NTSB Safety Recommendation Letter P-21-015 through P-21-017

Page 1Official PDFAugust 10, 2021 Mary Ellen Carroll Executive Director San Francisco Department of Emergency Management 1011 Turk Street San Francisco, CA 94102 The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. The attached letter from the NTSB Chairman provides information about the NTSB’s July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. The details of this accident investigation and the resulting safety recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, P-21-15). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov. Executive Secretariat-LRM Office of the Managing Director National Transportation Safety Board 490 L’Enfant Plaza SW Washington, DC 20594 Email: ExecutiveSecretariat@ntsb.gov#

Page 2National Transportation Safety Board Washington, DC 20594 Office of the Chairman August 10, 2021 Mary Ellen Carroll Executive Director San Francisco Department of Emergency Management 1011 Turk Street San Francisco, CA 94102 Dear: Ms. Carroll: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the San Francisco Department of Emergency Management to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. This letter provides information about our July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. The details of this accident investigation and the resulting safety recommendations can 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: • Third-party excavation damage to buried natural gas pipelines. • Enforcement challenges of California’s damage prevention law. • Pacific Gas & Electric Company’s data integration gaps during the development of the valve isolation plan. • Insufficient joint emergency response planning between Pacific Gas & Electric Company and San Francisco, California, emergency response agencies. [Type text]#

Page 32 Accordingly, the NTSB makes the following safety recommendation to the San Francisco Department of Emergency Management. Additional information regarding this recommendation can be found in the noted sections of the report. • Work with Pacific Gas & Electric Company to establish an agreement to provide a coordinated response and reduce response times for Pacific Gas & Electric Company’s crews to arrive at the scene of a pipeline accident. (P-21-15) (See section 2.5.) The NTSB is vitally interested in this recommendation because it is 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 this recommendation. When replying, please refer to the safety recommendation by number P-21-15. 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. Sincerely, [Original Signed] Bruce Landsberg Acting Chairman#

Page 4August 10, 2021 Jeanine Nicholson Chief of Department San Francisco Fire Department 698 2nd Street San Francisco, CA 94107 The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. The attached letter from the NTSB Chairman provides information about the NTSB’s July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. The details of this accident investigation and the resulting safety recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, P-21-15). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov. Executive Secretariat-LRM Office of the Managing Director National Transportation Safety Board 490 L’Enfant Plaza SW Washington, DC 20594 Email: ExecutiveSecretariat@ntsb.gov#

Page 5National Transportation Safety Board Washington, DC 20594 Office of the Chairman August 10, 2021 Jeanine Nicholson Chief of Department San Francisco Fire Department 698 2nd Street San Francisco, CA 94107 Dear Ms. Nicholson: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the San Francisco Fire Department to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. This letter provides information about our July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. The details of this accident investigation and the resulting safety recommendations can 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: • Third-party excavation damage to buried natural gas pipelines. • Enforcement challenges of California’s damage prevention law. • Pacific Gas & Electric Company’s data integration gaps during the development of the valve isolation plan. • Insufficient joint emergency response planning between Pacific Gas & Electric Company and San Francisco, California, emergency response agencies. Accordingly, the NTSB makes the following safety recommendation to the San Francisco Fire Department. Additional information regarding this recommendation can be found in the noted section of the report. [Type text]#

Page 62 • Work with Pacific Gas & Electric Company to establish an agreement to provide a coordinated response and reduce response times for Pacific Gas & Electric Company’s crews to arrive at the scene of a pipeline accident. (P-21-15) (See section 2.5.) The NTSB is vitally interested in this recommendation because it is 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 this recommendation. When replying, please refer to the safety recommendation by number, P-21-15. 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. Sincerely, [Original Signed] Bruce Landsberg Acting Chairman#

Page 7August 10, 2021 William Scott Chief of Police San Francisco Police Department 1245 3rd Street San Francisco, CA 94158 The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. The attached letter from the NTSB Chairman provides information about the NTSB’s July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. The details of this accident investigation and the resulting safety recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, P-21-15). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov. Executive Secretariat-LRM Office of the Managing Director National Transportation Safety Board 490 L’Enfant Plaza SW Washington, DC 20594 Email: ExecutiveSecretariat@ntsb.gov#

Page 8National Transportation Safety Board Washington, DC 20594 Office of the Chairman August 10, 2021 William Scott Chief of Police San Francisco Police Department 1245 3rd Street San Francisco, CA 94158 Dear Mr. Scott: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the San Francisco Police Department to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. This letter provides information about our July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. The details of this accident investigation and the resulting safety recommendations can 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: • Third-party excavation damage to buried natural gas pipelines. • Enforcement challenges of California’s damage prevention law. • Pacific Gas & Electric Company’s data integration gaps during the development of the valve isolation plan. • Insufficient joint emergency response planning between Pacific Gas & Electric Company and San Francisco, California, emergency response agencies. [Type text]#

Page 92 Accordingly, the NTSB makes the following safety recommendation to the San Francisco Police Department. Additional information regarding this recommendation can be found in the noted section of the report. • Work with Pacific Gas & Electric Company to establish an agreement to provide a coordinated response and reduce response times for Pacific Gas & Electric Company’s crews to arrive at the scene of a pipeline accident. (P-21-15) (See section 2.5.) The NTSB is vitally interested in this recommendation because it is 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 this recommendation. When replying, please refer to the safety recommendation by its number, P-21-15. 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. Sincerely, [Original Signed] Bruce Landsberg Acting Chairman#

Page 10August 10, 2021 Patricia K. Poppe Chief Executive Officer Pacific Gas & Electric Company 77 Beale Street San Francisco, CA 94105 The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. The attached letter from the NTSB Chairman provides information about the NTSB’s July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. The details of this accident investigation and the resulting safety recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 recommendation by number (for example, P-21-16 and P-21-17). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov. Executive Secretariat-LRM Office of the Managing Director National Transportation Safety Board 490 L’Enfant Plaza SW Washington, DC 20594 Email: ExecutiveSecretariat@ntsb.gov#

Page 11National Transportation Safety Board Washington, DC 20594 Office of the Chairman August 10, 2021 Patricia K. Poppe Chief Executive Officer Pacific Gas & Electric Company 77 Beale Street San Francisco, CA 94105 Dear Ms. Poppe: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Pacific Gas & Electric Company (PG&E) to act on the safety recommendations in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. This letter provides information about our July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. The details of this accident investigation and the resulting safety recommendations can 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: • Third-party excavation damage to buried natural gas pipelines. • Enforcement challenges of California’s damage prevention law. • PG&E’s data integration gaps during the development of the valve isolation plan. • Insufficient joint emergency response planning between PG&E and San Francisco, California, emergency response agencies. Accordingly, the NTSB makes the following safety recommendations to PG&E. Additional information regarding these recommendations can be found in the noted sections of the report. [Type text]#

Page 122 • In collaboration with the San Francisco Police Department, San Francisco Fire Department, and the San Francisco Department of Emergency Management, establish an agreement to provide a coordinated response and reduce response times for your crews to arrive at the scene of a pipeline accident. (P-21-16) (See section 2.5.) • Complete the integration of detailed location data into your hydraulic modeling software so that this information is readily available for all system assets when developing a valve isolation plan. (P-21-17) (See section 2.4) 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 R-21-16 or R-21-17. 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. Sincerely, [Original Signed] Bruce Landsberg Acting Chairman#