NTSB Safety Recommendation Letter P-77-016 through P-77-017

Page 1Official PDFWASHINGTON, D.C. I S S U E D : July 15, 1977 M r . Edward L. Patton Chairman Alyeslca Pipeline Service Company I \ SAFETY RECOMMENDAT ION ( S I About 3:45 p.m. Anchorage Time, July 8, 1977, an explosion and f i r e occurred a t Alyeslca Pipeline Service Company’s Pump S t a t i o n No. 8 on the Trans-Alaska pipeline. A s a r e s u l t of the accident one person died and a number of persons were injured. The National Transportation Safety Board’s ongoing i n v e s t i g a t i o n i n d i c a t e s t h a t the explosion a t Pump S t a t i o n No. 8 occurred when crude o i l was turned i n t o Pump No. 1 while the workers were servicing the pump’s s t r a i n e r . The o i l under a pressure of about 400 p.s.i. sprayed out of the open cover and rapidly f i l l e d the building with vaporized crude o i l . The vapor was ignited by one of s e v e r a l possible sources and exploded The force of the explosion heavily damaged the building and the gushing crude o i l was i g n i t e d . Control personnel a t Valdez, Alaska, immediately shut down the system. The damage to the environment was minimal, but the pump s t a t i o n was p r a c t i c a l l y destroyed. We do n o t know y e t why the employees opened the s t r a i n e r cover without complying with Alyeslca’s printed procedures. The procedures, among o t h e r things, required t h a t the c o n t r o l l e r a t Pump S t a t i o n No. 8 request from, and be granted permission by, the c e n t r a l c o n t r o l l e r a t Valdez before working on the pump. In addition, the procedures required, a f t e r permis- sion was granted, t h a t those persons a t Pump S t a t i o n No, 8 who were going t o do the work i s o l a t e the pump e l e c t r i c a l l y by locking out the c i r c u i t , tagging the switch with a d i s t i n c t i v e prescribed warning tag, and applying tags to the valves on both sides of the pump before beginning the work. None of the foregoing was done. It appears t h a t communications between the Pump S t a t i o n No. 8 c o n t r o l l e r and the s t a r t u p team broke down. Although not v e r i f i e d a t t h i s point, i t appears t h a t the technicians,intent on expediting the o i l flow through Pump S t a t i o n No. 8,may have inadvertently disregarded the proce- dures i n t h e i r d e s i r e t o change the f i l t e r while the No. 1 pump was shut PA&-78- 2- 2 145 - A#

Page 2- 2 - down but not i s o l a t e d . Once the s u c t i o n o i l was not r e v e r s i b l e immediately, and the volume of o i l under high pressure and t h e r explosion was almost i n e v i t a b l e . The S a f e t y Board's preliminary study o plans i n d i c a t e s t h a t Alyeslca recognized the the large number of Alyeska technicians and supervisor loan from Alyeska's parent companies, and c cians who were required i n the s t a r t u p of t a l s o foresaw the need f o r assigning s p e c i f i c res personnel i n a d d i t i o n to t h e i r routine d u t i e s . However, a t Pump S t a t i o n No. 8, there appare completely coordinate the w r i t ten s t a r t u p and ope t i o n between established s t a r t u p procedures procedures is c r i t i c a l i n assuring t h a t b o t employees understand t h e i r r e s p o n s i b i l i t i e s with procedures. It i s within t h a t a r e a of t u n i t y f o r e r r o r and deviation from procedures may be g r e a t day of the accident i f the procedures i n e i operating plan had been complied with p r e c i have happened. Because of the loss of Pump S t a t i o n be a c t i v a t e d ahead of its o r i g i n a l schedule. Inherent i n t h i s s t a r t up Pump S t a t i o n No. 9 e a r l i e r than planned is the i n c r e a tunity f o r e r r o r and the i n c l i n a t i o n emphasis upon proper management and and i n s i s t e n c e upon p r e c i s e complian insure the s a f e s t a r t u p and operatio f a c i l i t i e s whose schedules must be advanced. Therefore, t o minimize the poss pumping resumes, the National Transportation Saf the Alyeska P i p e l i n e Service Company: Designate a manager o r management t e a m s t a t i o n with the r e s p o n s i b i l i t y and au v i s e and r e q u i r e a l l perso of t h e pump s t a t i o n t o com with a l l w r i t t e n procedure the continuing operations Urgent Followup) (P-77-16 ) Review a l l procedures and l i n e s t a r t u p and the ensuing operation t c r i t i c a l a c t i o n s w i l l be done i n a s a f e m#

Page 3- 3 - a t t e n t i o n should be given to the i n t e r r e l a t i o n s h i p s between those procedures which apply t o s t a r t u p and those which apply t o the ensuing operations to insure complete coordina- t i o n of functions. (Class I, Urgent Followup) (P-77-17) TODD, Chairman, BAILEY, Vice Chairman, McADAMS, HOGUE and HALEY, Members, concurred i n the above recommendations. & B y : Webster B. Todd, Jr. I Chairman#