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8/2/2019
1
Investigate – Analyze – Prevent
Office of Pipeline SafetyPipeline and Hazardous Materials Safety Administration
Accident Investigation Division
August 21, 2019
TX-RRC Pipeline Safety
Conference
Investigate – Analyze – Prevent
Discussion Topics
• Who/What is PHMSA/AID?
• Failures We Can All Learn From
• 30-Day Report/NRC Issues
• How We Can Get Better – Preventing Failures
Investigate – Analyze – Prevent
OST
PHMSA
HMT OPS
OIG
FHWA
FRA
FAA
SLSDC
NHTSA
MARAD
FMCSA
FTA STB
Who is PHMSA?U. S. Department of Transportation (DOT)
Pipeline and Hazardous Materials Safety Administration
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Investigate – Analyze – Prevent
PHMSA’s FY2015 IT Portfolio
4
Regulated Facilities, Entities and Commodities
Gas Transmission
Pipeline
300,324 miles
1033 pipeline
operators
Gas Gathering Pipeline
17,605 miles
367 pipeline
operators
Hazardous Liquid
Pipeline
212,635 miles
514 pipeline
operators
7,864 b.o.tanks
Gas Distribution
Pipeline
Mains and Services
2,210,066
miles
1,361 pipeline
operators
Liquified Natural Gas
152 plants
223 tanks
84 operators
Pipeline Facilities by System Type – CY 2016 PDM’s data as-of 11/1/2017
Investigate – Analyze – Prevent
PHMSA Regional Offices
PHMSA
Accident Investigation Division(AID)
Motto: Investigate – Analyze – Prevent
Established April 1, 2017
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Investigate – Analyze – Prevent
PHMSA Accident Investigation Division
• AID Objective
– Establish Consistent Repeatable Process Agency-Wide
– Perform/Coordinate All Failure Investigations
– Process All NRCs and 30-Day Reports
– Improve Data Quality, Consistency, Timeliness, Analysis
Investigate – Analyze – Prevent
Failure Investigation Form (PHMSA Form 11)
– All-Encompassing Reference – Modify to your Systems/Facilities
– Help to establish consistency in your internal failure investigations
– Useful guide for data gathering, documentation
– Provides excellent input into Root Cause Failure Analysis
Investigate – Analyze – Prevent
Metallurgical Examination Protocol
– Identify primary/secondary causes of failure
– Apply/Compare characteristics to other areas of system
– Include provisions for background information, evidence preservation, chain of custody, material testing, etc.
– Recently revised (05/16/2018) – Available Upon Request
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Investigate – Analyze – Prevent
PHMSA Accident Investigation Division
• Activities
– Daily Telephonic Investigation Report (NRCs)
– Conduct On-Site Accident Investigations
– Review 30-Day Reports (Approximately 650/year)
– Conduct outreach to help advance pipeline safety
– Evaluate and identify emerging safety trends
Investigate – Analyze – Prevent
Meet AID– Director, Peter Katchmar
– Operations Supervisor, Chris Ruhl
– Investigators
- Brian Pierzina
- Julie Halliday
- Kim West
- Darren Lemmerman
- Gery Bauman
- Ashley Horton
- Wesley Matthews
- Curtis Huff
- Alvaro Rodriguez
Investigate – Analyze – Prevent
AID contact info
–NPIC toll-free: (888) 719-9033
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Investigate – Analyze – Prevent
AID Investigation CriteriaA release of product and one or more of the following:
✓ Death✓ Personal injury necessitating hospitalization✓ Property damage exceeding $500K✓ Hazardous liquid spill of 500 or more barrels✓ Fire or explosion✓Major spill into a body of water✓ Pipeline systems with recent failure history✓ Significant media attention✓ Release impacted:
- an HCA- High Population Area- Other Populated Areas- Commercially navigable waterway, or major waterbody- Unusually Sensitive Area (USA) ‐ (drinking water resource, ecological, threatened species)
Investigate – Analyze – Prevent
Emergency Response
- Many High Consequence Failures Show Ineffective Emergency Response
- The Cause of the Release isn’t always the Story
- Does the Inherent Safety of Gas result in Complacency? Bad Practices? Overconfidence?
- Would your procedures allow this?
- Use your CGIs – Isolate a Safe Distance From the Release
Investigate – Analyze – Prevent
November 16, 2016 - Canton, IL
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Investigate – Analyze – Prevent
November 16, 2016 - Canton, IL
Investigate – Analyze – Prevent
November 16, 2016 - Canton, IL
• https://www.youtube.com/watch?v=8jpzsvSjRqk
• Damage to a 1-inch PE service line due to directional drilling
• 911 Was Not Contacted Immediately
• Gas Company was On-site
• 1 Fatality - 12 Injuries
• Approximately 2-Hours until Explosion
Investigate – Analyze – Prevent
November 16, 2016 - Canton, IL
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Investigate – Analyze – Prevent
Investigate – Analyze – Prevent
Sun Prairie, WI - July 10, 2018,
Investigate – Analyze – Prevent
Investigate – Analyze – Prevent
Sun Prairie, WI - July 10, 2018
- Cable installation using HDD- Damaged 2-inch main- 1 Fatality- 1 Injury requiring overnight
hospitalization- Over $20 million in damages- One hour from damage to ignition
Investigate – Analyze – Prevent
July 15, 2019 – Murrieta, CA
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Investigate – Analyze – Prevent
July 15, 2019 – Murrieta, CA
• Installation of a ground rod for a solar array
• Residential service line was damaged
• No locates were requested
• Damaged at 10:46 am – Exploded at 12:02 pm
• One fatality
• Seven injuries requiring hospitalization
Investigate – Analyze – Prevent
April 10, 2019 – Durham, NC
Investigate – Analyze – Prevent
April 10, 2019 – Durham, NC
- Cable installation using HDD
- Damaged 2-inch main
- 2 Fatalities
- 5 Reported Injuries requiring overnight hospitalization
- Over $20 million in damages
- Approximately one hour from damage to ignition
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Investigate – Analyze – Prevent
Trenchless Technology
• Is damage frequency due to directional drilling on the increase?
• Unique characteristics increase the potential consequences of damage
– Typically congested areas/pavement
– Gas migration vs. direct to atmosphere
– Release isolation complexity increases
– Are emergency procedures adequate?
Investigate – Analyze – Prevent
Trenchless Technology
• Maintain visual verification (daylighting) of utility crossings, both on the initial bore, and the pull-back– This happens, but obviously not enough– What will it take to see improvement?
• Do pipeline operators have specific damage prevention procedures for trenchless excavation?– Evaluate excavation notices– Excavation oversight – Do you know which excavators
need more attention?– Is it practical to implement a better program?
Investigate – Analyze – Prevent
Investigate – Analyze – Prevent
November 16, 20November 16, 2017 – Amherst, SD17 – Amherst, SD
November 16, 2017 November 16, 2017– Amherst, SD
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Investigate – Analyze – Prevent
Investigate – Analyze – Prevent
Investigate – Analyze – Prevent
November 16, 2017 – Amherst, SD
• Mechanical Damage from Original Construction
• Rupture of a 30-inch diameter crude oil pipeline
• No injuries or fatalities
• Estimated 6592 bbls released
• $44 million total costs
Investigate – Analyze – Prevent
December 5, 2017 – Dixon, IL
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Investigate – Analyze – Prevent
December 5, 2017 – Dixon, IL
Investigate – Analyze – Prevent
December 5, 2017 – Dixon, IL
• Excavation Damage During Installation of Agricultural Drain Tile
• Ruptured a 20-inch diameter natural gas transmission line
• 2 Fatalities, 2 Injuries
• Notice of Excavation Was Not Provided
• Excavators Frequently Provided Notice – But not this time
Investigate – Analyze – Prevent
Written (30-Day) Reports
• Approximately 650 per year – Twice as many Hazardous Liquid
• Gas Transmission & Gas Distribution roughly about the same number of each
• Process is Most Likely Different than Pre-AID– Review is almost Real-Time Basis
– Provide more Immediate Feedback
– Identify/Discuss Errors and Inconsistencies when they’re Fresh in our Minds
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Investigate – Analyze – Prevent
Common 30-Day Report Issues
• A-4 Local Time and Date of Incident/Accident
– Nothing to with NRCs or Confirmation
– Determined as a result of your overall investigation
– Does not start a one-hour clock for NRC report
• Reported Injuries
– Requires in-patient overnight hospitalization
– HIPPA regulations make confirmation difficult
Investigate – Analyze – Prevent
Common 30-Day Report Issues
• Pipeline/Facility Shutdown Due to Failure
– Doesn’t mean due to discovery of the failure
– Answering No requires an explanation
– Pipeline not running at time of discovery isn’t an adequate explanation
• Other Chronological Questions
– Operator Identified = first initial awareness
– The first thing that initiates your response
Investigate – Analyze – Prevent
Common 30-Day Report Issues
• Other– Provided as an option throughout the Form
– Should only be used rarely
– Selections are available most common elements
– Use Narrative Description for explanations
• Costs– Include all costs – damages, personnel time,
equipment, materials, etc.
– Don’t report zero just because they’re not Final
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Investigate – Analyze – Prevent
NRC Issues• New Requirement as of 1/1/2018:• 48 Hour report – 191.5(c) - (c) Within 48 hours after the
confirmed discovery of an incident, to the extent practicable, an operator must revise or confirm its initial telephonic notice required in paragraph (b) of this section with an estimate of
• the amount of product released, • an estimate of the number of fatalities and injuries, • and all other significant facts that are known by the
operator that are relevant to the cause of the incident • or extent of the damages. • If there are no changes or revisions to the initial report, the
operator must confirm the estimates in its initial report.
Investigate – Analyze – Prevent
NRC Issues
• Avoid a Potential Compliance Issue for Late NRC Notification– Establish written procedures for performing the
cost and volume estimates when a release is discovered
– Train those responsible for performing them, so they’re performed consistently
– Monitor through the response and repair
– Avoid “underestimating” the magnitude of an event to prevent reporting.
Investigate – Analyze – Prevent
Latent Cause Analysis
• Recently received training on this topic– What is it about the way we are that contributed to
the failure?
– What is it about the way I am that contributed to the failure?
• Application to Excavation Damage, Incorrect Operations & Integrity Management failures– Would be particularly insightful
– Requires commitment and involvement from all stakeholders
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Investigate – Analyze – Prevent
Latent Cause Analysis
• Excavation Damages Have Typically Been the Blame Game
– That approach misses opportunities to learn valuable lessons
– Every single instance of excavation damage is a story that should be told differently
– Two sides to every story
Investigate – Analyze – Prevent
QUESTIONS?
–NPIC toll-free: (888) 719-9033