NTSB Safety Recommendation Letter P-91-005 through P-91-010

Page 1Official PDFNational Transportation Safety Board Washington, D.C. 20594 Safety Recommendation Date: J u l y 17, 1991 In reply refer to: P-91-5 through -10 Mr. Michael D. Burke President . . . . . -. . . . Texas Eastern Products Pipe1 ine C0mpan.y Post Office Box 2521 Houston, Texas 77252-2521 On March 13, 1990, the Texas Eastern Products Pipeline Company (TEPPCO) line P-41, an 8-inch-diameter liquid propane pipeline, ruptured within a pipeline casing beneath County Road 43 (CR 43) near the Village of North Blenheim, New York. Liquid propane gas escaped from the ends of the casing, vaporized, and formed a white, heavier-than-air gas cloud. The gas cloud flowed downhill along CR 43 until it entered North Blenheim and ignited. The fire quickly consumed the propane vapor and flashed back to the pipeline rupture. Two people were killed, seven persons injured, and more than $4 million in property damage and other costs resulted.' The TEPPCO does not have a program to identif,y individual employee needs for initial or recurrent training. The TEPPCO's management failed to recognize the need to provide progressive technical training to supplement its employees' operational experience. In this accident, the TEPPCO misplaced its reliance on experience because the maintenance supervisor, with more than 20 years experience, had never performed the type of work required and had never seen the TEPPCO's written procedures for clearing casings, even if the usefulness of the procedures was limited. The control point operator's (CPO's) actions were also insufficient, which brings the adequacy of the TEPPCO's training for CPOs into question. The maintenance supervisor notified the CPO on duty of the work to be performed at CR 43, including the moving of the pipe. Had the CPO been trained on the TEPPCO procedure No. 70, he likely would have questioned the maintenance supervisor about performing such work without first isolating the pipe section and requesting a reduction in pressure. In addition, on the day of the accident when the resident's call alerted the CPO then on duty about the possibility of a rupture, that CPO did not effectively use available operating data within the supervisory control and data acquisition (SCADA) system to determine if the pressure was dropping. ' F o r P i p e l i n e B l e n h e i m , m o r e R u p t u r e New Y o r k , d e t a i l e d a n d F i r e , M a r c h i n f o r m a t i o n , T e x a s 1 3 , 1 9 9 0 " r e a d P i p e t i n e E a s t e r n P r o d u c t s ( N T S B / P A R - 9 1 / 0 1 ) . A c c i d e n t P i p e l i n e R e p o r t - - " P r o p a n e C o m p a n y , N o r t h 5 3 19A#

Page 22 f The TEPPCO’s management b e l i e v e d t h a t t h e maintenance s u p e r v i s o r ’ s t r a i n i n g was adequate because he had attended 54 t r a i n i n g sessions i n t h e p r e v i o u s 4 years. However, he had no experience i n t h e work he performed on February 20-21, 1990; he had minimal t r a i n i n g on a p p l i c a b l e Federal r e g u l a t i o n s ; and he had no t r a i n i n g on TEPPCO’s procedures f o r c l e a r i n g c a s i n g s h o r t s . Likewise, management b e l i e v e d t h a t t h e CPO’s t r a i n i n g was adequate. However, t h i s t r a i n i n g d i d n o t i n c l u d e e i t h e r i n f o r m a t i o n on Federal r e g u l a t i o n s o r on t h e TEPPCO procedures t h a t r e q u i r e d p i p e l i n e segments t o be i s o l a t e d and pressure reduced b e f o r e work begins. Also, it d i d n o t adequately prepare t h e CPO t o use t h e SCADA system computer c a p a b i l i t i e s t o i d e n t i f y abnormal o p e r a t i n g c o n d i t i o n s . The TEPPLO procedure No. 70 on r e p a i r s t o p i p e l i n e s i n c l u d e d t h e Federal requirement f o r l o w e r i n g t h e pressure i n t h e l i n e s e c t i o n t o be moved, and i n a d d i t i o n , it r e q u i r e d t h a t t h e l i n e s e c t i o n be i s o l a t e d b e f o r e movement. However, i t d i d n o t i n c l u d e t h e Federal requirement f o r p r o t e c t i n g t h e p u b l i c , by adequate warning t o evacuate, from t h e hazards o f moving h i g h l y v o l a t i l e l i q u i d (HVL) p i p e l i n e s . A d d i t i o n a l l y , n e i t h e r t h i s procedure n o r t h e Federal r e g u l a t i o n s c o n t a i n guidance o r c r i t e r i a on t h e e x t e n t t h a t a p i p e o f s p e c i f i c s t r e n g t h , grade, diameter, and w a l l t h i c k n e s s t h a t c o n t a i n s hazardous p r o d u c t s may be s a f e l y moved, n o r do t h e procedure and r e g u l a t i o n s r e q u i r e t h a t t h i s i n f o r m a t i o n t o be c a l c u l a t e d b e f o r e movement. Although t h e p i p e d i d n o t f a i l d u r i n g i t s movement, a d d i t i o n a l e l e v a t i o n by j a c k i n g p r o b a b l y would have caused a f a i l u r e . F o r t u n a t e l y , t h e TEPPCO s u p e r v i s o r a t t a i n e d t h e clearance he needed between t h e p i p e and i t s c a s i n g b e f o r e t h e p i p e f a i l e d . T h i s was a f o r t u i t o u s event r a t h e r t h a n t h e r e s u l t o f a prudent judgment. T h i s a c c i d e n t shows t h a t t h e s t r e s s l i m i t s can be e a s i l y exceeded d u r i n g r e p a i r s . It underscores t h e need f o r operators t o make s i t e s p e c i f i c s t r e s s c a l c u l a t i o n s r e l a t i v e t o t h e p i p e t o determine how t o move it s a f e l y . Because o f t h e low f r a c t u r e toughness o f most p i p e s t e e l , p i p e s are most s u s c e p t i b l e t o f a i l u r e a t low ambient temperatures. Therefore, p i p e l i n e o p e r a t o r s should determine b e f o r e p i p e movement, e s p e c i a l l y on HVL pipe1 ines, t h e amount o f p i p e t o be uncovered, t h e p r o p e r s i t e f o r f o r c e a p p l i c a t i o n , and t h e maximum movement a p i p e can s a f e l y withstand. The TEPPCO r e p a i r program d i d n o t i n c o r p o r a t e s e v e r a l e s s e n t i a l industry-recommended p r a c t i c e s t h a t : r e p a i r s be covered i n t h e maintenance plan, t h e y be performed under q u a l i f i e d supervision, t h e y be performed by t r a i n e d personnel, and a l l employees be b r i e f e d on t h e procedures t o be f o l l o w e d f o r accomplishing t h e r e p a i r s . I n d e c i d i n g t o implement a s p e c i a l program t o c o r r e c t l o n g s t a n d i n g d e f i c i e n c i e s , t h e TEPPCO’s management should have recognized t h a t t h i s program was d i f f e r e n t from r o u t i n e maintenance work because t h e TEPPCO had n o t p r e v i o u s l y assigned such work t o i t s employees. The TEPPCO t h e n should have evaluated i t s procedures, % p e r v i s i o n requirements, and t h e experience and t r a i n i n g o f i t s maintenance employees i n l i g h t o f t h e i n d u s t r y recommended p r a c t i c e s . Had t h e TEPPCO recognized t h a t t h e c a s i n g r e p a i r program was d i f f e r e n t from r o u t i n e maintenance and evaluated t h e procedures, maintenance personnel would have been b e t t e r d i r e c t e d and guided t o c o r r e c t l y p e r f o r m t h e r e q u i r e d ,#

Page 33 work. A r e v i e w o f t h e experience and t r a i n i n g o f employees r e v e a l e d t h a t many had n o t been t r a i n e d on a p p l i c a b l e procedures o r d i d n o t possess t h e work experience needed f o r moving p r e s s u r i z e d p i p e f o r t h e purpose o f e l i m i n a t i n g c a s i n g e l e c t r i c a l shorts. These d e f i c i e n c i e s should have been recognized by t h e TEPPCO's management and c o r r e c t e d b e f o r e t h e program was implemented. A t a minimum, t h e TEPPCO management should r e q u i r e t h a t work be c l o s e l y supervised by a person knowledgeable o f t h e procedures and t h e methods t o s u c c e s s f u l l y perform t h e work. Also, employees should be b r i e f e d on t h e procedures t h e y are t o perform. An e v a l u a t i o n might have made t h e TEPPCO management aware t h a t t h e CPOs' r e s p o n s i b i l i t i e s f o r o p e r a t i n g l i n e P - 4 1 would be a f f e c t e d a t times when a segment o f p i p e was t o be moved. T h i s should have prompted a r e v i e w o f t h e t r a i n i n g and experience o f t h e CPOs on t h e TEPPCO procedures and Federal requirements a p p l i c a b l e t o t h e i r r e s p o n s i b i l i t i e s . T h i s would i d e n t i f y whether t h e CPOs had been t r a i n e d on t h e TEPPCO requirements f o r reducing t h e pressure and i s o l a t i n g p i p e segments t o be moved. By p r o v i d i n g a d d i t i o n a l t r a i n i n g t o t h e CPOs, t h e TEPPCO would then be a b l e t o have them a s s i s t maintenance employees t o comply w i t h t h e TEPPCO procedures and t h e Federal requirements about work t o be performed on t h e p i p e l i n e . Although t h e crew, s e l e c t e d t o perform t h e work a t C R 43 i n February 1990, d i d n o t possess t h e knowledge and experience t o s a f e l y perform t h e work assigned, o p p o r t u n i t i e s were a v a i l a b l e t o c o r r e c t t h i s e r r o r . The maintenance s u p e r v i s o r should have acknowledged a t t h e t i m e t h e work was assigned t h a t he was n o t experienced i n moving p r e s s u r i z e d pipes, t h a t he had never been i n s t r u c t e d on t h e use o f t h e l i n k seal, and t h a t he had n o t r e c e i v e d t r a i n i n g f o r t h i s work. Had he advised h i s s u p e r v i s o r o f these f a c t s , h i s s u p e r v i s o r might have delayed t h e work u n t i l a q u a l i f i e d person c o u l d perform t h e work or, a t l e a s t , supervise it. Although t h e maintenance s u p e r v i s o r may n o t have known a t t h e t i m e o f t h e work assignment t h a t t h e p i p e r e q u i r e d l i f t i n g t o i n s t a l l t h e new c a s i n g seal, he should have recognized t h i s when he inspected t h e c a s i n g and saw t h e broken i n s u l a t o r . A t t h a t time, he should have a l e r t e d h i s superintendent t h a t he was n o t q u a l i f i e d t o perform t h e work. Instead, he e l e c t e d t o use h i s "good judgment." Although t h e S a f e t y Board b e l i e v e s t h a t t h e maintenance s u p e r v i s o r should have advised h i s superintendent t h a t he needed assistance, it i s n o t reasonable f o r management t o r e l y on such n o t i c e t o f u l f i l l i t s s u p e r v i s o r y r e s p o n s i b i l i t y . Rather, i t i s incumbent on t h e TEPPCO's management t o assign work p r o j e c t s o n l y t o employees who possess t h e t r a i n i n g and experience e s s e n t i a l t o t h e s a f e performance o f t h e work, t o determine t h a t i t s employees a r e knowledgeable o f thP procedures a p p l i c a b l e t o t h e work assigned, and t o p e r i o d i c a l l y check t h a t work has been completed c o r r e c t l y . I n t h i s accident, t h e volume o f l i q u i d propane i n a I - m i l e l e n g t h o f t h i s p i p e l i n e would have provided a s u f f i c i e n t q u a n t i t y o f propane vapor t o e n g u l f t h e nearby v i l l a g e . Because i g n i t i o n o f t h e propane occurred w i t h i n 10 minutes a f t e r t h e l e a k was detected, t h e delayed shutdown d i d n o t cause#

Page 44 a d d i t i o n a l c a s u a l t i e s o r l o s s o f p r o p e r t y . However, prompt d e t e c t i o n and i s o l a t i o n o f a r u p t u r e would p r o v i d e more t i m e t o evacuate r e s i d e n t s i f i t s l o c a t i o n was f a r t h e r from populated areas. A f t e r t h e CPO was a l e r t e d about t h e r e l e a s e o f propane, it r e q u i r e d more t h a n an hour t o shut down t h e pumps and t o c l o s e t h e m a i n l i n e v a l v e s n e a r e s t t h e r u p t u r e . Although t h e CPO and t h e TEPPCO employees dispatched t o c l o s e t h e v a l v e s d i d a l l t h e y c o u l d t o shut down t h e system, t h e i r a c t i o n s were l i m i t e d because o f t h e d i s t a n c e o f t h e v a l v e from t h e r u p t u r e . The r e l e a s e o f propane from TEPPCO’s p i p e l i n e c o u l d have been s u b s t a n t i a l l y l i m i t e d i f remote- o r automatic-operated v a l v e s were i n s t a l l e d . A f t e r t h e CPO remotely c l o s e d t h e v a l v e a t G i l b e r t s v i l l e , a check v a l v e l o c a t e d j u s t e a s t o f t h e r u p t u r e c o u l d have prevented t h e r e l e a s e o f propane from f l o w i n g t o t h e r u p t u r e from p i p e l o c a t e d a t h i g h e r e l e v a t i o n s . I n r e c o g n i t i o n o f t h i s , t h e TEPPCO i n s t a l l e d a check v a l v e near t h e m a i n l i n e b l o c k v a l v e on t h e east s i d e o f t h e Schoharie Creek; a manual m a i n l i n e v a l v e on t h e west s i d e o f CR 43; remote-operated v a l v e s a t Marathon, J e f f e r s o n , and Oneonta; and remote t e r m i n a l u n i t s a t Marathon, J e f f e r s o n , Oneonta, and S e l k i r k . A d d i t i o n a l l y , a t a l l pump s t a t i o n s , t h e TEPPCO s e t t h e pressure d i f f e r e n t i a l m o n i t o r u n i t s t o d e t e c t pressure l o s s r a t e s o f 20 p s i g p e r minute i n s t e a d o f 80 p s i g p e r minute. Although these a c t i o n s have improved t h e TEPPCO’s o v e r a l l m o n i t o r i n g and c o n t r o l c a p a b i l i t i e s , t h e y have n o t improved i t s a b i l i t y t o remotely i s o l a t e a p i p e l i n e l e a k near t h e v i l l a g e . Because t h e v a l v e a t CR 43 must be manually operated, it would t a k e more t h a n an hour f o r an employee from t h e c l o s e s t attended f a c i l i t y t o a r r i v e a t t h i s l o c a t i o n t o c l o s e it. The TEPPCO needs t o modify t h e m a i n l i n e valves near populated areas and remote- o r automatic-operated v a l v e s should be i n s t a l l e d t o enable t h e r a p i d i s o l a t i o n o f any f a i l u r e i n those sections. The TEPPCO procedure No. 270 r e q u i r e d t h a t l i a i s o n be e s t a b l i s h e d and maintained w i t h f i r e , p o l i c e , and o t h e r a p p r o p r i a t e o f f i c i a l s , who may respond t o an emergency i n v o l v i n g TEPPCO p i p e l i n e s , t o l e a r n each p a r t y ‘ s r e s p o n s i b i l i t i e s and resources and t o acquaint them w i t h TEPPCO‘s response c a p a b i l i t i e s and means o f communication. The TEPPCO o p e r a t i n g personnel were r e s p o n s i b l e f o r conducting p e r i o d i c b r i e f i n g s t o p r o v i d e p u b l i c o f f i c i a l s w i t h i n f o r m a t i o n about t h e p i p e l i n e system, i t s o p e r a t i o n , and c u r r e n t s a f e t y and emergency procedures. The TEPPCO had implemented these procedures o n l y w i t h p u b l i c agencies l o c a t e d near pumping and r e c e i v i n g f a c i l i t i e s . Before t h e accident, t h e TEPPCO r e p r e s e n t a t i v e s had n o t contacted t h e Schoharie County Emergency Management O f f i c e t o advise or t o c o o r d i n a t e w i t h them TEPPCO’s response procedures. A d d i t i o n a l l y , procedure No. 270 r e q u i r e d t h a t each r e g i o n p r o v i d e i n f o r m a t i o n t o government agencies, excavators, and t h e p u b l i c on r e c o g n i z i n g an emergency c o n d i t i o n t h a t may i n v o l v 2 a hazardous l i q u i d (HL) p i p e l i n e and r e p o r t i n g i t t o t h e TEPPCO. The i n f o r m a t i o n d i s t r i b u t e d a t l e a s t a n n u a l l y by t h e TEPPCO personnel i n c l u d e d emergency telephone numbers, pocket calendars w i t h emergency n o t i f i c a t i o n i n s t r u c t i o n s , maps o f t h e general l o c a t i o n o f TEPPCO’s p i p e l i n e f a c i l i t i e s i n t h e r e g i o n , and d a t a sheets f o r t h e v a r i o u s l i q u i d s t r a n s p o r t e d i n t h e r e g i o n . I#

Page 5(Class II, Priority Action) (P-91-7) Use only qualified employees to move pressurized liquid pipelines. (Class II, Priority Require that all employees be briefed on the work to be performed before work is begun. Action) (P-91-6) taken for protection of the public. movement of the pipe, and actions to o the extent to which the pipe may be safely moved, required for procedures specific Phael ines containing highly volatile Yiquids to require conducted analyses be movement, determine: Develop explicit procedures on the physical movement of (Class II, Priority assigned to them. Action) (P-91-5) programs training and testing to annually qualify employees to perform each responsibility conduct employee Develop Therefore, the National Transportation Safety Board recommends that the Texas Eastern Products Pipeline Company: lower than and within 1 mile of its response agencies adjacent to its pipelines and its public education program persons who reside at elevations pipelines. TEPPCO to extend its emergency preparedness liaison program to all community information to persons most likely The Safety Board urges the to be harmed by a release of HVL from pipelines. essential hazard recognition and response This accident again demonstrates the need to provide injuries caused by releases from liquid pipelines occurred between 1/8 and 1 mile of the pipeline. and Proposals for Change," 24 percent of the fatalities and 7 percent of the As noted in the July 1987 American Petroleum Institute research study, An Evaluation of Present Levels "The Safety of Interstate Liquid Pipeline: of year and day, unless residents had knowledge of the characteristic of HVLs to form vapor clouds. a condition normal for that time was the TEPPCO required to add one, the vapor cloud could be perceived as fog, naturally nave a distinctive odor, propane dia not since Additionally, received the information. fived beyond the mite mit and had This action exceeded information appeared to be effective as it was used by the resident who first alerted the CPO of the leak. residents injured in this accident of the pipeline. Federal requirements. public about how to recognize and provided only protective residents living within 1/8 report The TEPPCO information to 5#

Page 66 Install, at intervals sufficient to rapidly stop the flow of product in the event of a rupture, remote- and automatic-operated valves (including check valves) on pipeline segments that pass through or are adjacent to populated areas. (Class 11, Priority Action) (P-91-8) Extend your emergency preparedness 1 iaison program to include all community response agencies adjacent to your pipelines. (Class 11, Priority Action) (P-91-9) Extend your public education program on recognizing and responding to highly volatile liquid pipeline emergencies to include all persons who reside at elevations lower than and within 1 mile of your pipelines. (Class 11, Priority Action) (P-91-10) Also, the Safety Board issued Safety Recommendations P-91-1 through -4 and reiterated P-84-26 and P-87-2 and -22 to the Research and Special Programs Administration of the U.S. Department of Transportation and issued P-91-11 to the American Petroleum Institute, the Interstate Natural Gas Association of America, and the American Gas Association. The National Transportation Safety Board is an independent Federal agency with the statutory responsibility "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 action taken as a result of its safety recommendations. Therefore, it 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-91-5 through -10 in your reply. KOLSTAD, Chairman, COUGHLIN, Vice Chairman', LAUBER, BURNETT, Members, concurred in these recommendations and HART, 7 Chairman#