NTSB Safety Recommendation P-11-025

NTSB safety recommendation P-11-025.

TO PACIFIC GAS AND ELECTRIC COMPANY: Establish a comprehensive emergency response procedure for responding to large-scale emergencies on transmission lines; the procedure should (1) identify a single person to assume command and designate specific duties for supervisory control and data acquisition staff and all other potentially involved company employees; (2) include the development and use of trouble-shooting protocols and checklists; and (3) include a requirement for periodic tests and/or drills to demonstrate the procedure can be effectively implemented.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2011-09-26

Adopted Date: 2011-09-12

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 is pleased that PG&E established a comprehensive emergency response procedure for responding to large-scale emergencies involving transmission lines, which includes the use of troubleshooting protocols and checklists, and which requires periodic tests and/or drills to demonstrate that the procedure can be effectively implemented. Accordingly, Safety Recommendation P-11-25 is classified CLOSED—ACCEPTABLE ACTION.

Addressee Acronym: PG&E

Addressee Organization Type: P-Private Industry

Communication Date: 2012-02-06

Communication Type: Official Correspondence

Communication Contents: Correspondence control 201200077 was closed administratively. It was combined with correspondence control 201100506. The reply to 201200077/ 201100506 was mailed on 3/13/2012.

Addressee Acronym: PG&E

Addressee Organization Type: P-Private Industry

Communication Date: 2012-01-27

Communication Type: Official Correspondence

Communication Contents: -From Christopher P. Johns, President: Pacific Gas and Electric Company (PG&E) fully embraces the safety recommendations outlined by the National Transportation Safety Board as part of the agencies review of the 2010 San Bruno pipeline accident. We recognize the importance of preventing a tragedy like this from occurring again and that is why we are committed to successfully implementing the NTSB's recommendations. To date, PG&E has taken numerous actions to make fundamental changes to our operations and management -all with a focus on putting public and employee safety first. In response to your September 26, 2011 letter, PG&E sent to you on December 22, 2011, an update on the progress we have made toward implementing the recommendations and the plans we have in place. This letter included an update on activities related to integrity management, emergency response, public awareness, threat assessment and recordkeeping, among other aspects of our operations and management. Since that time, members of our team have had the opportunity to meet with NTSB technical staff to discuss our submission and review our activities. We are grateful for the guidance and feedback provided at that meeting. As a result of those discussions, we recognize that it is incumbent upon us to provide a greater level of detail than was previously provided in the December 22, 2011 update. Therefore, we would like to take the opportunity to supplement our December 22, 2011 response by providing an amended response with the requisite detail within 45 days. PG&E will continue to meet with NTSB staff in the coming weeks to seek additional guidance to ensure that the update we provide is fully responsive and will allow the NTSB to more ably assess our progress and plans.

Addressee Acronym: PG&E

Addressee Organization Type: P-Private Industry

Communication Date: 2013-01-31

Communication Type: Official Correspondence

Communication Contents: -From Christopher P. Johns, President: Pacific Gas and Electric Company (PG&E) continues to make substantial progress implementing the safety recommendations outlined by the NTSB's investigation of the September 2010 San Bruno pipeline accident. This status report provides details on the actions we are taking to assure public safety remains the company's highest priority. In 2012, the NTSB evaluated PG&E's progress and closed four recommendations: 1. pe10-2: Search for Records 2. P-11-3: 911 Notifications 3. P-11-25: Emergency Response Procedures 4. P-11-28: Toxicology Testing In this report, we are submitting three additional recommendations for closure consideration by the NTSB: 1. P-10-3: MAOP Validation 2. P-11-24: Work Clearance Procedures 3. P-11-31: Public Awareness Program Continuous Improvement For recommendation P-10-3 (MAOP Validation), PG&E has completed the determination of the valid maximum allowable operating pressure (MAOP), based on the weakest section of the pipeline or component. The purpose of the MAOP validation is to ensure safe operation of natural gas transmission lines in class 3 and class 4 locations and class 1 and class 2 high consequence areas (HCA) that have not had a MAOP established through prior hydrostatic testing. In total, MAOP validation was performed for all 2,088 miles of these transmission pipelines. In addition to completing NTSB Recommendation P-10-3, PG&E is validating all remaining transmission lines in non-HCAs by mid- 2013. In 2012, PG&E completed the MAOP validation of 4, 199 miles of non-HCA pipelines. For recommendation P-11-24 (Work Clearance Procedures), PG&E has completed the revision and issuance of work clearance procedures that include requirements for identifying the likelihood and consequences of failure associated with planned work. The development of contingency plans is now a part of this process. PG&E's new procedure ensures accurate and completed clearance forms and requires field crews, control room operators and individuals who have been assigned the clearance supervisor role to have complete knowledge of the intended work and written clearance procedure. PG&E has completed recommendation P-11-31 (Public Awareness Program Continuous Improvement) through the development and incorporation of written performance measurements and guidelines into our Public Awareness Plan (PAP) for evaluating the plan and for continuous program improvement. The primary objectives include awareness, damage prevention and emergency response readiness. PG&E has also completed two portions of recommendation P-11-29 (Integrity Management Program): Revisions to PG&E's Risk Model and Risk Analysis Methodology. Other recommendations with significant progress highlighted in the attachment include: • (P-10-4)-ln 2012, PG&E strength tested or verified an additional 202 miles for a total of 417 miles since 2011 • (P-11-2)-PG&E installed 46 valves in 2012 (for a total of 59 valves since 2010) • (P-11-29)-ln addition to revising the Integrity Management Risk Model and Risk Analysis Methodology, PG&E is continuing to revise other portions of its integrity management program PG&E thanks the NTSB for both its continuing guidance and leadership as the company works to address the remaining safety recommendations. Please contact me directly if you have any questions. Although NTSB has closed Recommendation P-11-25: Emergency Response. PG&E would like to provide additional information regarding our efforts in this area. PG&E has 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. In the area of training, PG&E has continued to identify ways to strengthen controls and, in fact, after the May update, PG&E identified additional opportunities to better manage the Incident Command System (ICS) training. PG&E's May update stated that ICS training had been completed for employees that were Emergency Operations Center (EOC) participants. PG&E would like to clarify that ICS training is an on-going and recurring training to ensure EOC employees remain up to date on the emergency protocols and have regular opportunities to exercises the required skills and knowledge. PG&E has implemented more stringent controls to manage the training implementation which includes "profiling" employees with emergency management responsibilities to ensure training is completed timely and on an on-going basis.

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 established a comprehensive emergency response procedure for responding to large-scale emergencies on transmission lines. The procedure: • Identifies a single person to assume command and designate specific duties for supervisory control and data acquisition staff and all other potentially involved company employees; • Includes the development and use of trouble-shooting protocols and checklists, and • Includes a requirement for periodic tests and/or drills to demonstrate the procedure can be effectively implemented A new Public Safety and Integrity Management team has been formed and is actively engaged in various facets of emergency preparedness planning. Responsibilities of this team include maintenance of the Gas Emergency Response Plan (GERP) to assist PG&E personnel in responding safely, efficiently and in a coordinated manner to emergencies affecting gas transmission and distribution systems. The plan describes roles and responsibilities of PG&E's emergency response personnel and includes a single person that assumes command and designates specific duties for SCADA staff and all other potentially involved company employees. In general, command will move to a higher level employee with increasing complexity as follows: • If there is an event on the pipeline, the person initially in control in the Control Room is the Sr. Transmission Controller. This individual is very experienced and has access to all pipeline information including alarm data and volume and pressure data. • If the event escalates, the Operations Emergency Center (OEC) in the division is activated and an incident commander is in place to manage the field operations and to coordinate with Gas Control. • If it escalates further, the Emergency Operations Center (EOC) is activated and the incident commander of the EOC is the single person in charge. • Co-location of control center (in first quarter of 2013) will facilitate command and control and will allow all information from transmission control, distribution control, and gas dispatch to be in one place. Attachment P-11-25A contains the pages in Section 2.6 of the GERP that discuss emergency center activation, triggers to activation/escalation, and parties involved. Attachment P-11-25B (Section 2.2 of the GERP), contains PG&E's emergency response protocol which includes two flow charts showing emergency call escalation through Dispatch and through Gas System Operations (GSO) and describes the resources assigned to gas emergencies. The GERP identifies when PG&E contacts 911 and also includes information regarding involvement of multiple agencies. Attachments P-11-25C and P-11-25D contain pages from the GERP that refer to PG&E coordination with 911 agencies. Attachment P-11-25E (Appendix C.1 of the GERP) discusses the responsibilities of the Incident Commander which include, but are not limited to: • Conducting the initial assessment and communication • Establishing the Incident Command and communication structure • Using emergency plan checklists to ensure that proper notifications are made PG&E's Gas Control team provides input and guidance regarding project requirements to ensure the proper SCADA equipment is deployed and control settings are enacted. Implementation of a robust near real-time Data Historian system will occur in control rooms and will also be available to emergency response teams, allowing enhanced situational awareness by those involved in emergency events. Attachment P-11-25F (PG&E's Utility Standard EMER-6010S -Training and Exercising Gas Emergency Response Plans) provides requirements for conducting training and exercises associated with gas emergency response including: • Annual joint exercise between PG&E and relevant first responders for each gas storage and gas regulation facility; • Annual exercises at each of PG&E's 18 divisions; and • Emergency Management Organization annual exercise involving PG&E's gas transmission pipeline system. These exercises may include read-through exercises, table-top exercises, games, drills, functional exercises and full scale exercises. PG&E's Utility Standard EMER-6010s also requires a multi-year exercising plan. Company Dispatch, Gas Control Operations and emergency response personnel must be trained on the Company's EMO dispatch and emergency response procedures annually, and any PG&E personnel with a role in an emergency operation are trained on the plan, as stated in EMER-1 001 S (Attachment P-1125G). These requirements are also contained in the GERP as shown in Attachment P-11-25H. PG&E has completed the following activities relative to training and measures have been utilized to evaluate effectiveness: • Conducted training exercises with public officials and first responders to simulate gas curtailment scenarios and build greater understanding of how to prepare for potential events • Increased the number of educational and interactive sessions, including practice drills, with first responders to meet demand and prepare for gas-related emergencies. • Established a first responder pilot training program with the City of San Francisco and City of Fremont to share critical information with first responders. • Completed Incident Command System training • Conducted CAISO Gas Curtailment Exercise in August, 2011 Other activities include: • Developed contact list for all local first responders (-1,800) to improve future communications and notifications • Launched PG&E first respond

Addressee Acronym: PG&E

Addressee Organization Type: P-Private Industry

Communication Date: 2011-12-22

Communication Type: Official Correspondence

Communication Contents: -From Christopher P. Johns, President: Pacific Gas and Electric Company (PG&E) has fully embraced the safety recommendations outlined by the National Transportation Safety Board (NTSB) as part of the agency's review of the September 2010 San Bruno pipeline accident. We at PG&E recognize the importance of preventing a tragedy like this from ever happening again, and we are grateful for the NTSB's guidance toward that goal. As requested in your September 26, 2011 letter, we are providing an update on the actions PG&E is taking, and the plans that are in place to implement the NTSB's thoughtful and thorough recommendations. These recommendations have prompted PG&E to take significant actions on many fronts, including pipeline leak and break identification, emergency response, integrity management, threat assessments, public awareness of pipeline safety measures, and recordkeeping. The NTSB's recommendations have helped propel PG&E to make fundamental changes to our operations and management-all intended to underscore our commitment to putting public and employee safety first. For example, we've completed Maximum Allowable Operating Pressure validation of more than 1,600 miles of high consequence area pipelines, with plans to complete all 2,000 miles by the end of January 2012. We are implementing a new data management system intended to address the NTSB's recommendations for traceable, verifiable and complete records. Additionally, PG&E has automated 11 shutoff valves in 2011. As part of the company's Pipeline Safety Enhancement Plan, which was presented for approval to the California Public Utilities Commission this year, PG&E has proposed automating a total of 228 valves through 2014. We've also updated our emergency response plans to reflect industry best practices and have begun training employees, public officials and first responders. In an effort to improve public gas safety awareness, we've mailed more than two million safety information letters to customers who live within 2,000 feet of a transmission pipeline. We realize we still have much to learn and do in the wake of the tragic San Bruno accident. As you'll see in the attachment, we have completed several of the recommendations and are in mid-stream on the remainder. We're working with urgency to complete all of the recommendations and we remain steadfast in our commitment to safety and to regaining the trust of the public and our regulators. The attachment to this letter provides a more detailed summary of each NTSB recommendation and the steps we are taking to act upon them. If you have any questions, please contact me directly. A new Public Safety and Integrity Management team has been formed and is actively engaged in various facets of operational planning. Responsibilities of this team include maintenance of the Gas Emergency Response Plan to assist PG&E personnel in responding safely, efficiently and in a coordinated manner to emergencies affecting gas transmission and distribution systems. The plan describes roles and responsibilities of PG&E's emergency response personnel. Roles and responsibilities include the following: 1. A single person that assumes command and designates specific duties for supervisory control and data acquisition (SCADA) staff and all other potentially involved company employees will vary depending on the complexity of the emergency. In general, command will move to a higher level employee with increasing complexity as follows: a. If there is an event on the pipeline, the person initially in control in the Control Room is the Sr. Transmission Controller. This individual is very experienced and has access to all pipeline information including alarm data and volume and pressure data. b. If the event escalates, the Operations Emergency Center (OEC) in the division is activated and an incident commander is in place to manage the field operations and to coordinate with gas control. c. If it escalates further, the Emergency Operations Center (EOC) is activated and the incident commander of the EOC is the single person in charge. d. As we implement plans for a co-located control center (active in first quarter 2013), all information -- from transmission control, distribution control, and gas dispatch -- will be in one place. Command and control will be facilitated by this arrangement. Interaction with the EOC will still occur and we will have to define the escalation path and the command hand offs. 2. PG&E's gas control team provides inputs and guidance regarding project requirements to ensure the proper SCADA equipment is deployed and control settings are enacted. Implementation of a robust near-real-time Data Historian system will occur in control rooms and will also be available to emergency response teams, allowing enhanced situational awareness by those involved in emergency events. 3. The following training and exercises have been completed. Measures have been utilized to evaluate the effectiveness of these programs. a. PG&E has conducted training exercises with public officials and first responders to simulate gas curtailment scenarios and build greater understanding of how to prepare for potential events b. Increased the number of educational and interactive sessions, including practice drills, with first responders to meet demand and prepare for gas related emergencies. c. Established a first responder pilot training program with the City of San Francisco and City of Fremont to share critical information with first responders. d. Developed contact list for all local first responders (1,800) to improve future communications and notifications e. Launched PG&E first responder website portal f. Conducted CAISO Gas Curtailment Exercise in August, 2011 g. Provided maps, GIS data, and other information to first responders h. Completed Incident Command System training i. Established and implemented a Gas Control Process (911 Notification Process) in August 2011 in response to the NTSB's recommendation P-11-3.