NTSB Safety Recommendation P-11-028

NTSB safety recommendation P-11-028.

TO PACIFIC GAS AND ELECTRIC COMPANY: Revise your postaccident toxicological testing program to ensure that testing is timely and complete.

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 is aware that PG&E has conducted U.S. Department of Transportation postaccident training for gas maintenance and construction team supervisors and has created a cross-department team to enhance the accident reporting process. The NTSB would appreciate learning of the specific details of these programs and evidence to support the implementation and effectiveness of these programs. Pending receipt of this amplifying information, Safety Recommendation P-11-28 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 revised its testing processes to address the timeliness in conducting post-accident toxicological testing and the breadth of the tested population in a U.S. Department of Transportation–reportable event. Accordingly, Safety Recommendation P-11-28 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 response for 201100506/ 201200077 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: 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 revised its testing processes to address two areas: 1) Timeliness in conducting post-accident testing and 2) breadth of the tested population in a DOT reportable event. PG&E convened a cross functional team in the spring of 2011 to address this recommendations. As a result, the Company revised the Gas CPUC On-Call manual. The On-Call manual includes procedures that the Company uses to report gas incidents. When there is a gas incident, the reporting person contacts Gas Control who in-turn contacts the On-Call representative. The On-Call manual was revised to include an additional step in the process which requires the On-Call representative to remind the supervisor to request drug and alcohol screening for all employees involved in a DOT reportable incident. The On-Call representative then emails the incident details to the GSa Gas Event Notification mailing list, which includes the PG&E Designated Employer Representative (DER). The DER is authorized by PG&E to take immediate action(s) to remove employees from safety-sensitive duties, or cause employees to be removed from these covered duties, and to make required decisions in the drug testing and evaluation processes. The DER also receives test results and other communications for PG&E, consistent with the DOT requirements and Company policies. The update to the On-Call procedures was made in July of 2011. Training for the On-Call representatives outlining the change in procedures was conducted by the Regulatory Support and Analysis team on July 18,2011. In November 2011 PG&E issued an update to its Gas Emergency Response Plan (GERP). Within this plan, PG&E provides instruction to PG&E personnel concerning when testing is required and the time limit requirements to perform testing. The requirement is set forth below: Appendix B.3 -DOT Drug and Alcohol Testing -Post Accident When is testing required? • Fatality or personal injury requiring admission to and an overnight stay in a hospital. • Estimated property damage of $50, 000 or more, including loss to the company and others, but excluding cost of gas lost. • Unintentional estimated gas loss of 3 million cubic feet or more. Use Attachment 2 to Utility Procedure TD-4413S -Gas Event Reporting Requirements to determine if this gas loss criterion has been reached for pipeline punctures and complete severing of the pipeline. • An event that results in an emergency shutdown of a liquefied natural gas (LNG) facility. • Rupture or explosion, fire, loss of service, evacuation of people in the area, involvement of local emergency response personnel (e.g., fire, police, ambulance). • All explosions, except those in areas where there is no gas service or where it is immediately clear that natural gas did not contribute to the explosion. Time Limit to Perform Testing If any of the above apply, DOT drug testing is required for all covered personnel involved at the time of the incident/accident. Testing is required within 2 hours ofincident/accident, but not to exceed 8 hours afterward. If the time to administer alcohol testing exceeds 2 hours, the reasons why the test was not promptly administered are documented. PG&E will be revising its procedures to comply with regulations to be promulgated by the Pipeline Hazardous Materials Safety Administration (PHMSA) pursuant to amendments to the Pipeline Safety Act which require that as of June 2013, accident or incident notification is to occur at the earliest practicable moment following confirmed discovery of an accident or incident and no later than 1 hour following such confirmed discovery. In July 2011 PG&E further revised its DOT administration practices to have the DER review all event notifications received via email. It is the DER's responsibility to contact local supervision and the On-Call representative to confirm the incident facts and the decision to conduct or forego post-accident testing following a DOT reportable incident. If the need for post-accident testing is indicated, the DER initiates contact with the external testing administrator who dispatches a collector. The DER will convey the time of the incident to the external testing administrator. Training All DOT leaders are required to complete DOT training every 2 years. In addition, employees are provided with checklists as quick reference guides. The most recent system wide training for Maintenance and Construction supervisors was conducted on June 14, 2011. The training material and roster are included as Attachments P-11-28A and P-11-28B. Additional training material is included in Attachment P-11-28B1 All new DOT covered employees are notified of their DOT-related responsibilities upon hire or transfer into a DOT-covered position. Materials provided to DOT covered employees are included as Attachment P-11-28C. The DOT Drug Free Workplace Administration team also conducts monthly training sessions and ad-hoc training to intact workgroups upon request. The Gas Operations Standards and Drug Free Workplace administration teams work together to notify supervisors and employees of changes in DOT requirements via bulletins to the Extended Leadership Team (ELT), which includes Supervisors, Managers, Directors and Officers -as well as through tailboards (scripted messages delivered directly to employees by local supervisors). In addition to providing training to DOT covered employees and leaders, PG&E provides training to its collectors on an annual basis (Attachments P-11-28D and P-11-28E). Training was c

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. • PG&E conducted Department of Transportation (DOT) Post Accident Training for first line supervisors of the Gas Maintenance and Construction team in June 2011. PG&E also created a cross department team to collaborate on ongoing improvements to the DOT process to ensure all reportable gas and commercial related accidents/ incidents are communicated to the DOT within two hours, but not to exceed eight hours. PG&E will revise its procedures to comply with any revisions to the Pipeline Safety Act which may require accident or incident notification at the earliest practicable moment, following confirmed discovery of an accident or incident and not later than 1 hour following such confirmed discovery. • In addition, PG&E has updated job tools and expanded responsibilities to ensure DOT compliance. For example, the on-call engineer is notified of all gas incidents/accidents and will be responsible for reaffirming DOT post accident criteria. DOT contact information is now included in the procedural checklist of the Emergency On-Call Binder. PG&E communicated the updated roles and made the new resources available to supervisors, managers and directors in July 2011.