NTSB Safety Recommendation Letter P-77-037

Page 1Official PDFNATIONAL TRANSPORTATION SAFETY BOARD E;fgc WASHINGTON, D.C. <\A’ I S S U E D : December 13, 1977 Chairman Alyeska P i p e l i n e Service Company ( SAFETY R E C , O M M E N D A T I O N ( 5 ) 1835 S. Brasaw I P-77-37 - Anchorage, Alaska 99504 Since the s t a r t u p of t h e Alaska p i p e l i n e on June 20, 1 9 7 7 , t o August 15, 1 9 7 7 , seven i n c i d e n t s and a c c i d e n t s have caused t h e p i p e l i n e t o be s h u t down p e r i o d i c a l l y . An accident on J u l y 8, 1977, i n which Pump S t a t i o n No. 8 was destroyed and one person was k i l l e d , r e s u l t e d from t h e f a i l u r e of t h e pump s t a t i o n personnel t o f o l l o w Alyeska P i p e l i n e Service Company (Alyeska) operating procedures. Another accident on August 15, 1977, i n which crude o i l s p i l l e d and could have i g n i t e d i n Pump S t a t i o n No. 9 , also r e s u l t e d from the f a i l u r e of pump s t a t i o n personnel to follow company procedures. The unique topography of t h i s p i p e l i n e system is such t h a t Pump S t a t i o n s no^ 3 and 10 or Pump S t a t i o n s No. 9 and 10 must be operating t o t r a n s p o r t t h e crude o i l t o Valdez, Alaska. I f Pump S t a t i o n No. 9 had been destroyed on August 1 5 a s Pump Stati,on No. 8 was e a r l i e r , t h e e n t i r e p i p e l i n e system would have been shut down i n d e f i n i t e l y . This would have r e s u l t e d i n a l o s s of crude o i l t o r e f i n e r i e s and would have created t h e p o t e n t i a l f o r crude o i l s o l i d i f i c a t i . o n i n the p i p e l i n e . The National Transportation Safety Board issued two recommendations (P-77-16 and 17) concerning t h e J u l y 8 accident on J u l y 15, 1977. The Board recommended t h a t Alyeska review a l l pump s t a t i o n s t a r t u p procedures f o r inadequacies and designate a manager a t each pump s t a t i o n who would r e q u i r e t h a t a l l personnel comply with t h e procedures. The Board issued t h r e e a d d i t i o n a l recommendations on September 9 , 1977, to c o r r e c t c e r t a i n design and operating d e f i c i e n c i e s i n the p m p rooms of each s t a t i o n . The recommended a c t i o n s , i f taken e a r l i e r a t Alyeska’s own i n i t i a t i v e , could have prevented t h e a c c i d e n t on August 15 a t Pump S t a t i o n No. 9. 2145C#

Page 2- 2 - Alyeska, i n its response t o t h e Board's recommendations, i n i t i a t e d a study of p o s s i b l e changes i n pump c o n t r o l l o c a t i o n s i n e a r l y J u l y and has c a r r i e d t h e study a s t e p f u r t h e r t o include a l l booster pumps and t h e Pump S t a t i o n 5 i n j e c t i o n pumps as w e l l a s t h e main l i n e pumps. However, because of t h e continuing occurrence of a c c i d e n t s and p a r t i c u l a r l y because of t h e August 15, 1977, a c c i d e n t a t Pump S t a t i o n No. 9, a c r i t i c a l s t a t i o n on t h i s system, the National Transportation Safety Board recommends t h a t t h e Alyeska P i p e l i n e Service Company: Review i t s t r a i n i n g program f o r adequacy, r e i n s t r u c t its personnel i n t h e procedures contained t h e r e i n , and monitor t h e employees t o a s s u r e t h e i r compliance with the required standards of s a f e t y f o r p i p e l i n e operation. (Class 11, P r i o r i t y Action) (P-77-37) SAILEP, Acting Chairman, McADXC3, IIOGUE, and K I N G , Hembers, c.oncurred i n t h e above recommendation. .A% By: Kay Bailey Acting Chairman#