Accident Investigations

The release of the impressive NTSB report on the San Bruno disaster contrasts strongly with some other serious incidents, particularly the 2004 catastrophe in Belgium (24 deaths) and the 2008 Varanus Is failure ($3 billion economic cost claimed).  In neither case has there yet been any comprehensive independent or official report on the causes of the failure.  In both cases the reason is much the same:  legal action.

Whatever the interests of the claimants in the cases, it should not be allowed to trump the interest of the public in understanding clearly the causes of serious failures so that lessons can be learned to prevent repetition.

There is a current article in the WA press about the unavailability of the investigation that was completed mid-2009.  I’m less familiar with the situation in Belgium but gather from the grapevine that there have been two trials (with the first exonerating the pipeline operator and the second convicting them) and now an appeal under way.  And meanwhile the industry and public have only sketchy information on what what really went wrong, limited to the mechanical details with nothing on the crucial organisational aspects of these serious events.

Whatever one might think about the safety record and practices of the US pipeline industry, the US accident investigation and reporting system embodied in the NTSB sets a very high standard.  NTSB investigators were on site within hours of the failure.  They have been able to complete a rigorous investigation of all relevant issues (technical and otherwise) without legal or political impediment.  As they identified key issues through the progress of the investigation they promptly issued urgent interim recommendations to all the stakeholders including the PHMSA (federal pipeline regulator), CPUC (state technical regulator) and PG&E (pipeline owner and operator), followed up by more comprehensive recommendations in the final report.  Those recommendations cut to the essence of the safety issues regardless of political or commercial sensitivities.  As far as I can tell the NTSB is a completely independent organisation.  It doesn’t regulate anything, has no turf to protect, all it does is investigate accidents and make recommendations.

You can tell that I’m impressed.  It’s a model of accident investigation that puts to shame the legal and/or political influence on the other cases I mentioned above.

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2 Responses to Accident Investigations

  1. Anonymous says:

    Hi Peter
    While I agree we havent seen a report on Varanus Island, I’m not sure we need an official report to identify the causes of that failure or the Belgium explosion.

    Anyone with experience in the field of corrosion and has seen a photo will tell you Varanus Island was caused by corrosion of the pipeline in the tidal zone. The direct cause is therefore a failure of the pipeline inspection and maintenece system to identify the failure of the corrosion prevention system in this area. This should have been identified as a risk in the projects design risk assessment which should have been done as part of the projects safety case.

    The underlying cause, and possible why the official investigation reports have not been released, is also probably clear to anyone who thinks about it. I’m sure multiple parties would be identified as having contributed in some way or another.

    Re Belgium, as I understand it, the pipeline was ruptured by an excavator and the gas cloud that formed was ignited as emergency teams responded. What the source of ignition was doesn’t really matter, there will always be one somewhere. Hence, I would attribute the failure to a lack of control of third party activities near the pipeline. No excavator of the type and size that caused the failure should be let anywhere near a pipeline.

    Adrian Amey

  2. Pingback: Varanus Island report | Pipelines OZ

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