PowerPoint Presentation · 2019-08-02 · 8/2/2019 3 Investigate –Analyze –Prevent PHMSA Accident Investigation Division • AID Objective –Establish Consistent Repeatable Process

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Investigate – Analyze – Prevent

Office of Pipeline SafetyPipeline and Hazardous Materials Safety Administration

Accident Investigation Division

August 21, 2019

TX-RRC Pipeline Safety

Conference


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


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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PHMSA’s FY2015 IT Portfolio

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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


PHMSA Regional Offices

PHMSA

Accident Investigation Division(AID)

Motto: Investigate – Analyze – Prevent

Established April 1, 2017

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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


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


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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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


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


AID contact info

–NPIC toll-free: (888) 719-9033

–[email protected]

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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)


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


November 16, 2016 - Canton, IL

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• 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



https://www.youtube.com/watch?v=8jpzsvSjRqk

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Sun Prairie, WI - July 10, 2018,



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


July 15, 2019 – Murrieta, CA

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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


April 10, 2019 – Durham, NC


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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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?


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?



November 16, 20November 16, 2017 – Amherst, SD17 – Amherst, SD

November 16, 2017 November 16, 2017– Amherst, SD

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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


December 5, 2017 – Dixon, IL

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• 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


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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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



• 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



• 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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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.


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.


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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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


QUESTIONS?

–NPIC toll-free: (888) 719-9033

–[email protected]

Documents

PowerPoint Presentation · 2019-08-02 · 8/2/2019 3 Investigate –Analyze –Prevent PHMSA Accident Investigation Division • AID Objective –Establish Consistent Repeatable Process