NTSB Safety Recommendation P-12-007

NTSB safety recommendation P-12-007.

TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Develop requirements for team training of control center staff involved in pipeline operations similar to those used in other transportation modes.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2012-07-25

Adopted Date: 2012-07-10

Overall Date Closed: 2017-12-01

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: PHMSA

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2017-12-01

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2015-08-18

Communication Type: NPRM Response

Communication Contents: Correspondence Control 201500682: The National Transportation Safety Board (NTSB) has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA) notice of proposed rulemaking (NPRM), Pipeline Safety: Operator Qualification, Cost Recovery, Accident and Incident Notification, and Other Pipeline Safety Proposed Changes, published on July 10, 2015. In this notice, PHMSA is proposing amendments to the pipeline safety regulations to address requirements of the Pipeline Safety, Regulatory Certainty, and Job Creation Act of 2011 and update and clarify certain regulatory requirements. We also note that the proposed rulemaking addresses recommendations issued by the NTSB to PHMSA. We are pleased that PHMSA continues to improve pipeline transportation safety through its proposals and amendments. We offer the following comments on sections of the proposed rulemaking listed below that respond to NTSB safety recommendations or relate to matters for which we have basis to comment. Section III. Operator Qualification Requirements The NPRM proposes changes to the regulations addressing gas and liquid pipeline operator qualification requirements. The proposed changes include expanding the scope to include new construction and certain previously excluded operation and maintenance tasks; extending the operator qualification requirements to operators of Type A gas gathering lines in Class 2 locations, Type B onshore gas gathering lines, and regulated rural hazardous liquid gathering lines; requiring a program effectiveness review; and adding new recordkeeping requirements. Related to this proposed amendment, the NTSB issued the following safety recommendations to PHMSA on July 25, 2012: Develop requirements for team training of control center staff involved in pipeline operations similar to those used in other transportation modes. (P–12–7), and Extend operator qualification requirements in Title 49 Code of Federal Regulations Part 195 Subpart G to all hazardous liquid and gas transmission control center staff involved in pipeline operational decisions. (P–12–8) The proposed NPRM adds team training requirements in §§ 192.631 and 195.446. It also adds language to §§ 192.631 and 195.446 that would require each operator to define “the roles, responsibilities and qualifications of others with the authority to direct or supersede the specific technical actions of a controller.” These proposed regulatory improvements were discussed in the April 8, 2015, NTSB letter to PHMSA where we accepted the PHMSA plan to codify the training guidance previously issued as an advisory bulletin. Therefore, we agree with the proposed changes related to operator qualifications.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2017-12-01

Communication Type: Official Correspondence

Communication Contents: We note that your January 23, 2017, final rule also revised the control room management regulations in sections 192.631 and 195.446 of the pipeline safety regulations to more explicitly require team training and to further define the roles and responsibilities of control room staff and those with the authority to direct or supersede the specific technical actions of control room staff. The final rule also brings control center staff involved in operational decisions under the requirements for training and qualification. We note that operators will now need to include this staff and the tasks they perform in their operator qualification programs and plans. Enacting the final rule satisfies Safety Recommendations P 12-7 and -8, which are classified CLOSED--ACCEPTABLE ACTION.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2018-02-21

Communication Type: Official Correspondence

Communication Contents: In our December 1, 2017, response to your May 25, 2017, letter, we classified recommendations P-12-7 and P-12-8 CLOSED--ACCEPTABLE ACTION.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2016-12-05

Communication Type: Official Correspondence

Communication Contents: On August 18, 2016, we provided comments to your NPRM, “Pipeline Safety: Operator Qualification, Cost Recovery, Accident and Incident Notification, and Other Pipeline Safety Proposed Changes,” proposing revisions to the control room management regulations in 49 CFR 192.631 and 195.446 to more explicitly require team training. We note that you are reviewing comments to the NPRM and expect to publish the final rule later this year. Further, you incorporated guidance on team training into AB 14-02, “Pipeline Safety: Lessons Learned from the Release at Marshall, Michigan,” at the Federal Register, citing our conclusion that Enbridge’s failure to train the control center staff in team performance resulted in poor communication and a lack of leadership, and the AB reinforces and recommends that operators consider training control room staff to recognize and respond to emergencies or unexpected conditions as a team. Pending our review of the final rule, Safety Recommendations P-12-7 and -8 are classified OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2014-01-03

Communication Type: Official Correspondence

Communication Contents: We note that PHMSA is discussing team training with representatives of other Department of Transportation (DOT) modes and the US Coast Guard, is disseminating information about other DOT Operating Administration (OA) team training efforts and requirements through its control room management website, and is engaging other OAs to train PHMSA and state inspectors, particularly in the area of fatigue risk mitigation. We are also encouraged to learn that Enbridge is implementing team training in response to this recommendation. At the September 2013 meeting of our staffs, we learned that PHMSA is considering issuing a regulation for team training and is developing various guidance materials. Pending PHMSA’s completing the recommended action, Safety Recommendation P-12-7 remains classified OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2015-04-08

Communication Type: Official Correspondence

Communication Contents: As stated above, we are disappointed that you still have not issued the NPRM Pipeline Safety: Operator Qualification, Cost Recovery, and Other Proposed Changes in 2013 as you anticipated; however, we are encouraged that you expect to publish it later this year, and that it will propose requiring the recommended team training. We are pleased that you included team training guidance in ADB 14 02, Pipeline Safety: Lessons Learned from the Release at Marshall, Michigan. Pending timely issuance of the recommended requirement, Safety Recommendation P 12 7 is classified OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2013-01-11

Communication Type: Official Correspondence

Communication Contents: The NTSB notes that PHMSA continues action on this issue through a number of initiatives, that it can now inspect and enforce all Control Room Management (CRM) requirements, and that inspection and enforcement of CRM training is now included in operator qualification regulations. Pending completion of the recommended action, Safety Recommendation P-12-7 is classified OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2017-05-25

Communication Type: Official Correspondence

Communication Contents: -From Howard W. McMillan, Acting Deputy Administrator: PHMSA's "Pipeline Safety: Operator Qualification, Cost Recovery, Accident and Incident Notification, and Other Pipeline Safety Proposed Changes" final rule (82 FR 7972) revises the Control Room Management regulations in§§ 192.631and195.446 of the Pipeline Safety Regulations to more explicitly require team training and to further define the roles and responsibilities of control room staff and those with the authority to direct or supersede the specific technical actions of control room staff. The revision also requires operators to have a training program that includes control room team training and exercises that include both controllers and other individuals. PHMSA is requiring operators comply with the revised team training requirements no later than one year after the rule's publication date. PHMSA believes a requirement for control room team training would better prepare all individuals who would be reasonably expected to interface with controllers during these situations. A number of the sections in the current Control Room Management regulations, the inspection guidance, and related Frequently Asked Questions also relate to the concept of team training for control room personnel (controllers) and others who would likely work together as a team during normal, abnormal, and emergency situations. In addition to rulemaking action, PHMSA provided guidance on team training in ADB 14-02, "Pipeline Safety: Lessons Learned From the Release at Marshall, Michigan" (https://www.federalregister.gov/articles/2014/05/06/2014-10248/pipeline-safety-lessonslearned- from-the-release-at-marshall-michigan). This advisory bulletin cites the NTSB's conclusion that Enbridge's failure to train the control center staff in team performance resulted in poor communication and a lack of leadership. The bulletin reinforces and recommends that operators consider training control room staff to recognize and respond to emergencies or unexpected conditions as a team. The NTSB noted in its comments on the notice of proposed rulemaking for this rule that it accepts PHMSA's plan to codify the training guidance previously issued as an advisory bulletin and, therefore, agrees with the changes related to operator qualifications for control center staff.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2017-11-13

Communication Type: Official Correspondence

Communication Contents: -From Howard R. Elliott, Administrator: PHMSA proposed closure of this recommendation to NTSB on May 25, 2017, PHMSA looks forward to NTSB's response.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2016-08-17

Communication Type: Official Correspondence

Communication Contents: -From Marie Therese Dominguez, Administrator: While a number of the sections in the current Control Room Management regulations, the inspection guidance, and related Frequently Asked Questions already relate to the concept of team training for control room personnel (controllers) and others who would likely work together as a team during normal, abnormal, and emergency situations, PHMSA believes a requirement for control room team training would better prepare all individuals who would be reasonably expected to interface with controllers during these situations. Therefore, on July 10, 2015, PHMSA published its NPRM titled "Pipeline Safety: Operator Qualification, Cost Recovery, Accident and Incident Notification, and Other Pipeline Safety Proposed Changes," proposing revisions to the Control Room Management regulations in Sections 192.631 and 195.446 of the Pipeline Safety Regulations to more explicitly require team training. PHMSA is in the process of addressing comments on the NPRM. PHMSA also conducted an Advisory Committee meeting to discuss the final rule on June 1-3, 2016. The Committee approved tl1e rule with amendments and we will continue work toward publication of a final rule. We anticipate publication by October 2016. In addition to considering rulemaking action, PHMSA incorporated guidance on team training in ADB 14-02, "Pipeline Safety: Lessons Learned From the Release at Marshall, Michigan" (https://www.federalregister.govIarticles/2014/05/06/2014-10248/pipeline-safety-lessonslearned-from-the-release-at-marshall-michigan). The ADB cites NTSB's conclusion that Enbridge's failure to train the control center staff in team performance resulted in poor communication and a lack of leadership. The ADB reinforces and recommends that operators consider training control room staff to recognize and respond to emergencies or unexpected conditions as a team.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2013-08-29

Communication Type: Official Correspondence

Communication Contents: -From Cynthia L. Quarterman, Administrator: There has been good progress on Control Room Management (CRM) implementation, including CRM training. PHMSA discussed the specific initiatives referenced in the NTSB report regarding team training with other DOT modes, including the Federal Aviation Administration, Federal Railroad Administration, and the United States Coast Guard/DHS. Additionally, PHMSA was provided training content from Enbridge. Enbridge is implementing team training based on the recommendation. As we reported in our June 26, 2013 report to Congress, PHMSA is an active participant on the DOT’s Human Factors Coordinating Committee. PHMSA has disseminated information about other DOT Operating Administration (OA) team training efforts and requirements through the CRM website (http://primis.phmsa.dot.gov/c1m/fm.htm) and has engaged other OAs to train PHMSA and State inspectors, particularly in the area of fatigue risk mitigation. PHMSA will develop a guidance document and an advisory bulletin in the context of CRM regulations rather than address the issue through rulemaking. PHMSA has developed the draft requirements for team training and is circulating the document with others on the CRM team for comment. PHMSA is also drafting guidance material in the context of the current requirements.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2015-01-22

Communication Type: Official Correspondence

Communication Contents: -From Timothy P. Butters, Acting Administrator: While a number of the sections in the current Control Room Management regulations, the inspection guidance, and related Frequently Asked Questions already relate to the concept of team training for control room personnel (controllers) and others who would likely work together as a team during normal, abnormal, and emergency situations, PHMSA agrees that a requirement for control room team training would better prepare all individuals who would be reasonably expected to interface with controllers during these situations. Therefore, PHMSA is considering revisions to the Control Room Management regulations in§§ 192.631 and 195.446 of the Pipeline Safety Regulations to more explicitly require team training. PHMSA plans to consider this option through the NPRM titled "Pipeline Safety: Operator Qualification, Cost Recovery, and Other Proposed Changes." The NPRM is currently under agency review, and we expect to publish it in spring or summer 2015. In addition to considering rulemaking action, PHMSA incorporated guidance on team training in ADB-14-02, "Pipeline Safety: Lessons Learned from the Release at Marshall, Michigan" (https://www.federalregister.gov/articles/20 14/05/06/2014-1 0248/pipeline-safety-lessonslearned- from-the-release-at-marshall-michigan). The ADB cites the NTSB's conclusion that Enbridge's failure to train the control center staff in team performance resulted in poor communication and a lack of leadership. The ADB reinforces and recommends that operators consider training control room staff to recognize and respond to emergencies or unexpected conditions as a team.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2012-11-01

Communication Type: Official Correspondence

Communication Contents: -From Cynthia Quarterman, Administrator: PHMSA is taking action through a number of ongoing and new initiatives to help address this recommendation. The implementation of the Control Room Management (CRM) regulations continues to provide valuable lessons learned that are being incorporated into guidance for compliance with all aspects of CRM, including training. The development of CRM procedures was required by PHMSA regulation to go into effect no later than August 1, 2011. Implementation of procedures for CRM provisions with training components was required no later than October 1, 2011. Implementation of other CRM provisions including related training, was required no later than August 1, 2012. PHMSA has been actively inspecting control rooms since August 1, 2011, and has taken enforcement actions as needed. Now that all implementation deadlines have passed, PHMSA will be able to inspect and enforce the entire set of CRM requirements, including training implementation. Inspection and enforcement of CRM training is also contained in operator qualification regulations. In other related initiatives, PHMSA continues to be an active participant on the Department of Transportation’s Human Factors Coordinating Committee and engages in information exchange with other transportation modes. To the extent practical, PHMSA has disseminated information on other modal efforts and requirements through its CRM website, and engaged other modes in the training of PHMSA and State inspectors, particularly in the area of fatigue risk mitigation. Our colleagues from the Federal Aviation Administration’s Civil Aerospace Medical Institute (FAA-CAMI) attended and participated in training classes at PHMSA’s training facilities in Oklahoma City in 2011. PHMSA will engage with, and seek input from, other DOT modes about requirements they have in place that may help further address this recommendation. Finally, PHMSA held a Research and Development Forum in July 2012 where it incorporated aspects of this NTSB recommendation and others into the discussions concerning research topics to be included in the next project solicitation.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Type: Official Correspondence