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.
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.
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.
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.
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.