NTSB Safety Recommendation P-12-008

NTSB safety recommendation P-12-008.

TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: 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.

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 understand that PHMSA is proposing to modify the NPRM titled Pipeline Safety: Operator Qualification, Cost Recovery, and Other Proposed Changes, Section 195.446, to include the roles, responsibilities, and qualifications of those who have the authority to direct, or supersede, the specific technical actions of controllers. Pending publication of the final rule, currently expected by the end of 2013, Safety Recommendation P-12-8 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. We understand that the NPRM will propose changes to operator qualification requirements to include the roles, responsibilities, and qualifications of those who have the authority to direct, or supersede, the specific technical actions of controllers. We encourage you to expedite action to issue the NPRM. Pending timely publication of a final rule that satisfies this recommendation, Safety Recommendation P-12-8 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 has assembled a CRM team and is reviewing existing regulations, answers to frequently asked questions, and other material to determine the best way to clarify or enhance operator qualifications to ensure that requirements address all operator staff involved in pipeline operational decisions. We also note that one of the options being considered is to add language to 49 CFR 195.446(b) to further define the roles and responsibilities of anyone having authority to direct or supersede the specific technical action of controllers. Pending an update from PHMSA after the control room management team has completed its review, Safety Recommendation P-12-8 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) also adds language to the Control Room Management regulations in§§ 192.631 and 195 .446 to bring control center staff involved in operational decisions under the requirements for training and qualification. Operators will now need to include those persons and the tasks they perform into their Operator Qualification Programs and Plans. The NTSB noted in its comments on the notice of proposed rulemaking for this rule that it accepted PHMSA's plan to address this recommendation and agrees with the proposed 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: PHMSA is proposing changes to operator qualification requirements in the NPRM titled “Pipeline Safety: Operator Qualification, Cost Recovery, and Other Proposed Changes” that will satisfy the recommendation. Specifically, PHMSA will take action to modify Section 195.446 to include the roles, responsibilities, and qualifications of those who have the authority to direct, or supersede, the specific technical actions of controllers. This NPRM is expected to be published in 2013.

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, along with the inspection guidance and related Frequently Asked Questions, touch on the topic of qualification of supervisors or others intervening in control room operations, PHMSA believes a more explicit requirement would help reinforce the need to qualify these other individuals. PHMSA is proposing changes to operator qualification requirements in the NPRM titled "Pipeline Safety: Operator Qualification, Cost Recovery, and Other Proposed Changes" that to address the recommendation. Specifically, PHMSA proposes to take action to modify Sections 192.631 and 195.446 to include the roles, responsibilities, and qualifications of those who have the authority to direct, or supersede, the specific technical actions of controllers. The NPRM is currently under agency review, and we expect to publish it by Summer 2015.

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 has assembled a control room management team and is reviewing existing regulations, answers to frequently asked questions (FAQs), and other material to determine the best way to clarify and/or enhance operator qualifications to ensure requirements address all operator staff involved in pipeline operational decisions. One of the options being considered is to add language to 49 CFR 195.446(b) that would further define the roles and responsibilities of anyone having authority to direct or supersede the specific technical action of controllers. PHMSA will follow-up with NTSB when the CRM team has completed its review.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Type: Official Correspondence