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Safety Recommendation Details

Safety Recommendation P-11-012
Details
Synopsis: On September 9, 2010, about 6:11 p.m. Pacific daylight time,1 a 30-inch-diameter underground natural gas transmission pipeline (which is identified by the company as Line 132), owned and operated by Pacific Gas and Electric Company (PG&E), ruptured in a residential area in San Bruno, California. The accident killed eight people, injured many more, and caused substantial property damage. The rupture on Line 132 occurred near mile point 39.28, at the intersection of Earl Avenue and Glenview Drive in San Bruno. About 47.6 million standard cubic feet of natural gas were released as a result of the rupture. The released natural gas was ignited after the rupture; the subsequent explosion created a crater about 72 feet long by 26 feet wide, and the resulting fire destroyed 38 homes and damaged 70. A ruptured pipe segment about 28 feet long was found about 100 feet away from the crater. The safety recommendations in this letter address the importance of pipeline operators’ communications with the local 911 emergency call center(s), both before and in the event of a pipeline rupture. Effective emergency preparedness plans need to include appropriately detailed and accurate maps of the pipelines located within the area of the accident. These local maps are a crucial component of the emergency response planning process and of the emergency response itself. In addition to the exact path of each pipeline, which is shown on the maps, other system-specific technical information for each pipeline, such as pipe diameter, operating pressure, product transported (by shipping name and 4-digit U.S. Department of Transportation Hazard Identification Code UN number2), depth (soil coverage), potential damage impact distance (potential impact radius, defined in Title 49 Code of Federal Regulations 192.903), and specific emergency contact information (that is, telephone numbers), also is needed by emergency responders to plan and execute a timely and effective response to a pipeline emergency. At the National Transportation Safety Board’s (NTSB) public hearing3 on the accident, which was held March 1–3, 2011, in Washington, DC, testimony of the chief of the San Bruno Fire Department (SBFD) indicated that before the accident, the SBFD was aware of the PG&E gas distribution system, but it was neither aware of nor had information about the natural gas transmission line that ruptured in the accident. The SBFD had not accessed the National Pipeline Mapping System that displays the location of the nation’s natural gas transmission and hazardous liquid pipelines. The chief also indicated that since the accident, the SBFD has made contact with PG&E and obtained maps showing the locations of PG&E natural gas transmission pipelines. The PG&E program manager for safety, health, and claims testified that after the accident PG&E made maps of its natural gas transmission pipelines available to all of the communities and jurisdictions in which PG&E pipelines are located. When compared to distribution pipelines, transmission pipelines have different operating characteristics, such as pipeline diameter and operating pressures. Because of the differences in operating characteristics, transmission pipelines have different safety risks and concerns for the emergency response, including the pipeline company’s ability to shut down the pipeline rapidly. NTSB investigations in all transportation modes have shown that the most successful emergency responses occur when the responders are prepared through training, drills, and exercises and have readily available information to assess the event. Prior to the accident, PG&E’s public awareness program for emergency responders did not include identification of pipeline locations. At the NTSB’s public hearing, the SBFD fire chief testified, “The benefit of having knowledge of the location of the pipelines [is] because it gives the fire service the ability to pre-plan, to do scenario-based training.” The U.S. Department of Transportation has established regulations and programs aimed at providing information to responders (for example, pipeline markers, pipeline maps, railcar and truck placards). First responders can provide timely and valuable information to pipeline operators for the emergency response only when the responders know that a pipeline is involved and the name of the pipeline operator.
Recommendation: TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Amend Title 49 Code of Federal Regulations 199.105 and 49 Code of Federal Regulations 199.225 to eliminate operator discretion with regard to testing of covered employees. The revised language should require drug and alcohol testing of each employee whose performance either contributed to the accident or cannot be completely discounted as a contributing factor to the accident.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Pipeline
Location: San Bruno, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA10MP008
Accident Reports:
Pacific Gas and Electric Company Natural Gas Transmission Pipeline Rupture and Fire
Report #: PAR-11-01
Accident Date: 9/9/2010
Issue Date: 9/26/2011
Date Closed: 12/1/2017
Addressee(s) and Addressee Status: PHMSA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: PHMSA
Date: 2/21/2018
Response: In our December 1, 2017, response to your May 25, 2017, letter, we classified this recommendation CLOSED--ACCEPTABLE ACTION.

From: NTSB
To: PHMSA
Date: 12/1/2017
Response: We note that, on January 23, 2017, you published a final rule, “Pipeline Safety: Operator Qualification, Cost, Recovery, Accident and Incident Notification, and Other Pipeline Safety Proposed Changes,” requiring employees to be tested for drugs and alcohol after an accident, with an exemption only when there is sufficient information that establishes that the employee had no role in the accident. On August 18, 2015, we commented on the notice of proposed rulemaking (NPRM) for this final rule that, if enacted, the proposed rule would satisfy our recommendation. Accordingly, Safety Recommendation P-11-12 is classified CLOSED--ACCEPTABLE ACTION.

From: PHMSA
To: NTSB
Date: 11/13/2017
Response: -From Howard R. Elliott, Administrator: PHMSA proposed closure of this recommendation to NTSB on May 25, 2017. PHMSA looks forward to NTSB's response.

From: PHMSA
To: NTSB
Date: 5/25/2017
Response: -From Howard W. McMillan, Acting Deputy Administrator: On January 23, 2017, PHMSA published the "Pipeline Safety: Operator Qualification, Cost. Recovery, Accident and Incident Notification, and Other Pipeline Safety Proposed Changes" final rule (82 FR 7972). This rule modifies 49 CFR §§ 199 .105 and 199 .225 to require drug testing of employees after an accident with an allowed exemption only when there is sufficient information that establishes the employee(s) had no role in the accident. PHMSA is requiring documentation of decisions not to administer post-accident employee drug tests and the retention of those records for at least three years. PHMSA's previous regulations required the documentation of decisions not to administer a post-accident drug or alcohol test, but the requirement to document those decisions was implied and not explicit. The NTSB noted in its comments on the notice of proposed rulemaking for this rule that the proposed change was responsive to its recommendation.

From: NTSB
To: PHMSA
Date: 12/5/2016
Response: On August 18, 2015, we commented on your NPRM, “Pipeline Safety: Operator Qualification, Cost Recovery, Accident and Incident Notification, and Other Pipeline Safety Proposed Changes,” noting that the proposed rulemaking addresses our recommendations. We understand that you are in the process of addressing comments on the 2015 NPRM; you have assembled an advisory committee meeting to discuss the proposed final rule, which the committee approved with amendments, in June 2016; and that you are working toward publishing a final rule within the next few months. Accordingly, pending publication of a final rule addressing this issue, Safety Recommendation P-11-12 is classified OPEN—ACCEPTABLE RESPONSE.

From: PHMSA
To: NTSB
Date: 8/17/2016
Response: -From Marie Therese Dominguez, Administrator: PHMSA proposed to modify 49 CFR 199.105 and 49 CFR 199.225 by requiring drug testing of employees and allowing exemption from drug testing only when there is sufficient information that establishes the employee(s) had no role in the accident in an NPRM titled "Pipeline Safety: Operator Qualification, Cost Recovery, Accident and Incident Notification, and Other Pipeline Safety Proposed Changes, published on July 10. 2015. PHMSA is in the process of addressing comments on NPRM and conducted an Advisory Committee meeting to discuss the proposed final rule on June 1-3.2016. The Committee approved the rule with amendments. PHMSA will continue work toward publication of a final rule. We anticipate publication in October 2016.

From: NTSB
To: PHMSA
Date: 8/18/2015
Response: Correspondence Control 201500682: The National Transportation Safety Board (NTSB) has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA) notice of proposed rulemaking (NPRM), Pipeline Safety: Operator Qualification, Cost Recovery, Accident and Incident Notification, and Other Pipeline Safety Proposed Changes, published on July 10, 2015. In this notice, PHMSA is proposing amendments to the pipeline safety regulations to address requirements of the Pipeline Safety, Regulatory Certainty, and Job Creation Act of 2011 and update and clarify certain regulatory requirements. We also note that the proposed rulemaking addresses recommendations issued by the NTSB to PHMSA. We are pleased that PHMSA continues to improve pipeline transportation safety through its proposals and amendments. We offer the following comments on sections of the proposed rulemaking listed below that respond to NTSB safety recommendations or relate to matters for which we have basis to comment. Section VIII. Post-Accident Drug and Alcohol Testing The NTSB issued the following safety recommendation to PHMSA on September 26, 2011: Amend §§ 199.105 and 199.225 to eliminate operator discretion with regard to testing of covered employees. The revised language should require drug and alcohol testing of each employee whose performance either contributed to the accident or cannot be completely discounted as a contributing factor to the accident. (P-11-12) The current PHMSA regulations require alcohol testing but do not explicitly require drug testing. PHMSA proposes to clarify the drug and alcohol testing requirement to specifically add the requirement to conduct drug testing of employees after an accident and require documentation of the decision not to administer an after-accident drug test if an employee(s) had no role in the accident. The NTSB believes this proposed change is responsive to the recommendation.

From: NTSB
To: PHMSA
Date: 4/8/2015
Response: We are disappointed that you still have not issued the NPRM Pipeline Safety: Operator Qualification, Cost Recovery, and Other Proposed Changes expected in 2013; however, we are encouraged that you expect to publish it later this year. We are aware that the NPRM will propose (1) requiring employee drug testing following an accident and (2) exempting from testing only those employees who clearly had no role whatsoever in the accident. We encourage you to expedite this action. Pending timely publication of a final rule that satisfies this recommendation, Safety Recommendation P-11-12 remains classified OPEN—ACCEPTABLE RESPONSE.

From: PHMSA
To: NTSB
Date: 1/22/2015
Response: -From Timothy P. Butters, Acting Administrator: PHMSA is addressing this recommendation in an NPRM titled "Pipeline Safety: Operator Qualification, Cost Recovery, and Other Proposed Changes." Through this rulemaking, PHMSA is proposing to modify § § 199.105 and 199.225 by requiring drug testing of employees and allowing exemption from drug testing only when there is sufficient information that establishes the employee(s) had no role in the accident. The NPRM is currently under agency review, and we expect to publish in 2015.

From: NTSB
To: PHMSA
Date: 1/3/2014
Response: We understand that PHMSA is drafting an NPRM, titled Pipeline Safety: Operator Qualification, Cost Recovery, and Other Proposed Changes, expected to be published in late 2013, that proposes to modify 49 CFR 199.105 and 199.225 to require employee drug testing following an accident and to allow an exemption from testing only when it can be firmly established that the employee had no role in the accident. Pending publication of a final rule, Safety Recommendation P-11-12 remains classified OPEN—ACCEPTABLE RESPONSE.

From: PHMSA
To: NTSB
Date: 8/29/2013
Response: -From Cynthia L. Quarterman, Administrator: PHMSA is addressing this recommendation in a rulemaking titled “Pipeline Safety: Operator Qualification, Cost Recovery, and Other Proposed Changes.” Through this rulemaking, PHMSA is proposing to modify 199.105 and 199.225 by requiring drug testing of employees and allowing exemption from drug testing only when there is sufficient information that establishes the employee(s) had no role in the accident. PHMSA anticipates this NPRM will be published in November 2013.

From: NTSB
To: PHMSA
Date: 4/24/2012
Response: The NTSB understands that PHMSA is reviewing its legal authority and policy with the U.S. Department of Transportation (DOT) to clarify the regulatory language identified in Title 49 CFR 199.105(b) and .225(a)(1), and that, following those discussions, PHMSA will clarify the regulations as needed. Accordingly, pending completion of this review and receipt of further information about PHMSA’s intended course of action, Safety Recommendation P-11-12 is classified OPEN—ACCEPTABLE RESPONSE.

From: PHMSA
To: NTSB
Date: 12/14/2011
Response: -From Cynthia L. Quarterman, Administrator: PHMSA is consulting within the U.S. DOT, as its broader authority and policy is relevant in this matter, and will seek to clarify the regulatory language identified in § 199.105(b) and .225(a)(1), as appropriate, following those discussions.

From: NTSB
To: PHMSA
Date: 12/7/2011
Response: Notation 8360: The National Transportation Safety Board (NTSB) has reviewed the Pipeline and Hazardous Materials Safety Administration (PHMSA) Advance Notice of Proposed Rulemaking (ANPRM), “Pipeline Safety: Safety of Gas Transmission Pipelines,” that was published in the Federal Register on August 25, 2011. PHMSA is considering whether changes to the regulations governing the safety of gas transmission pipelines are needed, and is inviting comments on 14 specific topic areas in 2 broad categories—integrity management-related requirements and nonintegrity management requirements. In the area of integrity management, PHMSA is seeking comments and information about revising the definition of high consequence areas (HCA), including more prescriptive language, and placing additional restrictions on the use of specific pipeline assessment methods. In the nonintegrity management area, PHMSA is seeking information and comments about strengthening or expanding requirements for the spacing of mainline valves; installation of remotely operated or automatically operated valves; and corrosion control of steel pipelines, gas gathering lines, and underground gas storage facilities. The NTSB believes that the regulations for gas transmission pipelines can and should be improved and supports the overall intent of the ANPRM. However, the publication of the ANPRM 5 days before the NTSB public meeting on the Pacific Gas and Electric Company (PG&E) natural gas transmission pipeline rupture in San Bruno, California, precluded any mention in the ANPRM of the safety recommendations the NTSB adopted at the public meeting held on August 30, 2011, and issued on September 26, 2011. As a result of the Board Meeting, the NTSB issued 13 safety recommendations (P-11-8 through P-11-20) to PHMSA to improve the safety of natural gas transmission pipelines. The NTSB believes PHMSA should seek comments and information related to its safety recommendations to PHMSA issued as a result of the San Bruno investigation to take certain regulatory actions. In the ANPRM, PHMSA is also seeking information that would be relevant to Safety Recommendation P-93-9 the NTSB issued as a result of its accident investigation of an explosion and fire of a natural gas pipeline from a salt dome storage cavern in Brenham, Texas, on April 7, 1992. The accident resulted in 3 fatalities and 21 injuries. Safety Recommendation P-93-9 was classified “Closed—Unacceptable Action” on July 27, 1998, after a rulemaking proceeding to regulate underground gas storage was terminated in 1997. The NTSB supports PHMSA’s intention to reconsider regulating underground gas storage and is pleased PHMSA is revisiting this issue by seeking information and comment in this ANPRM. In support of our position, the NTSB is providing the following table listing the NTSB’s responses (that is, previously issued safety recommendations) to certain specific questions posed by PHMSA in the ANPRM: PHMSA’s ANPRM Questions NTSB’s Responses (Safety Recommendations) K.1. Should PHMSA develop Federal standards governing the safety of underground gas storage facilities? If so, should they be voluntary? If so, what portions of the facilities should be addressed in these standards? Develop safety requirements for storage of highly volatile liquids and natural gas in underground facilities, including a requirement that all pipeline operators perform safety analyses of new and existing underground geologic storage systems to identify potential failures, determine the likelihood that each failure will occur, and assess the feasibility of reducing the risk; require that operators incorporate all feasible improvements. (P-93-9) K.6. What standards are used for emergency shutdowns, emergency shutdown stations, gas monitors, local emergency response communications, public communications, and O&M Procedures? Require operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines to provide system-specific information about their pipeline systems to the emergency response agencies of the communities and jurisdictions in which those pipelines are located. This information should include pipe diameter, operating pressure, product transported, and potential impact radius. (P-11-8) L.1. Are there standards used by the pipeline industry to guide management processes including management of change? Do standards governing the management of change process include requirements for IM procedures, O&M manuals, facility drawings, emergency response plans and procedures, and documents required to be maintained for the life of the pipeline? Require operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines to ensure that their control room operators immediately and directly notify the 911 emergency call center(s) for the communities and jurisdictions in which those pipelines are located when a possible rupture of any pipeline is indicated. (P-11-9) PHMSA’s ANPRM Questions NTSB’s Responses (Safety Recommendations) B.4. What measures, if any, should operators be required explicitly to implement? Should they apply to all HCAs, or is there some reasonable basis for tailoring explicit mandates to particular HCAs? Should additional preventative and mitigative measures include any or all of the following: Additional line markers (line-of-sight); depth of cover surveys; close interval surveys for cathodic protection (CP) verification; coating surveys and recoating to help maintain CP current to pipe; additional right-of-way patrols; shorter ILI run intervals; additional gas quality monitoring, sampling, and in-line inspection tool runs; and improved standards for marking pipelines for operator construction and maintenance and one-calls? Require that all operators of natural gas transmission and distribution pipelines equip their supervisory control and data acquisition systems with tools to assist in recognizing and pinpointing the location of leaks, including line breaks; such tools could include a real-time leak detection system and appropriately spaced flow and pressure transmitters along covered transmission lines. (P-11-10) Amend Title 49 Code of Federal Regulations 192.935(c) to directly require that automatic shutoff valves or remote control valves in high consequence areas and in class 3 and 4 locations be installed and spaced at intervals that consider the factors listed in that regulation. (P-11-11) M.4. Are there any standards that exist that PHMSA could adopt or from which PHMSA could adapt concepts for Quality Management System (QMS)? Amend Title 49 Code of Federal Regulations 199.105 and 49 Code of Federal Regulations 199.225 to eliminate operator discretion with regard to testing of covered employees. The revised language should require drug and alcohol testing of each employee whose performance either contributed to the accident or cannot be completely discounted as a contributing factor to the accident. (P-11-12) Issue immediate guidance clarifying the need to conduct postaccident drug and alcohol testing of all potentially involved personnel despite uncertainty about the circumstances of the accident. (P-11-13) N.2. Should PHMSA repeal the MAOP exemption for pre-1970 pipelines? Should pre-1970 pipelines that operate above 72% SMYS be allowed to continue to be operated at these levels without increased safety evaluations such as periodic pressure tests, in-line inspections, coating examination, CP surveys, and expanded requirements on interference currents and depth of cover maintenance? N.3. Should PHMSA take any other actions with respect to exempt pipelines? Amend Title 49 Code of Federal Regulations 192.619 to delete the grandfather clause and require that all gas transmission pipelines constructed before 1970 be subjected to a hydrostatic pressure test that incorporates a spike test. (P-11-14) G.9. Should a one-time pressure test be required to address manufacturing and construction defects? Amend Title 49 Code of Federal Regulations Part 192 of the Federal pipeline safety regulations so that manufacturing- and construction-related defects can only be considered stable if a gas pipeline has been subjected to a postconstruction hydrostatic pressure test of at least 1.25 times the maximum allowable operating pressure. (P-11-15) PHMSA’s ANPRM Questions NTSB’s Responses (Safety Recommendations) C.7. Should PHMSA adopt standards for conducting in-line inspections using ‘‘smart pigs,’’ the qualification of persons interpreting in-line inspection data, the review of ILI results including the integration of other data sources in interpreting ILI results, and/or the quality and accuracy of in-line inspection tool performance, to gain a greater level of assurance that injurious pipeline defects are discovered? Should these standards be voluntary or adopted as requirements? Require that all natural gas transmission pipelines be configured so as to accommodate in-line inspection tools, with priority given to older pipelines. (P-11-17) B.3. Are any additional prescriptive requirements needed to improve selection and implementation decisions? If so, what are they and why? Revise your integrity management inspection protocol to (1) incorporate a review of meaningful metrics; (2) require auditors to verify that the operator has a procedure in place for ensuring the completeness and accuracy of underlying information; (3) require auditors to review all integrity management performance measures reported to the Pipeline and Hazardous Materials Safety Administration and compare the leak, failure, and incident measures to the operator’s risk model; and (4) require setting performance goals for pipeline operators at each audit and follow up on those goals at subsequent audits. (P-11-18) (1) Develop and implement standards for integrity management and other performance-based safety programs that require operators of all types of pipeline systems to regularly assess the effectiveness of their programs using clear and meaningful metrics, and to identify and then correct deficiencies; and (2) make those metrics available in a centralized database. (P-11-19) A.7. What, if any, input and/or oversight should the general public and/or local communities provide in the identification of HCAs? If commenters believe that the public or local communities should provide input and/or oversight, how should PHMSA gather information and interface with these entities? If commenters believe that the public or local communities should provide input and/or oversight, what type of information should be provided and should it be voluntary to do so? If commenters believe that the public or local communities should provide input, what would be the burden entailed in providing provide this information? Should state and local governments should be involved in the HCA identification and oversight process? If commenters believe that state and local governments be involved in the HCA identification and oversight process what would the nature of this involvement be? Work with state public utility commissions to (1) implement oversight programs that employ meaningful metrics to assess the effectiveness of their oversight programs and make those metrics available in a centralized database, and (2) identify and then correct deficiencies in those programs. (P-11-20) The NTSB appreciates the opportunity to comment on this ANPRM. Should you require additional information or clarification, please contact us.