NTSB Safety Recommendation P-93-022

NTSB safety recommendation P-93-022.

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

Priority: CLASS II

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 Gas Association

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2007-06-05

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2004-07-29

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 8/5/2004 2:26:58 PM MC# 2040488 AGA has a standing Gas Control Committee in its Operations Section, which includes members from gas transmission and distribution companies. Several members of this committee have volunteered to provide their expertise as the American Petroleum Institute (API) develops a recommended practice to address graphic information displays systems for pipeline control rooms. It is AGA's practice to make the completed draft recommended practice available to all member companies for comment during the public ballot process of the consensus standard. AGA believes the development of the standard will address the concerns in this safety recommendation.

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2005-06-22

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 6/28/2005 8:46:35 AM MC# 2050270 An American Petroleum Institute (API) committee is developing a recommended practice to address graphic information displays systems for pipeline control rooms. AGA's Operating Section Gas Control Committee will have a representative from our gas distribution and transmission companies providing expertise and serving on this API committee. AGA will make the completed draft recommended practice available to all member companies for comment during the public ballot process of the consensus standard. AGA represents 195 local energy utility and transmission companies. AGA believes the development of the standard and broad industry review will address the concerns in this safety recommendation. Please do not hesitate to contact Ms. Lori Traweek, AGA senior vice-president, at 202-824-7330, or me should you have questions or require further information. Dave N. Parker

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2000-08-23

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 08/30/2000 4:14:50 PM MC# 2001184 The objectives of these recommendations were completed with the publishing of two API standards. RP 1114, Design of Solution-Mined Underground Storage Facilities and RP 1115, Operation of Solution-Mined Underground Storage Facilities provide guidance to address the concerns of safety recommendations P-93-21 and P-93-22. Accordingly, AGA urges the NTSB to close this safety recommendation.

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 1994-04-19

Communication Type: Official Correspondence

Communication Contents: WE HAVE ASKED OUR GAS CONTROL & AUTOMATION & TELECOMMUNICATIONS COMMITTEES TO CONSIDER YOUR SECOND RECOMMENDATION INVOLVING THE DESIGN & USE OF GRAPHIC DISPLAY SYSTEMS. IT APPEARS THAT THE MAJOR PROBLEM IN THE BRENHAM ACCIDENT WAS NOT THE METHOD OF DISPLAYING DATA BUT RATHER THAT THERE DID NOT APPEAR TO TO BE APPROPRIATE ALARMS TO ALERT THE OPERATOR OF ABNORMAL OPERATION. THEREFORE, WE FEEL THAT THE BEST COURSE OF ACTION TO PREVENT A RECURRENCE OF ACCIDENTS LIKE BRENHAM WOULD BE TO DEVELOP RECOMMENDATIONS FOR EFFECTIVE DATA MONITORING & ALARMING, NOT NECESSARILY WITH A GRAPHICAL DISPLAY GUIDELINE. OUR COMMITTEES HAVE AGREED TO DEVELOP SUCH RECOMMENATIONS.

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2002-05-28

Communication Type: Official Correspondence

Communication Contents: The Safety Board is interested in knowing whether and how its recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety, and to identify creative solutions that might be shared with others. That is why we monitor the implementation of all our recommendations. We would appreciate an update from you regarding actions taken or planned to implement this recommendation.

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2007-06-05

Communication Type: Official Correspondence

Communication Contents: On February 22, 2007, the API notified the Safety Board that in January 2007, it issued Recommended Practice (RP) 1165, Recommended Practice for Pipeline SCADA Displays. Because the AGA and other industry representatives worked with the API to develop RP 1165, Safety Recommendation P-93-22 is classified Closed Acceptable Action

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2005-09-13

Communication Type: Official Correspondence

Communication Contents: The Safety Board notes that the AGA is working on the API committee that is developing a recommended practice to address graphic information displays systems for pipeline control rooms. Your letter indicated that the AGA, which represents 195 local energy utility and transmission companies, will make the completed draft recommended practice available to all member companies for comment during the public ballot process of the consensus standard. In October 2004, the Safety Board was informed that the AGA was participating on the API subcommittee on Cybernetic API 1130, Computation Pipeline Monitoring, and through correspondence with API, the Safety Board understood that the subcommittee was developing a recommended practice on Supervisory Control and Data Acquisition (SCADA) display standards for pipeline operators that was to be ready for balloting in 2004. The Safety Board encourages the AGA to expedite this action. Because the AGA is actively working with the API to develop the recommended standards and guidelines, Safety Recommendation P-93-22 is classified "Open--Acceptable Response."

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2004-04-21

Communication Type: Official Correspondence

Communication Contents: On June 10, 2003, in response to the American Petroleum Institute's (API's) update of March 25, 2003, of the companion recommendation P-93-20, the Safety Board wrote the following: 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 [Supervisory Control and Data Acquisition] 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. Because the AGA has been actively participating on the API subcommittees, Safety Recommendation P-93-22 is classified "Open-Acceptable Response."

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2004-10-21

Communication Type: Official Correspondence

Communication Contents: The Safety Board notes that the AGA has a standing Gas Control Committee in its Operations Section, which includes members from gas transmission and distribution companies, and that several of the members are participating on the American Petroleum Institute's (API's) subcommittee on Cybernetic API 1130, Computation Pipeline Monitoring. Through June 2003 correspondence with API, the Board became aware that the Operations Technical Committee approved the subcommittee's proposal to develop a recommended practice on SCADA display standards for pipeline operators. Further, the new group formed to address this issue anticipates that a recommended practice will be ready for balloting in 2004. Because the completed work is expected to satisfy the recommended action, Safety Recommendation P-93-22 is classified "Open--Acceptable Response."

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 1994-06-07

Communication Type: Official Correspondence

Communication Contents: THE BOARD BELIEVES THAT GUIDELINES FOR GRAPHICAL DISPLAYS SHOULD ALSO BE INCLUDED IN THE COMMITTEES' RECOMMENDATIONS. PENDING FURTHER RESPONSE FROM YOUR OFFICE, P-93-22 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2000-06-14

Communication Type: Official Correspondence

Communication Contents: THE SAFETY BOARD WOULD APPRECIATE LEARNING OF ANY ACTIONS TAKEN OR PLANNED TO COMPLY WITH THESE RECOMMENDATIONS.

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2001-03-29

Communication Type: Official Correspondence

Communication Contents: The Safety Board is disappointed that no standards or guidelines for the design and use of graphic information display systems used by dispatchers to control pipeline systems have been developed in cooperation with the API in the more than 7 years since they were requested. Safety Recommendation P-93-22 is classified "Open--Unacceptable Response," pending further response from the AGA.