Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation P-11-011
Details
Synopsis: On September 9, 2010, about 6:11 p.m. Pacific daylight time,1 a 30-inch-diameter underground natural gas transmission pipeline (which is identified by the company as Line 132), owned and operated by Pacific Gas and Electric Company (PG&E), ruptured in a residential area in San Bruno, California. The accident killed eight people, injured many more, and caused substantial property damage. The rupture on Line 132 occurred near mile point 39.28, at the intersection of Earl Avenue and Glenview Drive in San Bruno. About 47.6 million standard cubic feet of natural gas were released as a result of the rupture. The released natural gas was ignited after the rupture; the subsequent explosion created a crater about 72 feet long by 26 feet wide, and the resulting fire destroyed 38 homes and damaged 70. A ruptured pipe segment about 28 feet long was found about 100 feet away from the crater. The safety recommendations in this letter address the importance of pipeline operators’ communications with the local 911 emergency call center(s), both before and in the event of a pipeline rupture. Effective emergency preparedness plans need to include appropriately detailed and accurate maps of the pipelines located within the area of the accident. These local maps are a crucial component of the emergency response planning process and of the emergency response itself. In addition to the exact path of each pipeline, which is shown on the maps, other system-specific technical information for each pipeline, such as pipe diameter, operating pressure, product transported (by shipping name and 4-digit U.S. Department of Transportation Hazard Identification Code UN number2), depth (soil coverage), potential damage impact distance (potential impact radius, defined in Title 49 Code of Federal Regulations 192.903), and specific emergency contact information (that is, telephone numbers), also is needed by emergency responders to plan and execute a timely and effective response to a pipeline emergency. At the National Transportation Safety Board’s (NTSB) public hearing3 on the accident, which was held March 1–3, 2011, in Washington, DC, testimony of the chief of the San Bruno Fire Department (SBFD) indicated that before the accident, the SBFD was aware of the PG&E gas distribution system, but it was neither aware of nor had information about the natural gas transmission line that ruptured in the accident. The SBFD had not accessed the National Pipeline Mapping System that displays the location of the nation’s natural gas transmission and hazardous liquid pipelines. The chief also indicated that since the accident, the SBFD has made contact with PG&E and obtained maps showing the locations of PG&E natural gas transmission pipelines. The PG&E program manager for safety, health, and claims testified that after the accident PG&E made maps of its natural gas transmission pipelines available to all of the communities and jurisdictions in which PG&E pipelines are located. When compared to distribution pipelines, transmission pipelines have different operating characteristics, such as pipeline diameter and operating pressures. Because of the differences in operating characteristics, transmission pipelines have different safety risks and concerns for the emergency response, including the pipeline company’s ability to shut down the pipeline rapidly. NTSB investigations in all transportation modes have shown that the most successful emergency responses occur when the responders are prepared through training, drills, and exercises and have readily available information to assess the event. Prior to the accident, PG&E’s public awareness program for emergency responders did not include identification of pipeline locations. At the NTSB’s public hearing, the SBFD fire chief testified, “The benefit of having knowledge of the location of the pipelines [is] because it gives the fire service the ability to pre-plan, to do scenario-based training.” The U.S. Department of Transportation has established regulations and programs aimed at providing information to responders (for example, pipeline markers, pipeline maps, railcar and truck placards). First responders can provide timely and valuable information to pipeline operators for the emergency response only when the responders know that a pipeline is involved and the name of the pipeline operator.
Recommendation: TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Amend Title 49 Code of Federal Regulations 192.935(c) to directly require that automatic shutoff valves or remote control valves in high consequence areas and in class 3 and 4 locations be installed and spaced at intervals that consider the factors listed in that regulation.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Pipeline
Location: San Bruno, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA10MP008
Accident Reports:
Pacific Gas and Electric Company Natural Gas Transmission Pipeline Rupture and Fire
Report #: PAR-11-01
Accident Date: 9/9/2010
Issue Date: 9/26/2011
Date Closed:
Addressee(s) and Addressee Status: PHMSA (Open - Acceptable Response)
Keyword(s): Remote Operated Valves

Safety Recommendation History
From: PHMSA
To: NTSB
Date: 4/1/2019
Response: -From Howard R. Elliott, Administrator: PHMSA plans to address this recommendation in a future NPRM titled "Pipeline Safety: Amendments to Parts 192 and 195 to Require Valve Installation and Minimum Rupture Detection Standards." As discussed in our response to Recommendation P-11-10, according to the DOT's March 2019 Significant Rulemakings Report, PHMSA currently plans to publish the proposed rule in August 2019 and looks forward to the NTSB's comments.

From: NTSB
To: PHMSA
Date: 2/21/2018
Response: We note that you plan to address these recommendations in a notice of proposed rulemaking (NPRM) titled “Pipeline Safety: Amendments to Parts 192 and 195 to Require Valve Installation and Minimum Rupture Detection Standards,” which you had planned to publish during the spring of 2017. We further note that, although you continue to work on this NPRM, its issuance has been delayed by the governmentwide regulatory review required by executive order. Pending completion of the review and publication of the NPRM, followed by publication of the final rule, Safety Recommendations P-11-9 through -11 remain classified OPEN--ACCEPTABLE RESPONSE.

From: PHMSA
To: NTSB
Date: 11/13/2017
Response: -From Howard R. Elliott, Administrator: PHMSA plans to incorporate aspects of this recommendation into a future NPRM titled "Pipeline Safety: Amendments to Parts 192 and 195 to Require Valve Installation and Minimum Rupture Detection Standards." Publication of the proposed rule was initially expected to publish in spring 2017. Like many other issues before us, this is part of an ongoing regulatory review pursuant to the executive order issued by the President.

From: NTSB
To: PHMSA
Date: 12/5/2016
Response: We understand that you plan to incorporate aspects of this recommendation into your future NPRM, “Pipeline Safety: Amendments to Parts 192 and 195 to Require Valve Installation and Minimum Rupture Detection Standards,” with an expected publication date in late spring 2017. Pending our review of this NPRM and the final rules as requested, Safety Recommendation P-11-11 is classified OPEN—ACCEPTABLE REPSONSE.

From: PHMSA
To: NTSB
Date: 8/17/2016
Response: -From Marie Therese Dominguez, Administrator: PHMSA plans to incorporate aspects of this recommendation into a future NPRM titled "Pipeline Safety: Amendments to Parts 192 and 195 to Require Valve Installation and Minimum Rupture Detection Standards: Publication of the proposed rule is anticipated by late spring 2017.

From: NTSB
To: PHMSA
Date: 6/6/2016
Response: The National Transportation Safety Board (NTSB) has reviewed the Pipeline and Hazardous Materials Safety Administration (PHMSA) notice of proposed rulemaking (NPRM), Pipeline Safety: Safety of Gas Transmission and Gathering Pipelines, published on April 8, 2016. This NPRM addresses issues raised in an August 25, 2011, advance notice of proposed rulemaking (ANPRM) regarding the revision of pipeline safety regulations applicable to the safety of gas transmission and gas gathering pipelines, particularly those involving integrity management (IM). Proposal Topic H—Valve Spacing and the Need for Remotely or Automatically Controlled Valves Summary The installation of remote and automatic controlled valves was addressed in the NTSB accident report on the September 9, 2010, pipeline rupture in San Bruno, California. As a result of this investigation, the NTSB issued the following safety recommendation. Amend Title 49 Code of Federal Regulations 192.935 (c) to directly require that automatic shutoff valves or remote control valves in high consequence areas and in class 3 and 4 locations be installed and spaced at intervals that consider the factors listed in that regulation. (P-11-11) The NTSB recommendation P-11-11 called for PHMSA to improve the requirements for installing such valves in HCAs and in class 3 and 4 locations. PHMSA completed a valve study and submitted it to Congress in December 2012. Additionally, under the terms of the Act, the US Comptroller General is conducting a study on the ability of pipeline operators to respond to a hazardous material release. Response Although the NTSB is disappointed in the continued delay in completing the recommended action, we acknowledge that PHMSA is deferring action on this topic until the results of the US Comptroller General’s report addressing hazardous materials release response can be evaluated.

From: NTSB
To: PHMSA
Date: 4/8/2015
Response: We note that the NPRM titled Pipeline Safety: Amendments to Parts 192 and 195 to Require Valve Installation and Minimum Rupture Detection Standards will address aspects of this recommendation. Pending timely publication of a final rule that includes the recommended requirement, Safety Recommendation P-11-11 is classified OPEN—ACCEPTABLE RESPONSE.

From: PHMSA
To: NTSB
Date: 1/22/2015
Response: -From Timothy P. Butters, Acting Administrator: PHMSA plans to incorporate aspects of this recommendation into a future NPRM titled "Pipeline Safety: Amendments to Parts 192 and 195 to Require Valve Installation and Minimum Rupture Detection Standards," which would require mandatory installation of automatic shutoff valves, remote controlled valves, or equivalent technology. The NPRM is currently being drafted, and we expect to publish it in 2015.

From: NTSB
To: PHMSA
Date: 1/3/2014
Response: We note that, in August 2011 PHMSA published an Advance Notice of Proposed Rulemaking (ANPRM), titled Pipeline Safety: Safety of Gas Transmission Pipelines, in the Federal Register, conducted a study on ASV and RCV installation and use, and is considering rulemaking regarding the use of ASVs and RCVs. Pending publication of a final rule, Safety Recommendation P-11-11 remains classified OPEN—ACCEPTABLE RESPONSE.

From: PHMSA
To: NTSB
Date: 8/29/2013
Response: -From Cynthia L. Quarterman, Administrator: PHMSA conducted a non-mandatory study on ASV and RCV installation and use and transmitted the results to Congress in January 2013. PHMSA has also drafted a Regulatory Support Paper for proposed rulemaking regarding the use of ASVs and RCVs. The Regulatory Support Paper is under agency review.

From: NTSB
To: PHMSA
Date: 4/24/2012
Response: Because PHMSA initiated regulatory action to address these issues, with the August 2011 issuance of an ANPRM, Pipeline Safety: Safety of Gas Transmission Pipelines, Safety Recommendations P-11-11, -14, and -15 are classified OPEN—ACCEPTABLE RESPONSE, pending publication of the recommended final rule.

From: PHMSA
To: NTSB
Date: 12/14/2011
Response: -From Cynthia L. Quarterman, Administrator: PHMSA published an ANPRM on August 25, 2011 and invited comments on the need for revised mainline valve regulations for new pipeline construction or existing pipelines. The ANPRM discusses the issue of valve spacing and automatic shutoff valves (ASV) or remote control valves (RCV) in high consequence areas. PHMSA will hold a public workshop in the first quarter of 2012 on pipeline valve issues – including the need for additional valve installation on both natural gas and hazardous liquid transmission pipelines. We will also include this topic in our 2012 Pipeline Research Forum. We anticipate advancing rulemaking to address this recommendation following these actions.

From: NTSB
To: PHMSA
Date: 12/7/2011
Response: Notation 8360: The National Transportation Safety Board (NTSB) has reviewed the Pipeline and Hazardous Materials Safety Administration (PHMSA) Advance Notice of Proposed Rulemaking (ANPRM), “Pipeline Safety: Safety of Gas Transmission Pipelines,” that was published in the Federal Register on August 25, 2011. PHMSA is considering whether changes to the regulations governing the safety of gas transmission pipelines are needed, and is inviting comments on 14 specific topic areas in 2 broad categories—integrity management-related requirements and nonintegrity management requirements. In the area of integrity management, PHMSA is seeking comments and information about revising the definition of high consequence areas (HCA), including more prescriptive language, and placing additional restrictions on the use of specific pipeline assessment methods. In the nonintegrity management area, PHMSA is seeking information and comments about strengthening or expanding requirements for the spacing of mainline valves; installation of remotely operated or automatically operated valves; and corrosion control of steel pipelines, gas gathering lines, and underground gas storage facilities. The NTSB believes that the regulations for gas transmission pipelines can and should be improved and supports the overall intent of the ANPRM. However, the publication of the ANPRM 5 days before the NTSB public meeting on the Pacific Gas and Electric Company (PG&E) natural gas transmission pipeline rupture in San Bruno, California, precluded any mention in the ANPRM of the safety recommendations the NTSB adopted at the public meeting held on August 30, 2011, and issued on September 26, 2011. As a result of the Board Meeting, the NTSB issued 13 safety recommendations (P-11-8 through P-11-20) to PHMSA to improve the safety of natural gas transmission pipelines. The NTSB believes PHMSA should seek comments and information related to its safety recommendations to PHMSA issued as a result of the San Bruno investigation to take certain regulatory actions. In the ANPRM, PHMSA is also seeking information that would be relevant to Safety Recommendation P-93-9 the NTSB issued as a result of its accident investigation of an explosion and fire of a natural gas pipeline from a salt dome storage cavern in Brenham, Texas, on April 7, 1992. The accident resulted in 3 fatalities and 21 injuries. Safety Recommendation P-93-9 was classified “Closed—Unacceptable Action” on July 27, 1998, after a rulemaking proceeding to regulate underground gas storage was terminated in 1997. The NTSB supports PHMSA’s intention to reconsider regulating underground gas storage and is pleased PHMSA is revisiting this issue by seeking information and comment in this ANPRM. In support of our position, the NTSB is providing the following table listing the NTSB’s responses (that is, previously issued safety recommendations) to certain specific questions posed by PHMSA in the ANPRM: PHMSA’s ANPRM Questions NTSB’s Responses (Safety Recommendations) K.1. Should PHMSA develop Federal standards governing the safety of underground gas storage facilities? If so, should they be voluntary? If so, what portions of the facilities should be addressed in these standards? Develop safety requirements for storage of highly volatile liquids and natural gas in underground facilities, including a requirement that all pipeline operators perform safety analyses of new and existing underground geologic storage systems to identify potential failures, determine the likelihood that each failure will occur, and assess the feasibility of reducing the risk; require that operators incorporate all feasible improvements. (P-93-9) K.6. What standards are used for emergency shutdowns, emergency shutdown stations, gas monitors, local emergency response communications, public communications, and O&M Procedures? Require operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines to provide system-specific information about their pipeline systems to the emergency response agencies of the communities and jurisdictions in which those pipelines are located. This information should include pipe diameter, operating pressure, product transported, and potential impact radius. (P-11-8) L.1. Are there standards used by the pipeline industry to guide management processes including management of change? Do standards governing the management of change process include requirements for IM procedures, O&M manuals, facility drawings, emergency response plans and procedures, and documents required to be maintained for the life of the pipeline? Require operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines to ensure that their control room operators immediately and directly notify the 911 emergency call center(s) for the communities and jurisdictions in which those pipelines are located when a possible rupture of any pipeline is indicated. (P-11-9) PHMSA’s ANPRM Questions NTSB’s Responses (Safety Recommendations) B.4. What measures, if any, should operators be required explicitly to implement? Should they apply to all HCAs, or is there some reasonable basis for tailoring explicit mandates to particular HCAs? Should additional preventative and mitigative measures include any or all of the following: Additional line markers (line-of-sight); depth of cover surveys; close interval surveys for cathodic protection (CP) verification; coating surveys and recoating to help maintain CP current to pipe; additional right-of-way patrols; shorter ILI run intervals; additional gas quality monitoring, sampling, and in-line inspection tool runs; and improved standards for marking pipelines for operator construction and maintenance and one-calls? Require that all operators of natural gas transmission and distribution pipelines equip their supervisory control and data acquisition systems 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-11-10) Amend Title 49 Code of Federal Regulations 192.935(c) to directly require that automatic shutoff valves or remote control valves in high consequence areas and in class 3 and 4 locations be installed and spaced at intervals that consider the factors listed in that regulation. (P-11-11) M.4. Are there any standards that exist that PHMSA could adopt or from which PHMSA could adapt concepts for Quality Management System (QMS)? Amend Title 49 Code of Federal Regulations 199.105 and 49 Code of Federal Regulations 199.225 to eliminate operator discretion with regard to testing of covered employees. The revised language should require drug and alcohol testing of each employee whose performance either contributed to the accident or cannot be completely discounted as a contributing factor to the accident. (P-11-12) Issue immediate guidance clarifying the need to conduct postaccident drug and alcohol testing of all potentially involved personnel despite uncertainty about the circumstances of the accident. (P-11-13) N.2. Should PHMSA repeal the MAOP exemption for pre-1970 pipelines? Should pre-1970 pipelines that operate above 72% SMYS be allowed to continue to be operated at these levels without increased safety evaluations such as periodic pressure tests, in-line inspections, coating examination, CP surveys, and expanded requirements on interference currents and depth of cover maintenance? N.3. Should PHMSA take any other actions with respect to exempt pipelines? Amend Title 49 Code of Federal Regulations 192.619 to delete the grandfather clause and require that all gas transmission pipelines constructed before 1970 be subjected to a hydrostatic pressure test that incorporates a spike test. (P-11-14) G.9. Should a one-time pressure test be required to address manufacturing and construction defects? Amend Title 49 Code of Federal Regulations Part 192 of the Federal pipeline safety regulations so that manufacturing- and construction-related defects can only be considered stable if a gas pipeline has been subjected to a postconstruction hydrostatic pressure test of at least 1.25 times the maximum allowable operating pressure. (P-11-15) PHMSA’s ANPRM Questions NTSB’s Responses (Safety Recommendations) C.7. Should PHMSA adopt standards for conducting in-line inspections using ‘‘smart pigs,’’ the qualification of persons interpreting in-line inspection data, the review of ILI results including the integration of other data sources in interpreting ILI results, and/or the quality and accuracy of in-line inspection tool performance, to gain a greater level of assurance that injurious pipeline defects are discovered? Should these standards be voluntary or adopted as requirements? Require that all natural gas transmission pipelines be configured so as to accommodate in-line inspection tools, with priority given to older pipelines. (P-11-17) B.3. Are any additional prescriptive requirements needed to improve selection and implementation decisions? If so, what are they and why? Revise your integrity management inspection protocol to (1) incorporate a review of meaningful metrics; (2) require auditors to verify that the operator has a procedure in place for ensuring the completeness and accuracy of underlying information; (3) require auditors to review all integrity management performance measures reported to the Pipeline and Hazardous Materials Safety Administration and compare the leak, failure, and incident measures to the operator’s risk model; and (4) require setting performance goals for pipeline operators at each audit and follow up on those goals at subsequent audits. (P-11-18) (1) Develop and implement standards for integrity management and other performance-based safety programs that require operators of all types of pipeline systems to regularly assess the effectiveness of their programs using clear and meaningful metrics, and to identify and then correct deficiencies; and (2) make those metrics available in a centralized database. (P-11-19) A.7. What, if any, input and/or oversight should the general public and/or local communities provide in the identification of HCAs? If commenters believe that the public or local communities should provide input and/or oversight, how should PHMSA gather information and interface with these entities? If commenters believe that the public or local communities should provide input and/or oversight, what type of information should be provided and should it be voluntary to do so? If commenters believe that the public or local communities should provide input, what would be the burden entailed in providing provide this information? Should state and local governments should be involved in the HCA identification and oversight process? If commenters believe that state and local governments be involved in the HCA identification and oversight process what would the nature of this involvement be? Work with state public utility commissions to (1) implement oversight programs that employ meaningful metrics to assess the effectiveness of their oversight programs and make those metrics available in a centralized database, and (2) identify and then correct deficiencies in those programs. (P-11-20) The NTSB appreciates the opportunity to comment on this ANPRM. Should you require additional information or clarification, please contact us.