication Type: Official Correspondence

Communication Contents: -From Cynthia L. Quarterman, Administrator: PHMSA has already been assisting the California Public Utilities Commission (CPUC) in conducting its oversight responsibilities for which PHMSA provides substantial funding. In April of 2011, PHMSA sent a team of five engineers to help CPUC review the Risk Assessment and Threat Identification portion of their Gas Integrity Management audit of Pacific Gas and Electric (PG&E). In October 2011, PHMSA sent additional staff to assist the CPUC in its audit of PG&E’s public awareness program. PHMSA will continue to provide support to the CPUC with regard to the application of the integrity management and other pipeline safety regulations. I have spoken with the CPUC leadership offering them all the help they need to carry out their responsibilities.