NTSB Safety Recommendation P-87-002

NTSB safety recommendation P-87-002.

THE NTSB RECOMMENDS THAT THE RESEARCH AND SPECIAL PROGRAM ADMINISTRATION, U.S. DEPARTMENT OF TRANSPORATION: AMEND 49 CFR PARTS 192 AND 195 TO REQUIRE THAT OPERATORS OF PIPELINES DEVELOP AND CONDUCT SELECTION, TRAINING, AND TESTING PROGRAMS TO ANNUALLY QUALIFY EMPLOYEES FOR CORRECTLY CARRYING OUT EACH ASSIGNED RESPONSIBILITY WHICH IS NECESSARY FOR COMPLYING WITH 49 CFR PARTS 192 OR 195 AS APPROPRIATE.

Priority: CLASS III

Overall Status: Closed - Unacceptable Action

Issued Date: 1987-03-24

Adopted Date: 1987-02-18

Overall Date Closed: 1998-07-27

Synopsis: ON APRIL 27, 1985, NATURAL GAS UNDER 990 PSIG RUPTURED THE NO. 10 PIPELINE OF THE TEXAS GAS PIPELINE COMPANY SYSTEM. THE RUPTURE WAS IN AN AREA WEAKENED BY ATMOSPHERIC CORROSION THAT WAS LOCATED WITHIN THE PIPELINE'S CASING UNDER KENTUCKY STATE HIGHWAY 90 NEAR BEAUMONT, KENTUCKY. THE ENSUING FIRE KILLED FIVE PERSONS IN A HOUSE LOCATED NORTH OF THE RUPTURE, INJURED THREE PERSONS AS THEY FLED FROM THEIR HOUSE LOCATED SOUTH OF THE RUPTURE, AND DESTROYED SUBSTANTIAL AMOUNTS OF PROPERTY. ON FEBRUARY 21, 1986, NATURAL GAS UNDER 987 PSIG RUPTURED THE NO. 15 PIPELINE OF THE TEXAS EASTERN GAS PIPE LINE SYSTEM. THE RUPTURE WAS IN AN AREA WEAKENED BY GAL VANIC CORROSION AND WAS LOCATED SOUTH OF KENTUCKY STATE HIGHWAY 52 NEAR LANCASTER, KENTUCKY. THE FORCE OF THE ESCAPING GAS AND THE ENSUING FIRE INJURED THREE PERSONS AS THEY FLED FROM THEIR HOUSES, RESULTED IN THE EVACUATION OF 77 OTHER PERSONS, AND DESTROYED SUBSTANTIAL AMOUNTS OF PROPERTY.

Probable Cause: None

Keywords: Training and Education

Ntsbnumber: DCA85FP011

Report Number: PAR-87-01

Addressee Name: RSPA

Addressee Status: Closed - Unacceptable Action

Addressee Date Closed: 1998-07-27

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1999-01-26

Communication Type: NPRM Response

Communication Contents: Notation 7106: The National Transportation Safety Board has reviewed the Notice of Proposed Rulemaking (NPRM) concerning the qualification of pipeline personnel (Docket No. RSPA-983783; Notice 1). The Safety Board has long been concerned about training in all transportation modes, including pipelines. In a report adopted on February 18, 1987, concerning pipeline accidents in Kentucky during 1985 and 1986, the Safety Board recommended that Research and Special Program Administration (RSPA): Amend 49 Code of Federal Regulations (CFR) Parts 192 and 195 to require that operators of pipelines develop and conduct selection, training, and testing programs to annually qualify employees for correctly carrying out each assigned responsibility which is necessary for complying with 49 CFR Parts 192 or 195 as appropriate. (P-87-2) Because over ten years had passed since the recommendation was issued, the Safety Board classified Safety Recommendation P-87-2 "Closed-Unacceptable Action" on July 27, 1998. In support of the recommendation, the Safety Board noted that it had issued more than 100 recommendations about the training of pipeline workers. The Board had issued the recommendations as a result of various pipeline accidents that took place between 1975 and 1986, and the recommendations covered a wide variety of training deficiencies that applied to a broad segment of pipeline activities. As a result of its investigation of a pipeline accident in San Juan, Puerto Rico, on November 21, 1996,' that resulted in 33 fatalities, the Safety Board made the following safety recommendation to RSPA: Complete a final rule on employee qualification, training, and testing standards within 1 year. Require [pipeline] operators to test employees on the safety procedures they are expected to follow and to demonstrate that they can correctly perform the work. (P-97-7) On July 8, 1998, RSPA advised that it expected to issue a final rule by November 1998 on an employee qualification program. The Safety Board is evaluating this response. In the San Juan report, the Safety Board reached several conclusions related to training. In this accident, the gas company employee who received telephoned reports of gas odors failed to provide effective instruction to callers about the dangers of propane and the steps they should take to protect themselves because neither employee training nor supervision was adequate. The gas company's employees were not adequately trained in surveying and pinpointing leaks. Furthermore, the gas company's employees were not properly trained in testing for leaks; they did not locate and repair the leak in the week before the accident. In addition, the leak detection training given to the gas company's employees was inadequate partly because neither the gas company, nor its consultant, identified the tasks for which the employees needed to be trained or tested the employees to make sure the training had been effective. Further, following the Safety Board's investigation of a pipeline accident near Fork Shoals, South Carolina, on June 26,1996,' which resulted in the release of about 957,000 gallons of fuel oil, the Board addressed the lack of adequate training for pipeline controllers. According to the pipeline operator, before the accident, controllers learned to recognize and handle normal conditions or emergency situations by reading a training guide and having discussions with other controllers. Actual experience with such an event would only occur coincidentally, if a controller happened to be working on the involved line at the time of the event. However, the job descriptions for both regular and relief controllers at the company required that the controller monitor pressures and respond to alarms caused by abnormal situations, as well as know the correct response and quickly execute it to prevent emergency situations. In this accident, the controller mistakenly shut down a pump station, then attempted to keep the line running even while high pressures were being recorded at many locations, relief valves were opening, and numerous alarms were being reported by the supervisory control and data acquisition system. The Board concluded that the training provided to the pipeline operator's controllers was inadequate to prepare them to respond properly to abnormal conditions. Ensuring that controllers and supervisors respond appropriately in such a high-stress environment requires adequate training. Because the company's controller training program did not include such training, the Safety Board concluded that the training provided by the company to its shift supervisors and pipeline controllers before the accident was inadequate to prepare them to respond properly and in a timely fashion to abnormal conditions and pipeline emergencies. The subject NPRM provides for the identification of relevant operations and maintenance area tasks; an evaluation procedure to determine whether individuals performing such tasks are qualified to perform them, as well as to respond to abnormal operating conditions; and the maintenance of records of each individual's tasks and evaluations. However, the NPRM does not actually require that operating and maintenance personnel be trained. The approach taken by the NPRM is rather to evaluate each individual's ability to perform the required tasks. The NPRM proposes that this evaluation could be performed by methods such as written or oral examination, or observation during on-the-job perfom1ance. Observation during job performance is a routine supervisory function. Tests must be administered in conjunction with training so that an objective assessment can be made as to the success of the training. The Safety Board believes that strong training and testing requirements are needed to ensure that employees can properly perform their tasks. The NPRM includes provisions to re-evaluate individuals as their tasks change or if there are indications that an individual may no longer be qualified. A provision also allows operators to determine whether periodic re-evaluation is needed and what the time interval should be between evaluations. The Safety Board believes that requirements are needed for retraining and re-testing. The Board is disappointed that, although RSPA has been aware of the prevalence of accidents in the pipeline industry associated with deficient personnel training for a number of years, the proposed NPRM does not require training and associated testing for qualification. Therefore, the Safety Board urges RSPA to amend the final rule to require that individuals be trained, that they be tested to assess the success of the training, and that they be periodically retrained and re-tested. The Safety Board appreciates being provided the opportunity to comment on this rulemaking action. Should you require additional infom1ation or clarification, please advise.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-01-05

Communication Type: Recommendation Reiteration

Communication Contents: From the accident report of the over-pressure of Peoples Gas Light and Coke Company low-pressures distribution system in Chicago, IL on January 17, 1992, which the Board adopted on 1/5/1993. In addition to the above recommendations, the Safety Board reiterates to the Research and Special Programs Administration (P-87-2).

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1991-06-11

Communication Type: Recommendation Reiteration

Communication Contents: From the pipeline accident report of the liquid propane pipeline rupture and fire of the Texas Eastern Products Pipeline Company pipeline in North Blenheim, New York on March 13, 1990.The Board adopted this report on 6/11/1991. Also, the Safety Board reiterated the following safety recommendations to the Research and Special Programs Administration: P-84-26, P-87-2, and P-87-22.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1997-10-31

Communication Type: Official Correspondence

Communication Contents: NTSB REQUESTED A FOLLOWUP ON THIS DATE 10/31/97.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-01-26

Communication Type: Official Correspondence

Communication Contents: RSPA HAS ALREADY HAD ALMOST 5 YEARS TO ESTABLISH EMPLOYEE QUALIFICATION STANDARDS, AND THE SAFETY BOARD BELIEVES THAT ACHIEVING THIS OBJECTIVE SHOULD BE A RSPA PRIORITY. THE BOARD BELIEVES THAT RSPA SHOULD CONSIDER THE RULEMAKING A PRIORITY REGARDLESS OF THE DIRECTIVE, BECAUSE THE DIRECTIVE DOES NOT PERTAIN TO SAFETY REGULATIONS AND RULEMAKING MANDATED BY LEGISLATION. THE SAFETY BOARD REMAINS FIRMLY CONVINCED THAT THE RECOMMENDED TRAINING, QUALIFICATION, AND TESTING REQUIREMENTS AND STANDARDS ARE ESSENTIAL AND URGES RSPA TO ACT EXPEDITIOUSLY TO AMEND THE CFR TO REQUIRE THAT PIPELINE OPERATORS PERIODICALLY TRAIN AND TEST ALL EMPLOYEES ASSIGNED RESPONSIBILITIES THAT COULD AFFECT PUBLIC SAFETY.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-05-11

Communication Type: Official Correspondence

Communication Contents: RSPA HAS INDICATED TO THE BOARD STAFF THAT THE NPRM THAT ADDRESSES P-87-2 IS BEING PREPARED. PENDING FURTHER ACTION BY RSPA, P-87-2 HAS BEEN CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1998-07-27

Communication Type: Official Correspondence

Communication Contents: THE BOARD MAINTAINS, AS IT DID IN 1993 THE RECOMMENDED TRAINING, QUALIFICATION, & TESTING REQUIREMENTS & STANDARDS ARE ESSENTIAL. BECAUSE THE RSPA DOES NOT INTEND IMPLEMENT THE RECOMMENDATION, P-87-2 HAS BEEN CLASSIFIED "CLOSED--UNACCEPTABLE ACTION."

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1998-03-11

Communication Type: Official Correspondence

Communication Contents: (Letter Mail Controlled 3/17/98 5:55:08 PM MC# 980349) RSPA HAS INFORMED US THAT IN 1996 THE PROPOSED RULE WAS WITHDRAWN BECAUSE IT WAS "TOO PRESCRIPTIVE AND THAT RSPA NOW INTENDS TO FORM A "NEGOTIATED RULEMAKING COMMITTEE.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1991-10-18

Communication Type: Official Correspondence

Communication Contents: WE ANTICIPATE THAT A NOTICE OF PROPOSED RULEMAKING (NPRM) WILL BE ISSUED IN THE NEAR FUTURE SETTING OUT QUALIFICATION STANDARDS FOR PERSONNEL WHO PERFORM, OR DIRECTLY SUPERVISE THE PERFORMANCE OF REGULATED OPERATION, MAINTENANCE, AND EMERGENCY-RESPONSE FUNCTIONS ON GAS PIPELINES, HAZARDOUS LIQUID PIPELINES, AND CARBON DIOXIDE PIPELINES.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1992-09-02

Communication Type: Official Correspondence

Communication Contents: ISSUANCE OF A NOTICE OF PROPOSED RULEMAKING ON QUALIFICATION OF PIPELINE PERSONNEL HAS BEEN DELAYED PENDING THE PRESIDENT'S REGULATORY MORATORIUM AND EVALUATION OF ALL REGULATIONS TO IDENTIFY THOSE WHICH SUBSTANTIALLY IMPACT ECONOMIC GROWTH, MAY NO LONGER BE NECESSARY, OR IMPOSE NEEDLESS COSTS OR RED TAPE.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1992-12-24

Communication Type: Official Correspondence

Communication Contents: RSPA HAS ALREADY HAD ALMOST 5 YEARS TO ESTABLISH EMPLOYEE QUALIFICATION STANDARDS, AND THE SAFETY BOARD BELIEVES THAT ACHIEVING THIS OBJECTIVE SHOULD BE A RSPA PRIORITY. THE BOARD BELIEVES THAT RSPA SHOULD CONSIDER THE RULEMAKING A PRIORITY REGARDLESS OF THE DIRECTIVE, BECAUSE THE DIRECTIVE DOES NOT PERTAIN TO SAFETY REGULATIONS AND RULEMAKING MANDATED BY LEGISLATION. THE SAFETY BOARD REMAINS FIRMLY CONVINCED THAT THE RECOMMENDED TRAINING, QUALIFICATION, AND TESTING REQUIREMENTS AND STANDARDS ARE ESSENTIAL AND URGES RSPA TO ACT EXPEDITIOUSLY TO AMEND THE CFR TO REQUIRE THAT PIPELINE OPERATORS PERIODICALLY TRAIN AND TEST ALL EMPLOYEES ASSIGNED RESPONSIBILITIES THAT COULD AFFECT PUBLIC SAFETY.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1987-04-29

Communication Type: Official Correspondence

Communication Contents: RSPA RECENTLY PUBLISHED AN ADVANCE NOTICE OF PROPOSED RULE MAKING DIRECTED SPECIFICALLY TO THE SUBJECT OF EMPLOYEE QUALIFICATIONS (DOCKET PS-94). COMMENTS ON THIS NOTICE ARE DUE MAY 7, 1987 AND SHOULD BE HELPFUL IN PLANNING THE ACTION TO TAKE IN RESPONSE TO THIS RECOMMENDATION.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1987-06-24

Communication Type: Official Correspondence

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1991-12-20

Communication Type: Official Correspondence

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-05-10

Communication Type: Official Correspondence