NTSB Safety Recommendation P-12-001

NTSB safety recommendation P-12-001.

TO THE UNITED STATES DEPARTMENT OF TRANSPORTATION: Audit the Pipeline and Hazardous Materials Safety Administration’s onshore pipeline facility response plan program’s business practices, including reviews of response plans and drill programs, and take appropriate action to correct deficiencies.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2012-07-25

Adopted Date: 2012-07-10

Overall Date Closed: 2017-12-27

Synopsis: On Sunday, July 25, 2010, about 5:58 p.m., eastern daylight time, a segment of a 30-inch-diameter pipeline (Line 6B), owned and operated by Enbridge Incorporated (Enbridge) ruptured in a wetland in Marshall, Michigan. The rupture occurred during the last stages of a planned shutdown and was not discovered or addressed for 17 hours. During the time lapse, Enbridge twice pumped additional oil (81 percent of the total release) into Line 6B during two startups; the total release was estimated to be 843,444 gallons of crude oil. The oil saturated the surrounding wetlands and flowed into the Talmadge Creek and the Kalamazoo River. Local residents self-evacuated from their houses, and the environment was negatively affected. Cleanup efforts continue as of the adoption date of this report, with continuing costs exceeding $767 million. About 320 people reported symptoms consistent with benzene exposure. No fatalities were reported.

Probable Cause: The National Transportation Safety Board (NTSB) determines that the probable cause of the pipeline rupture was corrosion fatigue cracks that grew and coalesced from crack and corrosion defects under disbonded polyethylene tape coating, producing a substantial crude oil release that went undetected by the control center for over 17 hours. The rupture and prolonged release were made possible by pervasive organizational failures at Enbridge Incorporated (Enbridge) that included the following: Deficient integrity management procedures, which allowed well-documented crack defects in corroded areas to propagate until the pipeline failed. Inadequate training of control center personnel, which allowed the rupture to remain undetected for 17 hours and through two startups of the pipeline. Insufficient public awareness and education, which allowed the release to continue for nearly 14 hours after the first notification of an odor to local emergency response agencies. Contributing to the accident was the Pipeline and Hazardous Materials Safety Administration’s (PHMSA) weak regulation for assessing and repairing crack indications, as well as PHMSA’s ineffective oversight of pipeline integrity management programs, control center procedures, and public awareness. Contributing to the severity of the environmental consequences were (1) Enbridge’s failure to identify and ensure the availability of well-trained emergency responders with sufficient response resources, (2) PHMSA’s lack of regulatory guidance for pipeline facility response planning, and (3) PHMSA’s limited oversight of pipeline emergency preparedness that led to the approval of a deficient facility response plan.

Ntsbnumber: DCA10MP007

Report Number: PAR-12-01

Addressee Name: DOT

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2017-12-27

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2020-06-12

Communication Type: NPRM Response

Communication Contents: The National Transportation Safety Board (NTSB) has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA) April 16, 2020, notice of proposed rulemaking (NPRM), Pipeline Safety: Regulatory Reform for Hazardous Liquid Pipelines. In this notice, PHMSA is requesting comment on proposals to repeal, replace, or revise sections in Parts 190, 194, and 195 of the federal Pipeline Safety Regulations. Following its investigation of the Marshall, Michigan, accident, the NTSB issued safety recommendations to address deficient pipeline FRPs, including one to the US Department of Transportation (DOT): Audit the Pipeline and Hazardous Materials Safety Administration’s onshore pipeline facility response plan program’s business practices, including reviews of response plans and drill programs, and take appropriate action to correct deficiencies. (P-12-1) Closed–Acceptable Action On June 19, 2017, the DOT published an audit report assessing PHMSA’s Office of Pipeline Safety onshore pipeline FRP program in response to Safety Recommendation P-12-1. The audit report’s recommendations included, among other things, amending Part 194 to improve the clarity and specificity of the regulations by developing: • Specific requirements in 49 CFR 194.115(a) for the quantity of response resources needed to respond to a worst-case discharge; • Additional regulatory language that further defines the meaning of the response resources time tiers in 49 CFR 194.115(b), and what level of resources corresponds to each tier; and • Specific requirements to confirm the capability of response resources to arrive within the times required in the regulations in 49 CFR 194.115(b). As a result of this action, on December 27, 2017, the NTSB classified Safety Recommendation P-12-1 as Closed? Acceptable Action.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2013-09-30

Communication Type: Official Correspondence

Communication Contents: This letter concerns 22 open safety recommendations that the National Transportation Safety Board (NTSB) issued to the US Department of Transportation (USDOT) between 1997 and 2013. Enclosure 1 is a list of these recommendations; Enclosure 2 is a copy of the correspondence history regarding them. The NTSB is currently reviewing a July 24, 2013, update from the Pipeline and Hazardous Materials Safety Administration regarding Safety Recommendations I-02-1 and -2, which will be addressed in separate correspondence. We recently corresponded with the Federal Aviation Administration regarding Safety Recommendation A-06-43; Enclosure 3 provides a more detailed history of correspondence regarding this recommendation. The NTSB is interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. We are concerned because we have not received updates regarding action either taken or planned to address the remaining 19 open recommendations for some time—in some cases, over 10 years. We would like to point out that, when we issue a safety recommendation directly to the USDOT rather than to an individual modal agency, we do so because the scope of the recommendation falls outside the authority of the modal agency, or for some other specific reason. Failure to address these important safety issues places the public at risk.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2017-12-27

Communication Type: Official Correspondence

Communication Contents: We note that an independent evaluator within PHMSA’s Office of the Chief Safety Officer, outside the Office of Pipeline Safety (OPS), conducted an audit following program evaluation standards, and the results were reviewed by your staff. The final audit report, which Mr. Fulton included in his letter, included an addendum update by PHMSA describing the actions it had taken to address the identified deficiencies. These actions satisfy Safety Recommendation P-12-1, which is classified CLOSED--ACCEPTABLE ACTION.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2013-07-08

Communication Type: Official Correspondence

Communication Contents: The DOT’s plan (1) to audit the business practices of, and evaluate the resources allocated to, PHMSA’s onshore pipeline facility response plan program, (2) to review the response plans and drill programs, and (3) to take appropriate action to correct identified deficiencies, constitutes an acceptable plan for addressing Safety Recommendations P-12-1 and 2. Accordingly, pending completion of these efforts, these recommendations are classified OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2016-07-08

Communication Type: Official Correspondence

Communication Contents: On July 8, 2013, based on information in then-Secretary LaHood’s October 18, 2012, letter, we classified Safety Recommendations P-12-1 and -2 “Open—Acceptable Response,” pending completion of the proposed efforts to address them. On September 30, 2013, as part of a clean-up effort of 22 safety recommendations issued to the DOT, we also requested information on the status of action to implement Safety Recommendations P-12-1 and -2. To date, you have not provided any further information regarding your actions or intentions to address either recommendation. Accordingly, we would appreciate receiving a prompt update supplying this information. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Pending your response, Safety Recommendations P-12-1 and -2 remain classified OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2016-10-18

Communication Type: Official Correspondence

Communication Contents: We are pleased to learn that the requested audit was conducted by an independent evaluator within PHMSA’s Office of the Chief Safety Officer following program evaluation standards, that the audit report is in the process of final clearance, and that you expect to submit it by end of calendar year 2016. Pending our receipt of the final audit report, Safety Recommendation P-12-001 is classified OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2017-08-17

Communication Type: Official Correspondence

Communication Contents: -From Finch Fulton, Deputy Assistant Secretary for Transportation Policy: The audit was conducted by an independent evaluator within the Pipeline and Hazardous Materials Safety Administration's (PHMSA) Office of the Chief Safety Officer-which was outside the Office of Pipeline Safety (OPS)-following Program Evaluation Standards and was reviewed by my staff. I have enclosed a copy of the final audit report, which includes an addendum update by PHMSA that describes the actions taken to address the deficiencies identified in the report. Since the Marshall, Michigan, oil spill, PHMSA has improved the business practices of the program, and the U.S. Department of Transportation (DOT) believes OPS adequately responded to the findings of the audit. We request closure of this recommendation.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2012-10-18

Communication Type: Official Correspondence

Communication Contents: -From Ray LaHood, Secretary of the United States Department of Transportation: This letter responds to the National Transportation Safety Board's (NTSB) Safety Recommendations P-12-1 and P-1 2-2. which were issued on July 25, 2012, following NTSB's investigation of the July 25. 20 I 0, pipeline rupture in Marshall, Michigan. The pipeline was owned and operated by Enbridge Incorporated. The U.S. Department of Transportation takes NTSB 's safety recommendations seriously and is focused on appropriately addressing all of the pipeline safety recommendations in your report. The Department will conduct an audit of the effectiveness of the Pipeline and Hazardous Materials Safety Administration's onshore pipeline facility response plan program's business practices, including reviews of response plans and drill programs, and take appropriate action to correct deficiencies (P-12-1 ). In addition, we will evaluate the resources allocated to the onshore pipeline facility response plan program.

Addressee Acronym: DOT

Addressee Organization Type: G-Federal Government

Communication Date: 2016-08-19

Communication Type: Official Correspondence

Communication Contents: -From Antony R. Foxx, Secretary of Transportation: The audit was conducted by an independent evaluator within the Pipeline and Hazardous Materials Safety Administration's (PHMSA) Office of the Chief Safety Officer-which is outside the Office of Pipeline Safety-following Program Evaluation Standards. The audit report is in the process of final clearance, and we expect to submit it by end of the calendar year.