NTSB Safety Recommendation P-12-013

NTSB safety recommendation P-12-013.

TO ENBRIDGE INCORPORATED: Incorporate changes to your leak detection processes to ensure that accurate leak detection coverage is maintained during transient operations, including pipeline shutdown, pipeline startup, and column separation.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2012-07-25

Adopted Date: 2012-07-10

Overall Date Closed: 2014-11-20

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: 2014-11-20

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. We have addressed the recommendation to incorporate changes to our leak detection processes to ensure that accurate leak detection coverage is maintained during transient operations, including pipeline shutdown, pipeline startup, and column separation in the following manner: 1) 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. 2) We developed and have implemented procedures for Control Room Management (“CRM”) in accordance with new regulatory requirements. 3) We created and are implementing procedures to differentiate between transient conditions during a startup and transient conditions during a shutdown. 4) Enbridge has initiatives underway to improve controller decision support systems including development of tools to further support the analysis of abnormal conditions, column separation and identification of leak signatures. We are also implementing expert systems to support alarm analysis. 5) We have undertaken significant steps to reduce the number of overall alarms, reducing Leak Detection and CCO personnel workload and potential desensitization to active alarms. For example, dynamic alarm thresholds are being introduced on all systems to reduce or eliminate false alarms during transient conditions and to tighten leak sensitivity thresholds during normal or steady state conditions. 6) The Enbridge Leak Detection Analyst Training Program has been enhanced in several areas including On-The-Job training, Training Program Layout, Readiness Assessment, and Communications with CCO personnel. 7) We are implementing team training objectives for Leak Detection Analysts and working to develop line specific simulators for the purposes of scenario based team training. 8) Under the area of instrumentation addition and program enhancements, a leak detection equipment design standard was initiated to optimize the performance of the existing Leak Detection system. For example, the maintenance management program has been reviewed and restructured to formalize the inventory and management of critical leak detection equipment. In addition, as part of a Leak Detection Instrumentation Improvement project that started in 2011, Enbridge is adding flow meters, pressure and temperature sensors across our pipeline systems. 9) We are implementing a Quality Management Program (QMP) to ensure effective execution of critical work activities meeting pre-defined quality objectives. 10) Continuous improvement plans have been developed and are being implemented to tune the MBS leak detection system for optimal performance.

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-12-013: Enbridge Response: We have addressed the recommendation to incorporate changes to our leak detection processes to ensure that accurate leak detection coverage is maintained during transient operations, including pipeline shutdown, pipeline startup, and column separation in the following manner: 1) 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. 2) We developed and have implemented procedures for Control Room Management (“CRM”) in accordance with new regulatory requirements. Completed. 3) We created and are implementing procedures to differentiate between transient conditions during a startup and transient conditions during a shutdown. Completed. 4) Enbridge has initiatives underway to improve controller decision support systems including development of tools to further support the analysis of abnormal conditions, column separation and identification of leak signatures. We are also implementing expert systems to support alarm analysis. Completed. 5) We have undertaken significant steps to reduce the number of overall alarms, reducing Leak Detection and CCO personnel workload and potential desensitization to active alarms. For example, dynamic alarm thresholds are being introduced on all systems to reduce or eliminate false alarms during transient conditions and to tighten leak sensitivity thresholds during normal or steady state conditions. Completed. 6) The Enbridge Leak Detection Analyst Training Program has been enhanced in several areas including On-The-Job training, Training Program Layout, Readiness Assessment, and Communications with CCO personnel. Completed. 7) We are implementing team training objectives for Leak Detection Analysts and working to develop line specific simulators for the purposes of scenario based team training. Completed. 8) Under the area of instrumentation addition and program enhancements, a leak detection equipment design standard was initiated to optimize the performance of the existing Leak Detection system. For example, the maintenance management program has been reviewed and restructured to formalize the inventory and management of critical leak detection equipment. In addition, as part of a Leak Detection Instrumentation Improvement project that started in 2011, Enbridge is adding flow meters, pressure and temperature sensors across our pipeline systems. Leak Detection Equipment Design Standard - Completed. Addition of leak detection instrumentation is ongoing and has a target completion of the end of Q2 2014. 9) We are implementing a Quality Management Program (QMP) to ensure effective execution of critical work activities meeting pre-defined quality objectives. Completed. 10) Continuous improvement plans have been developed and are being implemented to tune the MBS leak detection system for optimal performance. Completed and ongoing.

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. We have addressed the recommendation to incorporate changes to our leak detection processes to ensure that accurate leak detection coverage is maintained during transient operations, including pipeline shutdown, pipeline startup, and column separation in the following manner: 1) 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. 2) We developed and have implemented procedures for Control Room Management (“CRM”) in accordance with new regulatory requirements. Completed. 3) We created and are implementing procedures to differentiate between transient conditions during a startup and transient conditions during a shutdown. Completed. 4) Enbridge has initiatives underway to improve controller decision support systems including development of tools to further support the analysis of abnormal conditions, column separation and identification of leak signatures. We are also implementing expert systems to support alarm analysis. Completed. 5) We have undertaken significant steps to reduce the number of overall alarms, reducing Leak Detection and CCO personnel workload and potential desensitization to active alarms. For example, dynamic alarm thresholds are being introduced on all systems to reduce or eliminate false alarms during transient conditions and to tighten leak sensitivity thresholds during normal or steady state conditions. Completed. 6) The Enbridge Leak Detection Analyst Training Program has been enhanced in several areas including On-The-Job training, Training Program Layout, Readiness Assessment, and Communications with CCO personnel. Completed. 7) We are implementing team training objectives for Leak Detection Analysts and working to develop line specific simulators for the purposes of scenario based team training. Completed. 8) Under the area of instrumentation addition and program enhancements, a leak detection equipment design standard was initiated to optimize the performance of the existing Leak Detection system. For example, the maintenance management program has been reviewed and restructured to formalize the inventory and management of critical leak detection equipment. In addition, as part of a Leak Detection Instrumentation Improvement project that started in 2011, Enbridge is adding flow meters, pressure and temperature sensors across our pipeline systems. Leak Detection Equipment Design Standard - Completed. Addition of leak detection instrumentation is substantially complete (96%); the target completion is the end of Q3 2014. 9) We are implementing a Quality Management Program (QMP) to ensure effective execution of critical work activities meeting pre-defined quality objectives. Completed. 10) Continuous improvement plans have been developed and are being implemented to tune the MBS leak detection system for optimal performance. Completed.

Addressee Organization Type: P-Private Industry

Communication Date: 2014-10-15

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 NTSB's investigation of Enbridge's July 25, 2010 pipeline incident in Marshall, Michigan. Enbridge has provided several updates, the latest of which was provided July 23, 2014. This letter provides a final status update on the remaining open recommendations (P-12-11 and P-12-13). As energy is essential for our society and lifestyles, Enbridge's purpose is to deliver that energy safely and reliably, every day. As such, we continue to press forward with continual improvements to our processes and procedures. We are pleased to report that we have now completed each of the 47 recommendations made by the NTSB. Specifically, Enbridge has completed its 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. As this analysis is a core part of our Integrity Management System, it will be subject to regular review and continual improvement processes. The completion of this document fulfills the remaining outstanding requirement of recommendation P-12-11. Furthermore, since the July 23, 2014 update, Enbridge has successfully completed the Lakehead System Leak Detection Instrumentation Improvement project that began in 2011. The completion of this significant project fully responds to recommendation P-12-13. We will continue to review and implement appropriate leak detection instrumentation improvements as part of our continual improvement processes on our network of pipeline systems. As such, the attached document summarizes the status of each item and indicates that each item is now complete. We would like to take this opportunity to thank the NTSB and its staff for your thorough investigation, development of meaningful recommendations and feedback in relation to our actions to fulfill the recommendations. The efforts and improvements that Enbridge has undertaken in response to those recommendations have improved our safety management, operational reliability and continual improvement processes. These improvements better position us to accomplish our purpose and vision of supporting both a strong economy and societal lifestyle expectations by delivering energy every day in a safe and reliable manner. Should you have any questions in relation to our update please feel free to contact me directly. P-12-013: We have addressed the recommendation to incorporate changes to our leak detection processes to ensure that accurate leak detection coverage is maintained during transient operations, including pipeline shutdown, pipeline startup, and column separation in the following manner: 1) 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. 2) We developed and have implemented procedures for Control Room Management (“CRM”) in accordance with new regulatory requirements. Completed. 3) We created and are implementing procedures to differentiate between transient conditions during a startup and transient conditions during a shutdown. Completed. 4) Enbridge has initiatives underway to improve controller decision support systems including development of tools to further support the analysis of abnormal conditions, column separation and identification of leak signatures. We are also implementing expert systems to support alarm analysis. Completed. 5) We have undertaken significant steps to reduce the number of overall alarms, reducing Leak Detection and CCO personnel workload and potential desensitization to active alarms. For example, dynamic alarm thresholds are being introduced on all systems to reduce or eliminate false alarms during transient conditions and to tighten leak sensitivity thresholds during normal or steady state conditions. Completed. 6) The Enbridge Leak Detection Analyst Training Program has been enhanced in several areas including On-The-Job training, Training Program Layout, Readiness Assessment, and Communications with CCO personnel. Completed. 7) We are implementing team training objectives for Leak Detection Analysts and working to develop line specific simulators for the purposes of scenario based team training. Completed. 8) Under the area of instrumentation addition and program enhancements, a leak detection equipment design standard was initiated to optimize the performance of the existing Leak Detection system. For example, the maintenance management program has been reviewed and restructured to formalize the inventory and management of critical leak detection equipment. In addition, as part of a Leak Detection Instrumentation Improvement project that started in 2011, Enbridge is adding flow meters, pressure and temperature sensors across our pipeline systems. Leak Detection Equipment Design Standard - Completed. Addition of leak detection instrumentation on Lakehead Lines - Completed. 9) We are implementing a Quality Management Program (QMP) to ensure effective execution of critical work activities meeting pre-defined quality objectives. Completed. 10) Continuous improvement plans have been developed and are being implemented to tune the MBS leak detection system for optimal performance. Completed.

Addressee Organization Type: P-Private Industry

Communication Date: 2012-12-18

Communication Type: Official Correspondence

Communication Contents: We note that Enbridge has implemented new procedures to clarify communications between Leak Detection and CCO personnel during periods of transient conditions, as well as column separation, and that the company has developed and implemented procedures for control room management in accordance with new regulatory requirements. We also note the many changes Enbridge is incorporating to satisfy this recommendation, including these: • Implementing procedures to differentiate between transient conditions during a startup and transient conditions during a shutdown • Improving controller decision support systems • Developing tools to further support the analysis of abnormal conditions, column separation, and the identification of leak signatures • Implementing expert systems to support alarm analysis • Implementing team training objectives for Leak Detection Analysts • Working to develop line specific simulators for the purposes of scenario-based team training • Implementing a QMP to ensure effective execution of critical work activities meeting pre-defined quality objectives • Adding flow meters, pressure, and temperature sensors across its pipeline systems Pending completion of these efforts, Safety Recommendation P-12-13 is classified OPEN—ACCEPTABLE RESPONSE.

Addressee Organization Type: P-Private Industry

Communication Date: 2014-11-20

Communication Type: Official Correspondence

Communication Contents: We are pleased that, since your July 23, 2014, letter, you have completed your Leak Detection Equipment Design Standard and leak detection instrumentation as recommended. Accordingly, Safety Recommendation P-12-13 is classified CLOSED—ACCEPTABLE ACTION.

Addressee Organization Type: P-Private Industry

Communication Date: 2014-03-21

Communication Type: Official Correspondence

Communication Contents: We are pleased to note that in addition to the new procedures discussed above, you have— • implemented new procedures that differentiate between transient conditions of a startup and those of a shutdown. • improved controller decision support systems. • developed tools to support the analysis of abnormal conditions, column separation, and the identification of leak signatures. • implemented expert systems to support alarm analysis. • implemented team training objectives for leak detection analysts. • developed line-specific simulators for the purposes of scenario-based team training. • implemented a QMP to ensure effective execution of critical work activities meeting pre-defined quality objectives. • added flow meters and pressure and temperature sensors across your pipeline systems. We understand that the addition of leak detection instrumentation is ongoing and is expected to be completed by mid-2014. Pending the completion of this effort, Safety Recommendation P-12-13 is classified OPEN--ACCEPTABLE RESPONSE.

Addressee Organization Type: P-Private Industry

Communication Date: 2014-09-16

Communication Type: Official Correspondence

Communication Contents: We understand that your Leak Detection Equipment Design Standard is complete and that the addition of leak detection instrumentation is scheduled for completion by the end of September 2014. Pending completion of the project as expected, Safety Recommendation P-12-13 is classified OPEN—ACCEPTABLE RESPONSE.