NTSB Safety Recommendation Letter P-90-026 through P-90-027

Page 1Official PDFNational Transportation Safety Board Washington, D.C. 20594 Safety Recommendation Date: October 1 , 1990 I n reply r e f e r t o : P-90-26 and -27 Mr. John Riordan President MidCon Corporation Room 498 701 East 22nd S t r e e t Lombard, I l l i n o i s 60148 On October 3 , 1989, t h e United S t a t e s f i s h i n g vessel NORTHUMBERLAND s t r u c k and ruptured a 16-inch-diameter natural gas transmission p i p e l i n e about 1/2 nautical mile offshore i n t h e Gulf o f Mexico, and about 5 1/3 nautical miles west o f t h e j e t t i e s a t t h e entrance t o Sabine Pass, Texas. Natural gas under a pressure of 835 psig was released. An undetermined source on board t h e vessel ignited t h e gas, and within seconds, t h e e n t i r e vessel was engulfed in flames. The f i r e on t h e vessel burned i t s e l f out on October 4. Leaking gas from t h e pipeline a l s o continued t o burn u n t i l October 4 . Of t h e 14 crewmembers, 11 died as a r e s u l t of t h e accident.’ According t o t h e r e s u l t s of t h e mechanical and chemical t e s t s conducted on samples o f t h e recovered pipe, t h e pipeline met t h e American Petroleum I n s t i t u t e s p e c i f i c a t i o n s f o r strength and chemical composition. The absence of any s i g n i f i c a n t corrosion o f t h e pipeline indicates t h a t t h e pipeline was not i n a weakened condition a t the time of the accident. When t h e accident occurred, t h e NORTHUMBERLAND was in shallow waters and c l o s e t o shore, which was normal and usual f o r i t s t r a d e . The water depth and t h e estimated d r a f t of t h e vessel a t t h e time of t h e accident were both about 10 f e e t . Consequently, t h e bottom of t h e vessel was c l o s e t o t h e sea bottom o r s l i g h t l y penetrating t h e bottom when i t s t r u c k the pipeline. The pipeline was n o t f u l l y buried when it was s t r u c k by the NORTHUMBERLAND. D i v i n g surveys conducted a f t e r t h e accident established t h a t the unburied segments of t h e pipeline were not confined t o a limited length, b u t extended f o r as much as 400 f e e t i n t h e immediate accident area. ’ Additional information i s given in the accident report. (National Transportation Safety Board. 1990. Fire on board the F / V NORTHUMBERLAND and rupture o f a natural gas transmission pipeline in the Gulf of Mexico near Sabine Pass, Texas, October 3, 1 9 8 9 . Pipeline Accident Report NTSB/PAR- 9 0 / 0 2 . Uashington, O C . ) 5208B#

Page 2n L The q u a n t i t y and type o f marine growth found on t h e p i p e l i n e indicated t h a t t h e p i p e l i n e had been unburied f o r a prolonged period. Damage t o t h e concrete coating also i n d i c a t e d t h a t t h e p i p e l i n e had been previously struck by other vessels o r equipment towed by vessels. The U.S. Army Corps o f Engineers (the Corps) issues permits t o operators p l a c i n g man-made objects i n navigable waters t o prevent t h e o b s t r u c t i o n o f such waterways. Therefore, i n i s s u i n g i t s permit t o t h e Natural Gas P i p e l i n e Company o f America (NGPL), operator o f the ruptured High I s l a n d (HI) l a t e r a l p i p e l i n e , the Corps required t h e p i p e l i n e t o be buried and maintained t o t h e b u r i a l depths shown on approved plans (about 9 f e e t below t h e seabed i n t h e case o f t h i s p i p e l i n e ) . To s a t i s f y the requirement t h a t t h e p i p e l i n e s be maintained i n accordance w i t h the permit, the Corps expects t h e operators t o conduct p e r i o d i c inspections. The NORTHUMBERLAND s t r u c k and ruptured t h e p i p e l i n e because the p i p e l i n e was not buried and maintained a t t h e b u r i a l depth required by t h e Corps' permit. When i t was constructed i n 1973, t h e H I l a t e r a l p i p e l i n e was placed i n the bottom o f a trench. The cover, as i n d i c a t e d on t h e a s - b u i l t construction plans, was t h e v e r t i c a l distance from t h e l e v e l o f t h e sea bottom down t o the top o f t h e p i p e l i n e ; t h e cover, however, was not necessarily the same as the actual depth o f t h e overburden ( t h e sediment) t h a t may have been over t h e p i p e l i n e . The i n v e s t i g a t i o n revealed t h a t the NGPL never inspected the p i p e l i n e a f t e r i t s c o n s t r u c t i o n t o confirm t h a t n a t u r a l sedimentation had f i l l e d i n t h e trench and had returned t h e sea bottom t o i t s n a t u r a l elevation; thus, it i s n o t c e r t a i n t h a t the trench f i l l e d i n and produced an overburden o f the depth shown on t h e a s - b u i l t construction plans and r e q u i r e d by t h e r i g h t - o f - way permit issued by t h e Corps. Because the p i p e l i n e was supposed t o have been buried a t t h e time o f construction but was unburied a t the time o f the accident, t h e Safety Board i s concerned t h a t NGPL's o t h e r submerged p i p e l i n e s may a l s o be unburied and vulnerable t o damage and rupture. The NGPL acknowledged t h a t i t d i d not have a program o f r e g u l a r inspections o f i t s offshore p i p e l i n e s t o determine if they were unburied o r vulnerable t o damage from surface vessels. Instead, t h e company adopted a r e a c t i v e p o l i c y o f w a i t i n g u n t i l t h e company was made aware o f a hazardous c o n d i t i o n before t a k i n g any remedial action, r a t h e r than an a c t i v e p o l i c y o f l o o k i n g f o r hazardous conditions and c o r r e c t i n g them before an accident occurred. Federal r e g u l a t i o n s (49 CFR 192.613), r e q u i r e t h a t each operator o f a gas p i p e l i n e must have a procedure f o r continuing s u r v e i l l a n c e t o determine unusual operating and maintenance conditions. To have an e f f e c t i v e procedure t h a t w i l l a c t u a l l y determine such conditions, an operator must r e g u l a r l y and a c t i v e l y inspect f o r these unusual conditions. According t o the O f f i c e o f P i p e l i n e Safety (OPS), o f t h e Research and Special Programs Administration, NGPL's r e l i a n c e on a e r i a l o v e r f l i g h t s was consistent w i t h the requirements o f 49 CFR 192.705 f o r p a t r o l l i n g o f f s h o r e pipe1 ines. Although a e r i a l o v e r f l i g h t s o r surface p a t r o l s are useful t o d e t e c t leaks, they do not, i n t h e Safety Board's view, s a t i s f y t h e needs f o r continuing i#

Page 33 surveillance required under section 192.613--to detect that a pipeline has become unburied and vulnerable to damage from surface vessels. Also, because the NGPL did not inspect the pipeline, the NGPL did not maintain the pipeline as required by the permit issued by the Corps. The HI lateral pipeline was exposed and vulnerable to damage from surface vessels because the NGPL did not have a program for continuing surveillance that incorporated regular inspections of the pipeline. The presence of a submerged pipeline, whether it is offshore or passes under a river or other body of water, is not obvious to a vessel operator. Navigation charts do not mark the location of all submerged pipelines, and charts that do mark some pipelines do not indicate whether or not the pipelines have become unburied. Further, fathometers on vessels cannot detect the presence of a pipeline. Because submerged pipelines transport natural gas and hazardous liquids that can endanger life and property if released, pipe1 ine operators have the primary responsibility to construct, maintain, and operate their pipelines in a manner that does not endanger the public. Therefore, the Safety Board urges the NGPL to establish and implement a program to conduct regular and adequate inspections of its submerged pipelines and to maintain the pipelines in accordance with as-built construction plans and all right-of-way permits. When NGPL's Gas Control was first notified about the accident at 6 : 4 5 p"m. by the Port Arthur, Texas, Fire Department, the duty controllers at Gas Control directed the fire department. to contact the NGPL superintendent. A more appropriate procedure would have called for the duty officer to contact the district superintendent. Notification procedures in the emergency plan, however, were based on the presumption that initial notification of an accident would be received by a field [district] employee rather than a controller at Gas Control. Because the emergency plan failed to address this second possibility, the controllers did not have adequate guidance that would have prompted them to contact the superintendent. After the superintendent was notified of the accident at home about 6:50 p.m., he properly called Gas Control to verify the pressure and flow rates at Compressor Station (CS) 344, the monitoring point closest to the reported accident site. Once Gas Control had verified that the pressure and flow rates for CS 344 were abnormal, the district superintendent had sufficient reason to believe that the HI lateral pipeline was leaking or had ruptured. After arriving at CS 344, the district superintendent had additional information from the metering charts to indicate that the HI lateral pipeline was definitely involved in the accident. In his initial telephone call to the U . S . Coast Guard Station at Sabine, Texas, the unit having search and rescue responsibilities for the area, the superintendent reported that there had been a sudden loss of flow and pressure in the pipeline; his report, however, failed to convey that the pipeline belonged to the NGPL and the superintendent's belief that the pipeline had ruptured. The superintendent obviously believed at that time that it was NGPL's pipeline that was involved because he made such a report to Gas Control shortly after#

Page 44 calling Station Sabine. Had the superintendent made the same report to Station Sabine as he did to Gas Control, subsequent confusion and uncertainty of Coast Guard Station Sabine and the Coast Guard Marine Safety Office (MSO), in Port Arthur, Texas, about ownership of the pipeline could have been avoided. Further, the superintendent failed to keep the Coast Guard informed about the status of the pipeline or about the actions taken by the NGPL to isolate the pipeline and to stop the flow of natural gas into the pipeline from four offshore platforms owned and operated by four separate producers. The superintendent also failed to maintain lines of communication with the employees sent to the offshore platforms to confirm shutdown; because he left his post to go to an unmanned offshore platform and was no longer in communication with his employees, he was not in a position to effectively serve as an emergency coordinator. The Safety Board believes that the proper role of an emergency coordinator i s to direct the actions of his employees and to be available at all times to the onscene commander or the public official directing the emergency response efforts. However, for an employee to fulfill these responsibilities, the employee must be given sufficient guidance to understand the duties and responsibilities of the emergency coordinator. Because of the superintendent's tenure in that position and his responsibility to review and modify the emergency plan as needed, he was familiar with the plan and understood the guidance it provided. NGPL's emergency plan, however, did not provide sufficient guidance to the district superintendent about emergencies involving the rupture of an offshore transmission pipe1 ine. For example, procedures regarding the communication with emergency responders, actions t o be taken for various emergency situations, and the supervision and use of company employees must be explicitly addressed in a company's emergency plan. The Safety Board, therefore, concludes that the failure of the district superintendent to properly fulfill his duties as an emergency coordinator can be attributed to the lack of guidance in the company's emergency plan. According to Department of Transportation (DOT) regulations in 49 CFR Parts 192 and 195, the pipeline operator is responsible for emergency planning and coordination with local emergency response officials. Under 49 CFR 192.615(c), an operator of a natural gas pipeline must establish liaison with police, fire, and other public officials to (1) learn the responsibilities of each government agency that may respond t o a pipeline emergency, (2) acquaint the officials with the operator's ability in responding to an emergency, ( 3 ) identify the types of emergencies in which an operator notifies these officials, and ( 4 ) plan how the operator and officials can engage in mutual assistance to minimize hazards to life and property. Although NGPL's emergency plan listed a telephone number for the Coast Guard, the NGPL had taken no action before the accident to establish liaison with local Coast Guard officials as required by the regulations. Consequently, the district superintendent and a corporate representative were both unaware of the respective missions and responsibilities of Coast Guard ( '#

Page 55 S t a t i o n Sabine and t h e MSO. During t h e investigation, an NGPL o f f i c i a l s t a t e d t h a t the company had expected t h a t t h e Coast Guard would d i r e c t NGPL t o t h e appropriate o f f i c i a l s i n an emergency. This expectation does not, i n t h e Safety Board’s view, s a t i s f y t h e obligation of an operator t o e s t a b l i s h and maintain l i a i s o n w i t h t h e Coast Guard r e p r e s e n t a t i v e s , a s public o f f i c i a l s , and t o be knowledgeable of t h e r o l e of t h e Coast Guard i n an offshore emergency. The NGPL had t o r e l y on t h e proper operation of t h e automatic shutdown systems on t h e four offshore platforms t o i s o l a t e t h e p i p e l i n e from offshore; t h e r e f o r e , i t was imperative f o r t h e d i s t r i c t superintendent t o be able t o contact each producer for confirmation t h a t each platform had shut- i n . While t h e Safety Board i s concerned t h a t t h e d i s t r i c t emergency plan did not include a telephone number f o r t h e owner of t h e HI 86 platform, the Board i s equally concerned t h a t t h e r e was no indication t h a t t h e superintendent attempted t o f i n d an emergency telephone number o r otherwise attempted t o contact t h e owner of HI 86. Because of t h e i n a b i l i t y t o contact t h e owner o f HI 86 and communications problems with t h e HI 71A platform, t h e superintendent c o r r e c t l y dispatched two employees by he1 i c o p t e r t o confirm t h a t a l l four platforms had shut-in. The f a i l u r e of t h e d i s t r i c t superintendent t o have an emergency telephone number f o r t h e owner of t h e HI 86 platform can be a t t r i b u t e d t o an absence of emergency planning and coordination between t h e pipel ine operators and t h e offshore producers. Because t h e operations of an offshore pipeline and platform a r e d i r e c t l y integrated, an emergency condition on one will necessarily a f f e c t t h e operation of t h e other. As shown i n t h i s accident, t o i s o l a t e t h e pipeline from offshore, t h e N G P L had t o r e l y on t h e operation of emergency shutdown systems on platforms t h a t were under t h e control of t h e producers. The f a i l u r e t o have a telephone contact f o r t h e owner of t h e HI 86 platform and t h e communications problems with t h e HI 71A platform may have been mitigated i f N G P L and t h e producers had previously planned and coordinated f o r emergency s i t u a t i o n s . Effective coordination requires t h a t t h e pipel ine operator and the producer have current emergency contacts and agreement on t h e i r respective procedures in t h e event of an offshore emergency. Although t h e N G P L has improved i t s emergency plan f o r offshore emergencies since t h e accident, the plan s t i l l does not provide adequate guidance about (1) n o t i f i c a t i o n procedures f o r c o n t r o l l e r s a t Gas Control, ( 2 ) t h e d u t i e s and r e s p o n s i b i l i t i e s of t h e emergency coordinator, and (3) l i a i s o n and coordination with public o f f i c i a l s and the offshore producers. Consequently, t h e Safety Board believes t h a t t h e emergency plan should be f u r t h e r revised t o provide e x p l i c i t guidance i n these a r e a s , and t h a t when t h e r e v i s i o n s have been made, t h e appropriate employees should be t r a i n e d and educated about t h e i r r e s p o n s i b i l i t i e s .#

Page 66 Therefore, as a result of this accident, the National Transportation Safety Board recommends that the Natural Gas Pipeline Company of America: Establish and implement a program to conduct regular and adequate inspections of the company's submerged pipelines and to maintain them in accordance with as-built construction plans and all right- of-way permits. (Class 11, Priority Action) (P-90-26) Revise the corporate and district emergency plans to include detailed guidelines about (1) the responsibilities and duties of emergency coordinators, (2) emergency planning and coordination with all public officials and offshore producers that may be involved in offshore accidents, and (3) accident notification procedures for system controllers and other non-district employees who may receive initial reports of an incident; and ensure that all employees understand their duties and responsibilities. (Class 11, Priority Action) (P-90-27) Also as a result of this investigation, the Safety Board issued recommendations to the Zapata Haynie Corporation, U.S. Department of Transportation, Research and Special Programs Administration, U.S. Coast Guard, U.S. Army Corps of Engineers, National Oceanic and Atmospheric Administration, Interstate Natural Gas Association of America, the American Gas Association, American Public Gas Association, American Petroleum Institute, National Fish Meal and Oil Association, Louisiana Shrimp Association, and National Council of Fishing Vessel Safety and Insurance. The National Transportation Safety Board is an independent Federal agency with the statutory responsibility 'I.. .to promote transportation safety by conducting independent accident investigations and by formulating safety improvement recommendations" (Public Law 93-633). The Safety Board is vitally interested in any actions taken as a result of its safety recommendations and would appreciate a response from you regarding action taken or contemplated with respect to the recommendations in this letter. Please refer to Safety Recommendations P-90-26 and -27 in your reply. KOLSTAD, Chairman, COUGHLIN, Vice Chairman, LAUBER, BURNETT, and HART, Members, concurred in these recommendations / James L. Kolstad Chairman#