NTSB Safety Recommendation P-12-019

NTSB safety recommendation P-12-019.

TO THE INTERNATIONAL ASSOCIATION OF FIRE CHIEFS AND THE NATIONAL EMERGENCY NUMBER ASSOCIATION: Inform your members about the circumstances of the Marshall, Michigan, pipeline accident and urge your member to aggressively and diligently gather from pipeline operators system-specific information about the pipeline systems in their communities and jurisdictions.

Priority: CLASS II

Overall Status: Closed - Exceeds Recommended Action

Issued Date: 2012-07-25

Adopted Date: 2012-07-10

Overall Date Closed: 2015-09-24

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: International Association of Fire Chiefs

Addressee Status: Closed - Exceeds Recommended Action

Addressee Date Closed: 2015-09-16

Addressee Acronym: IAFC

Addressee Organization Type: A-Associations

Communication Date: 2015-07-07

Communication Type: Official Correspondence

Communication Contents: -From Fire Chief G. Keith Bryant, President and Chairman of the Board: In response to this recommendation, the IAFC has taken the following steps: •?We are in the process of creating a section in our Hazardous Materials Data Integration Dissemination System (http://www.hazmatfc.com) dedicated to pipeline-specific incidents. This section will include data, resources, lessons learned and training available to both emergency responders and the pipeline industry. This section will have information about the July 25, 2010 Enbridge Incorporated incident. •?We are working in partnership with the TransCanada Corporation to educate the fire and emergency service about the energy sector, pipeline safety, and the effective response to emergency incidents involving pipelines. Our awareness effort will include expanded community relations programs to explain pipeline safety and provide training and education to first responders. •?We are developing a guide to assist local communities with emergency planning for pipeline incidents. The guide will show local communities how to collaborate with pipeline operators in order to design and review emergency response plans for pipeline emergencies. The guide will include information about how to obtain system-specific information about a pipeline and apply it to local emergency response plans. On behalf of the 11,000+ members of the IAFC, I would like to thank you and the NTSB for its continued dedication to ensuring that local fire and emergency response agencies have the training and information that they need to protect their communities. As the NTSB develops future information about pipeline incidents, we hope that you will continue to work with us to share this information with the approximately 33,000 fire and emergency departments around our nation.

Addressee Acronym: IAFC

Addressee Organization Type: A-Associations

Communication Date: 2015-09-16

Communication Type: Official Correspondence

Communication Contents: We are pleased that you posted the requested information about the 2010 Enbridge accident to the National Hazardous Materials Fusion Center website, and are in the process of creating a section in your Hazardous Materials Data Integration Dissemination System (http://www.hazmatfc.com) dedicated to pipeline incidents, which will be available to approximately 33,000 fire and emergency departments around our nation. We note that the new section will include data, resources, lessons learned, and training that will be available to emergency responders and the pipeline industry, as well as information about the 2010 Enbridge accident. We are also pleased that you are partnering with the TransCanada Corporation to educate the fire and emergency service about the energy sector, pipeline safety, and the effective response to emergency incidents involving pipelines, and that you plan to expand community relations programs to explain pipeline safety and provide training and education to first responders as part of these efforts. We note that you are developing a guide to assist local communities with emergency planning for pipeline incidents, which will show local communities how to collaborate with pipeline operators in order to design and review emergency response plans for pipeline emergencies. We also note that the guide will include information about how to obtain system-specific information about a pipeline and how to apply that information to local emergency response plans. We commend you for undertaking these efforts and look forward to their completion. Because you posted information about the 2010 Enbridge accident, as requested, and because you have taken these additional measures to improve safety, Safety Recommendation P 12-19 is classified CLOSED—EXCEEDS RECOMMENDED ACTION.

Addressee Acronym: IAFC

Addressee Organization Type: A-Associations

Communication Date: 2013-04-11

Communication Type: Official Correspondence

Communication Contents: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendation P-12-19, which the NTSB issued to the International Association of Fire Chiefs (IAFCS), on July 25, 2012, as a result of our investigation of the July 25, 2010, hazardous liquid pipeline rupture and release in a wetland in Marshall, Michigan. Although it has been almost a year since this recommendation was issued, we have received no information to date regarding IAFC’s actions to address it and would appreciate receiving a reply regarding any actions that you have either taken or planned to address this important safety issue. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our July 25, 2012, letter issuing Safety Recommendation P-12-19 is enclosed. The full report of our investigation of the July 25, 2010, pipeline accident in Marshall, Michigan (Report Number PAR-12-01), is available on our website at www.ntsb.gov.

Addressee Acronym: IAFC

Addressee Organization Type: A-Associations

Communication Date: 2015-06-11

Communication Type: Official Correspondence

Communication Contents: To date we have received no response from you regarding action you have either taken or intend to take to implement this recommendation, even after requesting such information on April 11, 2013. Recipients of our safety recommendations usually complete actions to address them within 3 to 5 years, and this recommendation is already nearly 3 years old. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Accordingly, we would appreciate receiving a prompt reply from you regarding your progress to address this recommendation. If we do not receive a response from you soon, we will have no alternative but to classify the recommendation “Closed—Unacceptable Action/No Response Received.” Pending your timely reply, Safety Recommendation P 12-19 remains classified OPEN—AWAIT RESPONSE. A copy of our July 25, 2012, letter issuing Safety Recommendation P-12-19; and our April 11, 2013, follow-up request letter are enclosed. The full report of our investigation of the July 25, 2010, pipeline accident at Marshall, Michigan, is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/PAR1201.aspx.

Addressee Name: National Emergency Number Association

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2016-02-12

Addressee Acronym: NENA

Addressee Organization Type: A-Associations

Communication Date: 2015-09-25

Communication Type: Official Correspondence

Communication Contents: -From Brian F. Fontes, CEO: Thank you for your letter of the second instant concerning safety Recommendations A-09-138 and P-12-19. In the since those recommendations were issued, and consistent with our mission to foster the technological advancement, availability, and implementation of a universal emergency telephone number system, NENA has worked diligently to improve coordination between emergency response telecommunicators, dispatchers, preparedness officials, and both the aviation and pipeline communities. In particular, we have taken several actions to improve our members' awareness of the unique issues that arise in aviation and pipeline emergencies. Prior to your agency's issuance of Recommendation A-09-138, NENA recognized the need to improve operational use of location data that is not in a "civic address" format. With the advent of cellular E9-1-1 service, the use of geodetic or "GPS" coordinates became commonplace in 9-1-1 centers. However, as your recommendation recognizes, the ability to receive such coordinates does not guarantee the ability to use them. Consequently, NENA undertook extensive standards development and educational activities aimed at operationalizing this new location paradigm. Moreover, we engaged with the vendor community to ensure the proliferation of PSAP software that could support both civic and geodetic location coordinates. Specifically, our conferences have, for many years now, included extensive programming related to the deployment, management, and use of Geospatial Information Systems (GIS) within 9-1-1 centers. This programming has brought special attention to the available GIS tools that allow telecommunicators and dispatchers to "reverse geo-code" geodetic coordinates to a civic address to which field responders can be dispatched. In a 2014 magazine article, we went further by explaining in detail how geodetic coordinates define a "fix," and how different technologies, such as GPS, use measurements of range and bearing to compute a fix. This information was well received, and NENA has fielded a number of inquiries from PSAPs that wished to better understand the purpose and use of geodetic coordinates. Finally, we are currently developing a 1.5 hour online training course on PSAP involvement with aviation emergencies. This course is being developed primarily by a NENA staffer who gained extensive experience with aviation-related PSAP operations while serving as Director of the on-site PSAP for Indianapolis International Airport (KIND). We anticipate that this training will be available sometime in late 2016. With respect to Recommendation P-12-19, we have worked closely with pipeline operators to ensure that PSAPs have access to timely, accurate information about pipeline emergencies, along with specialized training in handling such situations. First, we established the PSAP Information for Pipeline Emergencies database. This database allows pipeline operators to quickly contact PSAPs within the counties transited by their lines, using 24x7 emergency numbers that are normally answered with the same priority as 9-1-1 calls. As part of this effort, we have also communicated to PSAPs the importance of actively updating their contact information in the database, and stepped-up our own efforts to actively validate the data by regularly contacting PSAPs ourselves. Second, we published articles about the Marshall, Michigan incident in the Winter 2012 and Spring 2014 editions (both online and print) of our membership publication, The Call. Those articles can be accessed by NENA members at www.nena.org/thecall. Third, we collaborated with Enbridge Pipeline to develop a one hour online training course targeted specifically at 9-1-1 telecommunicators and dispatchers. That training is available for free to any 9-1-1 center at www.mypipelinetraining.org. Third, NENA staff acted as Subject-Matter Experts during the development of a pipeline industry standard for interaction with 9-1-1 centers. That document has now been jointly published by the American Petroleum Institute and the Association of Pipe Lines. Following that publication, NENA has initiated development of a complementary standard for PSAP interaction with pipeline operators. The development working group for that standard is currently forming, and should begin active development work in the first quarter of 2016. We appreciate the opportunity to assist NTSB in improving the safety and security of our nation's transportation networks and look forward to doing so again in the future. Should you have any further questions concerning Recommendations A-09-138 or P-12-19, or any other matter of mutual concern to the transportation and emergency response communities, please accept our open invitation to collaborate on future improvements.

Addressee Acronym: NENA

Addressee Organization Type: A-Associations

Communication Date: 2013-04-11

Communication Type: Official Correspondence

Communication Contents: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation?railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. This letter addresses Safety Recommendation P-12-19, which the NTSB issued to the National Emergency Number Association (NENA), on July 25, 2012, as a result of our investigation of the July 25, 2010, hazardous liquid pipeline rupture and release in a wetland in Marshall, Michigan. Although it has been almost a year since this recommendation was issued, we have received no information to date regarding NENA’s actions to address it and would appreciate receiving a reply regarding any actions that you have either taken or planned to address this important safety issue. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. A copy of our July 25, 2012, letter issuing Safety Recommendation P-12-19 is enclosed. The full report of our investigation of the July 25, 2010, pipeline accident in Marshall, Michigan (Report Number PAR-12-01), is available on our website at www.ntsb.gov.

Addressee Acronym: NENA

Addressee Organization Type: A-Associations

Communication Date: 2015-09-24

Communication Type: Official Correspondence

Communication Contents: In the 3 years since this recommendation was issued, we have received no information from you regarding actions you have either taken or planned to address it, despite our April 11, 2013, follow-up request for such information. Consequently, Safety Recommendation P-12-19 is classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

Addressee Acronym: NENA

Addressee Organization Type: A-Associations

Communication Date: 2016-02-12

Communication Type: Official Correspondence

Communication Contents: We are pleased you have informed your membership, and are actively addressing this issue with industry, as requested. Accordingly, Safety Recommendation P-12-19 is classified CLOSED—ACCEPTABLE ACTION.