Pointing the finger of blame squarely on the operator and regulators, federal safety officials at a meeting of the National Transportation Safety Board (NTSB) last Tuesday in Washington, DC, described last September’s fatal San Bruno, CA, natural gas transmission pipeline rupture and explosion as preventable and resulting from systemic “flawed” pipeline operations and regulatory oversight.

The rupture last year was caused by none of the usual suspects when it comes to high-pressure natural gas transmission pipeline failures, NTSB made clear in its final report adopted by the five-member panel. An explosion and ensuing fire that killed eight people and devastated a residential neighborhood about 10 miles south of San Francisco was not caused by corrosion or damage from a third-party contractor — the two most common causes. And in the earthquake-prone California suburban Bay Area region, ground movement played no part either, NTSB investigators told the five board members.

“Multiple, recurring deficiencies over many years indicate a systemic problem at PG&E,” NTSB Chairperson Deborah Hersman said.

In adopting 28 findings, a probable cause of lax utility work dating back 54 years, and 26 recommendations, the NTSB was unsparing in its criticism of the industry, federal and state regulators. The criticisms were directed among the U.S. Department of Transportation (DOT) (two); the Pipeline Hazardous Materials and Safety Administration (PHMSA, 13); governor of California (one); California Public Utilities Commission (CPUC, two); and Pacific Gas and Electric Co. (PG&E, eight).

Subsequently, during a discussion among the members, recommendations were added to require reports from the American Gas Association (AGA) and the Interstate Natural Gas Association of America, accounting for what their members and industry as a whole are doing to advance pipeline safety.

PG&E utility President Christopher Johns said the utility “embraces the recommendations and will incorporate them into our plans. Although we still have much to learn and do, we have already taken many immediate and long-term steps to promote safety.”

Noting that state regulators plan to complete an audit of PG&E’s integrity management pipeline safety program, CPUC Executive Director Paul Clanon said the agency will evaluate the NTSB’s specific recommendations and that by the end of this year the commission plans to adopt “a citation program” giving the staff ability to fine gas pipeline operators immediately if a violation is found.

Watchdog group The Utility Reform Network (TURN) urged the CPUC to reverse course and hold PG&E accountable by holding the utility to “a higher standard.” TURN called PG&E’s reaction to San Bruno a “slow, confused response.”

AGA last week commended NTSB for “providing further insight into how Pacific Gas & Electric and the entire pipeline industry can ensure such an accident never happens again.” The association added that the findings will allow it and its member companies “the opportunity to reinforce their ongoing commitment to enhancing the safety of the nation’s natural gas utilities and their customers.”

It was clear in the discussions and in the closing comments that the NTSB intends for regulation of the gas pipeline industry to be stepped up considerably on a national basis. They called for the DOT to audit the current effectiveness of PHMSA and make changes as appropriate.

“In the pipeline industry there must be effective oversight and strong enforcement,” said Hersman, who lamented the fact that in moving to integrity management programs federal oversight had shifted from “prescriptive regulation to performance-based regulation.” Her concern is that the performance-based approach places too much reliance on the operator’s integrity and often leaves regulators in a position in which they “really don’t know what is going on.”

Citing pipeline tragedies preceding San Bruno, Hersman said “multiple, recurring deficiencies over many years illustrate systemic problems at PG&E.” For regulators to do their jobs properly, she said, they “cannot trust [operators] alone; they must also verify. As we saw in San Bruno, when the oversight is lax, the consequences can be deadly.”

Specifically, the report concluded that the failed pipeline segment in San Bruno had been flawed since its installation in 1956, as was the installation by PG&E. Contributing to the failure was a badly flawed pipeline integrity management program that led to an “organizational failure,” which has continued for decades.

In listing more than four dozen findings and recommendations in the year-long investigation, an NTSB investigator told Hersman and her colleagues that “seismic activity was not a factor, nor was corrosion, direct third-party damage, or drug use at the [PG&E] Milpitas [pipeline control] terminal.” Allegations and suspicions had surrounded 2008 city sewer installation work near the site of the San Bruno pipe blast, but that was thoroughly studied and rejected, according to the NTSB report.

Instead, the federal report concluded that “…the rupture of Line 132 was caused by a fracture that originated in the partially welded longitudinal seam of one of six short pipe sections, which are known in the industry as ‘pups.’ The fabrication of five of the pups in 1956 would not have met generally accepted industry quality control and welding standards then in effect, indicating that those standards were either overlooked or ignored.” It also found that the “weld defect in the failed pup would have been visible when it was installed. [Separately,] an investigation also determined that a sewer line installation in 2008 near the rupture did not damage the defective pipe.”

One of the key conclusions was that PG&E’s inadequate and inaccurate record-keeping made it impossible for the utility to have an effective pipeline integrity management program. As a result, the system understated threats and caused the utility to select the wrong tests for the pipeline segment (Line 132) that failed at a pressure below its maximum allowable operating pressure (MAOP), the NTSB said.

A focus of the investigation was on one of six so-called pups that involved a number of welding defects that failed. A troubling conclusion, however, was that there is no way of knowing how extensive similar pups are in the PG&E system of 5,700 miles of transmission pipeline because the source of these welds and segments is unknown, based on the utility’s flawed record-keeping system.

PG&E said it was “grateful” to the NTSB in helping it “improve” its natural gas operations, along with listing seven actions it is already taking to the goal of “assuring that such an accident never happens again.”

Concerns going forward include greatly changed behavior by PG&E, the CPUC and PHMSA, along with a continuing concern about “how many other San Brunos” are simmering unnoticed around the nation’s 2.5 million-mile network of gas pipelines, NTSB members said.

“Today, [we heard] some troubling revelations about a company that exploited weaknesses in a lax safety system and a system of oversight,” Hersman said. She referred to government agencies placing a “blind trust” in PG&E “to the detriment of public safety.”

NTSB also concluded that PG&E’s response to the pipeline explosion in San Bruno was woefully inadequate. While praising local first responders from the San Bruno police and fire department for being on the scene within minutes of the rupture, NTSB said the utility took 95 minutes to stop the gas flow. “PG&E lacks a detailed and comprehensive procedure for responding to large-scale emergencies such as a transmission pipeline break,” the NTSB report said. Instead of ensuring safety in the pipeline system, PG&E’s pipeline integrity management program was “deficient and ineffective” because of at least five factors:

Most damning of all, and Hersman repeated it several times during nearly six-hour NTSB board meeting, PG&E failed to learn from two earlier NTSB-investigated pipeline incidents — the 1981 San Francisco rupture and the recent 2008 distribution pipeline break in the Sacramento suburb of Rancho Cordova.

“Several deficiencies revealed by the NTSB investigation [of Rancho Cordova] — such as PG&E’s poor quality control during the pipe installation and inadequate emergency response — were factors in the 2008 explosion. The 2008 accident involved the inappropriate installation of a pipe that was not intended for operational use and did not meet applicable pipe specifications. PG&E’s response to that event was inadequate.”

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