# NTSB Safety Recommendation P-11-031 - **operation:** document - **citation:** P-11-031 - **title:** NTSB Safety Recommendation P-11-031 - **source type:** guidance - **agency:** National Transportation Safety Board - **status:** guidance - **official:** true - **published on:** 2011-09-26 - **effective on:** 2011-09-26 - **summary:** TO PACIFIC GAS AND ELECTRIC COMPANY: Develop, and incorporate into your public awareness program, written performance measurements and guidelines for evaluating the plan and for continuous program improvement. - **machine formats:** - **json:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-11-031.json - **markdown:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-11-031.md - **app url:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-11-031 - **source url:** https://data.ntsb.gov/carol-main-public/sr-details/P-11-031 **body:** NTSB safety recommendation P-11-031. TO PACIFIC GAS AND ELECTRIC COMPANY: Develop, and incorporate into your public awareness program, written performance measurements and guidelines for evaluating the plan and for continuous program improvement. Priority: CLASS II Overall Status: Closed - Acceptable Action Issued Date: 2011-09-26 Adopted Date: 2011-09-12 Overall Date Closed: 2013-03-14 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: 2013-03-14 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 developed written public awareness performance measurements and guidelines for evaluating the plan and for continuous improvement, along with performance measures in cooperation with CPUC. However, PG&E has not provided NTSB with these measurements and guidelines or provided evidence to support the program implementation or effectiveness. Pending our review of these details, Safety Recommendation P-11-31 is classified OPEN—ACCEPTABLE ACTION. 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 PG&E has developed written public awareness performance measurements and guidelines for evaluating the plan and for continuous improvement, in cooperation with the CPUC. In 2012, PG&E will further evaluate the effectiveness of its public awareness communication strategy based on its survey findings, as well as initiate an advertising campaign to reach its broad stakeholder audience. Pending completion of these efforts, Safety Recommendation P-11-31 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 201100506. The reply to 201200077/ 201100506 was mailed on 3/13/2012. Addressee Acronym: PG&E Addressee Organization Type: P-Private Industry Communication Date: 2013-03-14 Communication Type: Official Correspondence Communication Contents: The performance measurements and guidelines you described that have been included in PG&E’s Public Awareness Plan satisfy the intent of Safety Recommendation P-11-31. Accordingly, this recommendation 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: 2013-01-31 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 has completed the development and incorporation of written performance measurements and guidelines into our Public Awareness Plan (PAP) (Attachment P-11-31 Public Awareness) for evaluating the plan and for continuous program improvement. The primary objectives include awareness, damage prevention and emergency response readiness. On an annual basis the PubliC Awareness Administrator or designated resource will conduct a review and develop a written report that summarizes program implementation details, outreach summary and an assessment of message comprehension and understanding - a summary of stakeholder feedback collected during the year and details regarding any notable fluctuations compared to previous years. Stakeholder feedback may include: • Survey data collected at meetings from emergency responders and excavators • Stakeholder feedback collected through business reply cards • Stakeholder feedback collected through phone surveys, mail surveys, online surveys, focus groups or stakeholder interviews • Pre-Testing-reports from focus groups, employee interviews or online panels conducted to gauge message clarity and understandability of program materials. Bottom-line results will document the number of third-party incidents during the previous year, near misses and any additional data tracked by Damage Prevention that is helpful in understanding excavator needs, issues and trends. Planned program changes for the upcoming year based on recommendations provided by the Public Awareness Program Committee, employees or vendors that support the program will also be included. PG&E identified additional stakeholder audiences to receive targeted communications. As an example, 3,800 brochures were mailed to communicate with farmers to educate them about 8111 Call Before You Dig and to promote the awareness and purpose of pipeline markers. PG&E also initiated e-mail communications, phone calls and face-to-face meetings with more than 7,000 administrative and safety contacts at public and private schools near our gas distribution and transmission pipelines. Outreach to teachers and students reached 8,243 classrooms at 5,372 different schools and resulted in more than 29,500 visits to the web site. PG&E also delivered emergency response training to 666 CERT and NERT members and volunteers using new training and reference materials specifically developed for this audience. 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. On January 30, 2012, PG&E forwarded to the California Public Utilities Commission PG&E's "2011 Customer Safety & Public Awareness Communication Activity Report (Attachment P-11-31 A). This report includes “Efforts to Measure the Impact of Safety Communications" using 1) the results of periodic surveys with targeted questions around the public awareness of pipeline and pipeline safety and 2) trends associated with damage during excavation. The initial results of the periodic surveys performed are included in the report, and show positive trends in the areas of Awareness of Pipeline Location, Awareness of Efforts to Maintain Safe Operations, Receiving Information, and Damage to PG&E's underground facilities. In order to track effectiveness of its public awareness program, PG&E participates in the American Petroleum Institute/Interstate Natural Gas Association of America/Association of Oil Pipe Lines (API/INGAAlAOPL) joint survey program for pipeline operators, implemented by Harris Interactive (Harris). Harris is a communications firm with extensive experience conducting surveys for the pipeline industry. This survey is conducted every 4 years. Details of the survey process may be found at the following link: http://www.api.org/oilb-and-natural-gas-overview/transporting-oil-and-naturalgas/pipeline/-/media/Files/Oil-and-Natural-Gas/pipeline/pipeline white paper statistical significance2.ashx In 2012, PG&E has plans to further evaluate the effectiveness of its Public Awareness communication strategy based on the survey findings, as well as initiate an advertising campaign to reach its broad stakeholder audience. 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. • Developed written public awareness performance measurements and guidelines for evaluating the plan and for continuous improvement. • Developed performance measures which will be filed with the CPUC by 2/1/12 • 2011 PHMSA and CPUC Audit of PG&E's Public Awareness Program made recommendations to enhance the public awareness plan, and recognized positive attributes of program. - **truncated:** false - **body characters:** 19518