National Transportation Safety Board
Office of Public Affairs
Washington, DC - The National Transportation Safety Board has determined that the rupture of a gasoline pipeline in Washington State in 1999 was probably caused by a number of factors, including excavation damage and inadequate inspection. The rupture and subsequent fire killed 3 people.
On June 10, 1999, a 16-inch-diameter steel pipeline owned by Olympic Pipe Line Company ruptured and released about 237,000 gallons of gasoline into a creek that flowed through Whatcom Falls Park in Bellingham, Washington. About 90 minutes after the rupture, the gasoline ignited and burned approximately 1 ½ miles along the creek. Two 10-year-old boys and an 18-year-old man died as a result of the accident; eight additional injuries were documented. A single-family residence and the city of Bellinghams water treatment plant were severely damaged.
Prior to the accident, the controller operating the accident pipeline rerouted
product flow from one facility into another. As the delivery points were switched,
pressure in the accident pipeline began to build back upstream. As a consequence
of this rising pressure in the pipeline, a block valve at Bayview (about 23
miles downstream from accident site) closed, completely blocking the flow of
product through the pipeline. This caused a pressure increase upstream towards
Bellingham where the pipeline ruptured. Simultaneous to this event, the supervisory
control and data acquisition system (SCADA) system that controllers used to
operate the pipeline became unresponsive, preventing the controller from starting
the additional pumps necessary to alleviate the pressure backup. Also, because
of the problems with the SCADA system, the rupture was not promptly recognized
by the controller who restarted the pipeline.
Based on information learned during its investigation, the NTSB determined that the probable cause of the accident was the damage done by an IMCO construction crew while conducting modifications to a water treatment plant and Olympic Pipe Line Companys inadequate inspection of work during the construction project. Investigators found that had the accident pipeline not been weakened by external damage, it likely would have been able to withstand the increased pressure that occurred on the day of the rupture, and the accident would not have happened. In addition was Olympic Pipe Line Companys inaccurate evaluation of in-line pipeline inspection results, which led to the companys decision not to excavate and examine the damaged section of pipe.
Other elements of the Boards findings of probable cause were: Olympics failure to test all safety devices associated with the Bayview products facility before activating the facility, Olympics failure to investigate and correct the conditions leading to the repeated unintended closing of the Bayview inlet block valve, and the companys practice of performing other duties on the SCADA system while it was being used to operate the pipeline. The last element led to the systems becoming non-responsive at a critical time during pipeline operations.
As part of its investigation, Safety Board investigators reviewed the operations
of the SCADA system, which operates and controls the pipeline. It consists of
field sensors and actuators, remote terminal units, a communications link, and
the main SCADA computer. Field sensors and actuators include pumps, valves,
temperature monitors, flow meters, and other devices for measurement of field
data and the signal input/output to those devices. The remote terminal units
collect signals from the field hardware and convert them to digital signals
for transmission to the control center.
In its findings cited in the report, the Board noted that if the SCADA system computers had remained responsive to the commands of the Olympic controllers, the controller operating the accident pipeline probably would have been able to initiate actions that would have prevented the pressure increase that ruptured the pipeline. The Board also noted that had the SCADA database revisions performed prior to the accident been adequately performed and tested, errors resulting from those revisions may have been identified and repaired before they could have had an affect on the operation of the pipeline. Overall, the development, implementation, and protection of Olympics SCADA system was not adequately managed.
As a result of the accident investigation, the Safety Board made the following
recommendations to the Research and Special Programs Administration:
· Issue an advisory bulletin to all pipeline operators who use SCADA systems, advising them to implement an off-line workstation that can be used to modify their SCADA system data base or to perform developmental and testing work independent of their on-line systems. Advise operators to use the off-line system before any modifications are implemented to ensure that those modifications are error-free and that they create no ancillary problems for controllers responsible for operating the pipeline.
· Develop and issue guidance to pipeline operators on specific testing procedures that can (1) be used to approximate actual operations during the commissioning of a new pumping station or installation of a new relief valve, and (2) be used to determine, during annual tests, whether a relief valve is functioning properly.
A summary of this report is available on the NTSB Web site at http://www.ntsb.gov, under Publications; the complete report will also be posted at that location in about a month. Printed copies will be available for purchase through the National Technical Information Service.
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The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause
of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.