Lessons Learned #1: Failure to Follow Written Procedures

Learning from past incidents allows operators to strengthen their procedures, training, and overall safety culture. While penalties can be costly, the impacts of a major spill on the environment, communities, and a company's reputation are far more devastating.

Learning from the mistakes of others is crucial for improving pipeline safety across the industry. In this issue of Pipeline Safety Insights, we examine a recent enforcement case that serves as a learning opportunity for all operators.

In February of 2024, the Pipeline and Hazardous Materials Safety Administration (PHMSA) issued a Notice of Probable Violation and Proposed Civil Penalty of $239,142 to an operator for failing to follow their written control room management procedures during a pipeline rupture incident. Despite receiving multiple leak alarms, the controller attempted to restart a pump station before assuring segment integrity and determining the cause of the pressure variance, contrary to the operator's procedures. This failure increased the severity of the rupture and resulting oil spill. It's important to note that this proposed penalty amount does not include potential fines from the EPA or costs associated with cleanup and remediation efforts.

By analyzing incidents like this, operators can implement some key lessons and tips on reviewing their current operations:

1. Strictly follow your control room management procedures, especially when responding to potential leak indications or alarms. Do not attempt to restart operations until segment integrity is assured and the cause of any pressure variance or alarm is thoroughly investigated and explained.
2. Ensure proper staffing and communication protocols in the control room. In this incident, a controller was left unmonitored when the supervisor unexpectedly left, contributing to the delayed response.
3. Provide comprehensive training to control room personnel on leak detection systems, alarm response procedures, and the importance of adhering to written procedures during potential emergency situations.
4. Regularly review and update your control room management procedures to address any gaps or areas for improvement identified during incident investigations or audits. Don't get complacent.
5. Foster a culture of safety and procedural adherence in your control room operations. Encourage controllers to prioritize caution and thorough investigation over expedient restart attempts when potential leaks or integrity issues are suspected.
6. Implement robust line monitoring and leak detection systems, and ensure controllers are properly trained to interpret and respond to alarms and pressure variations.
7. Review your environmental permits and response programs and protocols to ensure consistency throughout the operations and organization.

Learning from past incidents allows operators to strengthen their procedures, training, and overall safety culture. While penalties can be costly, the impacts of a major spill on the environment, communities, and a company's reputation are far more devastating. Studying federal level PHMSA enforcement cases and being proactive about implementing lessons learned, operators can prevent similar mistakes and continue driving toward safer, more compliant, and more reliable pipeline operations.

Contact Premier Safety Resources or visit our website to schedule a free consultation call to review your pipeline operations programs with an unbiased and fresh view.

Note: this edition of the Pipeline Safety Insights newsletter was written using publicly available PHMSA enforcement data. No names or company information was mentioned in this article.