Tag: NTSB

Second mate of tug Nathan E. Stewart asleep on watch when it grounded off Bella Bella: NTSB

The second mate of the tug Nathan E. Stewart fell asleep on watch when the tug grounded off Bella Bella, on October 13, 2016, according to an investigation report released by the United States  National Transportation Safety Board.

The NTSB also  said “Contributing to the grounding was the ineffective implementation of the company’s safety management system procedures for watchstanding.”

Both the NTSB and the Canadian Transportation Safety Board investigated the grounding. The tug was American owned and crewed while the accident happened in Canadian waters. The TSB investigation on the incident is continuing and no report has been released. 

The Nathan E. Stewart was pushing, not towing the barge, as the NTSB report notes:

The JAK system the tug used to push the barge (NTSB)

The tugboat Nathan E Stewart and the tank barge DBL 55 were connected through the JAK coupling system.1 Controlled from a panel on the tugboat’s bridge, this system uses a 16-inch-diameter, high-strength steel pin pneumatically actuated on each side of the vessel’s bow to lock the vessel into a fitted socket plate welded to each side of the barge’s inner notch. The plates have multiple sockets that run vertically, which allows the tugboat to position itself within the notch to accommodate changing barge drafts as well as to prevent, or minimize, the horizontal movement between the two units.

The NTSB says the grounding of the tug caused about  $12 million US in estimated damage to the tug itself and the barge it was pushing.

The Nathan E. Stewart and barge on the rocks (RCMP/TSB)

The Nathan E Stewart spilled 29,000 gallons of fuel and lube oil, released into the ocean off Edge Reef, off Athlone Island in Seaforth Channel in the traditional territory of the Heiltsuk Nation.

Although no petroleum products were released from the empty fuel barge, a subsequent marine survey found that post accident survey of the DBL 55 found that the barge’s external double hull was significantly damaged from its bow completely aft to the skegs on the stern. There were multiple areas where the hull plating had been inset and penetrated. Some of the framing also had been damaged, but none of the inner steel plating comprising the bottom, sides,or top of the cargo tanks had been breached. The JAK socket plates on the inside of the barge’s notch showed slight damage,with the second recess(fromthe bottom up) on both socket plates indicating scarring and heavy contact. Repair costs for the barge were estimated at $5.6 million.

Prior to thegrounding, all the vessel’s vital systems were functional, and there were noindications of a mechanical failure thatmay haveled to the accident.

The NTSB says the tug was on autopilot when the second mate fall sleep on watch and it missed course correction near Ivory Island. The tug had a computerized electronic chart system (ECS) on board that should have sounded an alarm when the way point for the course correction was missed, but the mate told the NTSB,  the tug was not using that navigation tool on the night of the accident. According to the second mate, it was
normal practice for the navigation team to not utilize that tool.

The NTSB report says had the ECS  been utilized, the ECS would
have entered into an alarm mode after the second mate missed the port course change required near Ivory Island. Based on time, speed, and distance calculations, the alarm would have activated at approximately 0055 and thereby provided ample time for the second mate to take
corrective action to return the Nathan E Stewart to the intended track.

Download the complete NTSB report:
 NTSB report MAB1738 NathanStewart (pdf)

A lesson for BC: Michigan 911 system failed during the Kalamazoo spill, NTSB says

The 911 system failed during the 2010 Marshall, Michigan, Enbridge pipeline breach, according to the full report in the incident released by the US National Transportation Safety Board.

The NTSB report says the 911 operators in Michigan dismissed eight calls reporting gas or petroleum odours over a period of 14 hours between the initial report of a bad odour and the actual discovery of diluted bitumen polluting Talmadge Creek.

The report also says the local firefighters were unfamiliar at that point with potential problems from a bitumen pipeline as opposed to a leak of a consumer natural gas pipeline.

Although the NTSB report puts most of the onus on an inadequate Enbridge “Public Awareness Program” (PAP) which failed to familiarize first responders to potential problems, the report raises questions whether British Columbia, especially the north, is properly prepared for all the energy development that is occurring. Whether or not the Enbridge Northern Gateway project proceeds, there are three active and possibly as many as three or four planned liquified natural gas projects for the northwest, ongoing exploration and production in the northeast and the proposed Kinder Morgan expansion in the lower mainland.

The NTSB says that Sunday, July 25, 2010, at 5:58 pm. EDT, a segment of a 30 inch (7.62 cm) diameter pipeline (Line 6B) operated by Enbridge ruptured in a wetland in Marshall, Michigan. The rupture occurred during the last stages of a pipeline shutdown planned by Enbridge. The leak was not discovered or addressed for over 17 hours, largely due to problems in the Enbridge control room in Edmonton.

During the time lapse, the NTSB says, Enbridge twice pumped additional oil (81 percent of the total release) into Line 6B during two pipeline start ups; the total release was estimated to be 843,444 gallons or 3.192 million litres of crude oil. The oil saturated the surrounding wetlands and flowed into the Talmadge Creek and the Kalamazoo River.

According to the NTSB time line, at 8:56 pm., Michigan Gas Utilities dispatched a senior service technician after residents reported a natural gas odour. At 9:25 pm. on July 25, a local resident called the Calhoun County 911 dispatch:

I was just at the airport in Marshall and drove south on Old 27 [17 Mile Road]
and drove back north again and there’s a very, very, very strong odour, either
natural gas or maybe crude oil or something, and because the wind’s coming out
of the north, you can smell it all the way up to the tanks, right across from where
the airport’s at, and then you can’t smell it anymore.

By 9:32 pm., the Marshall City Fire Department had been dispatched in response to the 9:25 pm. call to 911. The 911 dispatcher told the responders there was a report of a bad smell of natural gas near the airport. The responding firefighters were also dispatched. The firefighters checked pipelines and industrial building near the airport. “using a combustible gas indicator” to try to locate the origin of the odour, but did not detect anything.

NTSB map of first responders at Kalamazoo spill
A map from the NTSB report showing where the fire department responded to the reports of a gas smell at Marshall, MIchigan, and the location of the actual pipeline break. (NTSB)

The NTSB says the service technician from Michigan Gas Utilities “crossed paths with some of the fire department personnel” but found no evidence of a gas leak.

The fire department personnel departed the scene at 10:54 pm. to return to the station.

The NTSB report says: “ a combustible gas indicator measures percentage of the lower explosive limit, it likely would not detect the oil unless it was very close to the source.”

At 11:33 pm, the area’s 911 system received the first of the seven additional calls when an employee at a business called to report a natural gas odour.

The 911 dispatcher told the caller that the fire department had already responded
to calls in the area, and no more personnel were dispatched.

A map of the incident response by the NTSB shows that the area near the airport where the firefighters responded was actually some distance from the pipeline rupture.

Over the next 14 hours, the NTSB says, 911 received seven more calls reporting strong natural gas or petroleum odours in the same vicinity. “The 911 dispatcher repeatedly informed the callers that the fire department had been dispatched to investigate the reported odours.”

Enbridge had been working on restarting the pipeline all night. In Edmonton, at 10:16 am, the Enbridge control room spoke to the regional manager based in Chicago to send someone to
walk along the pipeline, upstream and downstream of the Marshall pumping station.

According to the NTSB, the Chicago regional manager replied, “I wouldn’t think so. If it’s right at Marshall—you know, it seems like there’s something else going wrong either with the computer or with the instrumentation. …you lost column and things go haywire, right?” He went on to say, “…I’m not convinced. We haven’t had any phone calls. I mean it’s perfect weather out here—if it’s a rupture someone’s going to notice that, you know and smell it.” The Chicago regional manager told shift lead C1 that he was okay with the control centre starting Line 6B again.

At 11:17 am, a caller from a second gas utility, Consumers Energy, called the Enbridge emergency line telling the control room: “I work for Consumers Energy[30] and I’m in Marshall. There’s oil getting into the creek and I believe it’s from your pipeline. I mean there’s a lot. We’re getting like 20 gas leak calls and everything.”

At 11:18 am Enbridge closed the remote valves sealing off the rupture site within a 2.95-mile section. By 11:20 am., the shift lead had called the Chicago regional manager to tell him about the notification. By 11:37 am., another Consumers Energy employee notified 911 about the crude oil leak in a creek near Division Drive.

The Fredonia Township Fire Department was dispatched by the 911 centre shortly after the call. At 11:41 am., the Edmonton control centre received confirmation from an Enbridge crossing coordinator located at the Marshall pipeline maintenance shop confirming the oil on the ground.

The NTSB says:

The 911 operators repeatedly informed the callers that the fire department had been dispatched to investigate the issue, but the 911 operators did not contact the pipeline operator or advise the public of health and safety risks. The 911 operators never dispatched the fire department in response to the subsequent calls even though these calls occurred over several hours, indicating an ongoing problem. The actions of both the first responders and the 911 operators are consistent with a phenomenon known as confirmation bias,128 in which decision makers search for evidence consistent with their theories or decisions, while discounting contradictory evidence. Although there was evidence available to the first responders that something other than natural gas was causing noticeable odours in the Marshall area, they discounted that evidence, largely because it contradicted their own findings of no natural gas in the area. Similarly, the 911 operators, with the evidence from the first responders of no natural gas in the area, discounted subsequent calls regarding the strong odours in the Marshall area. Those calls were inconsistent with their own views that the problem causing the odours was either nonexistent or had been resolved.

The NTSB report then says:

Although Enbridge had provided training to emergency responders in the Marshall area in February 2010, the firefighters’ actions showed a lack of awareness of the nearby crude oil pipeline: they did not search along the Line 6B right-of-way, and they did not call Enbridge. The NTSB concludes that had the firefighters discovered the ruptured segment of Line 6B and called Enbridge, the two start ups of the pipeline might not have occurred and the additional volume might not have been pumped.

The NTSB reviewed Enbridge’s PAP, which was intended to inform the affected public,
emergency officials, and public officials about pipelines and facilitate their ability to recognize
and respond to a pipeline rupture.

The report says:

Although RP 1162 requires operators to communicate with audiences every 1 to 3 years, Enbridge mailed its public awareness materials to all audiences annually. However, even with more frequent mailings, this accident showed that emergency officials and the public lacked actionable knowledge.

The NTSB goes on to say:

Public knowledge of pipeline locations and the hazards associated with the materials
transported is critical for successful recognition and reporting of releases, as well as the safe response to pipeline ruptures. The transportation of hazardous materials by pipeline is unlike hazardous materials transportation by railroad or highway because a pipeline is a permanent fixture. A pipeline presents a unique challenge to awareness because it is often buried. When pipeline releases occur, a properly educated public can be the first to recognize and report the emergency.

A survey quoted by the NTSB says that of those who responded in the United States. only 23 percent of the affected public and 47 percent of emergency officials responded that they were “very well informed” about pipelines in their community.

The NTSB says Enbridge failed to properly conduct and monitor its public awareness program and management’s “review of its PAP was ineffective in identifying and correcting deficiencies. The NTSB further concludes that had Enbridge operated an effective PAP, local emergency response agencies would have been better prepared to respond to early indications of the rupture and may have been able to locate the crude oil and notify Enbridge before control centre staff tried to start the line.”

In May 2011, Enbridge revised its public awareness plan and created a public awareness
committee, but just months later, in July 2011, the US Pipeline and Hazardous Materials Safety Administration conducted an audit of Enbridge’s plans and identified several
deficiencies in the company’s program evaluation and effectiveness reviews and required that
Enbridge correct the deficiencies.

Overall, the report says:

Although Enbridge and PHMSA have taken these actions, the NTSB is concerned that
pipeline operators do not provide emergency officials with specific information about their pipeline systems. The brochures that Enbridge mailed did not identify its pipeline’s location. Instead, the brochures directed the audiences to pipeline markers and to PHMSA’s National Pipeline Mapping System. In the NTSB’s 2011 report of the natural gas transmission pipeline rupture and fire in San Bruno, California, the NTSB made the following safety recommendation to PHMSA:

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.

The report concludes:

The NTSB recommends that the International Association of Fire Chiefs  and the National Emergency Number Association  inform their members about the circumstances of the Marshall, Michigan, pipeline accident and urge their members to aggressively and diligently gather from pipeline operators system-specific information about the pipeline systems in their communities and jurisdictions.

In Canada, the National Energy Board, which is responsible for overseeing pipeline operations did inspect the Enbridge control room after the NTSB report.

The NEB, of course, has nothing to do with the 911 system.

RCMP North District
RCMP map showing the extent of British Columbia’s “North District.” (RCMP)

One question for northern British Columbia is how prepared is the 911 system to handle a major pipeline incident now or in the future. For police and fire, the RCMP communications system must cover all of “North District” from Prince George. (The RCMP did not return a phone call requesting information on 911 training and procedures)

For BC Ambulance the dispatch centre is in Kamloops.

Fire departments in northwest British Columbia, so far, have had minimal training in potential pipeline problems, like the fire department in Michigan, enough to detect and deal with consumer and local industrial natural gas systems. It’s clear that the province of British Columbia, if it is going to promote liquified natural gas as a foundation of a new provincial economy, it must plan and budget for a major upgrade to the 911 system, with a new police, fire and ambulance dispatch centre.

 

 

 

 

 

Enbridge responds to NTSB criticism in e-mail to northwest BC “community leaders”

Enbridge Northern Gateway has issued a detailed reply to the criticism of its operations contained in a preliminary report from the US National Transportation Safety Board to the 2010 oil spill at Marshall, Michigan, which called the company’s response like the silent movie era “Keystone cops.”

The note from Michele Parrett,  Senior Manager, Community and Municipal Relations for Northern Gateway was sent to members of the District of Kitimat Council and presumably other politicians and community leaders along the proposed pipeline route.

The document was among those routinely released to the public at the regular council meeting on Monday, July 16, 2012 and is a much more detailed defence of Enbridge’s position than the news release issued after the NTSB report.

In the e-mail, Enbridge says it has updated its safety and response procedures and its corporate culture since the Michigan incident.

Despite widespread criticism of Enbridge from all sides of the political spectrum, that NTSB report does not seem to have had any impact on federal Environment Minister Peter Kent, who told The Canadian Press had had not yet read the NTSB report. Kent also said that unread report will not change the Conservative government’s mind about the Northern Gateway pipeline project, adding “Pipelines are still, by far, the safest way to transport petrochemicals in any form.”

 

 Overview of NTSB Report  into Line 6B  incident at Marshall, Michigan

July 12, 2012

Dear Community Leader,

I’m writing you today to provide information regarding the United States’ National Transportation Safety Board’s (NTSB) release of its conclusions and recommendations yesterday, with regard to the Enbridge pipeline leak in Marshall, Michigan in July 2010.

Enbridge has not been waiting for the NTSB’s report before furthering to improve our safety standards. Since the incident we have undertaken our own internal investigation and incorporated the findings of that investigation into new practices and processes to improve our safety and reliability.

Enbridge and Enbridge Energy Partners has been working with the NTSB and other regulators throughout the course of the investigation so that we can take the necessary steps to prevent such an accident from occurring again. We are now reviewing the NTSB reports in detail to determine whether any further changes are required.

Enbridge has already implemented, in 2010 and 2011, appropriate operational and procedural changes based on its own detailed internal investigation. Enbridge’s overarching objective and business priority is to ensure the safety and reliability of our delivery systems for the people who live and work near our pipeline systems across North America, our employees and our customers.

In direct response to the Marshall accident, or as part of our ongoing improvement initiatives and activities, Enbridge has taken the following steps:

Pipeline and Facility Integrity

· Further heightened the importance of our pipeline and facility integrity program.

· Re-organized the functional areas that are responsible for pipeline and facility integrity.

· Substantially increased capital and operating budgets associated with maintenance and integrity programs.

· Undertook hundreds of internal inspections and thousands of investigative digs.

· Placed a renewed emphasis on the safety of our overall system.

Leak Detection

· Established the Pipeline Control Systems and Leak Detection department, doubling the number of employees and contractors dedicated to leak detection and pipeline control.

· Enhanced procedures for leak detection analysis.

· Updated control room management procedures.

· Implemented a Leak Detection Instrumentation Improvement Program to add and upgrade instrumentation across our system.

Pipeline Control and Control Centre Operations (CCO)

· Developed a Control Room Management (CRM) plan based on the U.S. Code of Federal Regulations and implemented a number of the sections, October 1, 2011, remaining sections implemented by August 1, 2012.

· Revised and enhanced all procedures pertaining to decision making, handling pipeline start-ups and shutdowns, leak detection system alarms, communication protocols, and suspected column separations.

· Changed organizational structures to better align, focus and manage employees’ span of control and workloads.

· Augmented CCO (Control Centre Operations) staff, adding training, engineering and operator positions.

· We also completed the design and construction of a new, world-class CCO in Edmonton, Alberta which was underway at the time of the accident.

Public Awareness

· Reviewed and strengthened Public Awareness Programs in the U.S. and Canada.

· Developing an industry-leading online and in-person training tool to provide Enbridge-specific information to emergency responders.

· In the U.S, we:

o Formalized the U.S. Public Awareness Committee.

o Improved the Program Effectiveness Evaluation process.

o Provided annual employee training for field employees across the company’s U.S. operations.

o Created a Public Awareness Hotline.

· In Canada, we:

o Formalized the Canadian Public Awareness Committee.

o Are creating a Canadian Public Awareness Database.

o Improved the landowner/tenant database.

o Developed a landowner newsletter.

o Established Community Relations positions in each region.

Emergency Response

· $50 million spent between 2012 and 2013 (projected) to improve our equipment, training and capabilities.

· Develop better tools for waterborne spills.

· In 2011, a cross-business unit response team was created for large-scale events requiring more resources that a single region could provide.

· In 2011, created a dedicated Emergency Response group in Operation Services for increased regional support.

· Conducting an Emergency Response preparedness assessment to enhance abilities to more rapidly respond and contain a significant release.

Safety Culture

· Reinforced a high level of safety and operational integrity across Enbridge in integrity management, third-party damage avoidance and detection, leak detection, incident response capacity, worker and contractor occupational safety, public safety and environmental protection.

· Implemented “Lifesaving Rules” and training for all Enbridge employees and contractors. The Lifesaving Rules are applicable to all employees and contractors, and are communicated, clarified and reinforced across all business units at Enbridge.

· Introduced new Safety Culture training sessions for all employees.

Over the past two years we have made significant improvements in the above areas. The NTSB’s findings will provide us with regulatory guidance and important information to help improve our performance and achieve our goal of zero spills.

We remain committed to a respectful, open and transparent review and discussion of the Northern Gateway Project. Should you have any questions, please do not hesitate to contact me or a member of the Northern Gateway team at the information provided below.

Sincerely,

Michele Perret

Senior Manager, Community and Municipal Relations

Enbridge Northern Gateway Pipelines

US National Transportation Safety Board summary report on Marshall, MI, Enbridge oil spill incident blames deficient management and training

The United States National Transportation Safety Board has issued a summary report on the rupture of the the Enbridge pipeline and subsequent oil spill at Marshall, Michigan, in 2010.

The report says that the probable cause of the oil spill  included deficient integrity management at Enbridge, which allowed previously known crack defects in corroded areas to spread until the pipeline failed; inadequate training of control center personnel by Enbridge, which allowed the rupture to remain undetected for 17 hours and insufficient public awareness and education, which allowed the release to continue for nearly 14 hours after the first notification of an odor to local emergency response agencies.

The full NTSB report will be issued in the coming weeks.

Enbridge responded in a news release that quoted outgoing Enbridge CEO Pat Daniel, who was in Washington for the release of the report:

“We very much appreciate the patience of residents in the communities who were affected by the Line 6B release,” said Patrick D. Daniel, Chief Executive Officer, Enbridge Inc. “Under the direction of the U.S. Environmental Protection Agency and local health authorities, the Kalamazoo River was re-opened last month for recreational use. We are also pleased to note that wildlife has returned to the area.”

“We believe that the experienced personnel involved in the decisions made at the time of the release were trying to do the right thing. As with most such incidents, a series of unfortunate events and circumstances resulted in an outcome no one wanted,” said Mr. Daniel.

Skeena Bulkley Valley Member of Parliament and NDP House Leader, Nathan Cullen, issued his own news release, saying, “Today’s report by the US National Transportation Safety Board (NTSB) into the deadly July 2010 Enbridge spill in Michigan identifies ‘a complete breakdown of safety at Enbridge’ and notes the company knowingly ‘failed to accurately assess the structural integrity of the pipeline.'”

“The findings are actually worse than we feared,” Cullen said. “They are a body blow of breathtaking proportions to Enbridge and yet another wake-up call to the Northwest of the dangers of allowing big oil to run a pipeline through our Northwest watersheds.”

Cullen commended NTSB chair Deborah Hersman for her frankness in terming Enbridge’s Michigan spill “”an accident that is a wake-up call to the industry, the regulator, and the public.”

Here is the complete summary as posted on the NTSB website

Enbridge, Inc. Hazardous Liquid Pipeline Rupture

July 25, 2010
Marshall, MI

NATIONAL TRANSPORTATION SAFETY BOARD
Public Meeting of July 10, 2012
(Information subject to editing)
NTSB/PAR-12/01

This is a synopsis from the National Transportation Safety Board’s report and does not include the NTSB’s rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.

Executive Summary

On Sunday, July 25, 2010, at 5:58 p.m., eastern daylight time, a segment of a 30-inch-diameter pipeline (Line 6B), owned and operated by Enbridge Incorporated (Enbridge) ruptured in a wetland in Marshall, Michigan. The rupture occurred during the last stages of a planned shutdown and was not discovered or addressed for over 17 hours. During the time lapse, Enbridge twice pumped additional oil (81 percent of the total release) into Line 6B during two startups; the total release was estimated to be 843,444 gallons of crude oil. The oil saturated the surrounding wetlands and flowed into the Talmadge Creek and the Kalamazoo River. Local residents self-evacuated from their houses, and the environment was negatively affected. Cleanup efforts continue as of the adoption date of this report, with continuing costs exceeding $767 million. About 320 people reported symptoms consistent with crude oil exposure. No fatalities were reported.

Conclusions

1. The following were not factors in this accident: cathodic protection, microbial corrosion, internal corrosion, transportation-induced metal fatigue, third-party damage, and pipe manufacturing defects.

2. Insufficient information was available from the postaccident alcohol testing; however, the postaccident drug testing showed that use of illegal drugs was not a factor in the accident.

3. Had the firefighters discovered the ruptured segment of Line 6B and called Enbridge, the two startups of the pipeline might not have occurred and the additional volume might not have been pumped.

4. The Line 6B segment ruptured under normal operating pressure due to corrosion fatigue cracks that grew and coalesced from multiple stress corrosion cracks, which had initiated in areas of external of corrosion beneath the disbonded polyethylene tape coating.

5. Title 49 Code of Federal Regulations 195.452(h) does not provide clear requirements regarding when to repair and when to remediate pipeline defects and inadequately defines the requirements for assessing the effect on pipeline integrity when either crack defects or cracks and corrosion are simultaneously present in the pipeline.

6. The Pipeline and Hazardous Materials Safety Administration (PHMSA) failed to pursue findings from previous inspections and did not require Enbridge Incorporated (Enbridge) to excavate pipe segments with injurious crack defects.

7. Enbridge’s delayed reporting of the “discovery of condition” by more than 460 days indicates that Enbridge’s interpretation of the current regulation delayed the repair of the pipeline.

8. Enbridge’s integrity management program was inadequate because it did not consider the following: a sufficient margin of safety, appropriate wall thickness, tool tolerances, use of a continuous reassessment approach to incorporate lessons learned, the effects of corrosion on crack depth sizing, and accelerated crack growth rates due to corrosion fatigue on corroded pipe with a failed coating.

9. To improve pipeline safety, a uniform and systematic approach in evaluating data for various types of in-line inspection tools is necessary to determine the effect of the interaction of various threats to a pipeline.

10. Pipeline operators should not wait until PHMSA promulgates revisions to 49 Code of Federal Regulations 195.452 before taking action to improve pipeline safety.

11. PII Pipeline Solutions’ analysis of the 2005 in-line inspection data for the Line 6B segment that ruptured mischaracterized crack defects, which resulted in Enbridge not evaluating them as crack-field defects.

12. The ineffective performance of control center staff led them to misinterpret the rupture as a column separation, which led them to attempt two subsequent startups of the line.

13. Enbridge failed to train control center staff in team performance, thereby inadequately preparing the control center staff to perform effectively as a team when effective team performance was most needed.

14. Enbridge failed to ensure that all control center staff had adequate knowledge, skills, and abilities to recognize and address pipeline leaks, and their limited exposure to meaningful leak recognition training diminished their ability to correctly identify the cause of the Material Balance System (MBS) alarms.

15. The Enbridge control center and MBS procedures for leak detection alarms and identification did not fully address the potential for leaks during shutdown and startup, and Enbridge management did not prohibit control center staff from using unapproved procedures.

16. Enbridge’s control center staff placed a greater emphasis on the MBS analyst’s flawed interpretation of the leak detection system’s alarms than it did on reliable indications of a leak, such as zero pressure, despite known limitations of the leak detection system.

17. Enbridge control center staff misinterpreted the absence of external notifications as evidence that Line 6B had not ruptured.

18. Although Enbridge had procedures that required a pipeline shutdown after 10 minutes of uncertain operational status, Enbridge control center staff had developed a culture that accepted not adhering to the procedures.

19. Enbridge’s review of its public awareness program was ineffective in identifying and correcting deficiencies.

20. Had Enbridge operated an effective public awareness program, local emergency response agencies would have been better prepared to respond to early indications of the rupture and may have been able to locate the crude oil and notify Enbridge before control center staff tried to start the line.

21. Although Enbridge quickly isolated the ruptured segment of Line 6B after receiving a telephone call about the release, Enbridge’s emergency response actions during the initial hours following the release were not sufficiently focused on source control and demonstrated a lack of awareness and training in the use of effective containment methods.

22. Had Enbridge implemented effective oil containment measures for fast-flowing waters, the amount of oil that reached Talmadge Creek and the Kalamazoo River could have been reduced.

23. PHMSA’s regulatory requirements for response capability planning do not ensure a high level of preparedness equivalent to the more stringent requirements of the U.S. Coast Guard and the U.S. Environmental Protection Agency.

24. Without specific Federal spill response preparedness standards, pipeline operators do not have response planning guidance for a worst-case discharge.

25. The Enbridge facility response plan did not identify and ensure sufficient resources were available for the response to the pipeline release in this accident.

26. If PHMSA had dedicated the resources necessary and conducted a thorough review of the Enbridge facility response plan, it would have disapproved the plan because it did not adequately provide for response to a worst-case discharge.

27. Enbridge’s failure to exercise effective oversight of pipeline integrity and control center operations, implement an effective public awareness program, and implement an adequate postaccident response were organizational failures that resulted in the accident and increased its severity.

28. Pipeline safety would be enhanced if pipeline companies implemented safety management systems.

Probable Cause

The National Transportation Safety Board (NTSB) determines that the probable cause of the pipeline rupture was corrosion fatigue cracks that grew and coalesced from crack and corrosion defects under disbonded polyethylene tape coating, producing a substantial crude oil release that went undetected by the control center for over 17 hours. The rupture and prolonged release were made possible by pervasive organizational failures at Enbridge Incorporated (Enbridge) that included the following:

  • Deficient integrity management procedures, which allowed well-documented crack defects in corroded areas to propagate until the pipeline failed.
  • Inadequate training of control center personnel, which allowed the rupture to remain undetected for 17 hours and through two startups of the pipeline.
  • Insufficient public awareness and education, which allowed the release to continue for nearly 14 hours after the first notification of an odor to local emergency response agencies.

 

Contributing to the accident was the Pipeline and Hazardous Materials Safety Administration’s (PHMSA) weak regulation for assessing and repairing crack indications, as well as PHMSA’s ineffective oversight of pipeline integrity management programs, control center procedures, and public awareness.

Contributing to the severity of the environmental consequences were (1) Enbridge’s failure to identify and ensure the availability of well-trained emergency responders with sufficient response resources, (2) PHMSA’s lack of regulatory guidance for pipeline facility response planning, and (3) PHMSA’s limited oversight of pipeline emergency preparedness that led to the approval of a deficient facility response plan.

Recommendations

To the U.S. Secretary of Transportation:

1. Audit the Pipeline and Hazardous Materials Safety Administration’s onshore pipeline facility response plan program’s business practices, including reviews of response plans and drill programs, and take appropriate action to correct deficiencies.

2. Allocate sufficient resources as necessary to ensure that the Pipeline and Hazardous Materials Safety Administration’s onshore pipeline facility response plan program meets all of the requirements of the Oil Pollution Act of 1990.

To the Pipeline and Hazardous Materials Safety Administration:

3. Revise Title 49 Code of Federal Regulations 195.452 to clearly state (1) when an engineering assessment of crack defects, including environmentally assisted cracks, must be performed; (2) the acceptable methods for performing these engineering assessments, including the assessment of cracks coinciding with corrosion with a safety factor that considers the uncertainties associated with sizing of crack defects; (3) criteria for determining when a probable crack defect in a pipeline segment must be excavated and time limits for completing those excavations; (4) pressure restriction limits for crack defects that are not excavated by the required date; and (5) acceptable methods for determining crack growth for any cracks allowed to remain in the pipe, including growth caused by fatigue, corrosion fatigue, or stress corrosion cracking as applicable.

4. Revise Title 49 Code of Federal Regulations 195.452(h)(2), the “discovery of condition,” to require, in cases where a determination about pipeline threats has not been obtained within 180 days following the date of inspection, that pipeline operators notify the Pipeline and Hazardous Materials Safety Administration and provide an expected date when adequate information will become available.

5. Conduct a comprehensive inspection of Enbridge Incorporated’s integrity management program after it is revised in accordance with Safety Recommendation (11).

6. Issue an advisory to all hazardous liquid and natural gas pipeline operators describing the circumstances of the accident in Marshall, Michigan—including the deficiencies observed in Enbridge Incorporated’s integrity management program—and ask them to take appropriate action to eliminate similar deficiencies.

7. Develop requirements for team training of control center staff involved in pipeline operations similar to those used in other transportation modes.

8. Extend operator qualification requirements in Title 49 Code of Federal Regulations 195 Subpart G to all hazardous liquid and gas transmission control center staff involved in pipeline operational decisions.

9. Amend Title 49 Code of Federal Regulations Part 194 to harmonize onshore oil pipeline response planning requirements with those of the U.S. Coast Guard and the U.S. Environmental Protection Agency for facilities that handle and transport oil and petroleum products to ensure that pipeline operators have adequate resources available to respond to worst-case discharges.

10. Issue an advisory bulletin to notify pipeline operators (1) of the circumstances of the Marshall, Michigan, pipeline accident, and (2) of the need to identify deficiencies in facility response plans and to update these plans as necessary to conform with the nonmandatory guidance for determining and evaluating required response resources as provided in Appendix A of Title 49 Code of Federal Regulations 194, “Guidelines for the Preparation of Response Plans.”

To Enbridge Incorporated:

11. Revise your integrity management program to ensure the integrity of your hazardous liquid pipelines as follows: (1) implement, as part of the excavation selection process, a safety margin that conservatively takes into account the uncertainties associated with the sizing of crack defects from in-line inspections; (2) implement procedures that apply a continuous reassessment approach to immediately incorporate any new relevant information as it becomes available and reevaluate the integrity of all pipelines within the program; (3) develop and implement a methodology that includes local corrosion wall loss in addition to the crack depth when performing engineering assessments of crack defects coincident with areas of corrosion; and (4) develop and implement a corrosion fatigue model for pipelines under cyclic loading that estimates growth rates for cracks that coincide with areas of corrosion when determining reinspection intervals.

12. Establish a program to train control center staff as teams, semiannually, in the recognition of and response to emergency and unexpected conditions that includes supervisory control and data acquisition system indications and Material Balance System software.

13. Incorporate changes to your leak detection processes to ensure that accurate leak detection coverage is maintained during transient operations, including pipeline shutdown, pipeline startup, and column separation.

14. Provide additional training to first responders to ensure that they (1) are aware of the best response practices and the potential consequences of oil releases and (2) receive practical training in the use of appropriate oil-containment and -recovery methods for all potential environmental conditions in the response zones.

15. Review and update your oil pipeline emergency response procedures and equipment resources to ensure that appropriate containment equipment and methods are available to respond to all environments and at all locations along the pipeline to minimize the spread of oil from a pipeline rupture.

16. Update your facility response plan to identify adequate resources to respond to and mitigate a worst-case discharge for all weather conditions and for all your pipeline locations before the required resubmittal in 2015.

To the American Petroleum Institute:

17. Facilitate the development of a safety management system standard specific to the pipeline industry that is similar in scope to your Recommended Practice 750, Management of Process Hazards. The development should follow established American National Standards Institute requirements for standard development.

To the Pipeline Research Council International, Inc.:

18. Conduct a review of various in-line inspection tools and technologies—including, but not limited to: tool tolerance, the probability of detection, and the probability of identification—and provide a model with detailed step-by-step procedures to pipeline operators for evaluating the effect of interacting corrosion and crack threats on the integrity of pipelines.

To the International Association of Fire Chiefs and the National Emergency Number Association:

19. Inform your members about the circumstances of the Marshall, Michigan, pipeline accident and urge your members to aggressively and diligently gather from pipeline operators system-specific information about the pipeline systems in their communities and jurisdictions.

Previous Recommendation Reiterated in this Report

To the Pipeline and Hazardous Materials Safety Administration:

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)

A live and archived webcast of the proceedings will be available at http://www.capitolconnection.net/capcon/ntsb/ntsb.htm. To report any difficulties viewing the webcast, please call 703-993-3100 and ask for webcast technical support.

The complete report will appear on ntsb.gov in several weeks.

In its response, Enbridge went on to say:

“Safety has always been core to our operations. Our intent from the beginning of this incident has been to learn from it so we can prevent it from happening again, and to also share what we have learned with other pipeline operators,” said Stephen J. Wuori, President, Liquids Pipelines, Enbridge Inc. “Enbridge and EEP conducted a detailed internal investigation of this incident in the months following the release and have made numerous enhancements to their processes, procedures and training as a result of the findings of the investigation, including in the control center. Incident prevention, detection and response have also been enhanced. We will carefully examine the findings in the NTSB report to determine whether any further adjustments are appropriate.”

Enbridge  says it has e worked closely and cooperatively with the NTSB throughout its investigation.  The company isnow reviewing the summary report and  will not comment specifically on the contents of the Final Report until it is released by the NTSB Board and analysis of the report has been completed.

US National Transportation Safety Board releases photos, documents on Enbridge Kalamzoo oil spill

NTSB staff examine ruptured pipe
US National Transportation Safety Board staff examine a ruptured pipe from the Enbridge oil spill in August, 2010. The photo was released by the NTSB May 21, 2012. (NTSB)

The United States National Transportation Safety Board today released more than 5,000 pages relating to its investigation of the 2010 of the Marshall, Michigan, Enbridge pipeline rupture and oil spill.

The NTSB release says it is adding the documents to the “public docket” on the case.

About 11:17 a.m. EDT on July 26, 2010, Enbridge Energy Partners was notified of a leak on a 30-inch diameter crude oil pipeline (Line 6B) in Marshall, Michigan. The pipeline had ruptured 17 hours earlier and spilled about a million gallons of crude oil into the immediate area resulting in extensive environmental damage to Talmadge Creek and the Kalamazoo River.

Fifty-eight photographs and 170 documents totaling more than 5000 pages are in the docket. The information being released is factual in nature and does not provide any analysis.

Additional material may be added to the docket as it becomes available. Analysis of the accident, along with conclusions and its probable cause, will be determined at a later date.

This is a document release only; no interviews will be conducted.

Documents are available at this link

More than 800,000 gallons of heavy bitumen crude spilled from the pipeine near Marshall in Calhoun County, Michigan. NTSB spokesman Peter Knudson said Monday the NTSB expects to reach a conclusion on the spill sometime this summer.

On May 10, Enbridge announced it would spend $1.6 billion to upgrade and replace portions of the pipeline through Michigan and Indiana. The broken pipeline, however, would be decontaminated and “abandoned in place.”

Report on Enbridge Kalamazoo spill delayed until fall: Michigan media

The official United States National Transportation Safety Board report on the Enbridge pipeline breach and oil spill at Kalamazoo, Michigan has been delayed to the fall, according to local media reports.

The Kalamazoo Gazette and WDIV TV say the report will be six months late.

The Associated Press, quoting the Gazette says:

The National Transportation Safety Board attributed the delay to other investigations into separate pipeline incidents.

“Our investigations look at numerous aspects that could have played a role in the accident, such as maintenance, human factors, pipeline operations, and materials,” said NTSB spokesman Peter Knudson.

“We’ll also look at the emergency response and environmental remediation efforts to assess how they were handled.”

Local Enbridge spokesman Jason Manshum said the company will be able to finish its internal investigation after the report is released. Manshum said Enbridge is working to take what it’s learned from the spill and share that knowledge.