CI Boom 2008 To 2009

Download as pdf or txt
Download as pdf or txt
You are on page 1of 19

1

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM

Critical Infrastructure Disasters 2008 to 2009


News etc. digested by Alister William Macintyre

CI Boom 2008 to 2009 tracks critical infrastructure disasters time line. What can be done
to mitigate such disasters is in the main related document.1 Last updated 2014 Feb 04
Version 1.43

Table of Contents, thru level 3 Summary ..................................................................................................................... 1 Notable CI disasters 2008 to 2009 ...................................................................................... 2 2008 March 5 - Plum Borough PA Gas explosion and fire ........................................ 4 2008 May CPUC audited PG&E ............................................................................. 5 2008 Aug 1 CPUC informed PG&E........................................................................ 5 2008 Sep 14 Appomattox VA pipeline explosion ...................................................... 6 2008 Nov 5 PG&E replies to CPUC........................................................................ 6 2008 Nov 21 Plum Borough PA NTSB Report .......................................................... 7 2008 Dec 24 RC = Rancho Cordova CA ..................................................................... 9 RC Dec-24 9.16 am+ SOS-A to PG&E HQ ............................................................... 9 RC Dec-24 10.15 am+ Technician arrives at 10716................................................. 10 RC Dec-24 10.25 am+ request proper equipment of PG&E HQ.............................. 11 RC Dec-24 10.29 am+ SOS-B to PG&E HQ ........................................................... 11 RC Dec-24 time uncertain Technician finds gas leak............................................ 12 RC Dec-24 10.41 am+ PG&E maintenance dispatching begins............................... 13 RC Dec-24 11.11 am+ SOS-C to PG&E HQ ........................................................... 13 RC Dec-24 1.14 pm+ Maintenance arrives............................................................... 14 RC Dec-24 1.35 pm+ Explosion............................................................................... 15 RC Dec-24 1.43 pm+ First Responders arrive.......................................................... 16 2009 July 30 Bryan Texas...................................................................................... 16 2009 Oct 14 NTSB on Dixie in Carmichael MS ....................................................... 16 Dixie Carmichael Probable Cause and Safety Issues ............................................... 17 NTSB Recommendations re: Carmichael MS incident ............................................ 17 Continued in more documents .......................................................................................... 18

Summary
This time line installment is mainly official reaction to recent serious disasters what needs to be done better, to mitigate against history repeating. Some companies are organizational disasters, lacking proper controls to do their jobs properly. Should there come a time when they should be forcibly taken over, by more competent companies, by government command, like is done with some failing financial institutions?

http://www.scribd.com/doc/114094060/Indy-Boom

Critical Infrastructure disasters 2008 to 2009

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

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM

As usual there are some omissions. One recurring story is construction crews cutting into gas lines which they did not know were there. They smell gas, dont know that they caused the leak. They call 911, which ought to order an evacuation, when they confirm the gas smell. At least one building blows up. There is a general lack of recognition of the risks, of all sorts of behavior, until after the explosion, fire, massive harm. Gas lines should be on a city map, available to city engineers, 911, etc. so that when a fire or similar crisis called in, they know instantly if it is in proximity to what critical infrastructure. Also if any construction plans seek city approval, it is also known in advance if the plans are in proximity to gas lines. In either case, give rapid notification to the gas company. Gas lines should be clearly marked, in such a way that they do not get covered up by snow and ice in bad winter weather. It should be illegal for anyone to cover up the gas line markers, such as with advertisements. Construction crews should be trained to recognize the markings. The company, which owns the lines, should be notified, in advance, of any construction in proximity to their lines, so that their people can verify the safety. First responders need training specific to dealing with gas pipeline rupture fires. This should include authority to cut off the flow of gas to a fire, since gas companies are often much slower than fire depts to get to the scene and do what needs to be done. If either the gas company, or the fire dept, is responding to a reported gas leak, they should notify the other organization of where this is going on, and keep them in the loop of being informed on what they are finding out. There should be proper funding of regulatory agencies to inspect that these mitigation efforts are in place, so we can get fixes when they are not, before more disasters. Auditors and Insurance companies should be in the loop regarding both inspection discoveries and what regulatory inspectors are looking for, so that they can incorporate ISO 9000 safety standards into their work with the companies involved.

7 Tags Gas explosion, disaster causes, utilities, construction, mitigation, NTSB, dysfunctional companies,

Notable CI disasters 2008 to 2009


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
2

http://www.scribd.com/doc/114094060/Indy-Boom

Critical Infrastructure disasters 2008 to 2009

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

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM

name Indy Boom because I first started looking 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 industrial 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 USA. Incidents listed here include: Construction Excavation near a pipeline, can lead to damage to the pipeline, not noticed by the construction workers, who can lack the qualifications to notice the damage. The organization responsible for pipeline security should always inspect their infrastructure when there is construction touching, or almost touching it, to make sure that there is no damage, or if there is any, repair it promptly. Failure to do so, led to the 2008 Plumb Borough PA disaster. Counterfeit parts used in Pipeline Repair, can lead to later Pipeline Disasters. o See Pacific Gas & Electric (PG&E), for that happening. Dixie Pipeline disaster. o 2007 Nov 01 was the pipeline rupture and fire. o 2008 Oct 14 NTSB report Emergency Response, in name only, can make an emergency worse. o See Pacific Gas & Electric (PG&E), for that happening, with both the 2008 Dec Rancho Cordova (RC) and 2010 Sep San Bruno incidents. First 911 Responders need to have training in how to deal with pipeline disasters. Lack of such training contributed to the Dixie Pipeline disaster in 2007. Pacific Gas & Electric (PG&E) shows up in multiple serious incidents, with an associated record of warnings, which apparently were not heeded in time to avoid the incidents. o 2006 Sep 15 pipeline repair, not done properly, at site of 2008 Dec 24 Rancho Cordova Ca PG&E disaster. o 2007 Oct 7 identifies flaws in PG&E pipeline repair process, such as counterfeit parts getting into their inventory. o 2008 May California Public Utilities Commission (CPUC) audited Pacific Gas & Electric (PG&E). o 2008 Aug CPUC sent a letter to PG&E, identifying what needed to be fixed, which was found by the 2008 May audit. This included: Personnel to be properly trained in responding to leaks. PG&E documentation, on emergency response, needed some upgrades. o 2008 Nov PG&E responds to CPUC pledging to make all corrections by 2008 Dec 31. o 2008 Dec 24 Rancho Cordova Ca Pacific Gas & Electric (PG&E) Explosion, Leak Release, and Ignition of Natural Gas.

Critical Infrastructure disasters 2008 to 2009

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

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM


o 2010 May 18 NTSB report on PG&Es 2008-12-24 Rancho Cordova Ca Explosion and Fire.3 The NTSB found that there had been prior events, which contributed to the disaster. o 2010 Sep 9 San Bruno incident. Pipeline Installation and/or Repair, not done properly, and with poor or no quality control, can lead to later Pipeline Disasters. o See Pacific Gas & Electric (PG&E), for that happening, with both the 2008 Dec Rancho Cordova (RC) and 2010 Sep San Bruno incidents. Plumb Borough PA Natural Gas disaster o 2003 Oct 15 construction work, at the site which later had the disaster, is believed to have damaged the pipe, leading to corrosion and failure. This is because it was the only construction at the site, which had been registered with the proper authorities. o 2008 March 5 explosion & fire. It took the company 4 hours to shut down the gas leading to where the fire occurred. o 2008 Nov 21 NTSB report Rancho Cordova (RC) Ca disaster see Pacific Gas & Electric (PG&E). San Bruno Ca disaster see Pacific Gas & Electric (PG&E).

2008 March 5 - Plum Borough PA Gas explosion and fire


2008 March 5 Natural Gas disaster in Plum Borough PA. 1 person dead 1 seriously injured (4 year old girl) 3 homes destroyed 11 homes seriously damaged $ 1 million in property damage and losses See 2008 Nov 21, for NTSB report. Abbreviations and shortened references, relevant to this incident: Dominion = Dominion Peoples Natural Gas Company HPFD = Holiday Park Fire Department NTSB = National Transportation Safety Board PUC = Pennsylvania Public Utility Commission Time line:4 1.39 pm = Natural Gas Distribution Line Break, Subsequent Explosion and Fire. 1.40 pm = HPFD notified, about an explosion involving a home at 171 Mardi Gras Drive with two people inside, and they dispatched first responders. 1.44 pm = Dominion was notified by phone from someone in the neighborhood, and Dominion dispatched personnel to the scene. 1.45 pm = First responders arrive on scene. 1.50 pm = HPFD Fire chief arrives. 1.59 pm = victims get medical attention.
3

http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/fulltext/PAB1001.htm 4 All times, about this incident, are eastern standard time.

Critical Infrastructure disasters 2008 to 2009

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

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM


2.10 pm = helicopter takes victims to hospital. The man died en route. 2.12 pm = Dominion customer service arrives on scene. 2.17 pm = Dominion maintenance personnel arrive on scene. 2.17 pm, according to a Dominion crewmember interviewed by an NTSB investigator, Dominion crewmembers began bar-hole testing shortly after their arrival. Their initial bar-hole testing focused on the 8-inch pipeline because the 2inch pipeline was a loop off the 8-inch pipeline. However, after crewmembers noticed bubbling in wet ground above the 2 -inch pipeline, and in a sewer line in front of the accident residence, they started excavating these areas. 2.20 pm = Dominion supervisor arrives on scene. 2.20 pm = HPFD had things under control, but there were several small fires being fed by continuing gas leaks. Dominion personnel were trying to shut down the gas pipes, but were having difficulties, described in NTSB report. 5.50 pm = Dominion got the last of the gas pipes shut down. 6.59 pm = HPFD left, having extinguished all fires. 8.29 pm = Under PUC supervision, Dominion crews exposed the 2-inch pipeline. A circumferential crack ran about 270 degrees around the pipe; the top section of the pipe was not cracked. The pipe was bowed with a dented underside. The pipe was marked and photographed.5 A 90-inch section of the pipe, which contained the circumferential crack and the dented area, was sent to the NTSB Materials Laboratory for examination.

During the next 2 days, bar-hole testing was conducted every 30 minutes on the 2-inch pipeline, the 8-inch pipeline, and all service pipelines in the area. At 10:00 p.m. on March 6, the day after the explosion, gas readings were recorded as high as 18.8 percent along the 8-inch pipeline. Two days after the accident, at noon, the readings had diminished to zero. During pressure tests of the repaired 2-inch pipeline, no leakage occurred.

2008 May CPUC audited PG&E


The California Public Utilities Commission (CPUC) audited Pacific Gas & Electric (PG&E) in early May 2008. The audit determined that PG&E was in violation of Title 49 Code of Federal Regulations 192.615 (a)(3) and (a)(4) regarding emergency plans. It found that the PG&E procedure for field service representatives responding to gas leaks did not define the term hazardous leak, nor did PG&E qualify field service representatives on the use of gas detection equipment and grading leaks outdoors.

2008 Aug 1 CPUC informed PG&E


August 1, 2008, the California Public Utilities Commission (CPUC) sent a letter to Pacific Gas & Electric (PG&E) listing the areas of violation found during the May 2008 audit6 and requesting corrective action. In the letter, CPUC ordered PG&E to review its
5 6

This is illustrated in NTSB report. See 2008 May.

Critical Infrastructure disasters 2008 to 2009

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

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM

procedures and make certain that all personnel, who respond to reports of gas leaks, have the proper training and equipment. The letter also noted the following: The process in [Utility Operations] Standard UO-6434, wherein events, requiring immediate attention, are identified and classified by persons not qualified to make such decisions, has the real potential to prevent or delay qualified personnel from timely responding to, and correcting what can be, very hazardous conditions. 7

2008 Sep 14 Appomattox VA pipeline explosion


A pipeline ruptured, there was an explosion, destroying homes, injuring people. 95 homes were damaged, 2 destroyed. There was chaos for the people fleeing from their homes.8 However, it could have been much worse, had there not been advance training for first responders, working with the pipeline company, how to cope in case of emergency.

7:44 a.m.: Line B ruptured Gas control received the alarm About two minutes later, a downed power line ignited the gas 7:59 a.m.: Compressor station emergency shutdown Greg Heath, administrator, initiated the emergency shutdown (ESD) The compressors were shut down and bypassed the station 8:10 a.m.: Blocked upstream valve Eddie Glover, technician, closed valve 170B1 8:20 a.m.: Blocked downstream valve Three technicians closed valve 170B10 and the crossover valves

2008 Nov 5 PG&E replies to CPUC


PG&E responded to CPUC9 in a November 5, 2008, letter in which PG&E agreed with CPUC findings and said it would take certain actions. PG&E agreed to

Update the UO-6434, Gas Leak and Odor Response, procedure system wide, Define the term hazardous leak, and Properly train, qualify, and provide the proper equipment to the gas service representatives to grade outdoor leaks. This information was to be communicated to PG&E personnel no later than December 31, 2008, in the form of a gas information bulletin.

S. K. Shori, California Public Utilities Commission, letter (Notice of Violations of General Order 112E Compliance Inspection of PG&Es Fresno Division) to G. Carter, PG&E, August 1, 2008.
8

http://www.fireengineering.com/articles/2013/03/-lessons-learned--pipeline-emergency-response-at-2008appomattox.html 9 See 2008 Aug 1.

Critical Infrastructure disasters 2008 to 2009

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

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM

2008 Nov 21 Plum Borough PA NTSB Report


2008 Nov 21 = NTSB report10 on 2008 March 5 Plum Borough PA Natural Gas disaster. Abbreviations and shortened references, relevant to this incident: Dominion = Dominion Peoples Natural Gas Company DOT = US Department of Transportation NTSB = National Transportation Safety Board PUC = Pennsylvania Public Utility Commission NTSB determined that probable cause of the leak, explosion, and fire in Plum Borough, Pennsylvania, on March 5, 2008, was excavation damage, to the 2-inch natural gas distribution pipeline, that stripped the pipes protective coating, and made the pipe susceptible to corrosion and failure. The 2 inch pipeline had been installed Aug 9, 1961, as a distribution main pipeline; it had a maximum allowable operating pressure of 30 pounds per square inch, gauge (psig) and was operated at about 10 psig. Remember that the incident had occurred at 171 Mardi Gras Drive. On October 15, 2003, about 5 years before the accident, the owners of 171 Mardi Gras Drive had hired a master plumber to replace the sewage line so that the house would comply with the county code.11 The plumber hired an excavator to uncover the sewer line. Pennsylvania One-Call records verified that it had been notified of the excavation and that Dominion and the local water company had made the markouts. 12 During post accident interviews with an NTSB investigator, the plumber and excavator said that they had seen the markouts, and that the markouts had been properly placed. The excavator said that he had used a backhoe to uncover the sewer line, that he had replaced the sewers original terra cotta line with a plastic line, that he had backfilled most of the excavation with porous sandstone, and that he had not dug near the pipeline. The plumber said that he had done the digging near the pipeline and that he had done it by hand. Both said that they had not damaged the pipeline during the excavation. The sewer line that the plumber had installed was perpendicular to the pipeline and crossed below it on the north side of the driveway. The crack in the pipeline was 5 feet from the driveway; the sewer line was 3 feet, 8 inches, from the driveway. The gas service pipeline was on the south side of the driveway. 13

10

http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/fulltext/PAB0801.htm 11 Since this maintenance work was mandated by county code, maybe the county code should also include some standards, so that the work does not cause more problems. 12 A markout is a ground marking that is typically color coded and that indicates the location of underground utilities. 13 This is illustrated in the NTSB report.

Critical Infrastructure disasters 2008 to 2009

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

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM

No gas odor was reported to Dominion before the accident. Several neighbors, and a postal worker, who were on the property 30 minutes before the explosion, stated during post accident interviews that they had not smelled gas before the accident. PUC tested several homeowners to determine whether they could smell the odorant that indicates the presence of natural gas; each was able to smell the odorant at minimum levels. 14 The odorant used was a 50-50 blend of tertiary-butyl mercaptan and tetrahydrothiophene. Dominions records indicate that the odorant was in the piping system, that odorometer tests, conducted before and after the accident, met DOT and Pennsylvania State requirements, and that the odorant level was within prescribed concentrations. No leaks on the 2-inch pipeline had been reported since its installation. The cathodic protection pipe-to-soil potentials were all above DOT requirement15 of 0.85 volts. The pipeline failure was probably rapid since no one had smelled gas 30 minutes before the explosion. The porous backfill for the new sewer line could have provided an easy pathway for gas to migrate into the residence. Additionally, the pipeline crack, at 10 psig, could have quickly allowed a flammable amount of gas to collect within the residence, which had many potential ignition sources. According to Pennsylvania One-Call, the only recorded excavation was the plumbers replacement of the sewer line in 2003. The dents and the deformation in the pipeline indicate that it had been struck from below by something more powerful than a hand shovel. The extent of corrosion observed by NTSB Materials Laboratory is consistent with 5 years of in-ground exposure. Therefore, it is likely that the excavator struck the pipeline with the backhoe, thereby stripping the pipeline of its protective coating and making the pipeline susceptible to corrosion and failure. 16 Dominions explanation for taking 4 hours to shut down the pipelines: The two pipelines were two-way feeds in which pressurized gas flowed from either direction; thus, shutting them down required closing four valves. Two valves closed properly; however, two other valves did not close completely. A Dominion crew had to dig up and fix the faulty valves before they could completely shut off the gas flow. Since the fire department had the fire under control at 2:20 p.m., the 4 hours needed by Dominion to close all four control valves did not increase the severity of the accident. By Nov 2008, Dominion claimed it was adhering to a federal standard that critical valves should be inspected and serviced every calendar year, while
14

This is an important test. The first Al Mac learned of this kind of test being conducted was 2013 Jan 19. Then I incorporated it into my introductory section on what standards I believe should be applied, to learn from past disasters to mitigate future ones. 15 Title 49 Code of Federal Regulations 192.463 requires that a steel gas pipeline have a pipe-to-soil electrical potential that exceeds 0.85 volts. 16 Inspection of valves, whether annually, or once every 5 years, is not going to catch this type of incident. However, if the pipeline has good instruments on what is flowing down the pipe, they may be able to detect the fact that a leak may be occurring. Also I have mentioned elsewhere, the concept of sending tiny robots down the inside of pipes to inspect for leaks. Smaller pipes, like 2 inches, may not be able to handle such robots.

Critical Infrastructure disasters 2008 to 2009

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

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM


non-critical valves would get this every 5 years.

2008 Dec 24 RC = Rancho Cordova CA


Several deficiencies revealed by the NTSB investigation of the San Bruno 2010 Sept 9 incident,17 such as PG&E's poor quality control during the pipe installation and inadequate emergency response, were also factors in the 2008 explosion of a PG&E gas pipeline in Rancho Cordova, California.18 This 2008-Dec-24 incident involved the inappropriate installation of a pipe, which was not intended for operational use, and did not meet applicable pipe specifications. PG&E's response to that event was inadequate; PG&E initially dispatched an unqualified person to the emergency, causing an unnecessary delay in dispatching a properly trained and equipped technician. NTSB concluded that PG&E's multiple, recurring deficiencies are evidence of a systemic problem. 2008 12 24 1.35 pm19 was when Rancho Cordova Ca experienced Pacific Gas & Electric (PG&E) Explosion, Leak Release, and Ignition of Natural Gas. Fatalities: 1 Injuries: 5 Property Damage: $267,000 One house was destroyed at 10708 Paiute Way, adjacent houses severely damaged, other houses in the neighborhood had minor damage. See 2010 May 18 for more info, thanks to NTSB full report on Pacific Gas & Electric (PG&E)s 2008-12-24 Rancho Cordova Ca Explosion and Fire.20 Here is time line immediately before and after the incident.

RC Dec-24 9.16 am+ SOS-A to PG&E HQ


Quoting from the NTSB report, on the day of the Dec-24 explosion:21 9.16 a.m., PG&E received call from 10716 Paiute Way resident reporting gas odor outside her house. Customer service prepared paperwork 22 for dispatching technician to the location.
17 18

See 2011 Aug 30 NTSB report on San Bruno incident. See Explosion, Release, and Ignition of Natural Gas, Rancho Cordova, California, December 24, 2008 , Pipeline Accident Brief NTSB/PAB-10/01 [Washington, DC: National Transportation Safety Board, 2010]. 19 All info in NTSB report, about the Rancho Cordova incident, use Pacific Standard Time. 20 http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/fulltext/PAB1001.htm 21 It is nice that PG&E has a system which time stamps events like this. We can see how long it takes to respond to an incident, how long to react, how they react. However, is PG&E able to function in a natural disaster, when electricity, Internet, phones, etc. are likely down?
22

The Customer Contact Center creates a case number for each customers call.

Critical Infrastructure disasters 2008 to 2009

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

10

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM


9:21 a.m., PG&E dispatched technician to respond to 10716 Paiute Way with a field order to investigate an outside gas leak at a meter. The field order had a zero priority rating, which called for an immediate response. 9:30 a.m., technician entered code into PG&Es field automation system, using her laptop computer, confirming that she had received field order. 9:55 a.m., she entered another code indicating that she was en route to 10716 Paiute Way.

RC Dec-24 10.15 am+ Technician arrives at 10716


10:15 a.m., technician arrived at 10716 Paiute Way, 23 carrying a combustible gas indicator24 across yard to door of the house. o Before reaching door, she picked up natural gas readings in a water box 25 outside the house. Because she had picked up gas readings in the yard, rather than at the house meter as directed in the field order, she decided that she needed assistance and better detection equipment.26 o Technician met resident outside single-story house.27 She interviewed the resident and learned that 10716 resident no longer smelled gas outside her house, as she had when she called in leak earlier that morning. The resident told technician that she did, however, smell gas outside her next-

Then a case ticket, or case ticket package, is prepared for the case number and entered into PG&Es inf system. The case ticket consists of the printed request from the PG&E Dispatch Office, info from customers call, and sometimes a map of pipeline(s) at location to be investigated. The case ticket is used as a reference for all personnel responding, including technician and maintenance personnel.
23

This is approx 1 hour after the first customer report of a gas odor.

24

The combustible gas indicator that the technician carried was a type that can detect gas concentrations between 0 and 5 percent, primarily used to detect gas inside a building. Recall that the customer call had been about gas smelled outside the building. So why did field order direct technician to only be prepared to check inside the building, and at the gas meter? According to NTSB investigation, they found that it is standard practice for PG&E first responder to be a technician who carries a combustible gas indicator with a limited range designed only for indoor leaks. These technicians are not trained to grade outdoor leaks, even when a customer call identifies gas smelled outside a building. I believe it is always possible that a customer can be mistaken about where smell is coming from. How much trouble would it be to train technicians in use of different kinds of gas leak detectors, inside and outside ones, and send them equipped with both?
25

A water box is put on a water line by the water company, and it allows a junction of water lines, a location for a meter, or a way of dispensing water without a hose or a faucet. 26 The NTSB investigation determined, that in accordance with California Public Utilities Commission (CPUC) Utility Standard S6434 and PG&E Utility Work Procedure WP6434-01, Gas Leak Test Using a Combustible Gas Indicator. A technician who is confronted with an outdoor leak is to call Dispatch and request that a maintenance crew be sent to the scene. The maintenance crew is equipped with an ionization detector that can determine the exact leak location outdoors. The operator is also trained to determine the gas migration path. 27 All houses on the street were single-story houses on concrete slabs.

10

Critical Infrastructure disasters 2008 to 2009

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

11

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM


door neighbors house at 10712 Paiute Way, and she pointed out neighbor, who was standing at her 10712 door.28 10:24 a.m., technician spoke to 10712 next-door neighbor, who told technician that she had smelled a gas odor outside her house. Technician then asked 10712 resident to call PG&Es customer service to report a leak in her yard. o Why did the technician not immediately check the situation outside 10712, like she had done at 10716? o PG&E requires a field order to be completed before a technician may proceed to the next work location.

RC Dec-24 10.25 am+ request proper equipment of PG&E HQ


10:25 a.m., technician called PG&Es customer service on a dedicated tele phone line connected directly to Dispatch Office. Technician requested 10716 (first-A) case be forwarded to maintenance and construction department (maintenance) so a maintenance crew could be dispatched to assist with leak investigation. Maintenance crew would be equipped with a flame ionization detector (ionization detector) that can determine the location of a leak and its migration path, 29 whereas the technician only had a device that could deal with an inside leak. 10.28 a.m., PG&E customer service created a maintenance dept case ticket for 10716 Paiute Way. (SOS-A)

RC Dec-24 10.29 am+ SOS-B to PG&E HQ


10.29 a.m., PG&E customer service subsequently received a call from 10712 Paiute Way (SOS-B) resident reporting a strong gas odor outside her house in garage area. This call had been requested by technician initially dispatched to 10716 (A), in response to first call from the neighborhood. 10.32 a.m., recognizing immediate need for assistance from an ionization detector crew, because it was Christmas Eve, and she was unsure how quickly maintenance could dispatch a crew, technician then called Concord Dispatch 30 directly to request that a maintenance crew respond to both 10712 and 10716. 10:35 a.m., technician phoned PG&E customer service directly to request that a maintenance crew be dispatched to 10712 (B) to assist with leak investigation. o Remember how long it took for the first technician to arrive on scene. o 9.16 a.m., the first call from the neighborhood was received by PG&E.

28

There is a street map in the NTSB report. http://www.ntsb.gov/investigations/fulltext/PAB1001.htm The initial report was 10716. The second smell report to a PG&E employee was 10712, which was immediately next door.
29

The ionization detector, which the maintenance crew used, was a full-range detector that can detect gas concentrations between 0 and 100 percent and that is used to detect gas outdoors.

30

Concord Dispatch is for PG&E gas service technicians, and is used only by PG&E personnel. The customer contact center is for customers and others to report gas leaks or other emergencies.

11

Critical Infrastructure disasters 2008 to 2009

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

12

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM


o 10.15 a.m., the first PG&E technician arrived on the scene. o We do not yet know, from investigation report, what was holiday staffing, or condition of roads, due to the holiday, traffic, weather, etc. 10:38 a.m., having requested maintenance support for 10716 (A), the technician completed the field order for 10716 in the field automation system, so that she was then allowed by PG&E rules to respond to the 10712 situation (B), which had to be initiated by the resident calling customer service. o We do not know how long all the following steps took, but it sounds like the technician was pretty proficient at her job (where a big problem was were in sending someone only with inside-detector, to deal with problem correctly reported as being outside), so she would have been doing all this with due diligence speed. o She then entered a code into the system indicating that she was en route to 10712 Paiute Way (B next door). o Technician immediately proceeded to 10712 Paiute Way, knocked on door, and entered house at invitation of female resident. o Technician did not detect any gas inside 10712 house, with exception of a small, fuzz, leak at water heater, which was eliminated by tightening a fitting on the unit. o Next, technician went to garage where she smelled a little whiff of natural gas. o She then went back into kitchen to investigate further and met male resident, who indicated that source of leak was in his next-door neighbors yard.31 o The resident led technician outside and into yard of 10708 Paiute Way. (third house to come to PG&E attention)

RC Dec-24 time uncertain Technician finds gas leak


o Once in 10708 yard, technician detected a natural gas leak at a patch of dead grass in middle of the yard. Location of leak was about 5 feet west of driveway, about 45 feet from house. Technician checked gas meter at 10708 Paiute Way for leaks but did not find any. o After finding leak in 10708 yard and while returning to some houses to finish uncompleted clock tests,32 technician was evaluating terrain and her gas readings to try to judge migration path of natural gas. None of clock tests on the three houses showed excessive flow across meters. o Technician knocked on door of 10708 Paiute Way in an attempt to gain entry and determine whether any leaks existed inside the house, but she received no answer. She then returned to her truck, parked it on opposite side of street between 10712 and 10716 Paiute Way, facing in direction of 10708 Paiute Way, and waited beside it.

31 32

Next door, on same side of the street as 10712, could be 10716 or 10708. A clock test is used to determine whether there is unusual or excessive gas leakage inside a house. A gas service technician watches the gas meter to see how much gas is flowing per unit of time (typically, the number of cubic feet over 10 minutes).

12

Critical Infrastructure disasters 2008 to 2009

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

13

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM


Remember why the technician did not immediately check the situation outside 10712, like she had done at 10716, after learning that there was a problem there? PG&E requires a field order to be completed before a technician may proceed to the next work location, and for an investigation to be initiated by a call from the residents of where the problem was, now found at 10708, but they were not home. So theres a problem here with the system. She has found a serious leak, but with no one home at 10708, she needs better guidance from her supervisors, how to deal with the situation. She did not contact the fire department to request entry into the house, nor did she place signs on the doors, or string up tape to warn residents that entry could be hazardous. We do not yet know, from this investigation, whether she was authorized by PG&E to take such action. Technician later told investigators that she had become increasingly concerned about the leak at the time. As a result, over the next half-hour she made several phone calls to the PG&E customer service, the maintenance department, Concord Dispatch, and the responding leak investigator in an attempt to determine whether the maintenance crew was en route and its estimated arrival time. I am guessing this would have taken us to near 11.30 a.m., depending on how efficiently the technician had performed her duties so far. She had got to the scene 1 hour after the first call from the neighborhood. She had called to request the maintenance crew at 10.35 a.m.

o o o

RC Dec-24 10.41 am+ PG&E maintenance dispatching begins


10.41 a.m., field man was contacted, and dispatched to 10716 scene by the maintenance supervisor. 10:42 a.m., maintenance supervisor acknowledged second 10716 case ticket (for maintenance to aid first technician at first SOS) and dispatched a field man, a leak investigator, and a foreman to the scene. 10.42 a.m., leak investigator was contacted, and dispatched to 10716 scene by maintenance supervisor. 10.42 a.m., customer service created a case ticket for 10712 Paiute Way (SOS-B), in response to second customer call from neighborhood, a call which technician had asked that customer to make, after hearing about gas smelled outside second home, but before learning from other occupant of second house, about situation at third house.

RC Dec-24 11.11 am+ SOS-C to PG&E HQ


11:11 a.m., technician called Concord Dispatch to request a field order for 10708 Paiute Way. The field order documented leak in the front yard and that there was no excessive flow on the gas meter.

13

Critical Infrastructure disasters 2008 to 2009

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

14

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM


11:17 a.m., technician called PG&E customer service to request that the 10708 Paiute Way case be forwarded to maintenance department so a crew could be dispatched to the scene to assist with leak investigation. o Time is now 2 hours after original SOS received by PG&E. 11.22 a.m., customer service created a case ticket for 10708 Paiute Way. 11:26 a.m., maintenance department acknowledged the 10708 case. 11.30 a.m., maintenance department leak investigator arrived at PG&E service center to pick up ionization detector, but had problems with his truck brakes, which forced him to acquire another truck, and delayed his departure to Paiute Way. o He called technician three times, but he did not notify his supervisor, nor Dispatch, of his delay. o We do not yet know, from the investigation, whether the leak investigator was required, under PG&E rules, to inform HQ of his situation. 11:49 a.m., technician noted in 10712 Paiute Way field order (SOS-B) that it appeared that the leak was in vicinity of patch of dead grass in front yard of 10708 Paiute Way. After completing this in field automation system, technician made several calls to co-workers in an effort to determine status of responders. One of the gas service supervisors she spoke with, advised her to stay on scene until she was relieved by the maintenance department. Noon approx, residents of 10708 come home. They had not been home at time of technician knocking on the door. 12.30 p.m., foreman was contacted, and dispatched to first 10716 scene by maintenance supervisor. This was almost 2 hours after his services had been requested. 12.42 p.m., leak investigator left PG&E service center more than an hour after his arrival there.

RC Dec-24 1.14 pm+ Maintenance arrives


1.14 p.m., foreman arrived on scene, parked his truck behind technicians truck, and they had a brief discussion. o Technician told foreman that none of the clock tests showed excessive flow across the meter, and told him locations where she obtained gas readings, and smelled gas. She also told him that there was a leak in 10708 Paiute Way yard, but that she had been unable to gain entry into the house. o Foreman relieved technician, and she left the scene. o Leak investigator (equipped with the ionization detector) arrived a few minutes after the foreman, 2 hours 47 minutes since technician had called Concord Dispatch to request specialized equipment to locate leak. Field man arrived immediately after leak investigator; both parked near foremans truck. o Foreman asked leak investigator to display plat 33 on his laptop computer. Foreman and field man reviewed plat, then located and marked service

33

The plat is a map that shows the locations of the main and service pipelines.

14

Critical Infrastructure disasters 2008 to 2009

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

15

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM


pipelines and a portion of main pipeline with paint and flags. While foreman and field man were marking pipelines, leak investigator prepared ionization detector at his truck. 1:27 p.m., leak investigator was attempting to locate leak on main pipeline using ionization detector when a neighbor walked up to foreman and field man and told them that a leak in vicinity had been fixed once before. He was not sure of exact location of repair, but he said that he remembered that PG&E had dug two holes. Foreman then noticed sunken ground at two ends of yard at 10708 Paiute Way. 1:34 p.m., leak investigator located dead grass in front yard of 10708 Paiute Way and walked westward over main pipeline between two patches of sunken ground. o Ionization detectors initial reading was 60,000 parts per million. o Reading increased to 80,000 parts per million as leak investigator continued to walk westward. o When he reached location of leak, the device flamed out, meaning the flame of the ionization detector went out, and an alarm sounded. The flame-out signaled that the gas-to-air mixture was too rich to burn (that is, there was too much natural gas with the volume of air in the intake), which is indicative of a leak. o The three PG&E employees then agreed that they had identified leak location, and they discussed likelihood of its being a subsurface leak.

RC Dec-24 1.35 pm+ Explosion


1:35 p.m., foreman went to his truck to get a probe and to prepare for use another type of gas detector, a combustible gas indicator that helps pinpoint leaks. o Meanwhile, leak investigator knocked on door of 10708 Paiute Way and talked with a resident. When they had finished talking, he turned away from 10708 to begin further investigation, and the house exploded. o The homeowner sustained fatal injuries as a result of the explosion. o Dec-29, a Sacramento Metropolitan Fire Dept investigator interviewed the 17-year-old granddaughter of owner of 10708 Paiute Way at Shriners Hospital for Children. According to fire dept, granddaughter stated that her grandfather had told her of a gas odor in the house before she and her grandfather arrived home about 12:00 p.m. on December 24, 2008, and that she had smelled a strong odor of gas both outside and inside the house.34 She said that PG&E leak investigator had knocked on front door and that her grandfather and leak investigator had gone outside. She went into bathroom; shortly thereafter she heard a whoosh and two explosions, and she immediately escaped to the street. o That is one story, from someone recovering from a traumatic event. Here is another version.

34

But had they told PG&E about it before the incident arrived?

15

Critical Infrastructure disasters 2008 to 2009

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

16

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM


o January-15, lawyer for 10708 Paiute Way family provided information on behalf of the granddaughter in response to additional questions from National Transportation Safety Board (NTSB) investigators. According to lawyer info, granddaughter had not smelled gas inside house at any time. She stated through lawyer that she had arrived home shortly before noon and did not see any PG&E vehicles or personnel, nor did she see any kind of notice on door prohibiting entrance before PG&E could check the premises for gas. She also stated that PG&E leak investigator had not requested entry into house to check for gas. 1:35 p.m., two Rancho Cordova police officers heard a very loud noise that sounded like an explosion, and they immediately notified their dispatch center, which was the Sacramento County Sheriffs Department Dispatch. o After hearing from Sheriffs Dispatch that there had been calls about a possible explosion and learning of possible location of incident, the police officers drove toward the area. o While en route, the officers heard multiple units of the Sacramento Metropolitan Fire Department dispatched to an explosion.

RC Dec-24 1.43 pm+ First Responders arrive


1.43 p.m. first responders arrived on scene. As the fire department worked to extinguish the fire, paramedics prepared the injured for transport. There were six injured, 2.00 p.m., all injured had been transported to hospital. PG&E supervisors, and fire dept, verified that there was an active gas leak near explosion site. 2.04 p.m. an evacuation was enforced 10 houses away from the explosion site in both directions. Dec 25, 5.03 a.m., fire dept concluded tactical response, when evacuation was lifted.

2009 July 30 Bryan Texas


A plant in Bryan, Texas (El Dorado Chemical Company), which processes ammonium nitrate into fertilizer, caught fire at about 11:40 am. Over 80,000 residents in the Bryan/College Station area were asked to evacuate south of town due to the toxic fumes this fire generated. Texas A&M University provided shelter at Reed Arena, a local venue on campus. Only minor injuries were reported.35

2009 Oct 14 NTSB on Dixie in Carmichael MS


2009 10 14 was when NTSB summary report36 came out. See 2007 11 01 for the pipeline rupture and fire event.

35 36

https://en.wikipedia.org/wiki/Ammonium_nitrate_disasters http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/summary/PAR0901.htm

16

Critical Infrastructure disasters 2008 to 2009

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

17

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM

Dixie Carmichael Probable Cause and Safety Issues


National Transportation Safety Board (NTSB) determined that probable cause of Nov 1, 2007, rupture of liquid propane pipeline operated by Dixie Pipeline Company near Carmichael, Mississippi, was failure of a weld which caused the pipe to fracture along: the longitudinal seam weld, a portion of the upstream girth weld, and portions of the adjacent pipe joints.

Safety issues were identified as a result of the investigation of this accident:


Failure mechanisms and safety of low-frequency electric resistance welded pipe, Adequacy of Dixie Pipeline Companys public education program, Adequacy of federal pipeline safety regulations and oversight exercised by the Pipeline and Hazardous Materials Safety Administration (PHMSA) of pipeline operators public education and emergency responder outreach programs, and Emergency communications in Clarke County, Mississippi.

Safety recommendations to the Pipeline and Hazardous Materials Safety Administration (PHMSA), the Dixie Pipeline Company, the American Petroleum Institute, and the Clarke County Board of Supervisors are included in the report.

NTSB Recommendations re: Carmichael MS incident


As a result of its investigation of the Nov 1, 2007, rupture of the liquid propane pipeline operated by Dixie Pipeline Company, NTSB makes the following recommendations: To the Pipeline and Hazardous Materials Safety Administration: (PHMSA) Conduct a comprehensive study to identify actions that can be implemented by pipeline operators to eliminate catastrophic longitudinal seam failures in electric resistance welded (ERW) pipe; at a minimum, the study should include assessments of the effectiveness and effects of in-line inspection tools, hydrostatic pressure tests, and spike pressure tests; pipe material strength characteristics and failure mechanisms; the effects of aging on ERW pipelines; operational factors; and data collection and predictive analysis. (P-09-1) Based on the results of the study requested in Safety Recommendation P-09-1, implement the actions needed. (P-09-2) Initiate a program to evaluate pipeline operators' public education programs, including pipeline operators' self-evaluations of the effectiveness of their public education programs. Provide the National Transportation Safety Board with a timeline for implementation and completion of this evaluation. (P-09-3)

17

Critical Infrastructure disasters 2008 to 2009

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

18

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM

To the Clarke County Board of Supervisors: Require and document that the Clarke County Central Dispatch emergency 911 personnel receive regular training and participate in regional exercises and drills pertaining to pipeline safety. (P-09-4) To the American Petroleum Institute: Revise American Petroleum Institute Recommended Practice 1162 to explicitly identify 911 emergency call centers as emergency response agencies to be included in outreach programs under a pipeline operator's public education program. (P-09-5) To Dixie Pipeline Company: Take measures to determine that all residences and businesses within your operating regions are included on your mailing list and receive mailings of safety guidance information. (P-09-6) Implement procedures to evaluate the effectiveness of your public education program. (P-09-7) Verify that all 911 emergency centers within your operating regions are included on your mailing list, invited to participate in operator-sponsored training activities, and receive mailings of safety guidance information. (P-09-8)

Continued in more documents


Time Line of these disasters to be continued in related documents to be named: CI Boom 0 thru 199937 CI Boom 2000 to 200638 CI Boom 200739 CI Boom 2008 to 2009 CI Boom 2010 to 2011 CI Boom 201240 CI Boom 2013 Jan-Mar41 CI Boom 2013 Apr42 CI Boom 2013 May-Dec CI Boom 2014 Jan W Va Water43

37 38

http://www.scribd.com/doc/203317455/CI-Boom-0-thru-1999 http://www.scribd.com/doc/203688481/CI-Boom-2000-to-2006 39 http://www.scribd.com/doc/204262969/CI-Boom-2007 40 http://www.scribd.com/doc/204042682/CI-Boom-2012 41 http://www.scribd.com/doc/204889417/CI-Boom-2013-Jan-to-March 42 http://www.scribd.com/doc/204575461/CI-Boom-2013-April 43 http://www.scribd.com/doc/203973261/CI-Boom-2014-Jan-9-W-Va-Water

18

Critical Infrastructure disasters 2008 to 2009

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

19

Critical Infrastructure disasters 2008 to 2009 2/12/2014 11:01:32 AM

These other time line history segments shall be uploaded to the same SCRIBD Critical Infrastructure collection.44 Revision history will be maintained in the main parent document.

44

http://www.scribd.com/collections/4108500/Critical-Infrastructure

19

Critical Infrastructure disasters 2008 to 2009

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

You might also like