NTSB Safety Recommendation P-11-022

NTSB safety recommendation P-11-022.

TO THE CALIFORNIA PUBLIC UTILITIES COMMISSION: With assistance from the Pipeline and Hazardous Materials Safety Administration, conduct a comprehensive audit of all aspects of Pacific Gas and Electric Company operations, including control room operations, emergency planning, record-keeping, performance-based risk and integrity management programs, and public awareness programs.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2011-09-26

Adopted Date: 2011-09-12

Overall Date Closed: 2014-09-19

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: State of California, Public Utilities Commission

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2014-09-19

Addressee Acronym: CPUC

Addressee Organization Type: S-State Government

Communication Date: 2012-05-07

Communication Type: Official Correspondence

Communication Contents: -Paul Clanon, Executive Director: The California Public Utilities Commission (CPUC) thanks the National Transportation Safety Board (NTSB) for its thorough and thoughtful analysis of the tragic rupture of the natural gas pipeline, Line 132 located in San Bruno, owned by Pacific Gas and Electric Company (PG&E). The CPUC is committed to implementing each of the NTSB recommendations directed at our agency. Our goals are simple: • Reform the CPUC to make safety its first priority; • Ensure the safety of existing natural gas pipeline infrastructure; • Upgrade and replace existing natural gas pipeline infrastructure to improve safety; and • Instill safety culture in the natural gas pipeline operators we oversee. This letter serves as an update on our progress. NTSB Recommendation P-11-22 directs the CPUCI in conjunction with the Pipeline and Hazardous Materials Safety Administration (PHMSA), to conduct a comprehensive audit of all aspects of PG&E's natural gas operation. As you know, as one of PHMSA's regulatory partners, the CPUC already conducts regular audits focusing on Transmission Integrity Management and Operator Qualifications. We also plan to conduct regular audits of new programs such as Distribution Integrity Management, Public Awareness and Control Room Management. We will of course be continuing to perform these audits but our audit procedures and focus will be modified based on what we have learned from the San Bruno rupture. We have conducted the following PG&E audits with PHMSA in the last six months: Public Awareness (November 2011) and Operation, Maintenance, and Emergency Plans (February 2012). We will integrate all of the recommendations from these audits, our investigatory reports, and NTSB recommendations for PG&E into a comprehensive set of recommendations for PG&E. In your letter you requested that the CPUC complete this audit within six months. Because of the extensive scope of the audit, the sheer amount of material to audit, and the need to coordinate with PHMSA, we were unable to complete the audit within the six month period you recommended. The following table contains the audits we requested PHMSA to participate in. We would be happy to report to you on an ongoing basis about the status of our audit activities. PG&E Audits Dates Operator Qualifications 7/30 - 8/3/2012 Transmission Integrity Management Program 8/27 - 8/3 1/2012 & 9/10 - 9/14/2012 Control Room Management 10/22 - 10/26/2012 Kettleman District and Compressor Station 10/8 - 10/12/2012 Distribution Integrity Management Program 12/10 - 12/14/2012

Addressee Acronym: CPUC

Addressee Organization Type: S-State Government

Communication Date: 2013-06-03

Communication Type: Official Correspondence

Communication Contents: -From Paul Clanon, Executive Director, State of California, Public Utilities Commission: This letter serves as an update on the progress the California Public Utilities Commission (CPUC) has made in addressing Safety Recommendations P-10-5 and P-10-6, which the National Transportation Safety Board (NTSB) issued to the CPUC on January 2, 2011, and Safety Recommendations P-11-22 and P-11-23, which the NTSB issued to the CPUC on September 26, 2011, as a result of its investigation of the September 9, 2010, Pacific Gas and Electric Company (PG&E) natural gas pipeline rupture that occurred in a residential area in the City of San Bruno, California. As noted in our May 7, 2012, letter to the NTSB,ithe CPUC outlined four major goals in successfully implementing the NTSB recommendations. These goals are at the core of the CPUC's gas pipeline safety program and its commitment to protect the public and to promote gas pipeline safety throughout California: • Ensure the safety of existing natural gas pipeline infrastructure • Upgrade and replace existing natural gas pipeline infrastructure to improve safety • Reform the CPUC to make safety its first priority • Instill safety culture in the natural gas pipeline operators we oversee Californians deserve safe, reliable utility Services at reasonable rates. This is the core mission of the CPUC. In the two and a half years: since the tragic PG&E pipeline rupture the CPUC has made numerous improvements in safety rules,safety inspections, and safety enforcement. This letter provides a summary of not only the CPUC’s actions related to the NTSB's recommendations, but also of key activities of the CPUC's ambitious, two-pronged approach to meeting its safety goals, taking immediate actions to make California safer; and embarking on long-term changes to the internal safety culture at the CPUC and instilling a safety culture in the utility companies and other industries the CPUC regulates. As we reported in the last update provided on May 7, 2012, the CPUC has been working closely with PHMSA on a series of audits ofPG&E's operations. To date, the CPUC and PHMSA have conducted the following audits: PG&E Audit, Date Public Awareness Plan November 1-3, 2011 Operation, Maintenance, and Emergency Plans February 13-17, 2012 Transmission Integrity Management Program (TIMP) August 27-31, 2012, and September 10-14, 2012 Operator Qualification Program October 22-26, 2012 Control Room Management Program October 29-November 2,2012 Distribution Integrity Management Program December 10-14,2012 North Bay Division April 8-12, 2013 During the audits, the CPUC placed emphasis on the findings of the NTSB as noted in its report on the San Bruno incident. Specifically, the CPUC extensively reviewed the effectiveness of PG&E's Public Awareness Plan and TIMP, and noted several deficiencies. CPUC staff is continuing to work with PG&E to correct the various deficiencies identified in the audits. These comprehensive audits have proven to be beneficial to both the CPUC and PHMSA in that they provide regulatory insight by combining the strengths of both regulatory entities into one with the goal of ensuring the safety and reliability of gas pipeline systems.

Addressee Acronym: CPUC

Addressee Organization Type: S-State Government

Communication Date: 2014-08-14

Communication Type: Official Correspondence

Communication Contents: -From Paul Clanon, Executive Director: This letter and the attached Status Report provide an update of the progress the California Public Utilities Commission (CPUC) has made in addressing National Transportation Safety Board (NTSB) Safety Recommendations. The NTSB issued Safety Recommendations P-10-5, P-10-6 and P-10-7 on January 2, 2011, and Safety Recommendations P-11-22 and P-11-23 on September 26, 2011, as a result of its investigation of the September 9, 2010, natural gas pipeline rupture that occurred in a residential area in the City of San Bruno, California. As outlined in the attached Status Report on NTSB Recommendations to the C PUC (Status Report), the CPUC has completed actions on NTSB recommendations P-10-5 and P-1)-~22 and requests for these Safety Recommendations to be considered closed with acceptable actio!i.• The activities to fully implement Safety Recommendations P-1 0-6 and P-11-23 are ongoing, with a progress update provided in the Status Report. Safety Recommendation P-1 0-7 was closed by NTSB on March 29, 2011. As noted in our June 3, 2013, letter-to the NTSB, the CPUC outlined-four major goals that would serve to successfully implement the NTSB recommendations. These goals are at the core of the CPUC's Gas Safety and Reliability Program and its commitment to protect the public and to promote gas pipeline safety throughout California: • Reform the CPUC to make safety its first priority • Ensure the safety of existing natural gas pipeline infrastructure • Upgrade and replace existing natural gas pipeline infrastructure to improve safety • Instill safety culture in the natural gas pipeline operators we oversee Californians deserve safe, reliable utility services at reasonable rates. This is the: core mission of the CPUC. It's been almost four years since the tragic PG&E pipeline rupture in San-Bruno, and the CPUC has made many improvements in safety rules, safety inspections, and safety enforcement during that time. On July 10, 2014, the CPUC adopted a Safety Policy Statement, which defines the rule of the Commissioners, binds together the agency in constantly strengthening our safety efforts, and provides a unifying vision and- guidance for the organization's multiple and disparate functions. The safety mission and goal of the CPUC is to assure that the regulated "utilities the state of California depends on for critical services are as safe and resilient as they can possibly be. The goal of the CPUC is not only to assure compliance with safety laws and regulations, but also to challenge itself and the utilities to excellence. Ultimately, the CPUC strives to achieve a goal of zero accidents and injuries across all the utilities and businesses we regulate, and within our own workplace. P-11-022: The CPUC worked closely with PHMSA to complete a series of audits of PG&E's operations, including PG&E Audit .. Date Public Awareness Plan (PAP) November 1 -3, 2011 Risk Assessment Program April 5-8, 2011 Operation, Maintenance, and Emergency Plans February 13 -17, 2012 Transmission Integrity Management Program (TIMP), August . 27-31, 2012 and September 10-14, 2012' Operation Qualification Program October 22-26, 2012 Control Room Management Program, October 29- November 2, 2012 Distribution Integrity Management Program December 10-14, 2012 North Bay Division April 8- 12, 2013 During the audits, the CPUC placed emphasis on the findings of the NTSB as noted in its report on the San Bruno Incident. Specifically, the CPUC extensively reviewed the effectiveness of PGE's PAP and TIMP, and noted several deficiencies. CPUC staff is continuing to work with PG&E to correct the various deficiencies identified in the audits. These comprehensive audits have proven to be beneficial to both the CPUC and PHMSA, in that they provide regulatory insight by combining the strengths of both regulatory entities: into one with the goal of ensuring the safety and reliability of gas pipeline systems. The CPUC committed to continuing working closely with PHMSA and• submits for NTSB Recommendation P-11-22 to be considered closed with acceptable action.

Addressee Acronym: CPUC

Addressee Organization Type: S-State Government

Communication Date: 2012-05-09

Communication Type: Official Correspondence

Communication Contents: This letter was closed administratively, no response was sent on 5/8/2012 under correspondence control #201200253. See the response to correspondence control #201200239, a letter dated 8/2/2012.

Addressee Acronym: CPUC

Addressee Organization Type: S-State Government

Communication Date: 2012-08-02

Communication Type: Official Correspondence

Communication Contents: The NTSB understands that CPUC is working with PHMSA and PG&E as requested, and has completed the recommended audits of its public awareness programs (November 2011) and its operation, maintenance, and emergency plans (February 2012). In addition, CPUC plans to integrate the recommendations from these audits, those from its investigatory reports, and our recommendations for PG&E into a comprehensive set of recommendations for PG&E. Pending completion of these efforts, Safety Recommendation P-11-22 is classified OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: CPUC

Addressee Organization Type: S-State Government

Communication Date: 2013-11-14

Communication Type: Official Correspondence

Communication Contents: We note that the CPUC 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 our San Bruno accident investigation during these audits, the CPUC noted several deficiencies; it plans to work with PG&E to correct them. Pending completion of these efforts, Safety Recommendation P 11-22 is classified OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: CPUC

Addressee Organization Type: S-State Government

Communication Date: 2014-09-19

Communication Type: Official Correspondence

Communication Contents: We understand that, from November 2011 to April 2013, you worked with PHMSA and PG&E, as requested, to complete audits of numerous operations, plans, and programs. During these audits, you emphasized our San Bruno report findings, and extensively reviewed the effectiveness of PG&E’s Public Awareness Plan and its Transmission Integrity Management program. We also understand that you began working with PG&E to see that they correct the deficiencies that the audits identified. We are pleased that you believe the audits have proven beneficial to both you and PHMSA. The actions you have completed satisfy Safety Recommendation P-11-22, which is classified CLOSED—ACCEPTABLE ACTION.