# NTSB Safety Recommendation P-17-004

- **operation:** document
- **citation:** P-17-004
- **title:** NTSB Safety Recommendation P-17-004
- **source type:** guidance
- **agency:** National Transportation Safety Board
- **status:** guidance
- **official:** true
- **published on:** 2017-06-15
- **effective on:** 2017-06-15
- **summary:** TO THE ASSOCIATION OF OIL PIPE LINES AND THE AMERICAN PETROLEUM INSTITUTE: Communicate to your members the findings of this report on the susceptibility of dents to fatigue cracking even when the dent is acceptable under current criteria.
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- **app url:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-17-004
- **source url:** https://data.ntsb.gov/carol-main-public/sr-details/P-17-004
**body:**

NTSB safety recommendation P-17-004.

TO THE ASSOCIATION OF OIL PIPE LINES AND THE AMERICAN PETROLEUM INSTITUTE: Communicate to your members the findings of this report on the susceptibility of dents to fatigue cracking even when the dent is acceptable under current criteria.

Priority: CLASS II

Overall Status: Closed - Exceeds Recommended Action

Issued Date: 2017-06-15

Adopted Date: 2017-06-05

Overall Date Closed: 2019-06-25

Synopsis: On September 21, 2015, at 12:03 p.m., an employee of Bonefish Grill in Centreville, Virginia, called the Fairfax County 911 Center to report a gasoline odor.1 The Fairfax County Fire and Rescue Department (FCFRD) immediately dispatched units to the restaurant in the Centre Ridge Marketplace shopping center. (See figure 1.) After arriving at the scene, firefighters confirmed everyone had left the restaurant; they established an incident command center, and they began the investigation. They did not detect the presence of flammable vapor inside Bonefish Grill and ruled out a natural gas leak; however, they noted a gasoline odor coming from the storm drains at the shopping center. Firefighters detected the presence of flammable vapor in most of the storm drains behind Bonefish Grill and Chipotle. Flammable vapor in some storm drains in front of Bonefish Grill was as high as 100 percent of the lower explosive limit (LEL); however, no liquid was visible in the storm drains. After establishing that the gasoline did not come from the gas station that was located about 400 feet west of Bonefish Grill and that gasoline was not illegally dumped into a storm drain, firefighters considered that the odor could be coming from a leak in a nearby, buried Colonial Pipeline Company pipeline. Colonial confirmed the pipeline leak 2 days later.

Probable Cause: The National Transportation Safety Board determines that the probable cause of the release of gasoline and other refined petroleum liquids from the Colonial pipeline was a through-wall corrosion fatigue crack that developed at a dent in the pipeline due to residual and operational stress and exposure to the underground environment. Contributing to the accident were vague Pipeline and Hazardous Materials Safety Administration regulations that allowed the dent to remain in the pipeline. Also, contributing to the delay in recognizing the release were the limitations of pipeline Supervisory Control and Data Acquisition systems to detect small pipeline leaks.

Ntsbnumber: DCA15MP002

Report Number: PAB-17-01

Addressee Name: Association of Oil Pipe Lines

Addressee Status: Closed - Exceeds Recommended Action

Addressee Date Closed: 2019-06-25

Addressee Acronym: AOPL

Addressee Organization Type: A-Associations

Communication Date: 2017-06-15

Communication Type: Transmittal Letter

Communication Contents: On June 5, 2017, the NTSB adopted its report on the September 21, 2015, pipeline leak at a shopping center in Centreville, Virginia.1 The details of this accident and the resulting safety recommendations may be found in the investigative report, which can be accessed at http://www.ntsb.gov under report number PAB-17/1. As a result of this investigation, the NTSB is issuing four new recommendations, including two to the Pipeline and Hazardous Materials Safety Administration, one to Colonial Pipeline Company, and the following recommendation to the Association of Oil Pipe Lines and the American Petroleum Institute: P-17-004.

Addressee Acronym: AOPL

Addressee Organization Type: A-Associations

Communication Date: 2018-07-05

Communication Type: Official Correspondence

Communication Contents: -From Jack Gerard, President and CEO, American Petroleum Institute and Andrew J. Black, President and CEO, Association of Oil Pipe Lines: The American Petroleum Institute (API) and the Association of Oil Pipelines (AOPL) offer the following response to the National Transportation Safety Board’s (NTSB) Safety Recommendation P-17-4. This recommendation was issued to API and AOPL on June 15, 2017 as a result of the pipeline accident brief related to the Colonial Pipeline Company petroleum product leak in Centreville, Virginia. API is the only national trade association representing all facets of the oil and natural gas industry, which supports 10.3 million U.S. jobs and nearly 8 percent of the U.S. economy. API’s more than 625 members include large integrated companies, as well as exploration and production, refining, marketing, pipeline, and marine businesses, and service and supply firms. They provide most of the nation’s energy and are backed by a growing grassroots movement of more than 40 million Americans. AOPL is a national trade association that represents owners and operators of oil pipelines across North America and educates the public about the vital role oil pipelines serve in the daily lives of Americans. AOPL members bring crude oil to the nation’s refineries and important petroleum products to our communities, including all grades of gasoline, diesel, jet fuel, home heating oil, kerosene, propane, and biofuels. API and AOPL share the same goal as the NTSB of promoting public safety and enhancing the integrity of our nation’s pipeline system, and we agree that this objective includes our important role as trade associations to disseminate safety findings from NTSB investigations. API/AOPL and liquids pipeline operators have taken action to improve safety on the issues identified in the Centreville report. Steps taken include: • June 16, 2017 – On the first day after receiving NTSB Safety Recommendation P-17-4, API and AOPL forwarded the Recommendation to more than 700 liquid pipeline industry executives, operations leaders, pipeline integrity managers, and other key company personnel. • September 6, 2017 – API facilitated a discussion with integrity managers from different liquids transmission pipeline companies to develop and implement a strategy to provide guidance to industry on assessing and managing dents. Based on output from that discussion, a work group was established specifically to develop an API Recommended Practice (RP) 1183 for Dent Fatigue and Mechanical Damage Integrity Management. A significant amount of data and information exists from new research on dent fatigue that needs to be compiled in a document for pipeline operators to use as a practical tool for management of dents and deformations. When complete, the RP will update the prior API Report 1156 (1997) and PHMSA’s TTO-10 Technical Report (2004), with a focus on inspection, assessment, and repair of dents/deformations and mechanical damage. It will be based on the research completed and the practical experiences of pipeline operators. • October 2, 2017 – API hosted the 2017 Pipeline Information eXchange (PIX), with a presentation by Colonial Pipeline on the Centreville release, the NTSB Report, and actions taken to more than one hundred liquid pipeline industry attendees. API’s PIX is an annual event that provides operators a venue to share on lessons learned, allowing the entire community to be aware of ways to improve safety based on experiences from incidents and near misses. • February 27-28, 2018 – Ensuring RP 1183 is progressing to completion, API discussed the status of the new guidance to the industry on dent fatigue management during its Annual Pipeline Policy Week, where integrity and engineering managers from the API member companies gather and discuss ongoing policy work. • April 18, 2018 – The kick-off meeting for the development of RP 1183 for Dent Fatigue and Mechanical Damage Integrity Management was held. Recognizing the importance of having all stakeholders involved in the RP development, representatives from PHMSA, state regulatory agencies, operators, and service providers participated in this meeting. As a standard setting organization, API also recognized the importance of reviewing existing standards to determine the adequacy of existing guidance and practices associated with assessing and addressing dents to fatigue cracking. Based on that review, API has taken steps in partnership with AOPL through revisions to API Recommended Practice (RP) 1160, Managing System Integrity for Hazardous Liquid Pipelines, to include criteria on addressing dents that may have fatigue cracks due to the operating characteristics of the pipeline. API is engaging PHMSA as well in this revision process. Additionally, to ensure the science on which dent susceptibility criteria is based is sound, API and AOPL are collaborating with the Pipeline Research Council International (PRCI), a leading research and development organization for the pipeline industry, to confirm any process on identifying and addressing injurious dents is fit-for-purpose. This work will likely be incorporated in future editions of the current RP 1183 for Dent Fatigue and Mechanical Damage Integrity Management that is in development. It should be noted, too, that both the ongoing effort and any future work will be useful for all pipeline operators, gas and liquid transmission, as it will provide for an effective dent criterion all companies can implement, regardless of the operating parameters of their pipeline. This RP is anticipated to be completed in the first quarter of 2019. While a great deal of work to prevent incidents similar to Centreville has been completed, a large quantity of work is still ongoing. API and AOPL welcome the opportunity to update the NTSB Chairman and Members on these activities as well as answer any questions on our efforts in response to your recommendation as you consider closing it. Thank you for your involvement in confirming the safety of the nation’s pipeline system. We look forward to continuing our working with you.

Addressee Acronym: AOPL

Addressee Organization Type: A-Associations

Communication Date: 2019-06-25

Communication Type: Official Correspondence

Communication Contents: We note that you and your members have taken the following actions to improve safety based on the lessons learned from our investigation of the Centreville incident. 1. Shortly after you received the recommendation, you forwarded it to more than 700 liquid pipeline industry executives, operations leaders, pipeline integrity managers, and other key company personnel. 2. The API facilitated a discussion with integrity managers from different liquids transmission pipeline companies to develop industry guidance on assessing and managing dents. Based on output from that discussion, a work group was established to develop API Recommended Practice (RP) 1183, “Dent Fatigue and Mechanical Damage Integrity Management.” We note that, when complete, the RP will update the prior API Report 1156 (1997) and the federal Pipeline and Hazardous Materials Safety Administration’s (PHMSA’s) TTO-10 Technical Report (2004), with a focus on inspection, assessment, and dent, deformation, and mechanical damage repair. 3. RP 1183 development began on April 18, 2018. It is associated with Safety Recommendation P-17-1, which we issued to PHMSA as a result of the Centreville incident: Work with pipeline trade and standards organizations to modify the pipeline dent acceptance criteria to account for all the factors that lead to pipe failures caused by dents and promulgate regulations to require the new criteria be incorporated into integrity management programs. (P-17-1) 4. During the API’s 2017 Pipeline Information eXchangeon the way, Colonial Pipeline presented to more than 100 liquid pipeline industry attendees on the Centreville release, our report on that incident, and actions taken in response. We further note that the API is reviewing its standards to determine the adequacy of existing guidance and practices associated with assessing and addressing dents. Based on that review, the API and the AOPL are revising API RP 1160, “Managing System Integrity for Hazardous Liquid Pipelines,” to include criteria on addressing dents that may have fatigue cracks due to the pipeline’s operating characteristics. The API is working with PHMSA on this revision, as we recommended to PHMSA in P-17-1. Additionally, the API and the AOPL are working with the Pipeline Research Council International, a leading research and development organization for the pipeline industry, to perform research that will support improvements to the API’s standards and recommended practices. The work described in items 1 and 4 above satisfy Safety Recommendation P-17-4. Further, your review of the API standards addressing dents and your development of new RPs are significant and commendable actions that go above and beyond the scope of this recommendation. Accordingly, Safety Recommendation P-17-4 is classified CLOSED--EXCEEDS RECOMMENDED ACTION.

Addressee Name: American Petroleum Institute

Addressee Status: Closed - Exceeds Recommended Action

Addressee Date Closed: 2019-06-25

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2017-06-15

Communication Type: Transmittal Letter

Communication Contents: On June 5, 2017, the NTSB adopted its report on the September 21, 2015, pipeline leak at a shopping center in Centreville, Virginia.1 The details of this accident and the resulting safety recommendations may be found in the investigative report, which can be accessed at http://www.ntsb.gov under report number PAB-17/1. As a result of this investigation, the NTSB is issuing four new recommendations, including two to the Pipeline and Hazardous Materials Safety Administration, one to Colonial Pipeline Company, and the following recommendation to the Association of Oil Pipe Lines and the American Petroleum Institute: P-17-004.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2018-07-05

Communication Type: Official Correspondence

Communication Contents: -From Jack Gerard, President and CEO, American Petroleum Institute and Andrew J. Black, President and CEO, Association of Oil Pipe Lines: The American Petroleum Institute (API) and the Association of Oil Pipelines (AOPL) offer the following response to the National Transportation Safety Board’s (NTSB) Safety Recommendation P-17-4. This recommendation was issued to API and AOPL on June 15, 2017 as a result of the pipeline accident brief related to the Colonial Pipeline Company petroleum product leak in Centreville, Virginia. API is the only national trade association representing all facets of the oil and natural gas industry, which supports 10.3 million U.S. jobs and nearly 8 percent of the U.S. economy. API’s more than 625 members include large integrated companies, as well as exploration and production, refining, marketing, pipeline, and marine businesses, and service and supply firms. They provide most of the nation’s energy and are backed by a growing grassroots movement of more than 40 million Americans. AOPL is a national trade association that represents owners and operators of oil pipelines across North America and educates the public about the vital role oil pipelines serve in the daily lives of Americans. AOPL members bring crude oil to the nation’s refineries and important petroleum products to our communities, including all grades of gasoline, diesel, jet fuel, home heating oil, kerosene, propane, and biofuels. API and AOPL share the same goal as the NTSB of promoting public safety and enhancing the integrity of our nation’s pipeline system, and we agree that this objective includes our important role as trade associations to disseminate safety findings from NTSB investigations. API/AOPL and liquids pipeline operators have taken action to improve safety on the issues identified in the Centreville report. Steps taken include: • June 16, 2017 – On the first day after receiving NTSB Safety Recommendation P-17-4, API and AOPL forwarded the Recommendation to more than 700 liquid pipeline industry executives, operations leaders, pipeline integrity managers, and other key company personnel. • September 6, 2017 – API facilitated a discussion with integrity managers from different liquids transmission pipeline companies to develop and implement a strategy to provide guidance to industry on assessing and managing dents. Based on output from that discussion, a work group was established specifically to develop an API Recommended Practice (RP) 1183 for Dent Fatigue and Mechanical Damage Integrity Management. A significant amount of data and information exists from new research on dent fatigue that needs to be compiled in a document for pipeline operators to use as a practical tool for management of dents and deformations. When complete, the RP will update the prior API Report 1156 (1997) and PHMSA’s TTO-10 Technical Report (2004), with a focus on inspection, assessment, and repair of dents/deformations and mechanical damage. It will be based on the research completed and the practical experiences of pipeline operators. • October 2, 2017 – API hosted the 2017 Pipeline Information eXchange (PIX), with a presentation by Colonial Pipeline on the Centreville release, the NTSB Report, and actions taken to more than one hundred liquid pipeline industry attendees. API’s PIX is an annual event that provides operators a venue to share on lessons learned, allowing the entire community to be aware of ways to improve safety based on experiences from incidents and near misses. • February 27-28, 2018 – Ensuring RP 1183 is progressing to completion, API discussed the status of the new guidance to the industry on dent fatigue management during its Annual Pipeline Policy Week, where integrity and engineering managers from the API member companies gather and discuss ongoing policy work. • April 18, 2018 – The kick-off meeting for the development of RP 1183 for Dent Fatigue and Mechanical Damage Integrity Management was held. Recognizing the importance of having all stakeholders involved in the RP development, representatives from PHMSA, state regulatory agencies, operators, and service providers participated in this meeting. As a standard setting organization, API also recognized the importance of reviewing existing standards to determine the adequacy of existing guidance and practices associated with assessing and addressing dents to fatigue cracking. Based on that review, API has taken steps in partnership with AOPL through revisions to API Recommended Practice (RP) 1160, Managing System Integrity for Hazardous Liquid Pipelines, to include criteria on addressing dents that may have fatigue cracks due to the operating characteristics of the pipeline. API is engaging PHMSA as well in this revision process. Additionally, to ensure the science on which dent susceptibility criteria is based is sound, API and AOPL are collaborating with the Pipeline Research Council International (PRCI), a leading research and development organization for the pipeline industry, to confirm any process on identifying and addressing injurious dents is fit-for-purpose. This work will likely be incorporated in future editions of the current RP 1183 for Dent Fatigue and Mechanical Damage Integrity Management that is in development. It should be noted, too, that both the ongoing effort and any future work will be useful for all pipeline operators, gas and liquid transmission, as it will provide for an effective dent criterion all companies can implement, regardless of the operating parameters of their pipeline. This RP is anticipated to be completed in the first quarter of 2019. While a great deal of work to prevent incidents similar to Centreville has been completed, a large quantity of work is still ongoing. API and AOPL welcome the opportunity to update the NTSB Chairman and Members on these activities as well as answer any questions on our efforts in response to your recommendation as you consider closing it. Thank you for your involvement in confirming the safety of the nation’s pipeline system. We look forward to continuing our working with you.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2019-06-25

Communication Type: Official Correspondence

Communication Contents: We note that you and your members have taken the following actions to improve safety based on the lessons learned from our investigation of the Centreville incident. 1. Shortly after you received the recommendation, you forwarded it to more than 700 liquid pipeline industry executives, operations leaders, pipeline integrity managers, and other key company personnel. 2. The API facilitated a discussion with integrity managers from different liquids transmission pipeline companies to develop industry guidance on assessing and managing dents. Based on output from that discussion, a work group was established to develop API Recommended Practice (RP) 1183, “Dent Fatigue and Mechanical Damage Integrity Management.” We note that, when complete, the RP will update the prior API Report 1156 (1997) and the federal Pipeline and Hazardous Materials Safety Administration’s (PHMSA’s) TTO-10 Technical Report (2004), with a focus on inspection, assessment, and dent, deformation, and mechanical damage repair. 3. RP 1183 development began on April 18, 2018. It is associated with Safety Recommendation P-17-1, which we issued to PHMSA as a result of the Centreville incident: Work with pipeline trade and standards organizations to modify the pipeline dent acceptance criteria to account for all the factors that lead to pipe failures caused by dents and promulgate regulations to require the new criteria be incorporated into integrity management programs. (P-17-1) 4. During the API’s 2017 Pipeline Information eXchangeon the way, Colonial Pipeline presented to more than 100 liquid pipeline industry attendees on the Centreville release, our report on that incident, and actions taken in response. We further note that the API is reviewing its standards to determine the adequacy of existing guidance and practices associated with assessing and addressing dents. Based on that review, the API and the AOPL are revising API RP 1160, “Managing System Integrity for Hazardous Liquid Pipelines,” to include criteria on addressing dents that may have fatigue cracks due to the pipeline’s operating characteristics. The API is working with PHMSA on this revision, as we recommended to PHMSA in P-17-1. Additionally, the API and the AOPL are working with the Pipeline Research Council International, a leading research and development organization for the pipeline industry, to perform research that will support improvements to the API’s standards and recommended practices. The work described in items 1 and 4 above satisfy Safety Recommendation P-17-4. Further, your review of the API standards addressing dents and your development of new RPs are significant and commendable actions that go above and beyond the scope of this recommendation. Accordingly, Safety Recommendation P-17-4 is classified CLOSED--EXCEEDS RECOMMENDED ACTION.
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