NTSB Safety Recommendation P-11-030

NTSB safety recommendation P-11-030.

TO PACIFIC GAS AND ELECTRIC COMPANY: Conduct threat assessments using the revised risk analysis methodology incorporated in your integrity management program, as recommended in Safety Recommendation P-11-29, and report the results of those assessments to the California Public Utilities Commission and the Pipeline and Hazardous Materials Safety Administration.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2011-09-26

Adopted Date: 2011-09-12

Overall Date Closed: 2013-11-14

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: 2013-11-14

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 initiated action to address this recommendation. Accordingly, Safety Recommendation P-11-30 is classified OPEN—ACCEPTABLE RESPONSE, pending completion of these efforts.

Addressee Acronym: PG&E

Addressee Organization Type: P-Private Industry

Communication Date: 2012-08-29

Communication Type: Official Correspondence

Communication Contents: The NTSB notes that, when PG&E’s overall risk model is updated to more expressly consider threats such as internal corrosion, stress corrosion cracking, fatigue, and interacting threats, the updated risk model will be included in future threat assessments and integrated into future baseline assessment plans. Pending completion of these efforts, Safety Recommendation P-11-30 is classified OPEN—ACCEPTABLE RESPONSE.

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 to 201100506/ 201200077 was mailed on 3/13/2012.

Addressee Acronym: PG&E

Addressee Organization Type: P-Private Industry

Communication Date: 2013-11-14

Communication Type: Official Correspondence

Communication Contents: We note that PG&E completed the requested threat assessments using the revised risk analysis methodology, finalized the associated 2012 high consequence area assessment plan, and recently submitted the results of the assessments to the California Public Utilities Commission and the Pipeline and Hazardous Materials Safety Administration. These actions satisfy Safety Recommendation P-11-30, which is classified CLOSED—ACCEPTABLE ACTION.

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: 2013-06-18

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 taken to complete the NTSB's recommendations for PG&E's Integrity Management Program (P-11-29 and P-11-30). PG&E met with the NTSB staff on May 28, 2013, to provide an update on the completion of these recommendations and the processes in place to support continuous improvement of PG&E's integrity management program. PG&E has completed the assessment of every aspect of its Integrity Management Program (P-11-29) and implemented a revised program that includes: a revised risk model; consideration of all defect and leak data for the life of each pipeline; a revised risk assessment methodology; and an improved self-assessment process. As part of this work, PG&E updated eleven risk management procedures and added four new procedures. For the recommendations on Threat Assessment (P-11-30), PG&E has completed conducting the threat assessments using the revised risk analysis methodology as described in Recommendation P-11-29 and finalized the 2012 HCA Assessment Plan on April29, 2013. PG&E provided the results of those assessments to the California Public Utilities Commission and the Pipeline and Hazardous Materials Safety Administration on June 10, 2013. The attached status report provides additional details of the actions PG&E has taken to address these recommendations. PG&E requests the NTSB to close Safety Recommendations P-11-29 and P-11-30 with acceptable action. 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. Table 1 Threat Metric EC Leaks/mile IC Leaks/mile SCC Leaks/mile M&C Leaks/mile WROF Leaks/mile TPD Dig in rate/1000 USA tags E Number of inoperable valves IO Number of over-pressurization events P-11-30: Threat Assessment Conduct threat assessments using the revised risk analysis methodology incorporated in your integrity management program, as recommended in Safety Recommendation P-11-29, and report the results of those assessments to the California Public Utilities Commission and the Pipeline and Hazardous Materials Safety Administration. Update for P-11-30: PG&E has completed conducting the threat assessments using the revised risk analysis methodology as described in Recommendation P-11-29 and finalized the 2012 HCA Assessment Plan on April 29, 2013. PG&E has communicated the results to the California Public Utilities Commission and the Pipeline and Hazardous Materials Safety Administration on June 10, 2013. As a result of the new threat identification and risk analysis methodology, the number of miles to be assessed for internal corrosion, stress corrosion cracking and manufacturing (seam) threat, have increased as shown in Table 2. These numbers are provided to demonstrate the impact of the enhanced methodology on PG&E’s integrity management program. As new threat data is continuously analyzed and assessments are completed, the data will continue to change.

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. PG&E's risk model was updated in collaboration with industry consultants and internal subject matter experts (P-11-29, 1). The updated risk model is targeted to be applied in 2013 for the 2012 Baseline Assessment Plan.

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. As noted in response to NTSB Recommendation P-11-29, procedures and analysis tools for manufacturing and construction threat identification were developed by PG&E's consultant. The . consultant utilized these procedures and tools to perform a threat assessment on PG&E gas transmission pipelines using known pipeline values and, when necessary, a conservative assumption where pipeline: documentation was incomplete. The result of this evaluation was provided to the California Public Utility Commission on February 3,2012 (Attachments P-11-30A to P-11-30E. In addition, the results of the updated manufacturing and construction threat identification process were integrated into the 2011 Baseline Assessment Plan which was published in March 2012. Once the overall risk model is updated to more expressly consider threats including internal corrosion, stress corrosion cracking, fatigue and interacting threats, the updated risk model will then be included in future threat assessments and integrated into future Baseline Assessment Plans.

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 has hired several consultants to assist in creating new risk identification procedures for the following threats: manufacturing, construction, internal corrosion, stress corrosion cracking, incorrect operations, and interacting threats. • The manufacturing and construction threat identification procedures, including an analysis of its application, have been completed. • Completion of these analysis tools is expected during the 2nd quarter of 2012. Completion of this work will be reported to the California Public Utilities Commission and Pipeline and Hazardous Materials Safety Administration as soon as administratively possible during that quarter.