NTSB Safety Recommendation P-24-001

NTSB safety recommendation P-24-001.

TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Audit Beta Offshore’s drug-testing program to ensure compliance with postaccident drug-testing regulations.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2024-01-25

Adopted Date: 2024-01-02

Overall Date Closed: 2024-10-09

Synopsis: On October 1, 2021, at 1610 local time, San Pedro Bay Pipeline controllers received the first of a series of leak detection system alarms for their underwater pipeline, which was located in San Pedro Bay, 4.75 nautical miles off the coast of Huntington Beach, California. Over the next 13 hours, the controllers conducted seven pipeline shutdowns and restarts during troubleshooting of the alarms. At 0604 on October 2, controllers shut down the pipeline for the eighth and final time. A pipeline contractor vessel crew visually confirmed a crude oil release at 0809, and Beta Offshore, the pipeline operator, then initiated an oil spill response. An estimated 588 barrels of oil leaked from the pipeline. Damage, including clean-up costs, was estimated at $160 million. There were no injuries. A postaccident underwater examination of the pipeline found a crack along the top of the pipeline within a section of the pipeline that had been displaced from its originally installed location. Additionally, scarring consistent with anchor dragging was identified on the seafloor near the crack location. Postaccident investigation determined that the containerships MSC Danit and Beijing had dragged anchor near the pipeline months before the oil release, on January 25, 2021.

Probable Cause: The probable cause of the damage to and subsequent crude oil release from the San Pedro Bay Pipeline was the proximity of established anchorage positions to the pipeline, which resulted in two containerships’ anchors striking the pipeline when the ships dragged anchor in high winds and seas. Contributing to the crude oil release was the undetected damage to the pipeline, which allowed fatigue cracks to initiate and grow to a critical size and the pipeline to leak nearly 9 months later. Contributing to the amount of crude oil released was Beta Offshore’s insufficient training of its pipeline controllers, which resulted in the failure of the controllers to appropriately respond to leak alarms by shutting down and isolating the pipeline. Contributing to the pipeline controllers’ inappropriate response to the leak alarms was the water buildup in the pipeline, an incorrect leak location indicated by Beta Offshore’s leak detection system, and frequent previous communication-loss alarms.

Ntsbnumber: DCA22FM001

Report Number: MIR 24-01

Addressee Name: PHMSA

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2024-10-09

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2024-01-25

Communication Type: Transmittal Letter

Communication Contents: The attached letter from the NTSB Chair provides information about the NTSB’s January 2, 2024, report Anchor Strike of Underwater Pipeline and Eventual Crude Oil Release, San Pedro Bay near Huntington Beach, California, October 1, 2021, MIR-24-01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, P-24-1 and P-24-2). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. This letter provides information about the National Transportation Safety Board’s (NTSB) January 2, 2024, report Anchor Strike of Underwater Pipeline and Eventual Crude Oil Release, San Pedro Bay near Huntington Beach, California, October 1, 2021, MIR-24-01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, we identified the following safety issues: • Insufficient distance between anchorage locations and the pipeline • Need for notification of potential pipeline damage to the pipeline operator • Need for improvements to Vessel Traffic Service (VTS) vessel monitoring systems • Incorrect response by pipeline controllers to leak alarms • Lack of postaccident alcohol and other drug testing for pipeline controllers • Need for pipeline operators to implement pipeline safety management systems Accordingly, the NTSB makes the following safety recommendations to the Pipeline and Hazardous Materials Safety Administration. Additional information regarding these recommendations can be found in the noted sections of the report. • Audit Beta Offshore’s drug-testing program to ensure compliance with postaccident drug-testing regulations. (P-24-1) (See section 2.6) • Issue an advisory bulletin to all Pipeline and Hazardous Materials Safety Administration-regulated pipeline owners and operators, promoting the benefits of pipeline safety management systems and asking them to develop and implement such a system based on American Petroleum Institute Recommended Practice 1173. (P-24-2) (See section 2.7) The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (Safety Recommendations P-24-1 and P-24-2). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. From the report MIR-24-01 Anchor Strike of Underwater Pipeline and Eventual Crude Oil Release San Pedro Bay Near Huntington Beach, California October 1, 2021, published on January 25, 2024: 2.6 Drug-testing Deficiencies The pipeline controllers on duty were not tested for alcohol and other drugs following the oil release discovery. According to Beta, they did not conduct testing because at the time of the release the cause was unknown. Without drug test results, it was not possible to determine whether alcohol or other drug use contributed to the pipeline controllers’ actions on the night of the accident. Beta’s decision not to conduct required postaccident alcohol and other drug testing resulted in an absence of safety critical information. After the accident, Beta took no actions to improve their drug-testing program and PHMSA did not take exception to Beta’s absence of postaccident drug testing. The lack of action from PHMSA on this issue is concerning, as the current accident is not the first time that a pipeline operator’s decision not to conduct postaccident testing resulted in the loss of safety-critical information. After a catastrophic natural gas transmission pipeline rupture and fire in San Bruno, California, on September 9, 2010, the Pacific Gas and Electric Company decided not to perform any alcohol or other drug testing of its control room staff (NTSB 2011). As a result, NTSB issued Safety Recommendations P-11-12 and -13 to PHMSA to amend 49 CFR 199.105 and 49 CFR 199.225 to eliminate operator discretion for the testing of covered employees, and to issue immediate guidance clarifying the need to conduct postaccident alcohol and other drug testing of all potentially involved personnel despite uncertainty about the circumstances of the accident. On February 23, 2012, PHMSA issued advisory bulletin ADB-2012-02, “Pipeline Safety: Post Accident Drug and Alcohol Testing,” reminding pipeline operators of the need to conduct postaccident alcohol and other drug testing of all potentially involved personnel, despite uncertainty about the circumstances of the accident. On January 23, 2017, PHMSA published a final rule, “Pipeline Safety: Operator Qualification, Cost, Recovery, Accident and Incident Notification, and Other Pipeline Safety Proposed Changes,” requiring employees to be tested for drugs after an accident, with an exemption only when there is sufficient information that establishes that the employee had no role in the accident. PHMSA’s actions improved the regulations and reminded operators of the need to conduct alcohol and other drug testing despite uncertainty about the circumstances of the accident, thereby addressing the NTSB’s recommendations. As a result, both Safety Recommendation P-11-12 and -13 were classified Closed—Acceptable Action. However, as discussed above, even with the advisory bulletin and enhanced regulatory language, Beta did not test the controllers and PHMSA did not address Beta’s decision not to conduct postaccident alcohol and other drug testing. Therefore, the NTSB concludes that Beta Offshore was not in compliance with regulations when the company did not drug test the pipeline controllers following the accident. The NTSB recommends that PHMSA audit Beta Offshore’s drug-testing program to ensure compliance with postaccident drug-testing regulations.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2024-05-24

Communication Type: Official Correspondence

Communication Contents: We note that you have inspected Beta Offshore’s drug- and alcohol-testing program for compliance with postaccident drug-testing regulations and are conducting your postinspection analysis. Pending the completion of your audit, Safety Recommendation P-24-1 is classified OPEN-- ACCEPTABLE RESPONSE.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2024-10-09

Communication Type: Official Correspondence

Communication Contents: We note that you audited Beta Offshore’s drug-testing program to ensure compliance with drug-testing regulations. We further note that, as a result of your audit, on June 12, 2024, PHMSA issued a notice of probable violation and proposed civil penalty to Beta Offshore. These actions satisfy this recommendation. Accordingly, Safety Recommendation P-24-1 is classified CLOSED-- ACCEPTABLE ACTION.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2024-04-17

Communication Type: Official Correspondence

Communication Contents: -From Tristan H. Brown, Deputy Administrator: I am writing to provide the Pipeline and Hazardous Materials Safety Administration’s (PHMSA) intended actions to address the recommendations contained in the National Transportation Safety Board’s (NTSB) report, Anchor Strike of Underwater Pipeline and Eventual Crude Oil Release, MIR-24-01, following the October 1, 2021, release in San Pedro Bay near Huntington Beach, California. PHMSA continues our important work to help ensure the safe, reliable, and environmentally sound operation of the nation’s pipeline transportation system, and we share NTSB’s commitment to preventing pipeline accidents. PHMSA has a long history of cooperating and collaborating with NTSB, and we take our responsibility to address NTSB’s recommendations seriously. Pipeline failures like the subject of the aforementioned NTSB report are not acceptable. The NTSB’s report on the San Pedro Bay crude oil noted: The probable cause of the damage to and subsequent crude oil release from the San Pedro Bay Pipeline was the proximity of established anchorage positions to the pipeline, which resulted in two containerships’ anchors striking the pipeline when the ships dragged anchor in high winds and seas. Contributing to the crude oil release was the undetected damage to the pipeline, which allowed fatigue cracks to initiate and grow to a critical size and the pipeline to leak nearly 9 months later. Contributing to the amount of crude oil released was Beta Offshore’s insufficient training of its pipeline controllers, which resulted in the failure of the controllers to appropriately respond to leak alarms by shutting down and isolating the pipeline. Contributing to the pipeline controllers’ inappropriate response to the leak alarms was the water buildup in the pipeline, an incorrect leak location indicated by Beta Offshore’s leak detection system, and frequent previous communication-loss alarms. This letter describes the actions already taken as well as future actions PHMSA will take to address NTSB Safety Recommendations P-24-1 and P-24-2. PHMSA Response to P-24-1: Concur. From February 28 to March 22, 2024, PHMSA inspected Beta Offshore’s Drug & Alcohol (D&A) testing program for compliance with the D&A regulations in 49 Code of Federal Regulations (C.F.R.) Part 199 as well as the Department of Transportation’s testing procedures in 49 C.F.R. Part 40, which is incorporated by reference in Part 199. PHMSA will share these results, including any initiated enforcement proceedings, with NTSB after PHMSA completes its post-inspection analysis. CONCLUSION PHMSA continually seeks to use and evolve its oversight program, including improvements to pipeline safety policies, and inspection and enforcement approaches. A major tenet of PHMSA’s oversight program is that pipeline operators must know and understand their pipeline systems and use appropriate technologies and procedures to address risks in order to prevent pipeline failures while also considering the inherent limitations of technology. PHMSA requires operators of pipelines located in, or that could affect, a high consequence area to establish a risk-based integrity management framework, and to continually update the integrity management framework to reflect operating experience and the conclusions drawn from results of integrity assessments, other maintenance surveillance data, and the evaluation of consequences of a failure. 15 PHMSA prescribes factors to mitigate pipeline integrity risk and conducts inspections to ensure adequate measures are carried out effectively. PHMSA believes adoption of PSMS would support our pipeline safety regulatory framework by promoting and fostering a positive safety culture and continuous improvement in all aspects of operating our nation’s pipeline infrastructure safely. PHMSA values the role of the NTSB and our collective pipeline safety partnership, and we believe the actions described above will adequately address NTSB’s safety recommendations. We look forward to working with you and the dedicated staff at the NTSB as we continue our important work of conducting pipeline safety oversight to improve safety and protect Americans. Thank you for your consideration of PHMSA’s actions and additional plans to address Safety Recommendations P-24-1 and P-24-2. Should you require further information or assistance, please feel free to call me, or have your staff contact Max Kieba, Director, Program Development Division, in the Office of Pipeline Safety.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2024-08-09

Communication Type: Official Correspondence

Communication Contents: -From Tristan H. Brown, Deputy Administrator: I am writing to request closure of the National Transportation Safety Board (NTSB) Safety Recommendation P-24-001 to the Pipeline Hazardous Materials Safety Administration (PHMSA), which was made as part of the NTSB’s January 2, 2024, Marine Investigation Report 24-01 (MIR-24-01) regarding the anchor strike of an underwater pipeline and eventual crude oil release in San Pedro Bay off the coast of Huntington Beach, California, on October 1, 2021. Specifically, the NTSB recommended that PHMSA: • Audit Beta Offshore’s drug-testing program to ensure compliance with post-accident drug-testing regulations. (P-24-001) From February 28 to March 22, 2024, PHMSA inspected the Beta Offshore (Beta) drug and alcohol (D&A) testing program for compliance with Title 49 Code of Federal Regulations (C.F.R.) Part 199, as well as compliance with the Department of Transportation's testing procedures in 49 C.F.R. Part 40, which is incorporated by reference in Part 199. As a result of the inspection, on June 12, 2024, PHMSA issued to Beta a Notice of Probable Violation and Proposed Civil Penalty (Notice), which alleges two violations related to Beta’s failure to complete D&A tests post-accident in accordance with 49 C.F.R. § 199.105(b)(1) and § 199.225(a)(1). A copy of the Notice is enclosed. PHMSA believes the actions described above adequately address the concerns raised in NTSB’s Safety Recommendation P-24-001. PHMSA takes its responsibility to fully address all NTSB recommendations seriously and works hard to continuously improve its pipeline safety program. PHMSA looks forward to working with your office as it continues to strive to ensure the safe, reliable, and environmentally sound operation of the nation’s pipeline transportation system. If you have any questions or require additional information, please do not hesitate to contact me, or have your staff contact Damon Hill, Deputy Director of Governmental, International, and Public Affairs.