NTSB Safety Recommendation P-12-012

NTSB safety recommendation P-12-012.

TO ENBRIDGE INCORPORATED: Establish a program to train control center staff as teams, semiannually, in the recognition of and response to emergency and unexpected conditions that includes supervisory control and data acquisition system indications and Material Balance System software.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2012-07-25

Adopted Date: 2012-07-10

Overall Date Closed: 2014-03-21

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: Enbridge, Inc.

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2014-03-21

Addressee Organization Type: P-Private Industry

Communication Date: 2012-10-22

Communication Type: Official Correspondence

Communication Contents: -From Al Monaco, President and Chief Executive Officer: Enbridge Energy, Limited Partnership ("Enbridge") submits this letter and attachments in response to the National Transportation Safety Board's (NTSB) letter dated July 25, 2012 concerning the NTSB's July 10, 2012 Report on the release of crude oil from Enbridge's Line 6B pipeline near Marshall, Michigan on July 25,2010. We have either already, or will soon be, fully implementing all of the NTSB recommendations. The initiatives outlined in our response have enhanced previous efforts that were in progress before this accident. This includes an undertaking to review and improve our processes by incorporating an Integrated Management System, and revising the processes that will form the basis for our Safety Management System. Enbridge recognizes the critical role the NTSB is entrusted with to investigate transportation accidents to determine probable cause and make recommendations to mitigate the likelihood of recurrence, and we appreciate the significant effort the NTSB has made while investigating the accident on our Line 6B pipeline. Enbridge and the NTSB have a mutual goal in relation to safe operation of pipelines. To this end, Enbridge has been transparent and responsive while serving as a cooperative and integral member to the investigation team. The primary objective throughout the investigation has been to identify root cause and possible contributing factors so that we, and others, can implement appropriate measures to prevent reoccurrence and to continually improve the safety of pipeline operations. From the outset, Enbridge has taken every opportunity to learn from this accident and apply enhancements to the system, processes, procedures and our organizational structure, immediately and throughout the investigative process. We have developed a comprehensive plan to lead these and other safety related initiatives now and in the future, and will continue to utilize our leadership position in the liquids pipeline industry to share learnings and promote safety enhancements. Enbridge prides itself on having a culture that is focused on its values of Integrity, Safety and Respect in support of our communities, the environment and each other. Our employees take great pride in their work and also take responsibility and full accountability for actions when things go wrong. We believe that Enbridge's actions following the Marshall release have demonstrated adherence to these values. We committed to clean up the spill and we have delivered on that promise. In fact, we have received many testimonials that the river is in excellent condition. Enbridge has always emphasized the importance of safety in our operations. The pipeline industry has substantially improved its release performance in the last decade and Enbridge has led the way in that effort. Despite this record, we recognize that no accident is acceptable and continuous improvement is essential as we strive for operational excellence. Enbridge will continue to implement actions and system enhancements, focused on attaining our goal of zero incidents. I can assure you that Enbridge will remain diligent and determined in this regard. Please don't hesitate to contact me if you have any concerns. Enbridge Response: We have addressed the recommendation to establish a program to train control center staff as teams, semiannually, in the recognition of and response to emergency and unexpected conditions that includes supervisory control and data acquisition system indications and Material Balance System (“MBS”) software in the following manner: 1) The Control Center Operations (“CCO”) is developing and implementing enhanced team training to include the theory and practice of decision making (crew resource management) in a group environment. All team members involved in decision making related to emergency and unexpected conditions will participate in semiannual team training sessions, including: •?Operators •?On-shift Senior Technical Advisors •?Shift Supervisors •?Leak Detection Analysts (formerly MBS Analysts) •?CCO On-Call Personnel 2) Participants will gain a greater awareness of the concepts, philosophies and objectives of crew resource management, and demonstrate tools for effective teamwork in areas such as: •?Communication •?Attitudes and Behaviors •?Human Factors •?Leadership and Team Building •?Situational Awareness and Workload Management 3) Participants will apply and build upon the knowledge, skills and abilities of crew resource management and team effectiveness in case studies and simulated scenarios. 4) The CCO will further enhance its training program to incorporate Operator Qualification processes and methodologies to evaluate all CCO staff involved in pipeline operational decisions. The enhanced team training and predetermined technical training will support this enhancement. 5) We have implemented new procedures that have clarified communications between Leak Detection and CCO personnel, including during periods of transient conditions as well as column separation. These procedures also allow alternatives (e.g., Volume Balance and Pressure Monitoring) to complement and supplement the Leak Detection system during transient operations.

Addressee Organization Type: P-Private Industry

Communication Date: 2014-01-15

Communication Type: Official Correspondence

Communication Contents: -From Al Monaco, President and CEO: Enbridge Energy, Limited Partnership ("Enbridge") submits this letter and attachment as an update to our previous letter of October 22, 2012 and in response to the National Transportation Safety Board ("NTSB") letter dated July 25, 2012. Over the past year, Enbridge has made great progress in relation to implementing enhancements in the areas of safety and operational reliability. Our focus remains on delivering energy safely and reliably. As such, of the 47 commitments we made in our correspondence of October 22, 2012, 45 have been completed (some have ongoing reviews and implementations) and we expect the final two commitments to be completed by the end of 2014. In addition to the commitments made over a year ago, we have taken additional steps to enhance our safety performance and operational reliability. In 2013, Enbridge appointed a Senior Vice President of Enterprise Safety and Operational Reliability reporting directly to me. A key responsibility of this role is to coordinate a consistent approach across all of Enbridge's business activities to build, share, and promote industry-leading safety practices and culture. Throughout the past year, we continued, through communications and training programs, to actively involve our employees and contractors in achieving our goal of zero incidents – which we call our "Path to Zero". As such, we have provided additional guidance to our workforce through the establishment of Health & Safety Principles that supplement our existing Lifesaving Rules. To further our progress, one of our key initiatives in 2013 was to conduct an enterprise-wide safety perception survey to measure our advancements in relation to safety culture. More than 90% of Enbridge employees participated in the survey, a strong indicator on its own of the level of employee engagement in meeting our safety objectives. That survey, which is evaluated by DuPont, found that tremendous progress occurred in all aspects of safety (leadership, structure, processes and actions), such that Enbridge has achieved the Independent Stage of Safety Culture - a positive measure of the relative strength of our safety culture. Measuring our progress is important to us and to that end, Enbridge retained an independent consultant to verify and make suggestions for improvements in relation to pipeline integrity, leak detection, and public safety. That is in addition to the ongoing regular audits and inspections conducted by our various regulatory agencies. All of the information provided through regulatory or independent audits, is useful to Enbridge and our industry in order for us to all continue down the Path to Zero incidents. Finally, Enbridge has actively participated and presented in numerous industry and regulator led initiatives to advance industry safety, such as the National Energy Board Safety Forum and API's quarterly Hazardous Liquid Pipeline Shared Practices Virtual Tailgate conferences. As discussed earlier, Enbridge has made significant strides in the area of safety culture and performance and I am proud of what we have been able to accomplish during the past year. However, as I indicated previously, Enbridge will remain diligent and is determined to continually improve our safety culture, performance and to lead industry in safety best practices. As we continue on our Path to Zero, we will continue to improve our safety processes through the use of management systems, by monitoring our progress, and by seeking out opportunities to enhance our risk management processes. I trust the attachment provides a satisfactory update and I would ask that you contact me directly should you have any questions in relation to our update. P-12-012, Enbridge Response: We have addressed the recommendation to establish a program to train control center staff as teams, semiannually, in the recognition of and response to emergency and unexpected conditions that includes supervisory control and data acquisition system indications and Material Balance System (“MBS”) software in the following manner: 1) The Control Center Operations (“CCO”) is developing and implementing enhanced team training to include the theory and practice of decision making (crew resource management) in a group environment. All team members involved in decision making related to emergency and unexpected conditions will participate in semiannual team training sessions, including: • Operators • On-shift Senior Technical Advisors • Shift Supervisors • Leak Detection Analysts (formerly MBS Analysts) • CCO On-Call Personnel Completed. 2) Participants will gain a greater awareness of the concepts, philosophies and objectives of crew resource management, and demonstrate tools for effective teamwork in areas such as: • Communication • Attitudes and Behaviors • Human Factors • Leadership and Team Building • Situational Awareness and Workload Management Completed. 3) Participants will apply and build upon the knowledge, skills and abilities of crew resource management and team effectiveness in case studies and simulated scenarios. Completed. 4) The CCO will further enhance its training program to incorporate Operator Qualification processes and methodologies to evaluate all CCO staff involved in pipeline operational decisions. The enhanced team training and predetermined technical training will support this enhancement. Completed and ongoing. 5) We have implemented new procedures that have clarified communications between Leak Detection and CCO personnel, including during periods of transient conditions as well as column separation. These procedures also allow alternatives (e.g., Volume Balance and Pressure Monitoring) to complement and supplement the Leak Detection system during transient operations. Completed.

Addressee Organization Type: P-Private Industry

Communication Date: 2014-07-23

Communication Type: Official Correspondence

Communication Contents: -From Al Monaco, President and CEO: On July 25, 2012 the National Transportation Safety Board ("NTSB") issued safety recommendations to Enbridge Energy, Limited Partnership ("Enbridge") as a result of the investigation of the July 25, 2010 pipeline incident. Enbridge provided an initial response to the NTSB recommendations on October 22, 2012 and a subsequent update on January 15, 2014, to which the NTSB responded on March 21, 2014. The purpose of this letter is to provide an interim update on the remaining open recommendations (P-12-11 , P-12-1 3, and P-12-15). Enbridge continues to implement enhancements in the areas of safety and operational reliability. Our focus remains on delivering energy safely and reliably. Of the 47 identified commitments that address the NTSB's recommendations, Enbridge is pleased to report that, 45 are complete and 1 is substantially complete. I expect the final commitment in relation to conducting a reliability engineering analysis of the effectiveness of hydrostatic testing in conjunction with in-line inspection tools (ILl), based on Enbridge's most recent hydrostatic tested pipelines, to be complete prior to year-end 2014. The attached document summarizes the status of each item in the open recommendations. Additionally, we provide the following information to address items raised in your letter of March 21, 2014. Safety recommendation considered “Closed – Acceptable Action” as per NTSB letter of March 21, 2014.

Addressee Organization Type: P-Private Industry

Communication Date: 2012-12-18

Communication Type: Official Correspondence

Communication Contents: We note that Enbridge is developing and implementing enhanced team training for its control center operations (CCO) staff, as requested. Accordingly, Safety Recommendation P-12-12 is classified OPEN—ACCEPTABLE RESPONSE, pending implementation of the recommended training.

Addressee Organization Type: P-Private Industry

Communication Date: 2014-03-21

Communication Type: Official Correspondence

Communication Contents: We are pleased that you developed and implemented enhanced, semiannual team training for your control center operations (CCO) staff, including theory and practice of decisionmaking (crew resource management) related to emergency and unexpected conditions; concepts, philosophies, and objectives of crew resource management; tools for effective communication, attitudes, and behaviors; human factors; leadership and team building; and situation awareness and workload management using case studies and simulated scenarios. We are also pleased that the CCO will incorporate operator qualification processes and methodologies in the evaluation of all CCO staff involved in pipeline operational decisions, and that you have implemented new procedures clarifying communications between Leak Detection and CCO personnel that allow such alternatives as volume balance and pressure monitoring to complement and supplement the leak detection system during transient operations as well as column separations. These combined actions satisfy Safety Recommendation P-12-12, which is classified CLOSED—ACCEPTABLE ACTION.