NTSB Safety Recommendation P-93-020

NTSB safety recommendation P-93-020.

THE NTSB RECOMMENDS THAT THE AMERICAN PETROLEUM INSTITUTE: IN COOPERATION WITH THE AMERICAN GAS ASSOCIATION, DEVELOP STANDARDS AND GUIDELINES FOR THE DESIGN AND USE OF GRAPHIC INFORMATION DISPLAY SYSTEMS USED BY DISPATCHERS TO CONTROL PIPELINE SYSTEMS.

Priority: CLASS III

Overall Status: Closed - Acceptable Action

Issued Date: 1993-12-15

Adopted Date: 1993-11-04

Overall Date Closed: 2007-06-05

Synopsis: ON APRIL 7, 1992, AN UNCONTROLLED RELEASE OF HIGHLY VOLATILE LIQUIDS (HVLS) FROM A SALT DOME STORAGE CAVERN IN THE SEMINOLE PIPELINE SYSTEM NEAR BRENHAM, TEXAS, FORMED A LARGE, HEAVIER-THAN-AIR GAS CLOUD THAT EXPLODED. THREE PEOPLE DIED FROM INJURIES SUSTAINED EITHER FROM THE BLAST OR IN THE FIRE. AN ADDITIONAL 21 PEOPLE WERE TREATED FOR INJURIES AT AREA HOSPITALS. DAMAGE FROM THE ACCIDENT EXCEEDED $9 MILLION.

Probable Cause: None

Ntsbnumber: DCA92MP006

Report Number: PAR-93-01

Addressee Name: American Petroleum Institute

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2007-06-05

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2003-03-25

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 3/26/2003 2:11:06 PM MC# 2030182 During discussions related to API 1130, the Subcommittee on Cybernetics determined that the time had come for the pipeline industry to initiate the development of a set of recommendations for control center information display. This decision is based on three drivers, in addition to the recommendations by the Board: · Universal use of SCADA. Almost all pipeline companies now employee SCADA as part of system control and increasingly more complex operations are being handled remotely through SCADA. SCADA technology and tools have matured to a point where it is desirable to have a document that provides guidance on the standardization of SCADA displays. The Subcommittee on Cybernetics anticipates that the application of current human factors research to display standards may further enhance pipeline safety. · Lack of information. There is no one publication that contains all or sufficient information that can be used to standardize and improve pipeline SCADA displays. Bits and pieces of display information that is applicable are available in a number of sources. Examples include display parameters for air traffic controllers and for the military. · Timeliness. Display technology is now more mature and there may be sufficient information to develop guidance for graphical displays specific to pipeline applications. A great deal of research has been performed on how people interact with computer displays and outputs. Much of this information is in the public domain. The Subcommittee on Cybernetics sought approval for the development of a recommended practice on SCADA display standards for pipeline operators from API's pipeline Operations Technical Committee. The Operations Technical Committee approved the request at its meeting in September 2002. A work group has been formed that includes pipeline operators, a representative from the U.S. DOT Office of Pipeline Safety and the Board. The group is now meeting and anticipates that a recommended practice will be ready for balloting in 2004.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2007-02-22

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 3/1/2007 9:42:11 AM MC# 2070086:Enclosed is a copy of the press release for API Recommended Practice 1165 (RP 1165), Recommended Practice for Pipeline SCADA Displays, First Edition, as well as two advance copies of RP 1165. Copies are also being sent separately to Ms. Stacey Gerard, PHMSA Assistant Administrator and Chief Safety Officer. This is a new recommended practice (RP), which responds to a National Transportation Safety Board recommendation. The RP provides guidance to pipeline operators on the design and implementation of pipeline Supervisory Control and Data Acquisition Systems (SCADA). RP 1165 addresses the human factors element in control room operations, and enhances the human interface with SCADA systems. This also addresses NTSB's recommendations to API (P-93-20) and AGA (P-93-22). If you have any questions, please don't hesitate to contact me at lidiakp@api.org /202-682-8323 or Karen Simon at simonk@api.org / 202-652-8224. Sincerely, Peter T. Lindiak, Director Pipeline Segment

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2005-09-20

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 9/26/2005 1:36:20 PM MC# 2050449:This letter is in response to your letter of September 13, 2005, regarding the status o f efforts to produce an API recommended practice for design of supervisory control and data acquisition (SCADA) display systems. When finalized, this recommended practice will be designated as API Standard 1165. A draft version has been peer reviewed and the working group is in the process of responding to comments received. It is our expectation that the document will undergo formal balloting and be published either in the fourth quarter of 2005 or the first quarter of 2006. Robert Malloy of your staff was initially on the work group and participated in the recent stakeholder review o f the draft that concluded on August 19, 2005. He may be able to provide additional information to you. API remains committed to the completion of this recommended practice, which is intended to address NTSB Safety Recommendation P-93-20.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2001-06-08

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 06/08/2001 7:37:07 PM MC# 2010482 API responded to this recommendation on August 5, 1996 (letter to Charles Koval) as noted in NTSB letter of July 17, 2000. At that time, no further specific action by API was anticipated and we recommended that this safety recommendation be closed. In 2001, the API Subcommittee on Cybernetics is evaluating API 1130, Computation Pipeline Monitoring, for revision. API would welcome participation by NTSB on the work group that is reviewing API 1130. API 1130 includes guidance on data presentation, display ergonomics, alarm display, integration of the computation pipeline system with SCADA information and references the Instrument Society of America proceedings for additional guidance on CRT display. API member companies continue to believe that control room design and display require creative solutions that are unique to individual control room applications.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 1996-08-05

Communication Type: Official Correspondence

Communication Contents: API HAS NOT DEVELOPED NOR DOES IT PLAN TO DEVELOP A STANDARD SPECIFIC TO GRAPHIC INFO DISPLAY SYSTEMS IN CONTROL ROOMS.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 1994-01-12

Communication Type: Official Correspondence

Communication Contents: API AN AGA WILL WORK TOGETHER TO FIND A WAY TO DEVELOP A STANDARD FOR THE DESIGN AND USE OF GRAPHIC INFORMATION DISPLAY SYSTEMS IN PIPELINE AND STORAGE CONTROL SYSTEMS.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 1994-07-27

Communication Type: Official Correspondence

Communication Contents: OUR COMMITTEE ON PIPELINE CYBERNETICS IS MEETING IN THE EARLY FALL TO CONSIDER APPROPRIATE MEANS TO ADDRESS THIS SUBJECT. WE WILL BE COORDINATING OUR EFFORT WITH THE AGA.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 1994-11-02

Communication Type: Official Correspondence

Communication Contents: OUR SUBCOMMITTEE ON PIPELINE CYBERNETICS MET IN OCTOBER & DISCUSSED THE FEASIBILITY OF DEVELOPING GUIDANCE ON GRAPHIC INFO DISPLAY SYSTEMS. AS FIRST STEP, THE COMMITTEE IS SEEKING A SPEAKER ON THE SUBJECT OF GRAPHIC DISPLAY INFO SYSTEMS FROM OTHER INDUSTRIES WITH STANDARDS IN THIS AREA FOR INCLUSION IN THE 1995 API PIPELINE CONFERENCE.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2003-06-10

Communication Type: Official Correspondence

Communication Contents: The Safety Board appreciates receiving the update regarding the oil pipeline industry's reconsideration of control room design and information display. We note that the API Subcommittee on Cybernetic revised API 1130, Computation Pipeline Monitoring, and that the Operations Technical Committee approved the subcommittee's proposal to develop a recommended practice on SCADA display standards for pipeline operators. We further note that the new work group formed to address this issue anticipates that a recommended practice will be ready for balloting in 2004. Accordingly, Safety Recommendation P-93-20 remains classified "Open--Acceptable Response" pending adoption of the recommended standard.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2002-02-04

Communication Type: Official Correspondence

Communication Contents: The Safety Board notes that the API, through its subcommittee on cybernetics, is taking a fresh look at P-93-20 and is evaluating, with the intent to revise, API 1130, Computation Pipeline Monitoring, which includes guidance on data presentation, display ergonomics, and alarm display. We are aware through staff contact that the API subcommittee met in September 2001 to discuss revisions to API 1130. We would appreciate an update on the results of that meeting. In the meantime, P-93-20 is now classified "Open--Acceptable Response." We wish to emphasize, however, that this recommendation is now almost 8 years old. The Safety Board would be pleased to discuss the activities of the working group examining API 1130. Please contact Mr. Rod Dyke of our office of Rail, Pipeline, and Hazardous Materials Investigations at (202) 314-6469.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2005-09-13

Communication Type: Official Correspondence

Communication Contents: On June 22, 2005, the AGA, responding to the companion Safety Recommendation P-93-22, advised the Safety Board that it is working on the API committee that is developing a recommended practice to address graphic information displays systems for pipeline control rooms. In June 2003, the Board was informed that the API subcommittee on Cybernetic API 1130, Computation Pipeline Monitoring, was developing a recommended practice on Supervisory Control and Data Acquisition display standards for pipeline operators that was to be ready for balloting in 2004. The Board encourages the API to expedite this action. Because the API is actively working with the AGA to develop the recommended standards and guidelines, Safety Recommendation P-93-20 is classified "Open--Acceptable Response." The Safety Board would appreciate periodic updates from the API on the status of its efforts to implement Safety Recommendation P-93-20 and looks forward to receiving copies of standards and guidelines.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2007-06-05

Communication Type: Official Correspondence

Communication Contents: The Safety Board is pleased that the API, working with the American Gas Association and other industry representatives, developed, and in January 2007, issued, API Recommended Practice 1165, Recommended Practice for Pipeline SCADA Displays. These actions satisfy Safety Recommendation P-93-20, which is classified Closed Acceptable Action.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2006-01-03

Communication Type: Official Correspondence

Communication Contents: Because the API has taken the lead and is working with the AGA and others as requested to develop a recommended practice (API Standard 1165) for the design of supervisory control and data acquisition display systems, Safety Recommendation P-93-20 is classified "Open-Acceptable Response."

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 1994-02-22

Communication Type: Official Correspondence

Communication Contents: THE BOARD IS PLEASED TO LEARN THAT THE API WILL WORK WITH THE AGA IN DEVLOPING A STANDARD FOR THE DESIGN AND USE OF GRAPHIC INFORMATION DISPLAY SYSTEMS IN PIPLELINE AND STORAGE CONTROL SYSTEMS. PENDING FURTHER RESPONSE, RECOMMENDATION P-93-20 WILL BE CLASSIFIED AS "OPEN--ACCEPTABLE RESPONSE."

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 1994-10-17

Communication Type: Official Correspondence

Communication Contents: THE BOARD UNDERSTANDS THAT THE API COMMITTEE ON PIPELINE CYBERNETICS WILL MEET LATER THIS YEAR TO DISCUSS A STRATEGY FOR COMPLETING THIS RECOMMENDATION. PENDING FURTHER RESPONSE, P-93-020 IS CLASSIFIED "OPEN--ACCPETABLE RESPONSE."

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 1995-02-24

Communication Type: Official Correspondence

Communication Contents: THE BOARD NOTES THAT THE API SUBCOMMITEE ON PIPELINE CYBERNETICS HAS DISCUSSED DEVELOPING GUIDANCE ON GRAPHIC INFO DISPLAY SYSTEMS & IS SEEKING AN EXPERT TO SPEAK ON THE SYSTEMS TOPIC AT YOUR 1995 PIPELINE CONFERENCE. PENDING YOUR FURTHER RESPONSE, P-93-20 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 1997-03-20

Communication Type: Official Correspondence

Communication Contents: THE BOARD HAS REVIEWED THE API PUBLICATION, COMPUTATION PIPELINE MONITORING, WHICH THE API SUBCOMMITTEE ON CYBERNETICS HAD DEVELOPED. ALTHOUGH THIS PUBLICATION PROVIDES IMPORTANT INFO ON ALARM & DISPLAY ERGONOMIC ISSUES, IT DOES NOT ADEQUATLEY ADDRESS THE DESIGN & USE OF GRAPHIC DISPLAYS IN PIPELINE CONTROL FOR DISPATCHER. THE BOARD FOUND DURING ITS INVESTIGATION OF THE BREHAM ACCIDENT THAT DISPATCHER FAILED TO RECOGNIZE & CONSEQUENTLY TO TIMELY RESPOND TO DATA DISPLAYED IN AN ALPHA-NUMERIC FORMAT. RESEARCH HAS SHOWN THAT GRAPHIC DISPLAYS TO DATA PROVIDE BETTER HUMAN RESPONSE THAN TABULAR DISPLAYS FOR RELATIONS IN SPACE OR TIME, RELATED-SET COMPARSION OF DATA, THE MONITORING OF CHANGING DATA. HOWEVER, THE API RECOMMENDED PRACTICE STATES THAT TABULAR TRENDS ARE EFFECTIVE WAYS TO DISPLAY DATA. BECAUSE THE API HAS NOT DEVELOPED & MAINTAINS IT DOES NOT INTEND TO DEVELOP A STANDARD SPECIFIC TO GRAPHIC INFO DISPLAY SYSTEMS IN CONTROL ROOMS, THE BOARD HAS CLASSIFIED P-93-20 "OPEN--UNACCEPTABLE RESPONSE." THE BOARD ENCOURAGES THE API TO RECONSIDER ITS POSITION ABOUT THE DESIGN & USE OF GRAPHIC INFO DISPLAYS BY DISPATCHERS TO CONTROL PIPELINES SYSTEMS.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2000-07-17

Communication Type: Official Correspondence

Communication Contents: ON 3/20/97, BASED ON INFORMATION PROVIDED IN THE API LETTER OF 8/5/96, P-93-20 WAS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE," PENDING FURTHER RESPONSE FROM THE API. HOWEVER, NO FURTHER RESPONSE HAS BEEN RECEIVED. ENCLOSED ARE COPIES OF THE ORIGINAL RECOMMENDATION LETTERS FOR P-80-15, P-81-20, P-93-20, P-95-14, P-95-15, P-96-22, AND P-98-29, AS WELL AS SUBSEQUENT CORRESPONDENCE RELATED TO THESE RECOMMENDATIONS. THE SAFETY BOARD LOOKS FORWARD TO RECEIVING INFORMATION FROM YOU UPDATING THE ABOVE RECOMMENDATIONS.

Addressee Acronym: API

Addressee Organization Type: A-Associations

Communication Date: 2001-05-17

Communication Type: Official Correspondence

Communication Contents: On March 20, 1997, based on information provided in the API letter of August 5, 1996, Safety Recommendation P-93-20 was classified "Open-Unacceptable Response," pending receipt of further information from the API. As the API has not responded further on this issue, Safety Recommendation P-93-20 is now classified "Closed-Unacceptable Action."