CI Boom 2007

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Critical Infrastructure disasters 2007
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Critical Infrastructure Disasters 2007

News etc. digested by Alister William Macintyre This document (CI Boom 2007) lists info about a variety of critical infrastructure disasters, which were formerly included in a larger research document. I decided to split the disaster time line into smaller, digestible documents, keeping my notes on what more could be done to mitigate such disasters in the main related document.1 Last updated 2014 Feb 02
Version 1.42
Table of Contents, thru level 3 Summary ..................................................................................................................... 1 Notable CI disasters 2007 ................................................................................................... 2 2007 Spain .................................................................................................................. 5 2007 May 01 NTSB report on Bergenfield NJ PSE&G ................................................. 5 NTSB examines PSE&G pipe .................................................................................... 6 American Tank Procedures and Training ................................................................... 7 PSE&G Standards....................................................................................................... 8 Relevant Government Standards................................................................................. 8 NJ Board of Public Utilities........................................................................................ 8 U.S. Occupational Safety and Health Administration ................................................ 9 Federal Pipeline Safety Requirements ........................................................................ 9 Industry Guidance..................................................................................................... 10 Excess Flow Valves .................................................................................................. 10 Bergenfield Fire Department Procedures and Training ............................................ 11 NTSB Recommendations.......................................................................................... 12 2007 Jun 14 Kingman KS NTSB report ....................................................................... 13 Enterprise pipeline integrity standards...................................................................... 15 Enterprise procedures for abnormal conditions ........................................................ 15 Enterprise post accident procedural repairs .............................................................. 18 NTSB Recommendations.......................................................................................... 19 2007 July 17 Baltimore Md ................................................................................... 20 2007 Sep 10 Mexico .............................................................................................. 20 2007 Oct 7 Sacramento Ca PG&E pipeline repair problem ...................................... 20 Pipelines - how parts can be criminally defective .................................................... 20 Pipeline repair found defective parts ........................................................................ 22 2007 Nov 01 - Dixie Fire in Carmichael MS............................................................ 23 Continued in more documents .......................................................................................... 23
Summary
Heres my summary when I upload this time line installment to Scribd:
http://www.scribd.com/doc/114094060/Indy-Boom
Here is the main document: http://www.scribd.com/doc/114094060/Indy-Boom
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6 Tags: fire, solutions, NTSB, incompetence, training lacking, leak, We continue to see many of the same old human errors repeated in other communities, leading to death, mayhem, destruction, and environmental disasters. The only improvement I am seeing, is the quality of investigatinve reports. So long as companies may operate in defiance of safety standards, it does not matter how good those standards.
Notable CI disasters 2007

Here is an incident time line section of my notes on Critical Infrastructure (CI) disasters. I collect info about many disasters, see what they have in common, then consider what improvements could be made in efforts to mitigate risk of high damage in the next similar incident, or even reduce the frequency in which they occur. My overall analysis and mitigation evaluation is in a separate parent document, from these incident time-line chunks.2 Scribd loses statistics when we change document name, so I kept the original name Indy Boom because I first started lookin g into this topic on the occasion of a gas explosion which demolished a housing sub-division of Indianapolis. That incident turned out to be deliberate sabotage for insurance fraud, which is not the typical cause of these disasters. There seem to be many causes, such as unintentional criminal negligence, a lack of public education to get witnesses to promptly report leak odors and a lack of enforcement of national safety standards for companies mis-managing these dangerous chemicals. The events, in this time line segment, occurred in: Mexico; Spain; USA. Incidents listed here include: Bergenfield NJ had a gas line break, due to problems with a construction project at an apartment building which consequently exploded, killing several residents. The state of NJ had a safety process for making sure that construction work did not damage gas lines. As we walk thru the time line for this incident, we find problems implementing that process. 2005 Dec was when the disaster occurred. 2006 Nov authorities issued citations for safety violations, to the construction company and the gas company.. 2007 May, the NTSB report was published. There were errors in relevant records. Because it was winter time, PSE&G could not shut off the gas which apartment residents used for heat, cooking, and hot water. Instead, the construction work should have been rescheduled in a season when the gas could be shut off. The construction work exposed the gas line to potential trouble, but at the end of day the construction crew, and PDE&G inspector left the situation at risk of getting worse, when they knocked off work at end of day.
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http://www.scribd.com/doc/114094060/Indy-Boom
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Next morning it took the construction crew 20 minutes to recognize there was an emergency, and call 911 and the gas company. First responders arrived in 5 minutes, the gas company in 25 minutes. The gas company needs faster response. Despite strong evidence of a gas leak,3 first responders did not evacuate the building. The good news is that there is strong evidence that lessons learned from this incident have been communicated through training at the gas company, first responders throughout the state of NJ, and the construction company whose neglect triggered this disaster. Companies often have manuals for personnel spelling out how to deal with various crises, with good training to know that stuff. These guidelines start out in accordance with industry standards and government regulations, both of which change over time. Someone at the companies needs to notice when the source of the guidelines evolves, and update their manuals and training accordingly. Construction work scheduled, in the vicinity of a gas line, would normally call for the gas to be shut off for safety, but this is impractical in the middle of winter. So why not schedule the work during warmer weather? Construction work, in vicinity of a gas line, with inadequate measures taken to protect the gas line from mishaps. Critical Infrastructure personnel have awesome duties, whether they work air traffic control, operate nuclear power plants, or control pipelines. They can be overwhelmed with data and alarms. They need systems to manage the data and alarms wisely, such as color coding severity, and they need good training in interpreting what the data is telling them. Many disasters occur for lack of that support. Industry standards exist, which if followed, can avoid disasters. But they are not always followed. Kingman KS pipeline rupture: No one was killed or injured but 204 thousand gallons of anhydrous ammonia leaked into the environment. This accident cost $680,715 including $459,415 for environmental remediation. 1973, or later, construction damaged the pipeline. 2002-2004 events See PHMSA in this time line summary. 2004 Oct 27 the pipeline ruptured. Because of the scale of this disaster, I have a lot of info in my time lines about what we have learned about the circumstances. I include time line of this particular incident, and lots of other related info, in time line 2000 thru 2006; PHMSA Info. PHMSA = US pipeline and Hazardous Materials Safety Administration. I include links to various PHMSA info, and summarize what was in them.
In addition to the tenant who smelled gas, and failed to report it, all of the construction crew smelled the leak, and also a local businessman, who called 911.

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PHMSA safety advisory Aug 2002 to US industry in general. The Kingman disaster showed some challenges implementing this advisory in the real world. PHMSA audit 2003 Sep-Oct on the Kingman KS Pipeline which has a 2004 Oct incident, then 2007 June NTSB report on that incident. PHMSA notice 2004 Apr to the Kingman KS Pipeline, which has a 2004 Oct incident. The 2003 Sep-Oct audit had found many safety deficiencies at the company, and this notice identified what the company needed to fix, to avoid disaster. Kingman responded to the latest PHMSA notice in 2004 May-July, in which they said they had fixed some, but not all of what PHMSA had asked for. This led to PHMSA closing the notice 2004 Oct 18, a week and a half before the Kingman 2004 Oct disaster.
RC = Rancho Cordova CA PG&E

2006 Sep there was an odor report, leading to repair to a pipe, which was not conducted properly. 2007 Oct there was other incorrect repair of a pipe. 2008 Dec incident investigation found events, prior to the disaster, which had contributed to it. 2010 May the NTSB report was published. Supply Chain standard: Companies manufacture things using components from other companies, where the final product can have parts from many different suppliers. At all stages of production, the parts can be labeled: what company made what when, according to what standards. Companies, making parts, can be inspected for quality assurance. This adds to the cost of the parts. Sometimes the purchasers dont want this added cost. You get what you pay for. Date of manufacture is important, because nothing lasts forever, and in fact there are standards showing when something should no longer be used, because it is too old. There are products in the market place without these supply chain standards, opening the door to counterfeit and possibly defective parts. When such parts are used in critical infrastructure, the risk of disaster is increased. Utilities, and Pipeline operators, need to have some way of knowing when some construction activity is going on in the vicinity of their pipe lines, so they can ensure inspection to identify any risk of puncturing or damaging the line, try to prevent that, but if it happens, react fast to mitigate the consequences. Utilities can have instruments which detect a leak, and automatically shut off flow of additional fuel into a disaster, until situation can be repaired. Over the large volume of pipelines across the nation, it would be prohibitively expensive to install this protection nationwide, but it might be prudent to install it in areas of high population density. Critical Infrastructure disasters 2007
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Utilities need to be sure their curb valves can be turned off by their personnel in an emergency. This means either able to turn by hand, including in cold weather, or issue tools to personnel to get the job done when muscles cannot do the job. Vehicles carrying stuff, which might explode at any moment, going thru populated areas without police escort, or evacuation of people in harms way. Witnesses smell the distinct odor of a leak. They fail to notify authorities. The leak ultimately leads to a disaster.
2007 Spain
Estaca de Bares The NPK fertilizer cargo of the ship Ostedijk sustained a self-sustained decomposition (SSD) fire for 11 days. The fire plume reached 10 m in diameter and several hundred meters in length. Special water spears were inserted inside cargo to extinguish the fire. 4
2007 May 01 NTSB report on Bergenfield NJ PSE&G

2007 May 01 NTSB report5 on Bergenfield NJ Gas disaster See 2005 Dec 13 for the actual event. References in this write-up: American Tank = American Tank Service Company, hired by JP Mgmt, to do construction work on apartment property. DOT = U.S. Department of Transportation. EST = Eastern Standard Time. GPTC = Gas Piping Technology Committee = an American National Standards Institute technical committee composed of technical specialists from industry, government, and the public. JP Mgmt = JP Management = a real estate company which owned apartment building, destroyed in the incident. NJ = New Jersey NJBPU = NJ Board of Public Utilities NTSB = National Transportation Safety Board. OSHA = U.S. Occupational Safety and Health Administration. PHMSA = Pipeline and Hazardous Materials Safety Administration PSE&G = Public Service Electric and Gas Company Errors or problems apparent to Al in the time line, contributing to the disaster: o Amount of force needed to get PSE&G valves to close. o JP Mgmt decision to have the work done in winter, when shutting off the gas, as a precaution, would place residents at health risk. o Work Order wrong info about the underground tank.
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https://en.wikipedia.org/wiki/Ammonium_nitrate_disasters http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/fulltext/PAB0701.htm
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o American Tank failure to shore up the trench, so the gas pipe was not supported, fell down, pulled loose. o Apartment tenant smells gas, does not report it. o American Tank personnel slow to recognize there is an emergency, requiring faster reaction. PSE&G and first responders are not called until maybe 20 minutes after they see there is a problem. o Time it takes PSE&G personnel to arrive on scene where gas leak reported. 25 minutes better than some other incidents with other gas companies, but not as good as 5 minutes for first responders. Probable cause determined by NTSB: The NTSB determined that the probable cause of Dec 13, 2005, natural gas explosion and fire in Bergenfield, New Jersey, was the failure of American Tank Service Company to adequately protect the natural gas service line from shifting soil during excavation, which resulted in damage to the service line and the release and migration of natural gas into the apartment building. Contributing to the accident was failure of PSE&G to conduct effective oversight of excavation activities adjacent to the gas service line, and to be prepared to promptly shut off the flow of natural gas after the service line was damaged. Contributing to casualties in the accident was failure of Bergenfield Fire Department to evacuate the apartment building, despite strong evidence of a natural gas leak, 6 and the potential for gas to migrate into the building.
NTSB examines PSE&G pipe

When the pipeline was later uncovered during the post accident excavation, a frayed rope was found attached to the gas pipeline.7 Additionally, a broken piece of two -by-four lumber was found near the gas pipeline. During pressure tests on the steel service line, the only leak was found at the iron threaded tee connection about 7 feet 4 1/2 inches from the building wall, where the line made the 90 degree turn to go into the building. The tee had separated from the service line and had a gap of about 3 inches, between the tee and the building. (See diagram in NTSB report.) The tee and separated end of service line were removed and sent to NTSBs Materials Laboratory for analysis. The threaded end of the service line fractured at the connection. The exposed threads on either side of the mating surfaces showed no evidence of corrosion degradation or fatigue cracking. Microscopic examination of the fracture revealed features consistent with an overstress separation. The evidence is consistent with the pipeline separating in overstress after the ground collapsed into the trench and caused the pipeline to move.
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Gas had been smelled by the businessman who called 811, and by all the American Tank crew members. This was probably from American Tank effort to support the pipe Dec-13 morning, after the damage was done, from Dec-12 work.
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Thus, unlike many other gas disasters, there was nothing wrong with the gas pipe, although difficulty closing the valves means a related problem with PSE&G.
American Tank Procedures and Training

It is evident to Al, from the time line, and NTSB examination of the pipe, that the incident was caused by the American Tank excavation the day before the explosion and fire, even though that companys personnel had done many things correctly. American Tanks written procedures covered certifications and licensing, obtaining contracts, the steps from signed contract to job execution, and the steps for job completion. American Tanks written procedures for excavation work were limited to using the New Jersey One Call System for marking buried utilities, including gas pipelines. The company did not have written operating procedures for the protection of utilities while excavating. According to American Tank, its unwritten procedures for the protection of utilities included the following: Visit the job site to survey for hazards and logistical issues. Obtain all needed permits. Survey the job site to ensure markings are in place.
Uncover top of tank to determine its direction and hand excavation of nearby utilities. Evaluate nature of the soil to determine possibility of collapse. 8 Contact the utility company and request shutoff. Protect and support the utility; contact the utility company if damaged.
If damage to the utility is observed, call the emergency telephone numbers for the utility, and call 911 or fire and police department emergency telephone numbers. American Tank had no formal training program on the protection and support of utilities.
It sounds like this step got skipped in this incident.
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PSE&G Standards
PSE&G participated in the New Jersey One Call system, and also various damage prevention and awareness activities in 2005. These activities included distributing damage prevention materials to home improvement stores, contractors, equipment rental companies, retail stores, and municipalities. PSE&G has not been using direct mailing to contractors unless damage has been reported. Then, PSE&G sends information letters about New Jerseys damage prevention laws to contractors who have damaged their companys underground facilities. PSE&G has an emergency plan developed in accordance with State and Federal regulations. However, this plan does not have a provision requiring testing curb valves to determine whether the valves can be quickly operated to shut down a service line when excavation activities place the line at risk.
Relevant Government Standards

Applicable regulations and standards regarding excavation safety, include regulations and standards from the: o State of New Jersey, o U.S. Occupational Safety and Health Administration (OSHA), o U.S. Department of Transportation, and o industry standards and best practices.
NJ Board of Public Utilities

NJ Board of Public Utilities publishes a handbook which explains requirements of the New Jersey One Call law for excavators. Excavators are required to notify New Jersey One Call from 3 to 10 days before excavating and to immediately report any damage to the operator of the facility. Furthermore, the New Jersey Underground Facility Protection Act, section N.J.S.A. 48:2-82 d(2 and 3) requires excavators to plan the excavation or demolition to avoid damage to and to minimize interference with underground facilities and to use reasonable care during excavation or demolition to avoid damage to or interference with underground facilities. The Board of Public Utilities is charged with overseeing and enforcing compliance with the New Jersey Underground Facility Protection Act and the New Jersey One Call law. The Board of Public Utilities also has delegated authority to enforce Federal natural gas pipeline safety standards in 49 Code of Federal Regulations (CFR) Part 192. See 2006 Nov 28, where NJ BPU issues citations to American Tank and PSE&G in connection with this incident. 8 Critical Infrastructure disasters 2007
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U.S. Occupational Safety and Health Administration

OSHA investigated this accident. Title 29 CFR 1926.651 establishes excavation requirements designed to safeguard employees and prevent damage to underground utilities, including a requirement to establish the location of underground installations before excavating. OSHA and American Tank reached a stipulated agreement for two violations in which American Tank was fined for its conduct during this accident. American Tank was cited for o failure to use safe and acceptable means to exactly locate underground vent pipe for oil storage tank, and o failure to safeguard employees while the excavation was open.
Federal Pipeline Safety Requirements

PHMSAs pipeline safety regulations require that each operator of a buried natural gas pipeline must carry out a written program to prevent damage to pipeline from excavation activities. Specifically, in 49 CFR 192.614(c), damage prevention program must provide for inspection of those pipelines that an operator has reason to believe could be damaged by excavation activities. These inspections must be done as frequently as necessary during and after excavation activities to verify integrity of the pipeline. Title 49 CFR 192.615(a) requires that each natural gas pipeline operator have a written emergency plan that establishes procedures for minimizing the hazards resulting from a natural gas pipeline emergency. The emergency plan must address several emergency responses, including emergency shutdown and pressure reduction in any section of the pipeline system necessary to minimize hazards to life or property and elimination of any actual or potential hazard to life or property. In Al Mac opinion, there is grave risk of excavation and construction work near a gas pipeline, without gas company knowing whats going on. This means we need economical ways for gas companies to find out whats going on in proximity to their lines. In this particular instance, PSG&E needed to know when American Tank was going to knock off for end of Dec 12 day, then visit the site to inspect that the utility line was properly supported, at that time, not wait for disaster Dec 13 morning.
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Industry Guidance
GPTC9 publishes the Guide for Gas Transmission and Distribution Piping Systems to help natural gas operators ensure regulatory compliance. The section of the GPTC guide referring to Section 192.614c(6) states the following: Where required, the inspection may include periodic or full-time surveillance and may include leakage surveys during and after construction. The operator should consider maintaining field contact with the excavator during the excavation activities to avoid potential problems. Section of GPTC guide referring to Section 192.615(a) states, Emergency plan objective should be to ensure that personnel, who could be involved in an emergency are prepared to recognize and deal with the situation in an expeditious and safe manner. The Common Ground Alliance Best Practices10 manual, version 3.0, states that the excavator must use reasonable care to avoid damaging underground facilities. The excavator should plan the excavation to avoid damage or minimize interference with the underground facilities in or near the work area. The manual also states that the protection of exposed underground facilities is as important as preventing damage to the facility when digging around the utility. Section 522 of the manual indicates that excavators are to support or brace exposed underground facilities and protect them from moving or shifting, which could result in damage to the facility. Methods to support, brace, and protect these facilities include shoring the facility from below or providing a timber support with hangers across the top of the excavation to ensure that the facility does not move or bend. Thus, it is evident that industry standards existed, which were not followed by American Tank or PSG&E.
Excess Flow Valves

Excess flow valves are designed to respond to an excessive flow of gas by automatically closing and restricting the gas flow, thereby reducing the likelihood of an explosion and fire. Such valves are typically installed at the connection of a service line to a main pipeline. The valves can greatly reduce the consequences of service line breaks.
The GPTC is an American National Standards Institute technical committee composed of technical specialists from industry, government, and the public.
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The Common Ground Alliance, composed of technical specialists from industry, government, and the public, provides a guide on underground utility damage prevention best practices and promotes their use throughout the United States.
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The NTSB investigation examined whether an excess flow valve that was compatible with the operating conditions for the apartment building would have been effective. Had the break in the service line been exposed to the open atmosphere, an excess flow valve would have activated immediately to restrict the flow of gas; however, in this accident, the broken section of pipe was underground and under asphalt pavement. A leakage test conducted 2 days after the accident resulted in a flow rate of natural gas through the broken service line of about 1,600 standard cubic feet per hour. The leakage test could not be conducted until the excavation site was stabilized. 11 Soil conditions at the time of the leakage test were significantly different than at the time the service line was broken; this difference likely affected the flow rate measured during the test. Further, the flow rate of natural gas to the apartment building at the time the service line was fractured cannot be determined.12 At the time of the accident, it was quite cold; the temperature was about 18 F. It would be reasonable to assume that the heating system and the replenishment of hot water for the tenants would have been operating near maximum capacity. However, given the uncertainty in the leakage test results and the unknown flow rate to the building, NTSB was not able to determine whether an excess flow valve, had one been installed, would have activated after the service line was broken in this accident.
Bergenfield Fire Department Procedures and Training

According to the fire chief, BFD did not have written procedures for natural gas incidents. NTSB investigators were told in Fire Department interviews that the BFD relied heavily on the assistance of PSE&G in deciding whether to evacuate a structure. Effective July 5, 2005, the State of New Jersey improved its written course material regarding natural gas hazards for Firefighter I training. The new material is in the Firefighters Handbook: Essentials of Firefighting and Emergency ResponseNew Jersey Edition, and Addendum. In this handbook, Section D, Chapter II, Recognizing and Avoiding the Hazards of Natural Gas and Carbon Monoxide, describes properties of natural gas, natural gas delivery system, natural gas detection, and response to natural gas emergencies. In the section, Secure the Site, the man ual has the following recommendation:
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During firefighting operations, significant amounts of water had been used in the area. The trench adjacent to the broken section of pipe had been filled as a precautionary measure due to concerns that the building wall might collapse. Later, the trench was partially excavated then refilled because of unstable soil. Trench boxes were necessary to stabilize the excavation before NTSB investigators could access the site. 12 The flow rate to the building could not exceed 2,500 standard cubic feet per hour because of the capacity of the metering equipment.
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When the presence of gas is strong, the best rule is to evacuate people from the dwelling and move them across the street or a distance far away that would prevent injuries if the structure were to explode.13 The video Natural Gas: Recognizing and Avoiding the Hazards, which was produced with the cooperation of several companies and government agencies in New Jersey, including PSE&G, is also included as part of the Firefighter I course. As a result of a July 1999 accident in Fairlawn, New Jersey, and a March 2006 agreement with NJ Board of Public Utilities, PSE&G agreed to expand its emergency response training, coordinated with the Bergen County Fire Academy. As a result of the Bergenfield accident and a March 2006 agreement between NJ Board of Public Utilities and the PSE&G, the Board of Public Utilities obtained permission to distribute a PSE&G-produced video for firefighters and first responders in the State of New Jersey. This video includes information on how to handle gas leak emergencies, and when to check the building, and when to evacuate. October 2006, PSE&G mailed a computer disk containing electric and gas hazard awareness information to police departments, fire departments, and emergency management officials within PSE&Gs service area to help them to develop standard operating procedures for electrical and gas emergencies.
NTSB Recommendations
As a result of its investigation of the Bergenfield, New Jersey, pipeline accident, NTSB made safety recommendations listed below. For more information about these recommendations, see the safety recommendation letters14 to the recipients. To the Pipeline and Hazardous Materials Safety Administration: Provide a summary of the lessons learned from the Bergenfield, NJ, accident to recipients of emergency planning and response grants. (P-07-1) To the New Jersey Department of Community Affairs: Establish a requirement that all career and volunteer firefighters receive recurrent training on natural gas safety and incident response. (P-07-2) To the Borough of Bergenfield: Establish and implement written operating procedures for responding to natural gas incidents and emergencies. (P-07-3)
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However, as we see from the time line, gas was not smelled by first responders, and the explosion occurred immediately after PSE&G confirmed gas leak. 14 These letters are available on the National Transportation Safety Boards web site.
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To the American Tank Service Company: Establish and implement written procedures for safe excavation near pipelines, and provide initial and recurrent training on these procedures to employees. (P-07-4) To PSE&G: Modify your excavation damage prevention program and emergency plan to require sitespecific risk assessments of excavators plans, and implement procedures to effectively manage the risk, such as increased surveillance of excavator actions to protect the pipeline and ensuring that gas shut-off valves are tested so that they can be closed promptly if the pipeline is damaged. (P-07-5) To the International Association of Fire Chiefs: Notify your members of the circumstances surrounding the Dec 13, 2005, accident in Bergenfield, NJ, and urge them to establish and implement procedures for emergency responders to rapidly assess situations involving natural gas leaks and to determine whether prompt evacuations are warranted. (P-07-6)
2007 Jun 14 Kingman KS NTSB report

2007 Jun 14 Kingman Kansas 2004 Oct incidents NTSB report 15 comes out. See: 2004 Oct 27 for the incident. The NTSB determined that probable cause of the pipeline rupture near Kingman KS, Oct 27, 2004, was a pipe gouge created by heavy equipment damage to the pipeline during construction in 1973 or subsequent excavation activity at an unknown time that initiated metal fatigue cracking and led to the eventual rupture of the pipeline. Contributing to severity of the accident was pipeline controllers failure to accurately evaluate available operating data and initiate a timely shutdown of the pipeline. References in this write-up:
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Anhydrous ammonia16 = a highly corrosive and toxic hazardous liquid. CDT17
http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/fulltext/PAB0702.htm
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Anhydrous ammonia is classified in 49 Code of Federal Regulations (CFR) Part 195 as a highly volatile liquid. Anhydrous ammonia is transported as a liquefied gas in a pipeline and, when released, will immediately return to a gaseous state and rapidly expand. It is a hazardous liquid that is highly corrosive and toxic, and its vapors also are extremely irritating and corrosive. Anhydrous ammonia may be fatal if inhaled, ingested, or absorbed through the skin.
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All times in NTSB report are Central Daylight Time.
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Enterprise = Enterprise Products Operating L.P. EPA = U.S. Environmental Protection Agency. Magellan = Magellan Midstream Partners, L.P. NTSB = National Transportation Safety Board PHMSA = US Pipeline and Hazardous Materials Safety Administration SCADA = supervisory control and data acquisition. Williams = Williams Companies, Inc., the owner and operator of the pipeline, prior to Magellan being owner, and Enterprise being operator.
NTSB report provides technical detail about the pipe which ruptured. The pipe segment that ruptured was removed and sent to NTSBs Materials Laboratory for examination and testing. The segment had four external gouges. 18 The approx 11.7inch-long rupture occurred at one of the gouges. Over most of the rupture length, the gouge penetrated 0.019 inch (approx 12.2 % of the pipe wall thickness) into the pipe wall. Within the gouge, shear cracks penetrated the metal. From the base of the shear crack that led to the rupture, a fatigue crack propagated toward the interior of the pipe. The fatigue crack extended approximately 0.080 inch below the shear crack with no external corrosion that resulted in a loss of material thickness. A detailed examination showed that the fatigue region had five bands, each with a different shade of gray, consistent with crack arrest marks. The area below the fatigue crack had a shear lip created during the sudden and final rupture of the pipe. An examination of a cross section of the gouge at the fracture origin area showed that metal of a different composition had transferred to the wall of the pipe. Elemental analysis of a metal tooth from the backhoe bucket owned by the property owner did not provide a unique signature when compared to the transferred metal in the gouges. The examination of the cross section revealed no manufacturing defects (such as laminations, voids, or porosity) in the pipe material. The examination of the inside surface of the pipe showed no corrosion degradation or additional cracking. While these NTSB reports are highly technical, I am getting so I can read between the lines. I conclude that SOMEONE did excavation construction work and hit the pipeline, not once but several times. The NTSB was unable to determine if that SOMEONE was the Pipeline company installation in 1973; previous owner of the property; owner of the property since 1989; someone else doing construction work, for which no records could be found. The four gouges located longitudinally along the top half of the pipeline are consistent in shape and location with the type of mechanical damage caused by excavation equipment such as a backhoe.
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See NTSB report for photos of this damage.
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NTSB concludes that heavy equipment damage to the pipeline during construction or subsequent excavation activity created a pipe gouge that initiated metal fatigue cracking and led to the eventual rupture of the pipeline.
Enterprise pipeline integrity standards

Prior to Enterprise accepting responsibility for managing the Magellan pipeline, Williams prepared initial integrity management program for the ammonia pipeline. It used a relative risk assessment model that considered the following factors: third-party damage, corrosion, incorrect operation, design, and leak impact. It ranked various pipeline segments according to their risk with respect to each other. Using this model, a lower score indicated higher risk, and a higher score indicated lower risk. The risk scores were used with other input to prioritize scheduling of baseline assessments of pipeline segments. Pipe segments with risk scores of 0 to 35, 36 to 66, and 67 and above were considered high, medium, and low risk, respectively. When the baseline assessment plan was developed, the model assigned a risk score of 69 (low risk) to the segment on the Enid Lateral that ruptured in this accident. This Enid Lateral segment was scheduled for a baseline assessment in 2006. February 2003, Enterprise became operator for the pipeline under contract to a subsidiary of Williams. Enterprise has been responsible for the integrity management program for the pipeline since that time. Williams subsequently sold the pipeline to Magellan, and Enterprise continued as the operator. The original integrity management program remained in effect until 2004 when Enterprise finished developing its own integrity management program, which was in effect at the time of the accident. The risk model in the Enterprise program was the same as the one used by Williams, and the risk score for the pipeline segment that contained the rupture had not been revised. PHMSAs integrity management regulations list risk factors that must be considered in prioritizing the scheduling of baseline assessments. A pipeline segments leak history is specifically included in the list of risk factors. Although Enterprise had leak history data for the accident pipeline segment, Enterprise did not have complete instructions for calculating the leak history risk factor in its integrity management program. As a result, leak history was not used in calculating the relative risk scores, nor was it otherwise considered to classify pipe segments as high, medium, or low risk for the baseline assessment before the Kingman accident.
Enterprise procedures for abnormal conditions

While reviewing the company rules below, recall that the pipeline controller: First observed the alarms shortly after 11.15 pm, after leaving his station to get lunch, then had to deal with approx 120 alarms within about hour. He phoned a pumping station to ask personnel there, about the situation, but they knew nothing helpful. He assumed flow rate needed adj, and was waiting to see if
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that solved the problem. He expected that in 10 to 15 minutes, he would get more info to see if problem solved, or further analysis of alarms needed. 11.48 p.m., phone call arrived from 911 dispatch, was first pipeline controller knew there was a rupture, so he immediately started shutting down the pipeline. 12.15 p.m., he reported situation to his superiors, who were too busy to do anything about it, so they passed buck back to the controller to initiate required reporting to the government.
The controller who operated the pipeline during the accident started at Enterprise as an area operator and was promoted to operations supervisor in the field in 1996. He took controller training, consisting of classroom study of company procedures and manuals, operations, SCADA information retrieval, and site-specific information. He functioned as a pipeline scheduler from 1997 until 2003. In February 2003, he began on-the-job controller training. Enterprise assessed the effectiveness of his training by testing his knowledge and observing his actions in operating pipelines. He completed refresher training on May 21, 2003. His training included the study of procedural and training manuals for the ammonia pipeline. The study material explained how to respond to abnormal conditions and use trend screens with graphical displays. He successfully completed written examinations covering this material on September 13, 2003, and was qualified by Enterprise to operate the pipeline. Enterprise did not have a pipeline simulator for controller training but did use noncomputerized simulations in post accident controller training sessions in 2001. Review of non-computerized simulations of accidents is not a requirement listed in Enterprises training program. Enterprises procedure manual defined an abnormal operating condition as any condition that may cause, create, or contribute to a situation which exceeds the design or normal operating parameters of the pipeline. The manual instructed controllers to treat an unexplained variation in pressure or flow as an abnormal operating condition. It also instructed controllers to continue to monitor pipeline operations and follow specific steps that include checking with others involved with the operations to determine the cause of the variation and to be especially attentive for any sign that an emergency condition may follow. To investigate a variation in pressure or flow, control room personnel were to notify oncall field personnel or supervisors; review flow data; check instantaneous line balance by comparing simultaneous meter readings at point of origin, destination, and intermediate locations; and contact customers for possible explanation of the pressure or flow variation. If a logical reason for a variation could not be determined, the control room operator was to shut down the pipeline and monitor pressure. 16 Critical Infrastructure disasters 2007
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Enterprises draft Natural Gas Liquids Pipeline Control Operations and Maintenance Training Manual19 also contained information regarding the monitoring and control of anhydrous ammonia pipelines. The manual noted that rate-of-change alarms usually occur at the onset of an abnormal condition or a pipeline leak. Controllers were instructed to investigate all rate-of-change and parameter alarms immediately, and they were advised that if an alarm resulted from a known cause, the pipeline system in the area of the alarm would stabilize in a short period of time. If the cause of a rate-of-change or parameter alarm was not readily apparent and the alarm was accompanied by one or more indications of a product release, or the pressure or flow failed to stabilize, controllers were instructed to shut down and block in the line segment. If a sudden unexplained decrease in operating pressure without a corresponding increase in flow rate was observed, the controller was instructed to shut down and block in the line segment for 30 minutes and then observe the line segment for any sign of a leak. Controllers were instructed during training to use trend screens to monitor the pipeline pressure and, if the pressure continued to fall or did not stabilize, to perform an emergency shutdown. This procedure was included in the training manual. The alarm response matrix in the training manual described the SCADA alarm color scheme and listed a rate-of-change alarm as a high-level alarm. The matrix also indicated that rate-ofchange alarms for pressure and flow (high-level, immediate attention) were shown in red on the SCADA screen and that these alarms indicated a possible line break. Enterprise defined an emergency as a significant change from steady state operating conditions that could include an accidental release of hazardous vapors or liquid s from a pipeline causing a hazardous situation. When a controller determined that an emergency existed, the manual required him to shut down pumps that feed the affected facility and close the nearest upstream remotely operated block valve. Pump stations downstream of the facility were to remain operating until they shut down on low flow, and then the nearest remotely operated downstream block valve was to be closed. The controller also was to notify identified personnel within the company as well as customers and emergency response agencies. Enterprises Procedural Manual for Operations, Maintenance, and Emergencies stated that operations personnel are accountable for telephoning a report of an accident to the National Response Center. The procedure repeats the requirements for telephonic reporting in 49 CFR 195.52. Enterprises draft Natural Gas Liquids Pipeline Control Operations and Maintenance Training Manual stated that its reporting contractor would do all reporting of releases and accidents to Federal, State, and local authorities for Magellans ammonia pipeline, and that the Enterprise field supervisor was responsible for reporting releases and accidents to the contractor.
19
Enterprise used the draft manual for training controllers.
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Enterprise did not have a policy about who was responsible for deciding whether to send an additional report to the National Response Center in order to comply with the August 30, 2002, PHMSA advisory bulletin urging operators to update a telephonic report with significant new information, including a change in the estimate of the release volume. Before the accident, Enterprises central region operations manager had supplemental reporting guidelines drafted for training field personnel. The operations managers objective was to improve timely reporting of accidents in his region, using the reporting contractor. The guidelines identified reporting responsibilities and included a list of questions that the contractor would ask. However, the guidelines did not address how to estimate the quantity of product released or how to make a dollar estimate of damages. The draft guidelines were used in a training session conducted during a quarterly safety meeting in the quarter ending March 31, 2003. The draft guidelines, Release Reporting Roles and Responsibilities, dated June 3, 2003, was the last update of the draft.
Enterprise post accident procedural repairs

After the accident, Enterprise established a program to review the rate-of-change alarms system wide because the company believed that the alarms were not as effective as they should be. The goal of the review was to make the alarms more meaningful by significantly reducing the number of alarms that could distract controllers from more critical alarms. Before the review, controllers received about 10,000 SCADA alarms/events system wide on an average day. After the review, the average number of alarms per day dropped below 4,000. After determining that controllers would not be overwhelmed by reclassifying rate-of-change alarms to a higher priority, Enterprise changed the alarm from medium level (blue) to high level (red) to emphasize the need for immediate attention to those alarms. Enterprise supervisors reviewed the circumstances of the accident with the controller and identified deficiencies in his response. No disciplinary actions were taken against the controller. Enterprise conducted two training sessions for its entire staff of anhydrous ammonia and natural gas liquid pipeline controllers. In the training sessions, Enterprise used a noncomputerized simulation to analyze the ammonia pipeline accident. During this simulation, as each alarm came in, the associated trend screen was displayed. The SCADA tools available for analyzing incoming alarm data, including trend screens, were reviewed. Controllers were told that if they saw an abnormal condition that indicated a possible leak and they were unable to analyze the condition and determine the cause of the problem within approximately 5 minutes, the controller was to shut down and block in the
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pipeline. Enterprise has not made non-computerized simulations a part of its recurrent training program. Enterprise developed a new telephonic reporting procedure, dated January 20, 2006, for estimating the amount of product released and related damages based on pipeline physical characteristics and available operating data. When sufficient operating data are not available for anhydrous ammonia pipelines, the initial release amount to be reported will be the quantity of product contained between the valves closed on either side of the leak. The procedure also addresses a potential delay in telephonic reporting for releases that exceed the EPA reportable quantity. Specifically, to expedite the reporting to the National Response Center, Enterprise now requires the employee who reports the release to the reporting contractor to stay on the phone with the reporting contractor while the report is made. Enterprise also has designated company employees who will supply telephonic updates, as necessary, to the National Response Center. Since the accident, Enterprise has revised its risk assessment model to incorporate a pipeline leak history factor in its risk assessment calculation. It also has revised its baseline assessment of pipeline segments using all risk factors to schedule baseline assessments.
NTSB Recommendations
As a result of its investigation of the October 27, 2004, anhydrous ammonia pipeline accident, the NTSB made multiple safety recommendations. For more information about these recommendations, see the safety recommendation letters20 16 to the recipients. To PHMSA: Require in 49 Code of Federal Regulations 195.52 that a pipeline operator must have a procedure to calculate and provide a reasonable initial estimate of released product in the telephonic report to the National Response Center. (P-07-7) Require in 49 Code of Federal Regulations 195.52 that a pipeline operator must provide an additional telephonic report to the National Response Center if significant new information becomes available during the emergency response. (P-07-8) Require an operator to revise its pipeline risk assessment plan whenever it has failed to consider one or more risk factors that can affect pipeline integrity. (P-07-9) To Enterprise:
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These letters are available on the National Transportation Safety Boards web site.
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Provide initial and recurrent training for all controllers which includes simulator or noncomputerized simulations of abnormal operating conditions that indicate pipeline leaks. (P-07-10)
2007 July 17 Baltimore Md

Near Baltimore, Maryland, Columbia Gas has a serious incident.21
2007 Sep 10 Mexico

Monclova, Coahuila A trailer loaded with 22 tons of ammonium nitrate crashed into a truck leaving three dead in the crash. A fire then started in the trailer's cabin and approximately 40 minutes after that, a huge explosion occurred, resulting in around 150 people injured and 37 more dead. A crater 30 ft (9.1 m) wide and 6 ft (1.8 m) deep was created due to the explosion.22 See similar incidents with trucks carrying ammonium nitrate, which I think should have a police escort: 1959 Aug 7 Roseburg OR. 2004 Mar 9 Barracas Spain. 2004 May 24 Romania
2007 Oct 7 Sacramento Ca PG&E pipeline repair problem

2006 Sep 15 info about pipeline repair at the site of the 2008 Dec 24 Rancho Cordova Ca PG&E disaster. 2007 Oct 7 identifies flaws in PG&E pipeline repair process. 2008 May California Public Utilities Commission (CPUC) audited Pacific Gas & Electric (PG&E). 2008 Aug CPUC sent a letter to PG&E, identifying what needed to be fixed. 2008 Dec 24 info about Rancho Cordova Ca Pacific Gas & Electric (PG&E) Explosion, Leak Release, and Ignition of Natural Gas. 2010 May 18 info from NTSB full report on PG&Es 2008 -12-24 Rancho Cordova Ca Explosion and Fire.23 The NTSB report found that there had been prior events, which contributed to the disaster.
Pipelines - how parts can be criminally defective

These notes by Al Macintyre, draw heavily on government reports, news media reports, and other sources. Here I should interject some relevant info from my own career. I have worked since 1984 in manufacturing, where there is an optional standard, of manufactured parts being labeled with: Identification of manufacturer;
21
http://primis.phmsa.dot.gov/comm/reports/operator/OperatorIM_opid_2616.html?nocache=350#_Incidents _tab_4 22 https://en.wikipedia.org/wiki/Ammonium_nitrate_disasters 23 http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/fulltext/PAB1001.htm
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Identification of part specifications; Identification of industry standard(s) that the part meets. When manufactured, such as year. Sometimes more info.
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Knowing when manufactured is important, because nothing lasts forever. Different types of materials have different lengths of time before it tends to wear out, where various industry associations have figures on what that is. This is impacted by how heavily it is used, under what pressures, temperatures, other factors. Some public utility pipes, electrical wires, etc. really do need to be replaced every few decades, before they die of old age. If you are using materials which are not labeled as to age, and where you are not doing regular inspections of the older stuff, you dont know what the risks are. When product is purchased direct from domestic manufacturer, we have assurance of the industry standard label, because the industry standard associations do regular inspections of domestic manufacturers, using their standard, to verify they are meeting it. Applying this labeling, typically adds 1 cent to the cost of something which may total a few dollars. The customer, of the manufacturer, states whether or not they want this 1 cent cost included. Consequently, there are products in the market place which do not have this supply chain traceability, opening a door to counterfeit parts, which seldom measure up to industry standards. A major source of counterfeit parts are off-shore manufacturers, who apply labels to match what the domestic market wants. For example, something actually made in China, or Mexico, may say made in USA because that is labeling desired by buyers in the USA. These counterfeit parts might also be labeled with id of whatever standard, even though they do not satisfy it, and were never subject to any inspections by the standard associations to verify anything. The original manufacturer has pricing based on volume purchased. Some distributors order in such large quantities, that they get very low prices, and are able to resell to the market place at a lower price than the manufacturer is selling to customers which order low volumes. Some of these distributors may be in foreign nations, not subject to the same standards as the domestic market. When buyers are shopping around for lowest price, it is not always obvious where the supplier is really located. In addition to the product labeling, which can be fraudulent in the case of counterfeit parts, there are also accounting records of what was supposedly purchased from what suppliers, and similarly those suppliers have records of who they sold what stuff to. The materials have a life span much longer than the requirement how long to store these records. Supply chain may be able to trace supplier, through accounting records for a few years, while the materials have a life span of a few decades. So something goes haywire, it was purchased 20 years ago, you have no way of proving where it came from. There is also hacking and insider fraud. 21 Critical Infrastructure disasters 2007
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Pipeline repair found defective parts

Quoting from NTSB report:24 A PG&E attempt to repair a 1 1/4-inch polyethylene pipe used four Metfit couplings, each of which leaked and failed when it was tested during installation. PG&E sent sections of pipe and the four couplings to US Poly for evaluation because PG&E initially believed that the couplings were the cause of the installation failure. US Poly measured three of the fittings and the pipe and concluded that (1) the pipe did not meet the American Society for Testing and Materials (ASTM) tolerance for wall thickness and (2) the failure apparently occurred when the thin-walled pipe slipped out of the Metfit couplings. However, because the pipe was not long enough to contain the entire print line, including the manufacturers id, US Poly was not convinced that the pipe tested was US Poly pipe. PG&E, which stated that it used only US Poly pipe, checked its truck and yard stock for all unused 1 1/4-inch polyethylene pipes with matching print lines. These pipes were measured for wall thickness and outside diameter, and all were found to meet ASTM D-2513, Standard Specification for Thermoplastic Gas Pressure Pipe, Tubing and Fittings, specifications. o If one bunch of pipes were defective, there could be more, somewhere under the ground. o After the 2008 Dec-24 explosion incident, NTSB tested samples from PG&E yard stock. o One had correct Manufacturer id, and passed tests. o Three did not have Manufacturer id. o Of those, two passed, one failed, NTSB tests. PG&E felt that the October 7, 2006, incident was an isolated incident and as a result did not follow up with the manufacturer beyond the original contact with US Poly or perform further reviews within PG&E. JM Eagle, which purchased the assets of US Poly in 2007, conducted a search of its wall thickness monitor records for 2005 through 2007 and found no readings below the minimum specified in ASTM D-2513. Furthermore, JM Eagle surveyed its 10 largest customers, and none reported any wall thickness problems of any type with their specification pipe. The sections of pipe and couplings that PG&E reported were from the October 7, 2006, incident were submitted to the NTSBs Materials Laboratory for testing. o NTSB tested nine samples from that incident. o Four passed the tests. o Five failed. o All had correct Manufacturer id labeling.
24
http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/fulltext/PAB1001.htm
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2007 Nov 01 - Dixie Fire in Carmichael MS

2007 11 01 was the event: Carmichael MS / Dixie Pipeline Co Rupture of Hazardous Liquid Pipeline, with Release and Ignition of Propane See 2009 10 14 for NTSB report on this incident. On November 1, 2007, at 10:35:02 a.m. central daylight time, a 12-inch-diameter pipeline segment operated by Dixie Pipeline Company was transporting liquid propane at about 1,405 pounds per square inch, gauge, when it ruptured in a rural area near Carmichael, Mississippi. The resulting gas cloud expanded over nearby homes and ignited, creating a large fireball heard and seen from miles away. About 10,253 barrels (430,626 gallons) of propane were released. As a result of the ensuing fire: Killed = 2 people Minor Injuries = 7 people Houses Destroyed = 4 Houses Damaged = several About 71.4 acres of grassland and woodland were burned. Dixie Pipeline Company reported that property damages resulting from the accident, including the loss of product, were $3,377,247.
Continued in more documents

Time Line of these disasters to be continued in related documents to be named: CI Boom 0 thru 199925 CI Boom 2000 to 200626 CI Boom 2007 CI Boom 2008 to 2009 CI Boom 2010 to 2011 CI Boom 201227 CI Boom 2013 Jan-Mar CI Boom 2013 Apr CI Boom 2013 May-Dec CI Boom 2014 Jan W Va Water28 These other time line history segments, shall be uploaded to the same SCRIBD Critical Infrastructure collection.29 Revision history will be maintained in the main parent document.
25 26
http://www.scribd.com/doc/203317455/CI-Boom-0-thru-1999 http://www.scribd.com/doc/203688481/CI-Boom-2000-to-2006 27 http://www.scribd.com/doc/204042682/CI-Boom-2012 28 http://www.scribd.com/doc/203973261/CI-Boom-2014-Jan-9-W-Va-Water 29 http://www.scribd.com/collections/4108500/Critical-Infrastructure
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CI Boom 2007

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Critical Infrastructure disasters 2007

Critical Infrastructure Disasters 2007

Critical Infrastructure disasters 2007

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Critical Infrastructure disasters 2007

Notable CI disasters 2007

Critical Infrastructure disasters 2007

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Critical Infrastructure disasters 2007

Critical Infrastructure disasters 2007

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Critical Infrastructure disasters 2007

RC = Rancho Cordova CA PG&E

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Critical Infrastructure disasters 2007

2007 May 01 NTSB report on Bergenfield NJ PSE&G

https://en.wikipedia.org/wiki/Ammonium_nitrate_disasters http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/fulltext/PAB0701.htm

Critical Infrastructure disasters 2007

Here is the main document: http://www.scribd.com/doc/114094060/Indy-Boom

Critical Infrastructure disasters 2007

NTSB examines PSE&G pipe

Critical Infrastructure disasters 2007

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Critical Infrastructure disasters 2007

American Tank Procedures and Training

It sounds like this step got skipped in this incident.

Critical Infrastructure disasters 2007

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Critical Infrastructure disasters 2007

Relevant Government Standards

NJ Board of Public Utilities

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Critical Infrastructure disasters 2007

U.S. Occupational Safety and Health Administration

Federal Pipeline Safety Requirements

Critical Infrastructure disasters 2007

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Critical Infrastructure disasters 2007

Excess Flow Valves

Critical Infrastructure disasters 2007

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Critical Infrastructure disasters 2007

Bergenfield Fire Department Procedures and Training

Critical Infrastructure disasters 2007

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Critical Infrastructure disasters 2007

Critical Infrastructure disasters 2007

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Critical Infrastructure disasters 2007

2007 Jun 14 Kingman KS NTSB report

Anhydrous ammonia16 = a highly corrosive and toxic hazardous liquid. CDT17

All times in NTSB report are Central Daylight Time.

Critical Infrastructure disasters 2007

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Critical Infrastructure disasters 2007

See NTSB report for photos of this damage.

Critical Infrastructure disasters 2007

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Critical Infrastructure disasters 2007

Enterprise pipeline integrity standards

Enterprise procedures for abnormal conditions

Critical Infrastructure disasters 2007

Here is the main document: http://www.scribd.com/doc/114094060/Indy-Boom