NTSB -- NTSB SAFETY RECOMMENDATION P-11-24 through -31

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NTSB SAFETY RECOMMENDATION

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National Transportation Safety Board

Washington, DC 20594

September 26, 2011

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Safety Recommendation P-11-24 through -31

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The National Transportation Safety Board makes the following recommendations to the Pacific Gas and Electric Company:

Revise your work clearance procedures to include requirements for identifying the likelihood and consequence of failure associated with the planned work and for developing contingency plans. (P-11-24)

Establish a comprehensive emergency response procedure for responding to large-scale emergencies on transmission lines; the procedure should (1) identify a single person to assume command and designate specific duties for supervisory control and data acquisition staff and all other potentially involved company employees; (2) include the development and use of trouble-shooting protocols and checklists; and (3) include a requirement for periodic tests and/or drills to demonstrate the procedure can be effectively implemented. (P-11-25)

Equip your supervisory control and data acquisition system with tools to assist in recognizing and pinpointing the location of leaks, including line breaks; such tools could include a real-time leak detection system and appropriately spaced flow and pressure transmitters along covered transmission lines. (P-11-26)

Expedite the installation of automatic shutoff valves and remote control valves on transmission lines in high consequence areas and in class 3 and 4 locations, and space them at intervals that consider the factors listed in Title 49 Code of Federal Regulations 192.935(c). (P-11-27)

Revise your postaccident toxicological testing program to ensure that testing is timely and complete. (P-11-28)

Assess every aspect of your integrity management program, paying particular attention to the areas identified in this investigation, and implement a revised program that includes, at a minimum, (1) a revised risk model to reflect the Pacific Gas and Electric Company’s actual recent experience data on leaks, failures, and incidents; (2) consideration of all defect and leak data for the life of each pipeline, including its construction, in risk analysis for similar or related segments to ensure that all applicable threats are adequately addressed; (3) a revised risk analysis methodology to ensure that assessment methods are selected for each pipeline segment that address all applicable integrity threats, with particular emphasis on design/material and construction threats; and (4) an improved self-assessment that adequately measures whether the program is effectively assessing and evaluating the integrity of each covered pipeline segment. (P-11-29)

Conduct threat assessments using the revised risk analysis methodology incorporated in your integrity management program, as recommended in Safety Recommendation P-11-29, and report the results of those assessments to the California Public Utilities Commission and the Pipeline and Hazardous Materials Safety Administration. (P-11-30)

Develop, and incorporate into your public awareness program, written performance measurements and guidelines for evaluating the plan and for continuous program improvement. (P-11-31)

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http://www.ntsb.gov/doclib/recletters/2011/P-11-024-031.pdf

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The complete recommendation letter is available on the Web

at the URL indicated above.

The letter is in the Portable Document Format (PDF) and can

be read using the Acrobat Reader 5.0 or later from Adobe

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An archive of recommendation letters is available at

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Electronic versions of letters may or may not include enclosures; however, related publications, accident

briefs, and aviation accident synopses may be found

on the NTSB website.

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