NTSB Safety Recommendation P-14-002

NTSB safety recommendation P-14-002.

TO NISOURCE, INC. (FORMERLY COLUMBIA GAS TRANSMISSION CORPORATION): Implement a process for selecting alert setpoints, and provide guidance to pipeline controllers on the expected alert response time, ways to evaluate the significance of alerts, and actions the controller must take in response to those alerts.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2014-03-05

Adopted Date: 2014-02-19

Overall Date Closed: 2017-12-15

Synopsis: On December 11, 2012, at 12:41 p.m. eastern standard time, a buried 20-inch-diameter interstate natural gas transmission pipeline, owned and operated by Columbia Gas Transmission Corporation, ruptured in a sparsely populated area, about 106 feet west of Interstate 77 near Route 21 and Derricks Creek Road, in Sissonville, West Virginia. About 20 feet of pipe was separated and ejected from the underground pipeline and landed more than 40 feet from its original location. The escaping high-pressure natural gas ignited immediately. An area of fire damage about 820 feet wide extended nearly 1,100 feet along the pipeline right-of-way. Three houses were destroyed by the fire, and several other houses were damaged. There were no fatalities or serious injuries. About 76 million standard cubic feet of natural gas was released and burned. Columbia Gas Transmission Corporation reported the cost of pipeline repair was $2.9 million, the cost of system upgrades to accommodate in-line inspection was $5.5 million, and the cost of gas loss was $285,000. Major safety issues identified in this investigation were external corrosion mitigation of the ruptured pipeline, supervisory control and data acquisition alert setpoint configuration, use of automatic shutoff valves and remote control valves to improve isolation of high-pressure pipelines, and exclusion of pipelines in the vicinity of highways from integrity management regulation. The National Transportation Safety Board makes safety recommendations to Columbia Gas Transmission Corporation and the Pipeline and Hazardous Materials Safety Administration.

Ntsbnumber: DCA13MP003

Report Number: PAR-14-01

Addressee Name: NiSource, Inc. (formerly Columbia Gas)

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2017-12-15

Addressee Organization Type: P-Private Industry

Communication Date: 2017-08-14

Communication Type: Official Correspondence

Communication Contents: -From Charles (Randal) R. Broussard, TransCanada US Gas Operations, Senior Vice President, Operations: On behalf of TransCanada US Gas Operations, provided are the annual update to the National Transportation Safety Board (NTSB) with respect to the recommendations issued by the NTSB to Columbia Pipeline Group (CPG) in its report on the rupture of Line SM-80 in Sissonville, WV in 2012 (the Sissonville Report).1In addition to the annual update, we are requesting a determination from the NTSB that the two remaining open recommendations contained in the Sissonville Report (recommendations P-14-2 and P-14-3) should be classified Closed—Acceptable Action. Over the last three years, CPG has dedicated significant effort in carefully evaluating and implementing meaningful processes within the organization to address the recommendations contained within the Sissonville Report. Following the NTSB determination in 2016 that recommendation P-14-4 should be classified as Closed— Acceptable Action, CPG strongly considers that recommendations P-14-2 and P-14-3 should also be classified as Closed—Acceptable Action. This letter identifies the measures taken by CPG to address NTSB recommendations P-14-2 and P-14-3, which relate to the Control Room response following the incident that occurred on Line SM-80 in Sissonville, WV. This work was broken down into four main efforts: (1) removing the mental tally required by Controllers when confronted with multiple alerts, (2) providing easy access to additional information when alerts, alarms, or communication failures are received, (3) adding alarms to reinforce the severity of an event, and (4) defining expectations through documentation and training, around Controller actions and response times. In addition to providing detailed information on actions undertaken within the past year, this letter summarizes work that was initiated in prior years and reported through annual updates previously submitted to the NTSB. Additional details on work undertaken in prior years are contained in the annual updates submitted to the NTSB in 2015 and 2016. Thank you for the opportunity to provide this follow-up information. We look forward to a positive disposition on the remaining two open recommendations. CPG is continuing to drive improvement through internal initiatives, with an emphasis on its Plan-Do-Check-Act principles and a Root-Cause-Analysis program, as detailed below. CPG remains committed to advancing public safety and striving for zero incidents. CPG is requesting that NTSB Recommendation P-14-2 be classified as Closed—Acceptable Action based on the following work undertaken to address this recommendation. Following the SM-80 rupture, the CPG Control Room has developed and implemented a process that provides guidance to Controllers when selecting alert setpoints. A summary of actions taken to implement Recommendation P-14-2 is addressed in the following three parts. Part one (1) addresses the steps taken to develop guidance for the selection of setpoints, part two (2) addresses the work performed to define the significance of alerts and part three (3) addresses the measures taken to ensure appropriate response times. In the Sissonville Report, NTSB provided Recommendation P-14-2 for CPG to establish greater definition around alerts, response times, and the appropriate actions a Controller should take when confronted with an alert, or multiple alerts. CPG has addressed each of these elements when establishing its guidance to Controllers. Alerts remain an important feature in the SCADA system and are critical to pipeline operation; however, after careful assessment of the operational complexity and numerous combinations of events that can result in alerts, CPG has concluded that the setpoints must remain at the Controller’s discretion. In implementing P-14-2, CPG has reviewed all alerts and developed guidance that is applicable universally, not merely those alerts relevant to the SM-80 rupture. The revised process is described below and supported by Table 1. This process has been incorporated into and documented in accordance with the Control Room Training Plan. Training is administered though table top exercises, as well as on-the-job training for new Controllers. In addition, Controllers are expected to adhere to the guidance documents regarding appropriate alert response times and actions. To make certain that this remains at the forefront of operations, this guidance has been incorporated into the CPG Alarm Management Plan. Part 1: P-14-2(1) Selecting alert points: Controllers have been trained and provided guidance documentation related to alert setpoints (Table 1). This table identifies the different types of alerts and setpoint recommendations that are appropriate for most situations. Developing this guidance was a complex undertaking, due to the number, and types of alerts required. Alert setpoints are used to notify the Controller of changes in numerous aspects of the business, including operational parameters approaching a safety threshold, commercial operations, contractual obligation, quality of service, equipment efficiency, and reliability. In addition, alerts may be triggered by multiple events. While some alerts are repeatable with clearly defined limits, others are not, such as alerts aimed at notifying controllers of commercial changes. To accommodate these differences, the final guidance document includes both prescriptive and performance based recommendations. In general, setpoints are established within a range that offers sufficient time for the Controller to react to the changing analog value, but not so tight that it could cause an overreaction to minute differences in system operation. Table 1 provides guidance to the Controller and is to be used in the absence of better-quality operational information. At the same time, given that many alert setpoints will vary seasonally, as well as by region, it was determined that requiring the application of this guidance to all setpoints could create excessive risk, as opposed to giving a well-trained, qualified Controller the latitude to define alert setpoints based on the individual’s familiarity with the operational nuances of the regions they operate. The guidance in Table 1 does, however, improve Control Room Operations by offering greater definition around alert setpoints. To provide visibility of changes to the alert setpoints as a new shift begins, Controllers are presented with a display (see Figure 1), when they initially log onto SCADA, that details all limit changes for both alarms and alerts since their last shift. This ensures Controllers are aware of the latest setpoint limits when they begin operating the pipeline. Part 2: P-14-2(2) Significance of Alerts: To ensure that Controllers remain knowledgeable about the use and application of the alert guidance, and to further develop their ability to attribute significance to alerts, CPG has implemented periodic table top exercises, as well as extended on-the-job training for new controllers. The intent of the training is to expose controllers to the various tools available to them when evaluating the significance of an alert. Alerts can be generated by a single event or culmination of events. Rather than attempting to explicitly define every event that could result in an alert, the training focuses on increased awareness and use of additional data when assessing potential causes for an alert. A Controller with access to more information will have an enhanced ability to discern the significance of an alert. Training records are recorded in the electronic Learning Management System (LMS). This training includes use of the following tools: TOOLS: SCADA, OSI Pi ProcessBook, monitoring center logs, one call tickets, controller logs, and shift turnover documentation. INFORMATION: Information that may be used includes: upstream and downstream pressures, s

Addressee Organization Type: P-Private Industry

Communication Date: 2014-06-05

Communication Type: Official Correspondence

Communication Contents: -From Shawn L. Patterson, President, Operations and Project Delivery: We have initiated a process for enhancing and summarizing events within our SCADA system to better optimize controller response time. This enhancement includes capturing event history for the following: •?Opening an alarm/alert pop-up dialog box (alert or alarm panel) •?Elapsed time from opening the dialog box until the alert or alarm is acknowledged •?Dismissing the dialog box •?Emailing the alert or alarm to the monitoring center In each case, the user and machine name is recorded along with the point or alarm data as appropriate to the message. These custom event messages are searchable and filterable using the standard SCADA display tools. They can also be exported to an alarm management tool used by Columbia Gas (TiPs) for detailed analysis. Shown below are some examples of these event messages: This summary event information will be transparent to controllers, and will provide Columbia Gas Gas Control Management with the information necessary for reviewing alert response time. We have previously provided guidance for our controllers in regard to selecting alert set points for creep alerts. Section 7.5 of the Columbia Gas Alarm Management Philosophy document states that creep alerts are “recommended to be set at 5% or 5 units, whichever is greater.” This recommendation will not fit all circumstances and will vary depending on the magnitude of the values, how often value changes, market conditions, and controller preference. Based on the NTSB recommendation, we will implement a process for selecting alert set points for all types of alerts, expected alert response time, ways to evaluate the significance of alerts, and actions the controller must take in response to those alerts. The process will be completed by revising the Columbia Gas Alarm Management Philosophy and Alarm Management Plan. We will also develop metrics that measure alert response time and incorporate a review of these metrics as part of our alarm/alert review process. We plan to begin implementing these procedures in the fourth quarter of 2014. Controllers will be trained on all new or updated procedures.

Addressee Organization Type: P-Private Industry

Communication Date: 2015-01-15

Communication Type: Official Correspondence

Communication Contents: -From Shawn L. Patterson, President, Operations and Project Delivery: Columbia Gas has initiated a process for enhancing and summarizing events within our Supervisory and Control Data Acquisition (SCADA) system to better optimize controller’s response time. This enhancement includes capturing event history for the following: ??Time that alarm/alert pop-up dialog box (alert or alarm panel) was opened ??Elapsed time from opening the dialog box until the alert or alarm is acknowledged ??Dismissing the dialog box ??When an alarm/alert is emailed to the monitoring center In each case, the user and machine name is recorded along with the point or alarm data as appropriate to the message. These custom event messages are searchable and filterable using the standard SCADA display tools. They can also be exported to an alarm management tool used by Columbia Gas for detailed analysis. Shown below are some examples of these event messages: Figure 1: Screen shot showing times captured Figure 2: Screen shot showing events emailed, acknowledged, and opened in SCADA This summary event information will be transparent to controllers, and will provide Columbia Gas’ Gas Control Management with the information necessary for reviewing alert response time. We previously provided guidance for our controllers in regard to selecting alert setpoints for creep alerts. Section 7.5 of the Columbia Gas Alarm Management Philosophy document states that creep alerts are “recommended to be set at 5% or 5 units, whichever is greater.” This recommendation will not fit all circumstances and will vary depending on the magnitude of the values, how often values change, market conditions, and controller preference. Based on the NTSB recommendation, we will implement a process for selecting alert setpoints for all types of alerts, expected alert response time(s), ways to evaluate the significance of alerts, and actions the controller must take in response to those alerts. The process will be completed by revising the Columbia Gas Alarm Management Philosophy and Alarm Management Plan. Columbia Gas will also develop metrics that measure alert response time and incorporate a review of these metrics as part of our alarm/alert review process. Columbia Gas plans to begin implementing these procedures in 2015. Controllers will be trained on all new or updated procedures. In order to successfully implement additional changes suggested by the NTSB related to Alarm and Alert management, Columbia Gas’ Gas Control has developed a team focused specifically on items P-14-2 and P-14-3. This team was developed in August of 2014. Core members of the team include the Director of Gas Control, Gas Control Managers, Operations Support Manager, Operations Support personnel, and Gas Controllers. This team held a kickoff meeting on August 29, 2014. Topics covered during the first meeting included: Review of NTSB recommendations, Team purpose, Individual Roles and Responsibilities, Team Deliverables, Project Outline/Schedule, and Future Action Items. The team has been meeting every two weeks when possible, but not less than once per month. As part of the meetings held to date, the team began categorizing alert types and defining there use.

Addressee Organization Type: P-Private Industry

Communication Date: 2016-04-13

Communication Type: Official Correspondence

Communication Contents: -From Shawn L. Patterson, Executive Vice President and Chief Operating Officer, Operations and Project Delivery: In August 2014, Columbia Gas Transmission, LLC (“Columbia Gas”) formed a team to focus specifically on NTSB recommendations P-14-2 and P-14-3. Initially, this team’s core members included Columbia Gas’s Director of Gas Control, Gas Control Managers, Operations Support Manager, Operations Support personnel, and Gas Controllers. In early 2015, analysts from the Real Time Systems (RTS) department were added to the team. Using a Supervisory and Data Acquisition (SCADA) reporting tool, the team has completed identifying and defining types of alerts that are presented to controllers. Types of alerts were sorted and addressed by frequency of occurrence. Each type of alert was reviewed by the team to determine its use and typical response. Alerts that were identified as insignificant, redundant, or nuisance were removed to improve accuracy and efficiency of information presented to gas controllers. Removal of these alerts was completed using our SCADA Change Management tool. Currently, the team is working through each type of alert to: •?Identify a suggested set point range; •?Determine authority to change an alert set point; •?Delineate the set point management of change process; •?Provide guidelines regarding response actions and timing; and •?Identify information and tools that can be used to determine the significance of the alert. The team continues to meet regularly to work through the alert philosophy and rationalization process. Upon completion, any changes to Gas Control related policies and procedures will be communicated to Gas Controllers through formal training and documented using the company’s training record system.

Addressee Organization Type: P-Private Industry

Communication Date: 2017-12-15

Communication Type: Official Correspondence

Communication Contents: We note that you have developed and implemented a process that provides guidance to controllers when selecting alert setpoints, including defining the significance of alerts and measures to ensure appropriate response times. These actions satisfy Safety Recommendation P 14 2, which is classified CLOSED--ACCEPTABLE ACTION.

Addressee Organization Type: P-Private Industry

Communication Date: 2015-03-17

Communication Type: Official Correspondence

Communication Contents: We note that you are working to implement a process for enhancing your supervisory control and data acquisition system to improve controller response time, are revising your Alarm Management Philosophy and Alarm Management Plan, and expect to implement the resulting new procedures this year. We further note that you will develop metrics that measure alert response time(s), will incorporate a review of these metrics as part of your alarm/alert review process, and, as part of the new process, will record the user and machine name along with the point or alarm data, as appropriate to the message. We also understand that you will train controllers on all new and updated procedures. Pending completion of these efforts, Safety Recommendation P-14-2 and -3 are classified OPEN—ACCEPTABLE RESPONSE.

Addressee Organization Type: P-Private Industry

Communication Date: 2014-07-29

Communication Type: Official Correspondence

Communication Contents: We are encouraged that you have initiated a process for enhancing and summarizing events within your supervisory control and data acquisition (SCADA) system to improve controller response time, and that you will record the user and machine name along with the point or alarm data (as appropriate to the message). We appreciate that this process will not fit all circumstances and will vary depending on the magnitude of the values, how often values change, market conditions, and controller preference. We note that you will implement a process for selecting (1) alert setpoints for all types of alerts, (2) expected alert response time, (3) ways to evaluate the significance of alerts, and (4) actions the controller must take in response to those alerts, and that you will revise your Gas Alarm Management Philosophy and Alarm Management Plan following implementation of the process. We further note that you will develop metrics that measure alert response time and incorporate a review of these metrics as part of your alarm/alert review process. We are encouraged that you intend to begin implementing these procedures in the fourth quarter of 2014, and that you will train controllers on all new or updated procedures. Pending completion of this effort, Safety Recommendation P 14 2 is classified OPEN—ACCEPTABLE RESPONSE.

Addressee Organization Type: P-Private Industry

Communication Date: 2016-05-18

Communication Type: Official Correspondence

Communication Contents: We understand that you continue efforts to implement a process for enhancing and summarizing events within your SCADA system to better optimize controller response time. We note that your team used a SCADA reporting tool to identify and define the types of alerts presented to controllers, which the team sorted and reviewed to determine each alert’s use and typical response. The team removed alerts that were insignificant, redundant, or considered a nuisance to improve the accuracy and efficiency of information presented to gas controllers. We also note that the team continues to meet regularly to address the alert philosophy and rationalization process, and upon completion, any changes to gas control related policies and procedures will be communicated to gas controllers through formal training and will be documented using your training record system. Thank you for your efforts thus far to address Safety Recommendation P-14-2. Pending completion of this work, the recommendation is classified OPEN—ACCEPTABLE RESPONSE.