NTSB Safety Recommendation Letter P-72-001 through P-72-007

Page 1Official PDFin t h e i r own “Emergency Directory” regarding notification of outside, affected agencies, prevention of personal injury and property damage: use of fire foam to prevent vaporization; clearance of the - repair area of hazardous vapors; and location of equipment in relation to vapors and air movement. 11. Contractors’ work crews had received no f o r m a l training or indoctrination in p i p e l i n e m a i n t e n a n c e w o r k . T h e instruction received was “on-the-job” type training, with “seasoned” men working alongside “green” men. 1 2 . The Federal regulation on pipeline repairs, 49 CFR 195.422(a), is vague, nonobjective and does not provide for any specific action on the part of carriers. 1.3. Contractors’ work crews were improperly dressed to work in and around a hazardous vapor area. 14. Unnecessary personnel were allowed to stand over the ditch, watching the activity after they had been relieved by other workers. 15. The diesel engine backhoe did not have any exhaust protective equipment which might have prevented the vapor ignition. V. PROBABLE CAUSE The National Transportation Safety Board determines that the probable cause of the leak was a flaw of undetermined origin in the pipe wall, which failed after a period of constantly fluctuating pumping pressures. The probable cause of the explosion and f i r e s w a s t h e ingestion of the gasoline vapor-rich atmosphere by the diesel engine in a backhoe which resulted in the speeding up and b a c k f i r i n g of t h e e n g i n e , igniting the a t m o s p h e r e . T h e backhoe was working downhill and downwind of a ditch partially filled with gasoline. C o n t r i b u t i n g t o t h e ignition of the vapor-laden atmosphere was the lack of planning and precaution in the operation and positioning of the backhoe without the use of any vapor-detecting device. Contributing to the amount o f accumulated gasoline was the long period of dry weather precerling the accident (which had dehydrated the soil in the area), the existing rock strata which underlaid the pipeline from the leak site down to the accident area, and the more than usual amount of backfill over the pipeline which kept the gasoline lrom surfacing. The large underground column of entrapped gasoline, which was released suddenly by digging operations, deluged the work area with gasoline fumes. VI. RECOMMENDATIQNS The National Transportation Safety Board recommends that: 1. The Federal Railroad Administration of the Department of Transportation initiate an a m e n d m e n t t o t h e Code of Federal Regulations, Title 49, Section 195.206, Material inspection, requiring specific inspection criteria. This recommendation is not intended to delete or mitigate any visual, m e c h a n i c a l , or nondestructive inspection practices already in existence, but to prescribe a system of inspection at s t r a t e g i c p o i n t s in the manufacture, transportation, and further processing of the pipe before it is buried in the ground. 2 . T h e F e d e r a l Railroad Administration undertake a study of the current metering practices in the liquid pipeline industry, with the possible assistance of qualified pipeline groups, to determine the existing s t a t e of t h e a r t in detecting small pithole-type leakage by meter variante with particular regard to large diameter pipelines operating at high volumes. The study should 24 1#

Page 2include those pipelines whose pumping operations are regulated by the use of recording meters which monitor the receipts and deliveries and are set to shut down or otherwise inform the pipeline dispatcher upon the occurrence of a specified amount of inputloutput variance. The study should include meter accuracies with the intent to establish c e r t a i n minimum standards regarding receipt and delivery variances within which liquid pipelines shall operate. Based upon the results of this study, the n u m b e r of b a r r els-per -h o u r variance allowable between the input and output of l i q u i d p e t r o l e u m pipelines should be included in 49 CFR 195. p 7 2 - ?, 3 . T h e F e d e r a l Railroad Administration formulate and add to 49 CFR 195 the requirement that all pipeline companies formally notify appropriate State and local civil agencies of the route the pipelines follow in detail, the type of material they carry, and the lines of communication to be used in an emergency. i) 7%- 3 4 . T h e F e d e r a l Railroad Administration i n c o r p o r a t e by reference in 49 CFR 195.422, Pipeline Repairs, the American Petroleum Institute Petroleum Safety Data Sheer - Repairs to Crude Oil, Liquefied Petroleum Gas, and Products Pipelines, PSD 2200 -June, 1964. p )&-v 5. The Colonial Pipeline Company provide maps of the pipeline route in sufficient d e t a i l to establish clearly the system location with regard to the various affected civil agencies and residents along the right-of-way. These maps should be kept c u r r e n t b y t h e notation of pipeline additions or route changes as required. Specifically recommended to receive this information are fire departments, both civil and volunteer; State, county, and local police departments; departments of water resources; and any agency concerned with hazardous materials. p ) 2- . 6. The Colonial Pipeline Company meet with a p p r o p r i a t e S t a t e safety agencies to c o o r d i n a t e s a f e w o r k i n g r u l e s and regulations and hold periodic pipeline safety meetings with fire departments and other interested agencies, to familarize their personnel with basic pipeline operations, materials pumped, hazards encountered, and the procedures to be followed when e n c o u n t e r i n g pipeline leaks or other emergencies. ?!J3 - G 7. The Colonial Pipeline Company compose a f o r m a l , in-depth manual or procedure d e p i c t i n g t h e stepby-step method of handling petroleum spills, combating fires, notifying the various agencies, and the guidance of contractors’ crews in safe working procedures. Incorporate in this manual the American Petroleum Institute Petroleum Safety Data Sheet, PSD 2200, June 1964, as a minimum so as to comply fully with the Federal regulation 49 CFR 195.422. A list of hospitals and first aid u n i t s , c o m p l e t e w i t h addresses and telephone numbers, should be included. P 7a-? 25#