NTSB Safety Recommendation P-24-002

NTSB safety recommendation P-24-002.

TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: 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.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2024-01-25

Adopted Date: 2024-01-02

Overall Date Closed: 2025-05-09

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: 2025-05-09

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2024-01-25

Communication Type: Transmittal Letter

Communication Contents: 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: As of the date of this accident, Beta did not have a formal PSMS program; however, they had some internal programs that overlapped with elements of ANSI/API RP 1173. PSMS is the formal, organization-wide approach to managing safety risk, enhances the effectiveness of risk management, and enables continuous improvement of pipeline safety performance. A PSMS program can help pipeline operators ensure that pipelines are designed, constructed, operated, and maintained in a manner that complies with federal, state, and local regulations. After this accident, PHMSA conducted a compliance review and identified 10 probable violations of the Pipeline Safety Regulations. In addition to PHMSA’s preliminary findings, we found that Beta was not in compliance with regulations when the company did not drug test the pipeline controllers following the accident (see Section 2.6). A PSMS program includes maintaining procedures that address safe work practices and ensuring personnel follow these written procedures. In this accident, we found that the San Pedro Bay Pipeline controllers did not follow company procedures that required them to isolate their pipeline if a leak was indicated by the leak detection system. Further, PSMS assists pipeline operators in better ensuring a prompt and effective incident response that minimizes the adverse impacts on life, property, and the environment. This is done, in part, through training and improvements that are developed by incorporating previous lessons learned. However, as stated earlier, we found that the delayed response to this accident showed that previous issues, like communication-loss alarms, as well as insufficient training, contributed to a larger volume release (see Section 2.5.1). The NTSB believes that the implementation of a robust PSMS program would have helped Beta comply with regulations, ensure employees were following company procedures, and better prepare personnel to respond and react to the conditions found during this release. Therefore, the NTSB concludes that had Beta Offshore implemented a pipeline safety management system, they may have further evaluated their operations, identified continuous improvement opportunities, and better positioned their staff to respond and react to a leak. The NTSB has long advocated for the implementation of safety management systems that provide an organization-wide approach to managing safety risk in the pipeline industry.44 We acknowledge that there are several ongoing initiatives encouraging voluntary PSMS implementation and that some operators have implemented such programs. Survey results from PHMSA and the PSMS Industry Team indicated that the majority of pipeline industry mileage, about 85%, is covered by a PSMS. However, as we see in this accident, not all pipeline operators under PHMSA’s regulatory authority have implemented a formal PSMS program. Thus, the NTSB concludes that pipeline safety would be enhanced if pipeline companies implemented safety management systems. Therefore, the NTSB recommends that PHMSA issue an advisory bulletin to all PHMSA-regulated pipeline owners and operators, promoting the benefits of PSMS and asking them to develop and implement such a system based on API RP 1173.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2024-05-24

Communication Type: Official Correspondence

Communication Contents: We are pleased that you have encouraged and supported the voluntary implementation of pipeline safety management systems (PSMSs) at numerous industry meetings and events. We note that you plan to issue an advisory bulletin promoting the benefits of PSMS and to encourage pipeline operators to voluntarily adopt PSMS standards, such as API RP 1173. Pending the issuance of the advisory bulletin, Safety Recommendation P-24-2 is classified OPEN-- ACCEPTABLE RESPONSE.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2025-05-09

Communication Type: Official Correspondence

Communication Contents: We have long advocated for the implementation of SMSs that provide an organization-wide approach to managing safety risk in the pipeline industry. An SMS builds upon an operator’s existing practices, with a particular emphasis on proactively identifying safety gaps, encouraging nonpunitive reporting of safety issues, and promptly responding to those issues. On March 25, 2025, PHMSA published an advisory bulletin promoting the benefits of pipeline SMSs and encouraging all regulated operators to implement them. This action meets the intent of this recommendation. Accordingly, the Board has classified Safety Recommendation P-24-2 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-24-2: Concur. PHMSA concurs with NTSB’s statement “that pipeline safety would be enhanced if pipeline companies implemented safety management systems.” American Petroleum Institute (API) Recommend Practice (RP) 1173, Pipeline Safety Management Systems (API RP 1173), was developed by API in response to NTSB Safety Recommendation P-12-17.2 PHMSA has long encouraged and supported voluntary implementation of Pipeline Safety Management Systems (PSMS) consistent with API RP 1173 across the pipeline industry. The following examples demonstrate where PHMSA has promoted the benefit of PSMS and encouraged voluntary adoption by the pipeline industry: • Public Workshop on Safety Management Systems, Arlington, Virginia, February 27, 2014.3 • Technical Pipeline Safety Standards Committees, informally known as the Gas Pipeline Safety Advisory Committee (GPAC) and the Liquid Pipeline Advisory Committee (LPAC), Meeting, Arlington, Virginia, June 1, 2016.4 • 2017 South Dakota / North Dakota / Wyoming Pipeline Safety Conference: Safety Management Systems API RP 1173, March 29, 2017.5 • GPAC and LPAC Meeting, Arlington, Virginia, December 13, 2017.6 • GPAC and LPAC Meeting, Washington, D.C., November 14, 2019.7 • PHMSA Office of Pipeline Safety Operators Meeting, Sugar Land, Texas, February 25, 2020.8 • PHMSA Safety Management System/Safety Culture Workshop, Sugar Land, Texas, February 26, 2020.9 • GPAC and LPAC Meeting, Virtual, October 20, 2021.10 • 2022 Utah Pipeline Safety Seminar, September 13, 2022.11 • PHMSA Public Meeting, December 15, 2022. 12 • NAPSR Regional and National Meetings (national meeting held annually, regional meetings held every five years). American Gas Association’s PSMS Workshops (held annually, most recently September 18–19, 2023).13 • Promotion of voluntary adoption of PSMS in PHMSA administrative enforcement actions, when warranted. As you may be aware, in accordance with section 205 of the Protecting Our Infrastructure of Pipelines and Enhancing Safety (PIPES) Act of 2020, PHMSA will also submit to Congress a report on the implementation of PSMS by operators of natural gas distribution systems. PHMSA plans to issue an advisory bulletin promoting the benefits of PSMS and to encourage pipeline operators to voluntarily adopt PSMS standards such as API RP 1173. 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.