In This Issue

PHMSA Advisory Bulletin ADB-2014-02: Lessons Learned from the Release at Marshall, Michigan

[Docket No. PHMSA-2014-0020]

The Department of Transportation/Pipeline Hazardous Materials Safety Administration (PHMSA) issued an Advisory Bulletin to inform pipeline operators about the deficiencies identified in Enbridge’s integrity management program, control room operator training, and public awareness program which contributed to the accident at Marshall, Michigan.

NTSB’s report on the Marshall, Michigan incident noted the probable cause of the failure was stress corrosion cracking that grew and coalesced from crack and corrosion defects under disbonded polyethylene tape. The NTSB also noted the following organizational failures:

  1. Deficient integrity management procedures which allowed well-documented crack defects to propagate until the pipe failed,
  2. Inadequate control room operator training which resulted in failure to recognize the rupture for 17 hours, and
  3. Insufficient public awareness and education which allowed the release to continue for almost 14 hours after the first notification of an odor to local emergency response agencies.

The ADB addresses all 3 issues.

  1. Integrity Management (IM): An operator’s IM program must go beyond assessing integrity and repairing defects. Pipeline risk assessment should be a continuous process and risk analysis a continual reassessment process. Operators should evaluate any changes in how assessment data is analyzed, such as changes in tool tolerances, to determine if the changes will affect previous assessments.

    Threat and integrity data from multiple sources must be integrated and analyzed to ensure safety and integrity. Lack of data integration was a significant contributor to the accident at Marshall, Michigan.

    Refer to previous Advisory Bulletin ADB-2012-10, “Using Meaningful Metrics in Conducting Integrity Management Program Evaluations” (77 FR 72435, December 5, 2012).
  2. Control Room Operations: Operators are advised to regularly train their controllers and consider training controllers as teams in the recognition and response to emergency and unexpected conditions. This team training should include recognition of SCADA alarms and readings and understanding of leak detection software.

    Operators should also periodically evaluate their leak detection systems to ensure that they work during situations such as pipeline shutdowns, startups and column separation. If an unexpected loss of product occurs, operators should shut down the pipeline until the problem is resolved.

    In addition, operators should evaluate their control room scheduling policies and practices.

    Refer to previous Advisory Bulletins ADB 10-01, “Leak Detection on Hazardous Liquid Pipelines,” (75 FR 4134, January 26, 2010) and ADB 05-06, “Countermeasures to Prevent Human Fatigue in the Control Room” (70 FR 46917, August 11, 2005).
  3. Public Awareness Programs: Operators are advised to evaluate the effectiveness of their public awareness programs and ensure local emergency response agencies are prepared to respond to early indications of a possible rupture. Public Awareness programs should be assessed against API Recommended Practice 1162.

    Operators should also review their procedures for communications during emergencies to ensure they comply with previous Advisory Bulletins ADB 10-08, “Emergency Preparedness Communications” (75 FR 67807, November 3, 2010) and ADB 12-09, “Communication During Emergency Situations” (77 FR 61826, October 11, 2012).

In addition, the Advisory Bulletin recommends that operators review past and future NTSB incident investigations and implement the recommendations made in the investigation reports so the entire industry can benefit from the mistakes of one operator.

For further information contact Linda Daugherty by phone at 816-329-3821 or by email at For a copy of ADB-2014-02, contact Jessica Roger.