Thank you, Dave [McCurdy],
for that kind introduction, and thanks to AGA for inviting me to speak today on
behalf of the NTSB at your Executive Leadership Safety Summit. I am particularly pleased to be here because
it gives me an opportunity to give kudos to AGA regarding some progressive
actions it has taken to improve safety.
But before I do that,
let me give you a brief introduction about the NTSB and what we do, for those
of you who may not already know. The
NTSB investigates accidents in all modes of transportation, including
transportation by pipeline. We determine the probable cause of the accidents
and make recommendations in hopes of preventing recurrences.
Because we are not
regulators, we can’t require anybody to follow our recommendations. Nonetheless, it is a testament to our amazing
staff of investigators and our amazing staff of analysts that more than 4 out
of 5 times, the recipients of our recommendations consider them to be very
sound ideas for improving safety, and they act on them favorably.
Now to AGA’s
progressive actions to improve safety. Let’s
start with having this meeting of industry leaders, which demonstrates your
awareness that successful safety improvement programs must have support from
the top. Then there’s inviting us to
speak, which demonstrates your desire to inform your safety improvement process
with lessons learned from accident investigations.
So let’s talk about
what we’re learning from our investigations.
One lesson we are learning is that as the industries we investigate are
becoming safer, which they generally are, they face two challenges.
The first challenge is
that as safety improves, complacency often rears its ugly head. That’s not a criticism, but simply an
observation of human nature. \\
If we haven’t had an
accident recently, we can easily fall into the trap of thinking that we’ve got
this safety stuff figured out, so we often become less vigilant about noticing,
and reacting to, potentially troubling signals that can be warning signs and
harbingers of a future accident. That is
particularly easy to do if the signals are “weak” rather than glaring. Safety, however, is not a destination, not
something that we will ever reach and be done with, but a continuing journey.
The second challenge
is that as our safety improves, and as we’ve taken care of the “low hanging
fruit,” it becomes ever more challenging to continue improving safety. Continuing improvement of safety often
necessitates thinking out of the box and creating new improvement processes,
rather than tweaking or strengthening previous processes. The fact that a process has worked well to
improve safety in the past does not necessarily mean that it will be continue
to be effective in the future. Even
processes that have worked very well in that past may, with time and in
changing environments and circumstances, become obsolete and ineffective.
Today I would like to
focus on this second challenge of continuing to improve safety – the need for
“out of the box” thinking. In that vein,
I would like to give AGA kudos for two ways in which you have progressively thought
“out of the box:,” namely, commencing with safety management systems, and implementing
a peer review program.
Let’s start with
safety management systems. We have
recommended safety management systems in all transportation industries. With an effective SMS in place, an
organization not only takes reactive actions as a result of incidents and
accidents that have already happened. The organization also takes proactive
actions, actively seeking to identify hazards. Ideally, an effective SMS can
result in analysis of system processes and the environment to identify
potential and future problems and thus create a predictive aspect.
The SMS recommendation
that I’ll talk about today resulted from the oil pipeline release from an
Enbridge pipeline in Marshall, Michigan in 2010.
In Marshall, an oil
pipeline ruptured during the last stages of a planned shutdown. The rupture was
not discovered for more than 17 hours, during which there were two attempts to
restart the pumps. More than 840,000 gallons of crude oil was released, and more
than 80 percent of that was pumped into the line after the rupture occurred.
The oil saturated the
surrounding wetlands and flowed into the Talmadge Creek and the Kalamazoo River,
and local residents self-evacuated. As
of last year, cleanup costs had reached $1.2 billion, making it the most costly
cleanup involving an on-shore oil spill in US history.
By any measure, this
was a disastrous rupture. We found
safety deficiencies in Enbridge’s integrity management program, control center
staff training, leak detection processes, and emergency response and leak
We made several
recommendations to Enbridge, and I am pleased to note not only that they
cooperated with us very well in the investigation itself, which helped us
identify what caused the release, but they have also put a great deal of hard
work into implementing our recommendations.
What I would like to
talk about today is not our recommendations to Enbridge, but another very
important recommendation that came out of the investigation – a recommendation
that applies to all pipeline operators. This recommendation was directed to the
American Petroleum Institute, and it reads as follows:
Facilitate the development
of a safety management system standard specific to the pipeline industry that
is similar in scope to your Recommended Practice [RP] 750, Management of Process Hazards. The development should follow the
established American National Standards Institute requirements for standards
As many of you know, the
result of this recommendation was API’s creation of ANSI/API Recommended
Practice (or RP) 1173, Pipeline Safety
We generally endeavor
in our recommendations to set the bar pretty high and encourage “stretch”
thinking, so very rarely do recommendation recipients exceed what we recommend.
Thus, I am pleased to report that when API issued RP 1173, we closed our
recommendation as “exceeds recommended action.”
The API not only met our
recommendation but exceeded it, by setting forth in RP 1173 a framework for
continuous improvement in pipeline transportation safety. So what does this
have to do with you? What it has to do
with you is that AGA deserves a large share of the credit for this result. Kudos to Kate Miller, who represented the AGA
in the development process. Many AGA member companies were also on the
committee that drafted – and re-drafted – this standard. Not to be satisfied with merely creating the standard,
AGA is also promoting and facilitating the adoption of RP-1173 throughout the
gas pipeline industry. Many AGA member companies are now engaging in a pilot
implementation of the standard. They are committed to communicating with each
other throughout the pilot period and sharing their stories with other AGA
member companies at the conclusion of the pilot.
In drafting RP-1173,
API collaborated broadly across the pipeline industry. In addition to operators
of both gas and oil pipelines, and associations such as AGA and INGAA, API also
involved the regulator – PHMSA – and invited the NTSB to attend meetings in an
observer role. Representatives of the public with expertise in pipelines were
at the table, as were representatives of two state corporation commissions.
The idea was for everybody
who had a stake in the problem to have a voice in the solution.
We have seen the
enormous power of collaboration in other industries, most notably in commercial
aviation. Their fatal accident rate,
after declining marvelously for several decades, began to “flatten out” on a
“plateau” in the early 1990’s.
Meanwhile, the FAA was projecting that commercial aviation volume would
double in the next 15-20 years. It
didn’t take very advanced math to realize that doubling the volume, but
maintaining the same fatal accident rate, meant that the public would soon see
twice as many fatal accidents.
With the prospect of
twice as many accidents looming, the industry did something it had never done
before – work collaboratively to identify potential safety issues, prioritize
them, develop remedies, and evaluate whether the remedies were working. The collaboration, which operates under the
name CAST, or Commercial Aviation Safety Team, included the operators, the
manufacturers, pilots, air traffic controllers, and yes, even the regulator. Bringing together all of these factions of
the industry, with their differing and sometimes competing interests, was a
major challenge for a variety of reasons.
The challenge was
definitely worth it, however, and the CAST process has been a huge success. It resulted
not only in a reduction of the stuck, flat fatal accident rate by more than 80
percent in its first ten years, but productivity was improved as well. This flew in the face of conventional wisdom,
that improving safety usually undermines productivity, and vice versa. If that weren’t enough, it was also a success
regarding another issue that commonly attends efforts to make changes in
complex systems, namely, unintended consequences. With everyone at the table, unintended
consequences have been minimized.
This airline industry
collaboration was enabled, in part, by a cultural characteristic of that
industry that I believe your industry shares as well, namely, that anyone’s
accident is everyone’s accident. The
flying public is not assuaged by the knowledge that an accident occurred on
Airline X, but they are about to travel on Airline Y. To the contrary, the public is concerned even
by a German airplane crashing in the French Alps. Similarly, the public does not focus on which
pipeline operator suffered a release, or even whether the release involved oil
or gas. To the contrary, the public
forms a collective, negative image of pipeline energy transportation that
intensifies with every accident. I
suspect that your ability to collaborate in creating RP 1173 was helped
somewhat by this cultural characteristic.
Bottom line: kudos to you for your role in creating RP
1173, and I look forward to yet another example of the enormous power of
Now I’d like to move
to another example of progressive safety improvement thinking, and this one is
more specific to AGA: The peer review
As I have noted, RP
1173 resulted from one of our recommendations.
We have not, however, made any recommendations about the peer review
process. Nonetheless, I would like to
think that we played a role in it because after the gas pipeline explosion in San
Bruno, we had a very frank meeting with senior AGA representatives. One of the questions that we raised at that
meeting was whether AGA looked to other industries to learn about best
practices in safety. Our question was
essentially met with silence.
After that meeting, AGA
began actively reaching out to other industries. One that they reached out to was the nuclear
power industry. Nuclear power is
certainly another industry in which anyone’s accident is everyone’s accident,
and because of the accident at Three-Mile Island in 1979, they created a
collaborative organization called the Institute of Nuclear Power Operations, or
INPO. INPO demonstrated the power of collaboration long before the airline
industry started CAST. One of the many practices
that INPO instituted was peer review, which at that time was largely
INPO’s peer review
process enables a review of one nuclear plant by experts from several other
nuclear plants. The process is voluntary,
but it is widespread because the industry’s insurers pay close attention to the
results of the peer review. The process
has been hugely successful because each plant has its own culture, and not only
does the visited plant benefit from the look-see by experts from other
cultures, but the visiting experts also benefit from learning more about the
cultures of the visited plant and the other visiting experts.
So AGA looked into this
peer review process and decided to try it.
Bottom line here: kudos to Christina
Sames, of AGA, for pursuing the process of learning from other industries and
for implementing the peer review process.
I fully expect that this will become yet another demonstration of the
power of collaboration, both in terms of AGA’s collaboration with another
industry, and the collaboration of the participants in the peer review process.
To sum up, safety is
not a state of perfection. It is a continuing effort to catch imperfections before
they cause any unwanted outcomes. To do so requires concerted efforts of
management, employees, manufacturers, regulators, and the public, i.e., everybody
with a stake in the safe transportation of energy products.
So to the AGA member
companies who are implementing RP-1173, and to those who elect to be peer
reviewed, I applaud you for pursuing these new directions, and I wish you the
best of success.
Thanks again for
inviting the NTSB – and I hope that this proves to be a productive Executive
Leadership Safety Summit!