CI Boom 2008 To 2009
CI Boom 2008 To 2009
CI Boom 2008 To 2009
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
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,
http://www.scribd.com/doc/114094060/Indy-Boom
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.
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.
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.
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
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
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.
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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.
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
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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.
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?
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The Customer Contact Center creates a case number for each customers call.
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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.
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This is approx 1 hour after the first customer report of a gas odor.
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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?
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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.
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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.
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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.
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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.
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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).
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The plat is a map that shows the locations of the main and service pipelines.
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But had they told PG&E about it before the incident arrived?
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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.
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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)
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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.
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http://www.scribd.com/collections/4108500/Critical-Infrastructure
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