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Critical Infrastructure disasters 2010 to 2011

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Critical Infrastructure Disasters 2010 to 2011


News etc. digested by Alister William Macintyre

CI Boom 2010 to 2011 tracks critical infrastructure disasters. What can be done to
mitigate such disasters in my main related analysis document.1 Last updated 2014 Feb 13
Version 1.43

Table of Contents, thru level 4 Summary ..................................................................................................................... 1 Notable CI disasters 2010 to 2011 ...................................................................................... 2 2010..................................................................................................................................... 5 2010 New Delhi India radiation incident........................................................................ 5 2010 May 18 RC = Rancho Cordova CA NTSB Report ............................................. 5 NTSB found PG&E pipe repair and inventory quality problems ........................... 6 PG&E shortcomings illuminated ............................................................................ 7 PG&E pledges improvements................................................................................. 8 2010 June 07 West Virginia and Texas Gas Explosions ......................................... 9 2010 July 26 Marshall Mi Oil Spill - $1b damage................................................... 9 2010 July 30 LA California Gas Explosion........................................................... 10 2010 Sep 9 - San Bruno Ca Gas Pipeline Explosion Fire............................................. 10 2011................................................................................................................................... 12 2011 Feb 9 Allentown PA Gas Explosion ............................................................. 12 2011 April Leaks invite future Gas Explosions..................................................... 12 2011 July 1 Laurel Montana Yellowstone River Oil Spill .................................... 12 2011 Aug 25 = PHMSA rulemaking starts ............................................................... 13 2011 Aug 30 = NTSB report on San Bruno disaster .................................................... 13 San Bruno Executive Summary ............................................................................ 13 San Bruno Probable Cause.................................................................................... 14 San Bruno Investigation Synopsis ........................................................................ 14 San Bruno NTSB Safety Recommendations ........................................................ 16 New Recommendations ........................................................................................ 16 Previously Issued Recommendations ................................................................... 20 Previously Issued Recommendations Classified in This Report .......................... 22 2011 Sep 26 Seattle WA ........................................................................................... 22 2011 Oct = Denton Tx .............................................................................................. 22 2011 Nov New Albany In ...................................................................................... 23 Continued in more documents .......................................................................................... 23

Summary
There are pipelines, carrying dangerous chemicals, under most cities, and in fact the whole country. Statistically, they are safer than transport by rail or truck. But just as
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Critical Infrastructure disasters 2010 to 2011

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airline travel is safer than driving, when there is a disaster, the volume of damage, and number of victims, can be quite large. Investigations find how this or that disaster occurred, and what can be done to improve safety into the future. Unfortunately this guidance on what is needed, to mitigate against history repeating, is often voluntary, and only applies to the institution which experienced the latest disaster incident. Thus we are doomed to have the same thing happen again and again, with other companies in other communities. Familiar industrial disaster stories are repeated with great rapidity. The only revisions are the names of the communities and companies involved. This is because there is critical infrastructure neglect all over the place, where investigations often find the same kinds of causes, which were responsible for many earlier disasters. Industries involved, and other communities with same kinds of risks, are far too slow to learn from this. We seem doomed to suffer the same kinds of disasters again and again to infinity. They are man made, not deliberate, but severe negligence. Yes there are laws and regulations, but enforcement is often a joke. Companies produce, buy and sell, store,, transport dangerous chemicals. Local communities are often unaware of the risks until there is a disaster. Regulators also often do not know some time bomb is waiting to explode, until it does so. Heres what we learned about this dismal state of affairs 2010 to 2011. 6 Tags: San Bruno, NTSB, pipe line spill, radiation, dysfunctional companies, gas explosion,

Notable CI disasters 2010 to 2011


Here is an incident time line section of my notes on Critical Infrastructure (CI) disasters. I collect info about many disasters, see what they have in common, then consider what improvements could be made in efforts to mitigate risk of high damage in the next similar incident, or even reduce the frequency in which they occur. My overall analysis and mitigation evaluation is in a separate parent document, from these incident time-line chunks.2 Scribd loses statistics when we change document name, so I kept the original name Indy Boom because I first started looking into this topic on the occasion of a gas explosion which demolished a housing sub-division of Indianapolis. That incident turned out to be deliberate sabotage for insurance fraud, which is not the typical cause of these industrial disasters. There seem to be many causes, such as unintentional criminal negligence, a lack of public education to get witnesses to promptly report leak odors and a lack of enforcement of national safety standards for companies mis-managing these dangerous chemicals.

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The events, in this time line segment, occurred in: India; USA. Incidents listed here include: Construction work can damage pipelines unless the lines are carefully and accurately marked, construction crews trained in recognizing those markings, and in how to protect the fuel line from any damage, and there is proper inspection to identify any damage, or risk of damage, and get it resolved before that leads to a disaster. Lapses in this safety standard can be found: o 2010 June in West Virginia, 55 miles SW of Pittsburgh. Counterfeit parts used in Pipeline Repair, can lead to later Pipeline Disasters. o See Pacific Gas & Electric (PG&E), for that happening, as one of the causes of the 2008 Dec Rancho Cordova (RC) disaster, according to its 2010 May NTSB report. Emergency Response, in name only by the public utility, can make an emergency with its pipeline much worse, by continuing to provide fuel to the fires. o See Pacific Gas & Electric (PG&E), for that happening, with both the 2008 Dec Rancho Cordova (RC) and 2010 Sep San Bruno incidents.

Enbridge oil spill into the Kalamazoo river.


o 2010 July 25 the disaster began. Alarms went off for 17 hours, ignored by Enbridge employees, until local residents phoned to complain. The company sent personnel to investigate, who lacked the tools or training to do anything about it. Until the BP Gulf of Mexico oil spill, this became the most expensive oil pipeline disaster since the US government started keeping records in 1968. It has cost $ 1 billion and counting. o 2012 July 10 NTSB report came out.

Hydraulic fracturing, or fracking see GASLAND movie at start of 2010. Leaks are called in by witnesses and customers to public utilities, which send technicians to investigate. Sometimes they confirm there is a leak. At this point they should immediately inform 911 of the situation they are working on, and put up some kind of warning tape around the leak, so that people in the neighborhood know there is this situation, so they dont walk into danger. o Failure to do this was evident in Pacific Gas and Electric (PG&E) 2008 Dec incident, as reported by 2010 May NTSB report.

Pacific Gas & Electric (PG&E) shows up in multiple serious incidents, with
an associated record of warnings, which apparently were not heeded in time to avoid the incidents. 2006 Sep 15 pipeline repair, not done properly, at site of 2008 Dec 24 Rancho Cordova Ca PG&E disaster. 2007 Oct 7 identifies flaws in PG&E pipeline repair process, such as counterfeit parts getting into their inventory. 2008 May California Public Utilities Commission (CPUC) audited Pacific Gas & Electric (PG&E). Critical Infrastructure disasters 2010 to 2011

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2008 Aug CPUC sent a letter to PG&E, identifying what needed to be fixed, which was found by the 2008 May audit. This included: Personnel to be properly trained in responding to leaks. PG&E documentation, on emergency response, needed some upgrades. 2008 Nov PG&E responds to CPUC pledging to make all corrections by 2008 Dec 31. 2008 Dec 24 Rancho Cordova Ca Pacific Gas & Electric (PG&E) Explosion, Leak Release, and Ignition of Natural Gas. 2010 May 18 NTSB report on PG&Es 2008-12-24 Rancho Cordova Ca Explosion and Fire.3 The NTSB found that there had been prior events, which contributed to the disaster. 2010 Sep 9 San Bruno gas pipeline explosion and fire. Follow-up info on San Bruno disaster. o 2011 Aug 30 NTSB summary report. o 2012 June and July

Radiation Technology, when no longer needed, ought to go to a proper disposal area, with proper security and shielding in transit. It should never be exposed to hijacking nor sold for scrap. Violations of this principle have led to disasters in 1987 Brazil, 2010 India, 2013 Mexico. Systemic failures at companies mis-managing fuels, such as pipelines, as if the organization lacks the credentials to meet its heavy responsibilities Examples: Counterfeit and defective parts in inventory, and the company oblivious to this happening, or the risks involved. o See Pacific Gas and Electric (PG&E). Dispatching people, to deal with some crisis, who lacked the training and tools to do anything constructive about it. 2010 July Enbridge oil poured into Kalamazoo river, 2010 Sep PG&Es San Bruno incident. Inaccurate record keeping. See Pacific Gas & Electric (PG&E) Mapping system needed so company workers and first responders know what pipes are where, their age, when last inspected, what they are carrying. This was lacking: o 2010 Sep PG&Es San Bruno incident. Pipeline leak is fueling a fire and explosions. Pipeline company seems to take forever to shut down the fuel for the fire. 2010 Sep PG&Es San Bruno incident.

http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/fulltext/PAB1001.htm

Critical Infrastructure disasters 2010 to 2011

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2010
In 2010 the movie GASLAND came out, explaining and framing the debate around hydraulic fracturing or fracking. GASLAND II world premier will be April 2013. 4 2010 had the BP Deepwater Horizon Gulf Oil Spill.5 From 2001 to 2010, there were 992 oil and gas fluid spills in three Colorado counties alone.6 An analysis by CBS found more than 6,500 domestic chemical spill incidents in 2010 alone. Considering spills, leaks, fires, and accidents, an average of 18 per day took place in a single year.7

2010 New Delhi India radiation incident


In 2010 the University of Delhi realized a cobalt irradiator had been in storage for over a quarter century. Cobalt-60 has a half-life of only 5.27 years; after 5 half-lives the amount of radioactivity had decayed to only about 3% of the original activity. But 3% of a large number can still be significant. However, the university decided to simply sell the entire irradiator off as scrap metal. There were still about 20 curies of activity remaining; enough to be deadly under the right circumstances. Over 100 pieces of radioactivity were scattered through a number of scrap metal yards in the Delhi area, and other pieces were given to scrap metal workers. One worker died, two got sick but recovered. The Indian government soured scrap metal yards to try to locate and recover all the contamination.8 See similar incidents 1987 Brazil. 2013 Mexico

2010 May 18 RC = Rancho Cordova CA NTSB Report


2010 05 18 NTSB came out with a full report on Pacific Gas & Electric (PG&E)s 2008 12-24 Rancho Cordova Ca Explosion and Fire.9 See 2008 Dec 24 for time line of the incident. Quoting from NTSB report:10

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http://www.naturalgaswatch.org/?p=1788 See 25 page report = http://www.fas.org/sgp/crs/homesec/R43251.pdf I named my copy CRS Spill Response 2014 Jan. I found out about this report here: http://blogs.fas.org/secrecy/2014/01/usmcdrawdown/ 6 http://www.huffingtonpost.com/2011/05/31/992-oil-and-gas-fluid-spi_n_869182.html 7 http://www.businessweek.com/articles/2014-01-22/forget-west-virginia-dot-chemical-spills-are-anamerican-tradition This article referring to the 2014 Jan 9 chemical spill, which disrupted W Va water. http://www.cbsnews.com/videos/oil-spills-leaks-happen-daily-across-us/#ixzz1JQS21Jbw 8 http://blogs.fas.org/sciencewonk/2013/12/mexican-radiation-accident-ii/ 9 http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/fulltext/PAB1001.htm 10 http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/fulltext/PAB1001.htm

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The National Transportation Safety Board (NTSB) determined that the probable cause of the December 24, 2008, release, ignition, and explosion of natural gas in Rancho Cordova, California, was the use of a section of unmarked and out-of-specification polyethylene pipe with inadequate wall thickness that allowed gas to leak from the mechanical coupling installed on September 21, 2006. Contributing to the accident was the 2-hour 47-minute delay in the arrival at the job site of a Pacific Gas and Electric (PG&E) crew, properly trained and equipped to identify and classify outdoor leaks and to begin response activities to ensure the safety of the residents and public.

NTSB found PG&E pipe repair and inventory quality problems


Post accident excavation revealed that the natural gas leak source was the main pipeline, where a spool piece11 of pipe had partially pulled out of a 1 1/4-inch coupling. About 1/4 inch of polyethylene pipe was inside the Metfit 12 coupling, although at least 1 inch of pipe is held in a correctly assembled coupling. There are detailed illustrations of this in the NTSB report. PG&E had installed the spool piece of pipe and coupling during a September 21, 2006, repair of a leak to the 2-inch main pipeline. Sections of pipe and couplings from the accident were submitted to NTSBs Materials Laboratory for testing. o See the report for what was found. o Some of the pipe flunked quality tests. o See 2006 Sep 15, and 2007 Oct 7, for clues about problems with state of art of pipe quality assurance. The service pipeline to 10708 Paiute Way was a 1/2-inch DuPont Aldyl A polyethylene service pipeline fed by a 2-inch DuPont Aldyl A polyethylene gas main that had been installed in 1977. The maximum allowable operating pressure for the main and service pipelines was about 60 pounds per square inch, gauge (psig), and the working, or operational, pressure was about 55 psig. The NTSB report shows what US Poly (pipe manufacturer) allegedly does, when supplying and packing pipes; and PG&E claims, regarding their acquisition of the pipes. On February 19, 2009, PG&E and California Public Utilities Commission party representatives jointly inspected the PG&E storage yard in Sacramento, as part of the Rancho Cordova accident investigation. They found two pieces about 6 feet long of 1 1/4-inch polyethylene pipe that had no print line markings in a bin labeled Stub

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A spool piece of pipe is a short section of pipe used as a replacement pipe in a repair.

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Metfit is a type of pipe coupling owned by US Poly. When the pipeline was installed in 1977, the repair process and the Metfit name were owned by DuPont. Since then, the process and Metfit have changed hands several times. At the time of the repair (2006), US Poly owned both.

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Markers13 Only. PG&E sent the pipes to the NTSBs Materials Laboratory for examination and testing; one of the two pipes (C) had a wall thickness thinner than the minimum wall thickness required for ASTM D-2513 SDR 10 polyethylene pipe, and no print lines or indentations were observed on either C or D. Since PG&E claimed that they got all their pipes from US Poly, they conducted a search to try to figure out where the unmarked and defective pipes came from. They found that some US Poly packing, included such materials.14 Again from personal experience of Al Macintyre career: An optional standard in some industries, is for the process of receiving purchased parts to have a process that employees go thru for quality assurance. Verify that what has been delivered, matches that which was ordered. Conduct tests of samples, to make sure nothing is defective. 15 There is something specific which is done to update our inventory, so we know what we have received, so that vendor bills will get paid, and our inventory records are correct. There is something specific which is done to make sure the parts are properly labeled in our warehouses. There is something specific which is done with the packing materials. 16

PG&E shortcomings illuminated


This accident illuminates shortcomings in PG&Es response procedures. First, at the time of the accident, PG&E did not require any responders to periodically check in with their dispatch offices to communicate delays in responding. Second, PG&E sent technicians (gas service representatives) as first responders to leak complaints, irrespective of whether the customer reported leaks suspected as being outdoors rather than indoors. These technicians were neither trained in grading outdoor leaks nor equipped with the equipment required to do so under PG&Es operator qualification program. A technician who encountered an outdoor leak was required to call Dispatch and have a leak inspector (equipment operator) sent to grade the leak. Third, technicians responding to odor and/or leak complaints did not have barrier tape or notices which could be used to warn an absent homeowner that the house was dangerous because of leaking gas, and not to enter the house.
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A stub marker is a piece of pipe stuck in the ground to indicate that plastic pipe is buried there.

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The term packing pipe refers to unmarked pipe lengths included in the material used to pack pipe for transport.
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In one case, with my employer, something was in perfect condition when it was shipped by a supplier, but in transit to us, if fell off the truck, and so it was in a damaged unusable condition when we got it. 16 There was no official PG&E policy or practice in place at the time of the accident that provided direction on the use of packing pipe. Different PG&E sites were doing different things.

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NTSB report does not mention, but also apparent to me:17 Fourth, once PG&E personnel know there is a leak, there appears no interest in informing the fire dept that they are on scene tackling such a situation. Fifth, the fire dept was able to respond in less than 10 minutes. It typically took PG&E personnel hours to a day,18 to respond to gas leak SOS. They need to rethink their system.19 Sixth, doesnt PG&E have any inventory audits? 20 They should not have to wait for an accident investigation to find out that their inventory system is defective. Seventh, there appears to be blindness to the possible risk of counterfeit parts, or parts dying of old age.

PG&E pledges improvements


Since the December 24, 2008, accident, PG&E reported to NTSB that it has undertaken a number of process improvement initiatives to improve response time and efficiency and to preclude the introduction of non-specification pipe for repairs. The following is a summary list of those efforts:

Field service representatives have been trained, qualified, and given the necessary combustible gas detector equipment, in addition to the indoor natural gas detectors they previously carried, to conduct outdoor leak investigations and grade outdoor leaks. If gas above 1 percent is found indoors, the structure is to be evacuated and Dispatch is to be contacted to request 911 assistance. A prescriptive written evacuation policy has been established that utilizes the expertise of the fire department and first responders.

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These notes compiled by Al Macintyre. 2006 Sep 15 they get the call at 7 am, the crew arrives at 4 pm. 19 I live in Evansville Indiana. I see ambulances parked in shopping center malls, and other commercial establishments, near traffic light easy access to major thoroughfares and expressways. The purpose of this is so that in any emergency, first responders are only minutes away. After one responds, the rest of them do a kind of dance, adjusting their locations, so that they do not leave a gap, in their support network, where one just left. Obviously there needs to be personnel shift changes, and protection against expensive hardware disappearing from back of trucks via five fingered discount. If I was designing a city, with this kind of system, I would have lots of shielded parking areas, with engine turned off, until needed, to conserve fuel, and think through protection in case of a natural disaster. You dont want your first responders parked inside structures which fall down in an earthquake. 20 At my day job, we have an annual physical inventory, which is checked by auditors from an outside company. The physical includes, the parts we make, the tooling we use to make the parts, the machines the tooling are used on, everything of value. If the results of the physical show that our records were only 95% accurate, we think we have done a rotten job, because we had a 5% error rate. At a former employer, there was an annual physical, with no independent auditor checking. There we thought we were doing a good job if the records were as much as 10% correct (90% incorrect). Different companies have different standards of excellence. Some companies have no standards.

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Field technicians carry warning tape, which they can use to cover entrances to warn homeowners not to enter the premises during leak investigations in the event that PG&E is unable to gain access during an investigation. The term hazardous leak is now more specifically defined in the PG&E operating instructions, and the written instructions include two examples of leaks that qualify as hazardous. Packing pipe is explicitly prohibited from any use and must be discarded. 21 Written requirements have been established to check the wall thickness, outside diameter, and print line on all plastic pipes, before installation to be certain that the mechanical fittings are compatible with the pipe. Heat fusion saddle installation procedures previously used to join service lines to the 1 1/4-inch polyethylene distribution lines have been replaced with an electrofusion process, which is a safer and more reliable means of joining the service and distribution lines. Written requirements have been established such that all incoming plastic pipe be checked for dimensions with the national and/or PG&E specification standards by PG&E quality assurance personnel, and nonconforming materials be returned to the vendor or scrapped.22

2010 June 07 West Virginia and Texas Gas Explosions


o Utility workers accidentally hit a natural gas line in north Texas. The Texas natural gas explosion followed an earlier natural gas explosion in West Virginia. A pocket of methane gas is what triggered the explosion 55 miles southwest of Pittsburgh.23 See 2012 late November. The Springfield MA gas explosion was caused by an error with public utility work. o Cause-Mitigation (see Labeling Causes chapter) practical via: Utility Line Map resolution Corporate Training upgrading

2010 July 26 Marshall Mi Oil Spill - $1b damage


o This was no explosion, but rather a disaster which has cost $900 million and counting to clean up, and the job is far from over, worth mentioning from perspective of how expensive some disasters can be.24 The company blamed many things for the disaster, but the government said the company had been ignoring corrosion-fatigue cracks for years, and not paying attention to alarms. Once the pipeline did fail, alarms went off for 17 hours before Enbridge realized what was happening. o The disaster actually started July 25, but it was not discovered until July 26 when local residents started complaining. The first that corporation executives realized they had a problem, was when they got phone calls from people outside of the
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I suggest that US Poly be asked if shipping it back to them for re-use, is desirable. I suggest that the vendor be informed of all such instances, to help vendor improve their quality control. 23 http://news.gather.com/viewArticle.action?articleId=281474978285141 24 http://www.epa.gov/enbridgespill/ http://www.naturalgaswatch.org/?p=1632

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company. The first people sent to deal with the crisis, were not qualified to deal with the scale of it. o It is the most expensive oil pipeline spill since the U.S. government began keeping records in 1968. This is the Enbridge oil spill into the Kalamazoo river, with Canadian oil, the kind of risk that environmental opponents of the Keystone pipeline are up in arms about.25 See July 10, 2012, when the NTSB came out with a report on this incident:26 843,444 gallons of crude oil = estimated total release. About 320 people reported symptoms consistent with crude oil exposure. No fatalities were reported. As of Nov 12, 2012: 150 families have had to relocate; 1,149,120 gallons of oil collected; 180,205 cubic yards contaminated soil/debris disposed. There is more to be done. o Cause-Avoidance (see Labeling Causes chapter) practical via: Corporate Training upgrading Safety Standards improvement and enforcement

2010 July 30 LA California Gas Explosion


o A South L.A. building suffered catastrophic damage caused by a suspected natural gas explosion, at 6 am.27

2010 Sep 9 - San Bruno Ca Gas Pipeline Explosion Fire


Check out the San Bruno incident, allegedly the worst gas explosion, so far, in US history, except I am finding others, which seem worse, depending on statistics we use to measure size. I think worst needs to be quantified such as: most people killed; biggest geographical area affected; most human stupidity making disaster needlessly bad. http://www.sfgate.com/san-bruno-fire/ http://www.aolnews.com/2010/09/13/san-bruno-explosion-before-and-after-views-viagoogle-earth-pho/ https://projects.propublica.org/pipelines/ http://www.naturalgaswatch.org/?p=1384 https://en.wikipedia.org/wiki/2010_San_Bruno_pipeline_explosion See follow-up in this timeline: 2011 Aug; 2012 June and July. 1,000 feet high initial wall of flame, with explosion registering like a 1.1 magnitude earthquake

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http://insideclimatenews.org/news/20120626/dilbit-diluted-bitumen-enbridge-kalamazoo-river-marshallmichigan-oil-spill-6b-pipeline-epa 26 http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/summary/PAR1201.html 27 http://news.gather.com/viewArticle.action?articleId=281474978411146

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38 homes totally destroyed 53 homes were on fire at some point Over 120 homes with some kind of damage. 8 people killed

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San Bruno was a bigger disaster than Indianapolis. It was triggered by a gas explosion. This contradicts people who say they cannot believe a gas explosion can cause as much damage as what happened in Indianapolis. See CI Boom 2012 for details on Indianapolis gas explosion, which was triggered by an insurance scam. 28 A year long investigation by the National Transportation Safety Board blamed the San Bruno accident on Pacific Gas and Electric (PG&E) Company's inadequate quality control and testing of the over 50 year old pipeline, calling it an "organizational accident." See Labeling Causes chapter. This could have been avoided, or seriously mitigated via: o Audits, which were missing; o Follow-up, which was missing; o Inspections, which were absent; o Organizational Standards, which were absent; o Regulatory oversight competence, which was missing; o Safety standards, which were a joke; o Training standards, which were missing; o Utility Line Mapping, which was broken. I watched many of the BP Gulf of Mexico Oil Spill hearings. An organizational accident would be a good description for that also. There were people sent to sites without any relevant training, or access to relevant documents. They asked for this, and were met with a stone wall. So many people at the site had no idea what the safety procedures were, which had been carefully worked out, then deliberately withheld from them, by accident. Alarms were muted so people could sleep, instead of adjusting the systems, so only serious alarms would wake them. On Google Plus, I shared some of my conclusions with Vicky Gallardo who has worked in San Jose city government.29 She told me, QUOTE30 I am very familiar with the San Bruno incident. The tragedy was exacerbated by poor record keeping and the lack of a geographic information system accessible by emergency responders. After that incident, PGE was quite responsive supplying city and county officials in the bay area with requested information. PGE realigned and bulked up their mapping department, hiring an industry leader from Esri - the world's largest provider of mapping technology. PGE also
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http://www.scribd.com/doc/204042682/CI-Boom-2012 https://plus.google.com/u/0/118052684405036727054/posts 30 https://plus.google.com/u/0/118052684405036727054/posts/QSa1HQSjyz8

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began rigorous testing of the gas lines and began replacing pipe with the same structural defects as the pipeline that ruptured. There is probably more that needs to be done, but things are moving in the right direction. UNQUOTE This is good news. Can other public utilities learn from this, so as to avoid repeating history?

2011
The U.S. Environmental Protection Agency compiles a Toxics Release Inventory, tracking leaks into land, air, and water.31 Bloomberg analyzed discharges affecting streams, rivers, lakes, and oceans in 2011 and found some shocking results. All told, 1,374 different facilities were involved in leaking 287 chemicals, for a total of 194 million pounds of chemicals released.32

2011 Feb 9 Allentown PA Gas Explosion


A old gas line (installed in 1929) running beneath Allen Street died of old age, exploded, igniting a fire that killed five people including a four-month-old boy and an elderly couple. Over fifty homes and businesses were damaged and hundreds of residents were forced outside into 27 degree weather.33 The company was fined for not doing proper maintenance on pipes which showed sign of damage. See 2014 Feb 8 for an update to this story.

2011 April Leaks invite future Gas Explosions


Government Regulators, in multiple US States, are concerned about the volume of gas pipeline leaks discovered.34

2011 July 1 Laurel Montana Yellowstone River Oil Spill


This is one of the more expensive oil spills in the USA, prior to BP in the Gulf of Mexico, also not as bad as 2010 in Michigan. An ExxonMobil pipeline ruptured, dumping 63,000 gallons of crude oil into the fast moving river. Later reports raised the possibility that this pipeline may have sometimes carried tar sands crude, which environmentalists claim can be more damaging to a pipeline because of its corrosive chemical compounds, as well as more toxic to people and wildlife. 35

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http://www2.epa.gov/toxics-release-inventory-tri-program/learn-about-toxics-release-inventory http://www.businessweek.com/articles/2014-01-22/forget-west-virginia-dot-chemical-spills-are-anamerican-tradition This article is referring to the 2014 Jan 9 chemical spill contaminating W Va tap water. 33 https://projects.propublica.org/pipelines/ 34 http://www.naturalgaswatch.org/?p=268 35 https://projects.propublica.org/pipelines/

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2011 Aug 25 = PHMSA rulemaking starts


Following the San Bruno incident,36 NTSB recommended that DOT require natural gas pipeline operators install automated valves in all high consequence areas.37 NTSB told

GAO38 that PHMSA is in the process of responding to this recommendation. Specifically, August 25 2011, PHMSA began a rulemaking process that could address the extent to which operators will be required to install automated valves.39

2011 Aug 30 = NTSB report on San Bruno disaster


2010 09 09 was date of the San Bruno California Pacific Gas and Electric Company Natural Gas Transmission Pipeline Rupture and Fire, which many commentators have labeled as the worst such disaster in US history. 2011 08 30 was when the NTSB came out with a summary report on San Bruno. 40 Quoting from that report: Uncertain later date (I think 2013 January), theres an article (see footnote link) referring to some court case, where a PG&E consultant is disputing some of the NTSB findings. 41 Here is another article, from 2013 January, which I think is about the same scenario, and is more clearly structured.42

San Bruno Executive Summary


On September 9, 2010, about 6:11 p.m. Pacific daylight time, a 30-inch-diameter segment of an intrastate natural gas transmission pipeline known as Line 132, owned and operated by the Pacific Gas and Electric Company (PG&E), ruptured in a residential area in San Bruno, California. The rupture occurred at mile point 39.28 of Line 132, at the intersection of Earl Avenue and Glenview Drive. The rupture produced a crater about 72 feet long by 26 feet wide. The section of pipe that ruptured, which was about 28 feet long and weighed about 3,000 pounds, was found 100 feet south of the crater. PG&E estimated that 47.6 million standard cubic feet of natural gas was released.

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San Bruno, see incident 2010 Sep 9; NTSB report 2011 Aug 30; NTSB follow-up 2012 June 17; more info 2012 July 18. 37 See NTSB, Pipeline Accident Report: Pacific Gas and Electric Company Natural Gas Transmission Pipeline Rupture and Fire, San Bruno, California, September 9, 2010, NTSB/PAR11/01 (Washington, D.C: Aug. 30, 2011). 38 See: 2013 Jan 23. 39 76 Fed. Reg. 53086. 40 http://www.ntsb.gov/investigations/reports_pipeline.html http://www.ntsb.gov/investigations/summary/PAR1101.html 41 http://www.kionrightnow.com/story/20587454/new 42 http://www.sfgate.com/bayarea/article/PG-amp-E-consultant-defends-pipe-inspections-4191069.php

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The released natural gas ignited, resulting in a fire that destroyed 38 homes and damaged 70. Eight people were killed, many were injured, and many more were evacuated from the area.

San Bruno Probable Cause


The National Transportation Safety Board (NTSB) determines that the probable cause of the accident was the Pacific Gas and Electric Company's (PG&E) (1) inadequate quality assurance and quality control in 1956 during its Line 132 relocation project, which allowed the installation of a substandard and poorly welded pipe section with a visible seam weld flaw that, over time grew to a critical size, causing the pipeline to rupture during a pressure increase stemming from poorly planned electrical work at the Milpitas Terminal; and (2) inadequate pipeline integrity management program, which failed to detect and repair or remove the defective pipe section. Contributing to the accident were the California Public Utilities Commission's (CPUC) and the U.S. Department of Transportation's (DOT) exemptions of existing pipelines from the regulatory requirement for pressure testing, which likely would have detected the installation defects. Also contributing to the accident was the CPUC's failure to detect the inadequacies of PG&E's pipeline integrity management program. Contributing to the severity of the accident were the lack of either automatic shutoff valves or remote control valves on the line and PG&E's flawed emergency response procedures and delay in isolating the rupture to stop the flow of gas.

San Bruno Investigation Synopsis


The NTSBs investigation found that the rupture of Line 132 was caused by a fracture that originated in the partially welded longitudinal seam of one of six short pipe sections, which are known in the industry as "pups." The fabrication of five of the pups in 1956 would not have met generally accepted industry quality control and welding standards then in effect, indicating that those standards were either overlooked or ignored. The weld defect in the failed pup would have been visible when it was installed. The investigation also determined that a sewer line installation in 2008 near the rupture did not damage the defective pipe.

The rupture occurred at 6:11 p.m.; almost immediately, the escaping gas from the ruptured pipe ignited and created an inferno. The first 911 call was received within seconds. Officers from the San Bruno Police Department arrived on scene about 6:12 p.m.

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Firefighters at the San Bruno Fire Department heard and saw the explosion from their station, which was about 300 yards from the rupture site. Firefighters were on scene about 6:13 p.m. More than 900 emergency responders from the city of San Bruno and surrounding jurisdictions executed a coordinated emergency response, which included defensive operations, search and evacuation, and medical operations. Once the flow of natural gas was interrupted, firefighting operations continued for 2 days. Hence, the emergency response by the city of San Bruno was prompt and appropriate.

However, PG&E took 95 minutes to stop the flow of gas and to isolate the rupture sitea response time that was excessively long and contributed to the extent and severity of property damage and increased the life-threatening risks to the residents and emergency responders. The NTSB found that PG&E lacks a detailed and comprehensive procedure for responding to large-scale emergencies such as a transmission pipeline break, including a defined command structure that clearly assigns a single point of leadership and allocates specific duties to supervisory control and data acquisition staff and other involved employees. PG&E's supervisory control and data acquisition system limitations caused delays in pinpointing the location of the break. The use of either automatic shutoff valves or remote control valves would have reduced the amount of time taken to stop the flow of gas. PG&E's pipeline integrity management program, which should have ensured the safety of the system, was deficient and ineffective because it

Was based on incomplete and inaccurate pipeline information. Did not consider the design and materials contribution to the risk of a pipeline failure. Failed to consider the presence of previously identified welded seam cracks as part of its risk assessment. Resulted in the selection of an examination method that could not detect welded seam defects. Led to internal assessments of the program that were superficial and resulted in no improvements.

See: 1981Aug 25 San Francisco; and 2008 Dec 24 Rancho Cordova. These earlier PG&E disasters shared many of the same deficiencies as were found with the 2010 Sep 9 San Bruno incident. NTSB concluded that PG&E's multiple, recurring deficiencies are evidence of a systemic problem. The investigation also determined that the California Public Utilities Commission (CPUC), the pipeline safety regulator within the state of California, failed to detect the inadequacies in PG&E's integrity management program and that the Pipeline and Hazardous Materials Safety Administration (PHMSA) integrity management inspection protocols need improvement. Because the PHMSA has not incorporated the use of 15 Critical Infrastructure disasters 2010 to 2011

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effective and meaningful metrics as part of its guidance for performance-based management pipeline safety programs, its oversight of state public utility commissions regulating gas transmission and hazardous liquid pipelines could be improved. Without effective and meaningful metrics in performance-based pipeline safety management programs, neither PG&E nor the CPUC was able to effectively evaluate or assess PG&E's pipeline system.

San Bruno NTSB Safety Recommendations New Recommendations


To the U.S. Secretary of Transportation: (DOT) Conduct an audit to assess the effectiveness of the Pipeline and Hazardous Materials Safety Administration's oversight of performance-based safety programs. This audit should address the (1) need to expand the program's use of meaningful metrics; (2) adequacy of its inspection protocols for ensuring the completeness and accuracy of pipeline operators' integrity management program data; (3) adequacy of its inspection protocols for ensuring the incorporation of an operator's leak, failure, and incident data in evaluations of the operator's risk model; and (4) benefits of establishing performance goals for pipeline operators. (P-11-4) Include in the audit conducted pursuant to Safety Recommendation P-11-4 a review of the Pipeline and Hazardous Materials Safety Administration's enforcement policies and procedures, including, specifically, the standard of review for compliance with performance-based regulations. (P-11-5) Conduct an audit of the Pipeline and Hazardous Materials Safety Administration's state pipeline safety program certification program to assess and ensure state pipeline safety programs and Federal pipeline safety grants are used effectively to conduct oversight of intrastate pipeline operations, including an evaluation of state inspection and enforcement activities. (P-11-6) Ensure that the Pipeline and Hazardous Materials Safety Administration amends the certification program, as appropriate, to comply with the findings of the audit recommended in Safety Recommendation P-11-6. (P-11-7) To the Pipeline and Hazardous Materials Safety Administration: (PHMSA) 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, 16 Critical Infrastructure disasters 2010 to 2011

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product transported, and potential impact radius. (P-11-8) This recommendation supersedes Safety Recommendation P-11-1. 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) This recommendation supersedes Safety Recommendation P-11-2. 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) 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) 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) 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) Assist the California Public Utilities Commission in conducting the comprehensive audit recommended in Safety Recommendation P-11-22. (P-11-16) 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) Revise your integrity management inspection protocol to 17 Critical Infrastructure disasters 2010 to 2011

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(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 performancebased 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) 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) To the Governor of the State of California: Expeditiously evaluate the authority and ability of the pipeline safety division within the California Public Utilities Commission to effectively enforce state pipeline safety regulations, and, based on the results of this evaluation, grant the pipeline safety division within the California Public Utilities Commission the direct authority, including the assessment of fines and penalties, to correct noncompliance by state regulated pipeline operators. (P-11-21) To the California Public Utilities Commission: (CPUC) With assistance from the Pipeline and Hazardous Materials Safety Administration, conduct a comprehensive audit of all aspects of Pacific Gas and Electric Company operations, including control room operations, emergency planning, record-keeping, performance-based risk and integrity management programs, and public awareness programs. (P-11-22) Require the Pacific Gas and Electric Company to correct all deficiencies identified as a result of the San Bruno, California, accident investigation, as well as any additional deficiencies identified through the comprehensive audit recommended in Safety Recommendation P-11-22, and verify that all corrective actions are completed. (P-11-23) To the Pacific Gas and Electric Company: (PG&E)

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Revise your work clearance procedures to include requirements for identifying the likelihood and consequence of failure associated with the planned work and for developing contingency plans. (P-11-24) Establish a comprehensive emergency response procedure for responding to large-scale emergencies on transmission lines; the procedure should (1) identify a single person to assume command and designate specific duties for supervisory control and data acquisition staff and all other potentially involved company employees; (2) include the development and use of trouble-shooting protocols and checklists; and (3) include a requirement for periodic tests and/or drills to demonstrate the procedure can be effectively implemented. (P-11-25) Equip your supervisory control and data acquisition system 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-11-26) Expedite the installation of automatic shutoff valves and remote control valves on transmission lines in high consequence areas and in class 3 and 4 locations, and space them at intervals that consider the factors listed in Title 49 Code of Federal Regulations 192.935(c). (P-11-27) Revise your postaccident toxicological testing program to ensure that testing is timely and complete. (P-11-28) Assess every aspect of your integrity management program, paying particular attention to the areas identified in this investigation, and implement a revised program that includes, at a minimum, (1) a revised risk model to reflect the Pacific Gas and Electric Company's actual recent experience data on leaks, failures, and incidents; (2) consideration of all defect and leak data for the life of each pipeline, including its construction, in risk analysis for similar or related segments to ensure that all applicable threats are adequately addressed; (3) a revised risk analysis methodology to ensure that assessment methods are selected for each pipeline segment that address all applicable integrity threats, with particular emphasis on design/material and construction threats; and (4) an improved self-assessment that adequately measures whether the program is effectively assessing and evaluating the integrity of each covered pipeline segment. (P-11-29) Conduct threat assessments using the revised risk analysis methodology incorporated in your integrity management program, as recommended in Safety Recommendation P-11-

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29, and report the results of those assessments to the California Public Utilities Commission and the Pipeline and Hazardous Materials Safety Administration. (P-11-30) Develop, and incorporate into your public awareness program, written performance measurements and guidelines for evaluating the plan and for continuous program improvement. (P-11-31) To the American Gas Association and the Interstate Natural Gas Association of America: Report to the National Transportation Safety Board on your progress to develop and introduce advanced in-line inspection platforms for use in gas transmission pipelines not currently accessible to existing in-line inspection platforms, including a timeline for implementation of these advanced platforms. (P-11-32)

Previously Issued Recommendations


As a result of this accident investigation, the National Transportation Safety Board previously issued the following safety recommendations: To the Pipeline and Hazardous Materials Safety Administration: (PHMSA) Through appropriate and expeditious means such as advisory bulletins and posting on your website, immediately inform the pipeline industry of the circumstances leading up to and the consequences of the September 9, 2010, pipeline rupture in San Bruno, California, and the National Transportation Safety Board's urgent safety recommendations to Pacific Gas and Electric Company so that pipeline operators can proactively implement corrective measures as appropriate for their pipeline systems. (P10-1) (Urgent) Issue guidance to operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines regarding the importance of sharing system-specific information, including pipe diameter, operating pressure, product transported, and potential impact radius, about their pipeline systems with the emergency response agencies of the communities and jurisdictions in which those pipelines are located. (P-111) Issue guidance to operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines regarding the importance of control room operators immediately and directly notifying 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-11-2) To the California Public Utilities Commission: (CPUC)

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Develop an implementation schedule for the requirements of Safety Recommendation P10-2 (Urgent) to Pacific Gas and Electric Company (PG&E) and ensure, through adequate oversight, that PG&E has aggressively and diligently searched documents and records relating to pipeline system components, such as pipe segments, valves, fittings, and weld seams, for PG&E natural gas transmission lines in class 3 and class 4 locations and class 1 and class 2 high consequence areas that have not had a maximum allowable operating pressure established through prior hydrostatic testing as outlined in Safety Recommendation P-10-2 (Urgent) to PG&E. These records should be traceable, verifiable, and complete; should meet your regulatory intent and requirements; and should have been considered in determining maximum allowable operating pressures for PG&E pipelines. (P-10-5) (Urgent) If such a document and records search cannot be satisfactorily completed, provide oversight to any spike and hydrostatic tests that Pacific Gas and Electric Company is required to perform according to Safety Recommendation P-10-4. (P-10-6) (Urgent) Through appropriate and expeditious means, including posting on your website, immediately inform California intrastate natural gas transmission operators of the circumstances leading up to and the consequences of the September 9, 2010, pipeline rupture in San Bruno, California, and the National Transportation Safety Board's urgent safety recommendations to Pacific Gas and Electric Company so that pipeline operators can proactively implement corrective measures as appropriate for their pipeline systems. (P-10-7) (Urgent) To the Pacific Gas and Electric Company: (PG&E) Aggressively and diligently search for all as-built drawings, alignment sheets, and specifications, and all design, construction, inspection, testing, maintenance, and other related records, including those records in locations controlled by personnel or firms other than Pacific Gas and Electric Company, relating to pipeline system components, such as pipe segments, valves, fittings, and weld seams for Pacific Gas and Electric Company natural gas transmission lines in class 3 and class 4 locations and class 1 and class 2 high consequence areas that have not had a maximum allowable operating pressure established through prior hydrostatic testing. These records should be traceable, verifiable, and complete. (P-10-2) (Urgent) Use the traceable, verifiable, and complete records located by implementation of Safety Recommendation P-10-2 (Urgent) to determine the valid maximum allowable operating pressure, based on the weakest section of the pipeline or component to ensure safe operation, of Pacific Gas and Electric Company natural gas transmission lines in class 3 and class 4 locations and class 1 and class 2 high consequence areas that have not had a maximum allowable operating pressure established through prior hydrostatic testing. (P10-3) (Urgent) If you are unable to comply with Safety Recommendations P-10-2 (Urgent) and P-10-3 (Urgent) to accurately determine the maximum allowable operating pressure of Pacific 21 Critical Infrastructure disasters 2010 to 2011

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Gas and Electric Company natural gas transmission lines in class 3 and class 4 locations and class 1 and class 2 high consequence areas that have not had a maximum allowable operating pressure established through prior hydrostatic testing, determine the maximum allowable operating pressure with a spike test followed by a hydrostatic pressure test. (P10-4) Require your control room operators to notify, immediately and directly, the 911 emergency call center(s) for the communities and jurisdictions in which your transmission and/or distribution pipelines are located, when a possible rupture of any pipeline is indicated. (P-11-3)

Previously Issued Recommendations Classified in This Report


Safety Recommendations P-11-1 and P-11-2 to the Pipeline and Hazardous Materials Safety Administration are classified "Closed-Superseded" by Safety Recommendations P-11-8 and P-11-9, respectively, in this report (section 2.4.2, "Notifying Emergency Responders"). UNQUOTE

2011 Sep 26 Seattle WA


A gas leak explosion destroyed a North Seattle Washington home and injured the couple who lived there.43 i. It took until 2012 Dec 26 for the subsequent investigation to figure out what happened. ii. An electrical current surge from a downed Seattle City Light power line punched a hole in the natural gas line, causing the leak which led to the explosion. Puget Sound Energy was held responsible for not doing a thorough enough inspection following reports of smell of gas in the area. iii. The Sunday before the explosion, PSE gas workers found leaks in three pipes, but failed to find the leak at the exploded house until late Monday, too late to save the house, or protect its occupants,

2011 Oct = Denton Tx


Eagleridge Operating was implicated in a case of improperly disposing of fracking fluid in October 2011 when a Denton city inspector caught company personnel pumping used water near a hydraulic fracturing well from a waste pit into a trench that ultimately emptied into a nearby creek.44 For related incidents with Eagleridge Operating, see:
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http://www.king5.com/news/local/Pipleline-investigators-blame-PSE-for-2011-gas-leak-explosion-inNorth-Seattle-184848991.html 44 http://www.naturalgaswatch.org/?p=1958

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October 2011; April 18, 2013.

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2011 Nov New Albany In


There was an explosion in New Albany Indiana with a Vectren natural gas line. See 2012 Nov 28 for results of the investigation.

Continued in more documents


Time Line of these disasters to be continued in related documents to be named: CI Boom 0 thru 199945 CI Boom 2000 to 200646 CI Boom 200747 CI Boom 2008 to 200948 CI Boom 2010 to 2011 CI Boom 201249 CI Boom 2013 Jan-Mar50 CI Boom 2013 Apr51 CI Boom 2013 May-Dec CI Boom 2014 Jan W Va Water52 CI Boom 2014 Jan These other time line history segments shall be uploaded to the same SCRIBD Critical Infrastructure collection.53 Revision history will be maintained in the main parent document.

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http://www.scribd.com/doc/203317455/CI-Boom-0-thru-1999 http://www.scribd.com/doc/203688481/CI-Boom-2000-to-2006 47 http://www.scribd.com/doc/204262969/CI-Boom-2007 48 http://www.scribd.com/doc/206714326/CI-Boom-2008-to-2009 49 http://www.scribd.com/doc/204042682/CI-Boom-2012 50 http://www.scribd.com/doc/204889417/CI-Boom-2013-Jan-to-March 51 http://www.scribd.com/doc/204575461/CI-Boom-2013-April 52 http://www.scribd.com/doc/203973261/CI-Boom-2014-Jan-9-W-Va-Water 53 http://www.scribd.com/collections/4108500/Critical-Infrastructure

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