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Safety Recommendation Details

Safety Recommendation P-98-030
Details
Synopsis: ABOUT 11:54 P.M EASTERN DAYLIGHT TIME ON 6/26/96, A 36-INCH-DIAMETER COLONIAL PIPELINE COMPANY PIPELINE RUPTURED WHERE A CORRODED SECTION OF THE PIPELINE CROSSED THE REEDY RIVER AT FORK SHOALS, SOUTH CAROLINA. THE RUPTURE PIPELINE RELEASED ABOUT 957,600 GALLONS OF FUEL OIL INTO THE REEDY RIVER AND SURROUNDING AREAS. THE ESTIMATED COST TO COLONIAL FOR CLEANUP AND SETTLEMENT WITH THE STATE OF SOUTH CAROLINA WAS $20.5 MILLION. NO ONE WAS INJURED IN THE ACCIDENT.
Recommendation: THE NTSB RECOMMENDS THAT THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION (ORIGINALLY ISSUED TO RSPA): ASSESS THE POTENTIAL SAFETY RISKS ASSOCIATED WITH ROTATING PIPELINE CONTROLLER SHIFTS AND ESTABLISH INDUSTRY GUIDELINES FOR THE DEVELOPMENT AND IMPLEMENTATION OF PIPELINE CONTROLLER WORK SCHEDULES THAT REDUCE THE LIKELIHOOD OF ACCIDENTS ATTRIBUTABLE TO CONTROLLER FATIGUE.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Pipeline
Location: Fork Shoals, SC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA96MP005
Accident Reports:
Pipeline Rupture and Release of Fuel Oil in the Reedy River
Report #: PAR-98-01
Accident Date: 6/26/1996
Issue Date: 11/18/1998
Date Closed: 5/3/2006
Addressee(s) and Addressee Status: RSPA (Closed - Acceptable Action)
Keyword(s): Fatigue

Safety Recommendation History
From: NTSB
To: RSPA
Date: 12/23/2008
Response: In 2005, PHMSA issued an advisory bulletin titled "Pipeline Safety: Countermeasures to Prevent Human Fatigue in the Control Room" (ADB-05-06), which was designed to provide guidance to pipeline operators on factors that can affect controller fatigue and to ensure that controllers are not assigned to duties while fatigued. The advisory bulletin included the following advice for operators: (1) limit work schedules to no more than 12 hours in any 24-hour period, (2) develop procedures to manage unusual circumstances in which a controller must work more than 12 hours in a 24-hour period, (3) schedule at least a 10-hour break between work periods, and (4) develop shift rotation practices to minimize fatigue caused by the disruption of normal sleep patterns. Based on the issuance of Advisory Bulletin ADB-05-06, the Safety Board classified Safety Recommendation P-98-30 "Closed-Acceptable Action" on May 3,2006. Notation 8070: The National Transportation Safety Board has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA’s) notice of proposed rulemaking (NPRM), “Control Room Management/Human Factors,” that was published at 73 Federal Register 53076 on September 12, 2008. PHMSA is proposing to revise the Federal pipeline safety regulations, 49 Code of Federal Regulations (CFR) Parts 192, 193, and 195, to address human factors and other components of control room management. Overview The Safety Board notes that the NPRM would implement new requirements for control room management at 49 CFR Parts 192, 193, and 195 for natural gas pipelines, liquefied natural gas (LNG) facilities, and hazardous liquid pipelines, respectively. Under the proposed requirements, each operator of a natural gas pipeline, LNG facility, or hazardous liquid pipeline with a controller and control room would have to establish and follow written control room management procedures. The procedures also would have to be integrated into the operator’s operations and maintenance manual, qualification program, and emergency plan, all of which are currently required under 49 CFR Parts 192, 193, and 195. The Safety Board further notes that in order to implement the proposed control room management procedures an operator would be required to do the following: define the roles and responsibilities of the controllers; provide controllers with accurate and timely system data; implement methods to prevent controller fatigue; ensure appropriate controller response to alarms and notifications when Supervisory Control and Data Acquisition (SCADA) systems are used; establish thorough and frequent communications among controllers, management, and field personnel when planning and implementing physical changes to pipeline/facility equipment and configuration; review control room procedures following any event that must be reported under existing regulations; establish and implement a training program that includes an annual review to identify potential improvements; have a qualification program for controllers; and conduct an annual validation by a senior executive for the operator verifying that adequate control room management procedures have been implemented and are being followed. The Safety Board supports the overall direction of the NPRM and believes that the NPRM is comprehensive and focuses on the major elements of effective control room management. The Board also commends PHMSA for proposing to apply the standards to both natural gas and hazardous liquid pipelines and LNG facilities. Still, the Board has more detailed comments to provide concerning the specific safety recommendations discussed in the NPRM and the proposed requirements pertaining to mitigation of controller fatigue. Safety Board SCADA Safety Recommendations The Safety Board notes that the NPRM references the five safety recommendations, Safety Recommendations P-05-1 through -5, issued to PHMSA as a result of the Board’s 2005 safety study titled Supervisory Control and Data Acquisition (SCADA) in Liquid Pipelines. The NPRM specifically addresses Safety Recommendations P-05-1, -2, and -3, which, respectively, pertain to the use of graphics for SCADA systems, alarm management, and controller training. The three recommendations also were directly incorporated into the Pipeline Inspection, Protection, Enforcement, and Safety Act of 2006 (PIPES Act). These recommendations are listed below; a discussion of the related provisions in the NPRM follows. Require operators of hazardous liquid pipelines to follow the American Petroleum Institute’s Recommended Practice 1165 [API RP-1165] for the use of graphics on the SCADA screens. (P-05-1) The NPRM states that whenever a SCADA system is used, the operator must implement API RP-1165 in its entirety, unless the operator can adequately demonstrate that a provision of API RP-1165 is not applicable or is impracticable in the SCADA system used. Require pipeline companies to have a policy for the review/audit of alarms. (P-05-2) The NPRM, if implemented, would require that each operator using a SCADA system ensure appropriate controller response to alarms and notifications. Operators would be required to review SCADA operations at least once a week and review SCADA configuration and alarm management operations at least once each calendar year but at intervals not to exceed 15 months. Require controller training to include simulator or non-computerized simulations for controller recognition of abnormal operating conditions, in particular, leak events. (P-05-3) The NPRM proposed training provisions would require that training programs for controllers include the use of a simulator or noncomputerized (tabletop) method to enable controllers to recognize abnormal operating conditions, in particular leak and failure events. The Safety Board notes that under the NPRM, such simulations and tabletop exercises would include representative communications between controllers and individuals that operators expect to be involved during actual events. Further, controllers would also be required to participate in improving and developing tabletop or simulation training scenarios. The Safety Board believes that implementation of these proposed provisions will satisfy Safety Recommendations P-05-1, -2, and -3. Safety Recommendations P-05-4 and -5, the two remaining safety recommendations issued to PHMSA as a result of the SCADA study, are listed below. Change the liquid accident reporting form (PHMSA F 7000-1) and require operators to provide data related to controller fatigue. (P-05-4) Require operators to install computer-based leak detection systems on all lines unless engineering analysis determines that such a system is not necessary. (P-05-5) PHMSA states in the NPRM that it plans to address Safety Recommendation P-05-4 in a separate action. PHMSA published a notice at 73 Federal Register 51697 on September 4, 2008, requesting comments on its intention to revise the incident report forms for gas transmission and gathering systems, gas distribution systems, and hazardous liquid pipeline systems. Additionally, in a letter addressed to the Safety Board dated September 17, 2008, regarding Safety Recommendation P-05-5, PHMSA summarized its policies and requirements for leak detection systems. With the letter, PHMSA enclosed a copy of its report to Congress addressing leak detection systems and the development of more effective technologies. The report, which was mandated under the PIPES Act, was forwarded to Congress on June 23, 2008. The Board will address PHMSA’s actions on Safety Recommendations P-05-4 and -5 in separate correspondence and encourages PHMSA to complete action on these recommendations promptly. Controller Fatigue Mitigation Despite the many positive provisions included in the NPRM, the Safety Board does not believe the NPRM satisfactorily addresses mitigation of controller fatigue. The Board issued its first recommendation concerning pipeline controller fatigue based on its findings from the June 26, 1996, accident in Fork Shoals, South Carolina. As a result of the investigation, the Board recommended that the Research and Special Programs Administration (RSPA) do the following: Assess the potential safety risks associated with rotating pipeline controller shifts and establish industry guidelines for the development and implementation of pipeline controller work schedules that reduce the likelihood of accidents attributable to controller fatigue. (P-98-30) In 2005, PHMSA issued an advisory bulletin titled “Pipeline Safety: Countermeasures to Prevent Human Fatigue in the Control Room” (ADB-05-06), which was designed to provide guidance to pipeline operators on factors that can affect controller fatigue and to ensure that controllers are not assigned to duties while fatigued. The advisory bulletin included the following advice for operators: (1) limit work schedules to no more than 12 hours in any 24-hour period, (2) develop procedures to manage unusual circumstances in which a controller must work more than 12 hours in a 24-hour period, (3) schedule at least a 10-hour break between work periods, and (4) develop shift rotation practices to minimize fatigue caused by the disruption of normal sleep patterns. Based on the issuance of Advisory Bulletin ADB-05-06, the Safety Board classified Safety Recommendation P-98-30 “Closed—Acceptable Action” on May 3, 2006. On June 1, 1999, the Safety Board issued another fatigue-related recommendation to RSPA: Establish within 2 years scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest requirements. (P-99-12) The issue of fatigue has been on the Safety Board’s Most Wanted List of Transportation Safety Improvements since 1990. Safety Recommendation P-99-12 was added to the Most Wanted List in 1999 as the result of the Board’s evaluation of the U.S. Department of Transportation’s efforts to address operator fatigue in all modes of transportation. The 2008 Most Wanted List recommends that PHMSA “set working hour limits for pipeline controllers based on fatigue research, circadian rhythms, and sleep and rest requirements.” In this NPRM, PHMSA proposes that each operator implement methods to prevent controller fatigue. The proposed rules are similarly described in the sections discussing the transportation of natural gas (49 CFR 192.631(d)), LNG facilities (49 CFR 193.2523(d)), and the transportation of hazardous liquids (49 CFR 195.454(d)). Each of these respective sections has a “fatigue mitigation” heading, under which PHMSA discusses specific actions to be taken by operations, including the following: (1) establishing shift lengths and schedule rotations that provide controllers off-duty time sufficient to achieve 8 hours of continuous sleep; (2) educating controllers and their supervisors in fatigue mitigation strategies and how off-duty activities contribute to fatigue; (3) training controllers and their supervisors to recognize and mitigate the effects of fatigue; (4) implementing additional measures to monitor for fatigue when a single controller is on duty; and (5) establishing a maximum limit on controller hours of service, which may include an exception during an emergency with appropriate management approval. The Safety Board commends PHMSA for the efforts it has taken to address controller fatigue both through Advisory Bulletin ADB-05-06 and through this NPRM. The Board is particularly pleased with PHMSA’s proposed rule requiring that operators provide controllers an opportunity for 8 hours of continuous sleep. The Board, however, encourages PHMSA to amend the NPRM sections on fatigue mitigation to include additional instruction that is vital to establishing safe and effective work and rest schedules. Specifically, the Board believes that the NPRM should require that operators of these facilities incorporate fatigue research, circadian rhythms, and sleep and rest requirements when establishing a maximum limit on controller shift length, maximum limit on controller hours of service, and schedule rotations. In addition, the Safety Board notes that requiring operators to design their own plans to address controller fatigue is not the same as establishing scientifically based hours-of-service regulations. Rather, the latter is consistent with an approach that has been referred to as fatigue management systems or fatigue risk management systems. Such systems commonly incorporate various strategies to manage fatigue, such as scheduling policies and practices, attendance policies, education, medical screening and treatment, personal responsibility during nonworking periods, task/workload issues, rest environments, and commuting policies. Such systems also typically incorporate a plan for implementing, supervising, and evaluating the success of the system. The Board has stated that fatigue management systems appear to hold promise as a progressive approach to addressing problems associated with fatigue but has also noted that refinement and ongoing regulatory oversight are necessary to ensure that such systems will result in the intended outcomes. PHMSA has stated that its proposed rules are performance based because they describe the necessary elements and outcomes that operators must accomplish but do not prescribe exactly how operators must incorporate each element. Considering PHMSA’s nonprescriptive approach to fatigue management, the Safety Board would like PHMSA to provide additional information about its criteria for evaluating operators’ plans and to explain how it intends to monitor the effectiveness of implementing those plans. Establishing clear evaluation criteria for the plans and their outcomes will improve the likelihood that operators will design effective plans; it also will likely improve the success of their fatigue management systems. The revisions to the NPRM suggested by the Safety Board, combined with PHMSA’s proposed requirements, would be positive steps towards satisfying the intent of Safety Recommendation P-99-12. Oversight To ensure that the appropriate control room management/human factors elements are included in an operator’s plan and are satisfactorily implemented, PHMSA must establish an aggressive oversight program that thoroughly examines each operator’s process for implementing requirements for control room management. As mentioned earlier, the Safety Board encourages PHMSA to clearly define criteria for evaluation and to outline how PHMSA would monitor compliance with these regulations. The Safety Board appreciates the opportunity to comment on this proposed rulemaking. Should you require any additional information or clarification, please contact us.

From: NTSB
To: RSPA
Date: 5/3/2006
Response: PHMSA published Advisory Bulletin ADB-05-6 in the Federal Register on August 11, 2005. This bulletin provides industry guidelines developed in response to U.S. Department of Transportation Human Factors Coordinating Committee research of the potential safety risks associated with rotating pipeline controller shifts. Because the issuance of ADB-05-6 satisfies the intent of the recommendation, Safety Recommendation P-98-30 is classified "Closed-Acceptable Action."

From: RSPA
To: NTSB
Date: 4/14/2006
Response: In its 4/14/2006 report to Congress, "National Transportation Safety Board (NTSB) and DOT Office of Inspector General (OIG): After benchmarking risk controls of fatigue in other industries and meeting with our advisory committees, PHMSA developed guidance to help operators address circumstances where fatigue could reduce the ability of pipeline operators and their controllers to operate pipelines safely. PHMSA published the guidance in advisory bulletin ADB-05- 06 (70 FR 469 17; August 1 1,2005). On August 23,2005, PHMSA submitted a letter to NTSB requesting closure.

From: RSPA
To: NTSB
Date: 3/1/2006
Response: In its 3/1/2006 annual report to Congress, Regulatory Status of the National Transportation Safety Board's "Most Wanted" Recommendations to the Department of Transportation, the DOT wrote: The Department of Transportation has been working with the pipeline community, Federal agencies and other human factors experts to evaluate how rotating controller schedules relate to human fatigue. From this work, the Department developed guidance which can he applied in the pipeline environment to help operators address circumstances where fatigue could reduce the ability of pipeline operators and their controllers to operate pipeline safety. The Department obtained advice on this guidance from its two technical advisory committees in May 2005, and subsequently published the guidance in Advisory Bulletin ADB-05-06(70 FR 46917, August 11,2005). The Department submitted a letter on August 23, 2005, to NTSB requesting closure ofthe recommendation.

From: RSPA
To: NTSB
Date: 8/23/2005
Response: Letter Mail Controlled 8/30/2005 8:56:30 AM MC# 2050395 This recommendation resulted from a pipeline rupture where a corroded section of the pipeline crossed the Reedy River at Fork Shoals, South Carolina. The NTSB found the controller's work schedule may have affected his alertness, vigilance, and responsiveness during the accident sequence. PHMSA has been working with the pipeline community, Federal agencies with experience in human factors, and other human factors experts, to evaluate how rotating controller schedules relate to human fatigue. From this work, PHMSA developed guidance which can be applied in the pipeline environment to help operators address circumstances where fatigue could reduce the ability of pipeline operators and their controllers to operate pipelines safely. PHMSA obtained advice on this guidance from its two technical advisory committees at a meeting in May 2005. PHMSA subsequently published the guidance in advisory bulletin ADB-05-06 (70 FR 46917; August 11,2005). A copy of the advisory bulletin is enclosed.

From: NTSB
To: RSPA
Date: 4/29/2005
Response: The pipeline industry remains the only transportation mode that has no hours-of-service regulations. In 2002, the Safety Board was advised that PHMSA was tasking the Volpe National Transportation Systems Center to develop information about work-rest cycles, fatigue measurement, and fatigue management for pipeline controllers. According to PHMSA, this project determined that there was very little information available to assess the extent of fatigue issues in pipeline transportation or to provide industry and labor with tools and techniques to manage any problems. The Safety Board reviewed materials from the Volpe project submitted by PHMSA. Its statement of work lists three objectives including (1) a poll of industry and labor on their current scheduling practices, (2) a meeting with PHMSA, Safety Board, and Volpe staff regarding proposed responses to Board recommendations, and (3) preparation of a full field data collection activity to understand and manage fatigue in the pipeline industry. The documents submitted on the Volpe project suggest only the first objective was accomplished. The Board notes that had the third objective been completed as outlined in its statement of work, PHMSA would have better information with which to assess the extent of fatigue issues in pipeline transportation, and to establish industry guidelines to reduce the likelihood of accidents attributable to controller fatigue. The Safety Board notes that PHMSA's review of its accident records did not indicate that controller fatigue was a contributor to pipeline accidents. We do not find this outcome surprising because there are certain limits to PHMSA's pipeline accident database regarding fatigue data. The issue of fatigue is not directly solicited in the questions for the database. In addition, the reports are generally self-reported and require companies to collect fatigue data in their investigation and then report it to PHMSA. The Safety Board notes that PHMSA has contracted with Battelle Memorial Institute (Battelle) for a project titled, Human Factors Analysis of Pipeline Monitoring and Control Operations. As part of this project, Battelle plans to discuss with Safety Board staff the overall reasoning and issues underlying the Board's fatigue recommendations; to date this contact has not been initiated. Although supportive of efforts to better understand how human factors can adversely affect the safety of pipeline monitoring and control operators, the Board is concerned that the project will only result in laying the groundwork "for assessing the need for further regulatory action." This project is not expected to be completed until October 2006, more that 8 years after the first fatigue safety recommendation was issued to PHMSA. Because PHMSA continues to assess the fatigue issue in pipeline safety, Safety Recommendations P-98-30 and P-99-12 remain classified "Open--Acceptable Response." However, because the pipeline industry is the only mode of transportation without hours-of-service regulations, and because more than 7 years have elapsed since these recommendations were issued, the Safety Board strongly encourages PHMSA to commit to taking action soon, beyond investigations and studies, to address fatigue in the pipeline industry. Without such action, the Board may have no alternative than to reclassify these recommendations to an unacceptable status. We would appreciate receiving periodic updates on these initiatives as they near completion.

From: RSPA
To: NTSB
Date: 2/28/2005
Response: In its 2/28/2005 report to Congress, "Open Statutory Mandates Regarding Pipeline and Hazardous Materials Safety," the DOT wrote: RSPA continues its assessment of human fatigue in pipeline operations in a variety of research and standards efforts. Study results are expected in 18 months.

From: RSPA
To: NTSB
Date: 2/1/2005
Response: In its 2/1/2005 annual report to Congress, Regulatory Status of the National Transportation Safety Board's "Most Wanted" Recommendations to the Department of Transportation, the DOT wrote: The Department’s Human Factors Coordinating Committee maintains an ongoing commitment to the development of several non-prescriptive fatigue management tools for the transportation enterprise. These include work schedule representation software, a fatigue management reference guide, a business case development tool suite to help safety managers promote fatigue management activities, and a fatigue model validation procedure. RSPA recently tasked the VOLPE National Transportation Systems Center to develop information about work-rest cycles, fatigue measurement and fatigue management for pipeline controllers. Following the assessment of human fatigue in pipeline operations and the results of the research and standards efforts now underway, RSPA plans to evaluate the need for further development and application of guidelines to reduce the threat of pipeline incidents attributable to operator fatigue. RSPA plans to evaluate the need for further development and application of guidelines to reduce the threat of pipeline incidents attributable to operator fatigue. RSPA is also working with the Battelle Memorial Institute on an analysis of human factors issues in pipeline monitoring and control operations.

From: NTSB
To: RSPA
Date: 11/24/2004
Response: Can you email me something simple on where we are - what you are doing?

From: RSPA
To: NTSB
Date: 11/4/2004
Response: Letter Mail Controlled 12/3/2004 11:29:26 AM MC# 2040705 Several years ago, the Research and Special Programs Administration's (RSPA) Office of Pipeline Safety (OPS) tasked the Volpe National Transportation Systems Center to develop information about work-rest cycles, fatigue measurement, and fatigue management for pipeline controllers. This project determined that there was very little information available to assess the extent of fatigue issues in pipeline transportation or to provide industry and labor with tools and techniques to manage any problems. We considered examining the actual scope of the fatigue problem and applying the new Organizational Fatigue Management technologies and procedures developed by the Department's Human Factors Coordinating Committee. Since then, a review of our accident records has not, to date, indicated that controller fatigue is a contributor to pipeline accidents. Therefore, we decided to broaden our focus to include not just fatigue issues, but operator human factors issues in general. On June 5, 2002, and on December 30, 2002, RSPA/OPS issued a fourth Broad Agency Announcement (BAA#4) in an effort to solicit research projects on a number of critical pipeline safety issues including developmental needs related to improved human factors, including fatigue issues. Neither solicitation resulted with a viable project that would address the specific fatigue issues addressed in the NTSB recommendations. On January 7, 2004, another effort was undertaken to comply with the NTSB recommendations by listing a human factors topic in BAA#4. The topic area, "Enhanced Pipeline Operations, Controls and Monitoring," invited white papers and proposals to address needed research and development on pipeline operator fatigue and control room human factors. As a result of white papers and proposals submitted in response to BAA#4, we have instituted a broader investigation of human factors and pipeline control rooms. We believe the results of this investigation will help address the NTSB fatigue recommendations. Battelle Memorial Institute (Battelle) is the research contractor for a project on human factors titled, "Human Factors Analysis of Pipeline Monitoring and Control Operations." Battelle plans to contact NTSB to understand the overall reasoning and issues undergirding the NTSB fatigue recommendations to ensure that the issues are effectively addressed in this project. More detailed information on this and other research and development projects is accessible over the Internet at http://primis.rspa.dot.gov/. This nearly one million dollar project is co-funded by RSPA/OPS and the pipeline industry. It commenced on October 1, 2004, with an expected completion date of September 30, 2006. The project will systematically apply human factors research and development techniques in meeting two objectives: (1) to establish an understanding of the human factors that adversely affect the safety, reliability, and efficiency of pipeline monitoring and control operations, and (2) to develop guidelines that can be used by industry to identify human factors problem areas in their operations and develop continuous improvement strategies to improve the effectiveness of pipeline monitoring and control operations. Battelle researchers will work with the Pipeline Research Council International and industry partners to systematically apply human factors research and development techniques in meeting the objectives. The overall approach to data collection and analysis will have human factors researchers analyze a sample of control room incidents described in company incident reports, interview controllers, and conduct a series of operational reviews of control rooms. This data will allow the researchers to identify the most problematic human factors issues in pipeline operations based on risk metrics developed with industry input. Then, cost-effective strategies for addressing various human factors issues will be developed. This project will produce three products intended for future industry implementation: (1) human factors operational review procedures for identifying problematic issues at individual operating sites; (2) continuous improvement strategies for addressing selected high-priority human factors issues; and (3) guidelines for developing additional cost-effective continuous improvement strategies. Following the assessment of human fatigue in pipeline operations and the results of the research and standards efforts now underway, we will evaluate the need for further development and application of guidelines to reduce the threat of pipeline incidents attributable to operator fatigue. We believe these efforts will provide the necessary information for an assessment of the need for further regulatory action.

From: NTSB
To: RSPA
Date: 6/28/2002
Response: Although RSPA has not committed to establishing scientifically based hours-of-service regulations, because RSPA continues to make progress on assessing the fatigue issue in pipeline safety, both Safety Recommendations P-98-30 and P-99-12 remain classified "Open--Acceptable Response." We would appreciate another update on these initiatives as they near completion.

From: RSPA
To: NTSB
Date: 4/24/2002
Response: Letter Mail Controlled 05/07/2002 10:51:59 AM MC# 2020457 RSPA has been participating in the Department of Transportation Human Factors Coordinating Committee (HFCC) to assess approaches to the control of human fatigue in transportation, including pipeline operations HFCC has sponsored several research studies and conferences on transportation fatigue issues at which RSPA engineers and pipeline industry representatives made presentations on the pipeline worker fatigue issues. As a result of the NTSB recommendations and the work of the HFCC, we recognized the need to evaluate how rotating controller schedules in the pipeline industry may be related to human fatigue and safety outcomes in the pipeline industry. Fatigue and work-rest patterns are a continuing concern for all modes of transportation. Fatigue is a particular issue in transportation given the preponderance of night work, concentrated/compressed schedules, overtime and rotating work, etc Concerns include job critical safety-related performance, worker safety during their commute, and general health effects. RSPA recently tasked the Volpe National Transportation Systems Center (VNTSC) to develop information about work-rest cycles, fatigue measurement, and fatigue management for pipeline controllers. We will use this information, and, if upon review we conclude measures need to be taken, we will provide industry and labor with tools and techniques to manage the problem. In this project RSPA is approaching these concerns by examining the actual scope of the fatigue problem and applying the new Organizational Fatigue Management (OFM) technologies and procedures developed by the HFCC. The initial step in the study is to collect pipeline operator work and other fatigue-related scheduling data from selected companies and unions. This data will be used to identify existing and potential fatigue problems and develop a comprehensive work plan to address them. RSPA will analyze the data and the resulting plan will be provided as an initial report. The report will guide further work in this area and address issues raised by NTSB. The plan will chart a course of work focused on implementing the planned research and providing the pipeline enterprise with fatigue management tools tailored to its needs. In addition, RSPA will soon issue a second Broad Agency Announcement (BAA), to invite proposals for pipeline safety research, including research on fatigue-related problems, fatigue measurement, and fatigue management. The RSPA BAA is a two-step process: Step one is the submission of a "White Paper/Pre-Proposal" by interested offerors. Each submission is evaluated by a technical panel. Step two is the submission of full proposals by those offerors deemed to have the most technically promising projects. Full proposals are evaluated by the same technical team and projects are selected for funding. Following the assessment of human fatigue in pipeline operations and the results of the research and standards efforts now underway, RSPA will evaluate the need for further development and application of guidelines to reduce the threat of pipeline incidents attributable to operator fatigue. RSPA believes these efforts will provide the necessary information for an assessment of the need for further regulatory action. Action Requested: RSPA requests that NTSB Safety Recommendations P-98-30 and P-99-12 continue to be classified as "Open - Acceptable Action" while we continue to pursue the actions described above.

From: NTSB
To: RSPA
Date: 4/18/2001
Response: The Safety Board understands that RSPA is reviewing previous pipeline accidents and research on fatigue and rotating work schedules and has met with representatives of pipeline trade associations to discuss the issue of fatigue in the pipeline industry. RSPA is working cooperatively with the industry to determine the role of fatigue as a factor in pipeline incidents and to gather information on existing fatigue guidelines in pipeline operations. The RSPA is also monitoring the progress of a multi-year human factors research initiative by the American Petroleum Institute to develop industry guidelines covering, among other human factors, fatigue and successful mitigation and intervention techniques, which RSPA will closely monitor. The Safety Board further understands that RSPA is participating both on the DOT's effort to address fatigue issues across all modes of transportation and on the DOT Human Factors Coordinating Committee, which provides a mechanism to enhance planning, implementation, and education related to human factors research within the transportation community. RSPA advises that the goals of the committee are to assist in the development and implementation of a national strategic agenda for intermodal human factors research and applications in transportation; the committee also seeks to be a human factors information resource to the transportation community. Accordingly, because RSPA is making progress on the fatigue issue in pipeline safety, both Safety Recommendations P-98-30 and P-99-12 remain classified "Open--Acceptable Response," pending our receipt of further information on this issue. Specifically, the Board would appreciate being informed of the timeframe for issuing the advisory bulletin to the owners and operators as discussed in the April 24, 2000, letter.

From: RSPA
To: NTSB
Date: 4/24/2000
Response: RSPA is reviewing previous pipeline accidents and research on fatigue and rotating work schedules. RSPA has met with representatives of pipeline trade associations to discuss the issue of fatigue in the pipeline industry. We are working cooperatively with the industry to determine the role of fatigue as a factor in pipeline incidents and to gather information on existing fatigue guidelines in pipeline operations. We are also monitoring the progress of a multi-year human factors research initiative by the American Petroleum Institute to develop industry guidelines covering, among other human factors, fatigue and successful mitigation and intervention techniques. We will closely monitor this research initiative. The Dept. of Transportation (DOT) is addressing fatigue issues across all modes of transportation. RSPA is represented on the DOT Safety Council task force on hours-of service issues in motor carrier operations. It also participates in the DOT Human Factors Coordinating Committee, which provides a mechanism to enhance planning, implementation, and education related to human factors research within the transportation community. The goals of the committee are to assist in the development and implementation of a national strategic agenda for intermodal human factors research and applications in transportation and to be a human factors information resource to the transportation community. We believe these actions will provide adequate information to assess the safety risks associated with rotating pipeline controller shifts and to explore with pipeline industry and labor the establishment of work schedule guidelines that will reduce the likelihood of accidents attributable to controller fatigue. RSPA will soon issue an advisory bulletin to owners and operators of natural gas and hazardous liquid pipeline systems to advise them of possible dangers that can be associated with fatigue resulting from rotating pipeline controller shifts. The bulletin will include a list of factors that should be considered to reduce the impact of fatigue on controller performance. In addition, federal pipeline safety inspections for the year 2000 include specific questions on how each pipeline operator is addressing employee fatigue issues. These include questioning on factors relating to the fatigue of pipeline controllers and the company plan, if any, for addressing controller fatigue through adjustments in work schedules, health monitoring, and modification of the work. Following RSPA's assessment of human fatigue in pipeline operations and the results of the research and standards efforts now underway, we will evaluate the need for further development and application of industry guidelines or federal regulations to reduce the likelihood of accidents attributable to controller fatigue. If a need exists we will actively promote the development of additional guidelines.

From: NTSB
To: RSPA
Date: 5/25/1999
Response: THE SAFETY BOARD IS PLEASED THAT RSPA IS REVIEWING PREVIOUS PIPELINE ACCIDENTS AND RESEARCH ON FATIGUE AND ROTATING WORK SCHEDULES AND THAT RSPA IS ALSO COORDINATING WITH OTHER DOT AGENCIES AND THE PIPELINE INDUSTRY TO ADDRESS FATIGUE ASSOCIATED WITH ROTATING PIPELINE CONTROLLER SHIFTS. THE BOARD UNDERSTANDS THAT RSPA HAS BOLSTERED ITS EXAMINATION OF FATIGUE AS A CAUSATIVE FACTOR IN PREVIOUS PIPELINE ACCIDENTS AND HAS MODIFIED ITS INSPECTION PROCESS TO FOCUS ON THE INFLUENCE OF FATIGUE. ACCORDINGLY, PENDING A REPLY FROM RSPA ON THE STATUS OF THESE INITIATIVES, P-98-30 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: RSPA
To: NTSB
Date: 5/5/1999
Response: Letter Mail Controlled 5/10/99 3:05:28 PM MC# 990494 RSPA IS REVIEWING PREVIOUS PIPELINE ACCIDENTS AND RESEARCH ON FATIGUE AND ROTATING WORK SCHEDULES. RSPA IS ALSO COORDINATING WITH OTHER DEPT. OF TRANSPORTATION AGENCIES AND THE PIPELINE INDUSTRY TO ADDRESS FATIGUE ISSUES ASSOCIATED WITH ROTATING PIPELINE CONTROLLER SHIFTS. WE BELIEVE THESE ACTIONS WILL PROVIDE ADEQUATE INFORMATION TO ASSESS THE SAFETY RISKS ASSOCIATED WITH ROTATING PIPELINE CONTROLLER SHIFTS AND TO EXPLORE WITH PIPELINE INDUSTRY AND LABOR THE ESTABLISHMENT OF WORK SCHEDULE GUIDELINES THAT WILL REDUCE THE LIKELIHOOD OF ACCIDENTS ATTRIBUTABLE TO CONTROLLER FATIGUE. RSPA HAS BOLSTERED ITS EXAMINATION OF FATIGUE AS A CAUSATIVE FACTOR IN PREVIOUS PIPELINE ACCIDENTS. WE HAVE BEGUN AN ANALYSIS OF RECENT INCIDENTS TO ANSWER THIS QUESTION AND WE HAVE MODIFIED OUR INSPECTION PROCESS TO FOCUS ON FATIGUE'S INFLUENCE AND THE LEVEL OF INDUSTRY AWARENESS OF FATIGUE AS A CONTRIBUTOR TO PIPELINE ACCIDENTS. RSPA INSPECTORS WILL DISCUSS THIS ISSUE WITH ALL PIPELINE COMPANIES INSPECTED DURING 1999 TO DETERMINE WHETHER AND HOW THEY ARE IMPLEMENTING COUNTERMEASURES TO PREVENT AND MITIGATE CONTROLLER FATIGUE. TO HELP US GAIN A BROADER UNDERSTANDING OF FATIGUE ISSUES, RSPA'S VOLPE NATIONAL TRANSPORTATION SYSTEMS CENTER IS PERFORMING A REVIEW OF RESEARCH RELEVANT TO THE ISSUE OF PIPELINE CONTROLLER FATIGUE AND ROTATING WORK SCHEDULES. THIS PROJECT WILL ALSO EXAMINE RESEARCH IN THE NUCLEAR INDUSTRY THAT ADDRESSES THE IMPACT OF FATIGUE AND ROTATING WORK SCHEDULES ON CONTROL ROOM OPERATORS. RSPA IS ENGAGED IN THE BROADER ISSUE OF HUMAN FACTORS, INCLUDING FATIGUE, BY PARTICIPATION IN THE DOT HUMAN FACTORS COORDINATING COMMITTEE AND VARIOUS CONFERENCES. RSPA COSPONSORED THE 1996 INTERNATIONAL WORKSHOP ON HUMAN FACTORS IN OFFSHORE OPERATIONS AND PARTICIPATED IN THE 1995 NTSB/NASA MANAGING HUMAN FATIGUE IN TRANSPORTATION: PROMOTING SAFETY AND PRODUCTIVITY. WE WILL CONTINUE TO PARTICIPATE IN WORKSHOPS TO FURTHER OUR UNDERSTANDING OF FATIGUE AND HUMAN FACTORS IN PIPELINE TRANSPORTATION. IN ADDITION, WE RECENTLY CONTACTED SEVERAL INDUSTRY TRADE ASSOCIATIONS TO DETERMINE WHETHER THERE ARE PIPELINE INDUSTRY STANDARDS OR GUIDELINES ON CONTROLLER FATIGUE. THE RESPONSES INDICATE THAT NO STANDARDS OR GUIDELINES ARE CURRENTLY IN USE. HOWEVER, THE AMERICAN PETROLEUM INSTITUTE IS IN THE SECOND YEAR OF A RELATED MULTI-YEAR HUMAN FACTORS RESEARCH INITIATIVE. THIS PROJECT IS DESIGNED TO DEVELOP INDUSTRY GUIDELINES COVERING, AMONG OTHER HUMAN FACTORS, FATIGUE AND SUCCESSFUL MITIGATION AND INTERVENTION TECHNIQUES. WE WILL CLOSELY MONITOR THIS RESEARCH INITIATIVE. FOLLOWING RSPA'S ASSESSMENT OF HUMAN FATIGUE IN PIPELINE OPERATIONS AND THE RESULTS OF THE RESEARCH AND STANDARDS EFFORTS NOW UNDERWAY, WE WILL EVALUATE THE NEED FOR FURTHER DEVELOPMENT AND APPLICATION OF INDUSTRY GUIDELINES TO REDUCE THE LIKELIHOOD OF ACCIDENTS ATTRIBUTABLE TO CONTROLLER FATIGUE AND ACTIVELY PROMOTE THE DEVELOPMENT OF ADDITIONAL GUIDELINES. PENDING COMPLETION OF YOUR RECOMMENDED ASSESSMENT, WE REQUEST THAT P-98-30 BE CLASSIFIED AS "OPEN--ACCEPTABLE RESPONSE."