San Bruno report from NTSB – organisational failure

The US  National Transportation Safety Board (NTSB) has released a synopsis of its near-final report on the San Bruno pipeline failure of September 9 2010 in which eight people died and many more were injured.  Despite being a synopsis it’s quite long so I may comment on different aspects of it separately.  But I want to start with the report’s clear recognition that this was an organisational failure.

There is a long list of findings but I’ll highlight just a few that deal with organisational failure rather than the physical mechanisms:

21.  The deficiencies identified during this investigation are indicative of an organizational accident.

22. The multiple and recurring deficiencies in PG&E operational practices indicate a systemic problem.

27.  The ineffective enforcement posture of the California Public Utilities Commission permitted PG&E’s organizational failures to continue over many years.

It goes on to outline the probable causes of the accident of which the main features (paraphrased) are:

  • Inadequate QA and quality control during the 1956 construction of the pipeline (the longitudinal seam in the pipe was only half welded)
  • Inadequate pipeline integrity management, which failed to detect and repair or remove the defective pipe section
  • Regulations which “grandfathered” existing older pipelines, exempting them from pressure testing (the line had never been tested to the modern standard of 125% MAOP)
  • Lack of automatic or remotely controlled valves and flawed emergency response procedures, which resulted in a 90 min delay before the ruptured pipeline could be shut down

These are all ultimately organisational failures, in either PG&E itself as the pipeline owner and operator or in the pipeline regulators (both state and national).  The NTSB report recognises this and makes quite scathing criticisms of both PG&E and (to a slightly lesser extent) the regulators for their inadequate oversight and grandfathering of old pipelines built to inferior standards.

The report synopsis also contains a long list of findings about other physical and organisational aspects of the failure, and a long list of recommendations to both regulators and PG&E.  I may comment further on these in due course.

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4 Responses to San Bruno report from NTSB – organisational failure

  1. Anonymous says:

    Hi Peter,
    Regarding recommendation 11 of the report – ‘to delete the grandfather clause and require that all gas transmission pipelines constructed before 1970 be subjected to a hydrostatic pressure test’.

    It will be interesting to see if PHMSA proceed with this recommendation – considering approx 60% of gas pipelines currently in service in the US were installed prior to 1970 (according to the AGA) it could have quite an impact.

    Below is a link to an AGA white paper which gives a bit of a background on MAOP establishment on old pipelines in the US and discusses using ‘historical operating pressure’ for MAOP justification (i.e. the grandfathering clause). An interesting read.


    GPA Engineering

    • petertuft says:

      Thanks Josh, that’s very interesting. But I find the arguments unconvincing. So far I’ve only had time to read it quickly but it looks as if the San Bruno pipe would have passed all the criteria – in fact, it presumably must have passed or it would not have been allowed to remain in service. That alone is a pretty convincing counter-argument to the position presented in the AGA paper. My personal view is that the US community needs to decide whether it is (1) prepared to pay the higher pipeline tariffs that might result from rigorous demonstration of pipeline safety (by pressure testing if necessary) or (2) accept the risk of more San Bruno incidents.

  2. Pingback: Safety Culture Research | Pipelines OZ

  3. Pingback: San Bruno – organisational analysis | Pipelines OZ

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