NTSB Safety Recommendation P-12-010

NTSB safety recommendation P-12-010.

TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Issue an advisory bulletin to notify pipeline operators (1) of the circumstances of the Marshall, Michigan, pipeline accident, and (2) of the need to identify deficiencies in facility response plans and to update these plans as necessary to conform with the nonmandatory guidance for determining and evaluating required response resources as provided in Appendix A of Title 49 Code of Federal Regulations Part 194, “Guidelines for the Preparation of Response Plans.”

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2012-07-25

Adopted Date: 2012-07-10

Overall Date Closed: 2014-09-19

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: 2014-09-19

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2014-01-03

Communication Type: Official Correspondence

Communication Contents: In November 2012, PHMSA informed us that it would publish the requested ADB. We are disappointed that the document has not yet been issued; however, we are somewhat encouraged that it will be published soon. Pending completion of this effort in a timely manner, Safety Recommendation P 12 10 remains 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 will publish an AB that discusses the specific inadequacies of the Facility Response Plan for the pipeline involved in the Marshall, Michigan, incident. We also note that PHMSA plans to share lessons learned with industry organizations. Pending completion of these efforts, Safety Recommendation P-12-10 is classified OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2014-09-19

Communication Type: Official Correspondence

Communication Contents: Advisory Bulletin 2014-01, issued on January 28, 2014, satisfies Safety Recommendation P-12-10. Accordingly, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

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 will be publishing an advisory bulletin to address this recommendation. The advisory bulletin will advise operators of the circumstances of the pipeline incident, reminds operators to conform to the guidance provided in Appendix A, and advises operators to consider the incorporated-by-reference material in their facility response plans and determine whether that information needs to be replaced with copies or synopses of the originating documents. This advisory bulletin will be published in 2013.

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 will publish an Advisory Bulletin that discusses specific inadequacies of the Facility Response Plan for the pipeline involved in the Marshall, Michigan incident. One flaw was the undocumented incorporation by reference of operator manuals and procedures that were not available for emergency responders’ use. As a part of our compliance order with Enbridge regarding the Lakehead system, we plan to reach out to industry organizations to share lessons learned.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2014-08-18

Communication Type: Official Correspondence

Communication Contents: -From Cynthia L. Quarterman, Administrator: Response: On January 28, 2014, PHMSA published an advisory bulletin, Improvement in Preparing Oil Spill Facility Response Plans, which advises operators of the circumstances of the pipeline incident, reminds operators to conform to the guidance provided in Appendix A, and advises operators to consider the incorporated-by-reference material in their facility response plans and determine whether that information needs to be replaced with copies or synopses of the originating documents. https://www.federalregister.gov/articles/2014/01/28/2014-01515/improvements-in-preparingoil-spill-facility-response-plans PHMSA continues to make significant progress in continuous improvement of agencies of the pipeline safety program and seriously recognized our responsibility to fully address all NTSB recommendations. We therefore request your consideration for closing Recommendations P-12-6 and P-12-10. We will continue to work aggressively and without delay to close all remaining open recommendations.