The New Pipeline Rule I Waited Half a Career to See

By Charles Koval

One night, a couple feet underground outside an American home, the gas flowing in a service line began to escape through a puncture adjacent to a newly installed mailbox. A man and woman inside the home were watching the news. Their children were playing. Then, suddenly, without warning . . . nothing happened.

A simple and inexpensive device called an excess flow valve (EFV) kicked in, stopping the gas flow. There was no explosion, no fire, no injury or loss of life.

As a petroleum engineer and pipeline specialist for the NTSB, I know that the most important pipeline safety advance in recent decades has been the establishment of the national one-call 811 number. But EFVs may be the next most important life-saver, especially for homeowners.

Diagram of how an excess flow valve functionsGas companies install an EFV in a service pipeline where it meets the main line. The EFV shuts off the gas flow in the service line when it exceeds the normal flow rate; excess flow often indicates that gas is escaping the service line through a puncture or sever, potentially leading to an explosion or fire.

I’ve been working a long time to encourage the progress that came to fruition late last year regarding EFVs. The Pipeline and Hazardous Materials Safety Administration (PHMSA) quietly completed an important achievement and, in the process, closed an NTSB recommendation. PHMSA issued a rule expanding the use of EFVs to new or renewed service lines leading to almost all small commercial businesses and multi-residence buildings.

It’s taken decades to achieve this result. In all, the NTSB has made 24 safety recommendations related to EFVs.

When I came to the NTSB in 1990, the agency had already been endorsing EFVs for 20 years, beginning with recommending a shutoff valve after research that came out of a 1970 safety study.

I worked on accident after accident that may have been prevented by EFVs. Most of my work between 1990 and 1994 involved single-family residences, but many multi-residence accidents were just as horrible, if not worse. The incidents occurred in large cities like Tulsa, Oklahoma, and St. Paul, Minnesota, and in smaller towns like St. Cloud, Minnesota; Montezuma, Indiana; and Cliffwood Beach, New Jersey. I can still remember my first NTSB supervisor expressing exasperation that this simple and elegant solution was not in wider use.

Then came June 9, 1994. At about 6:45 that evening, a 2-inch-diameter steel gas service line that had been exposed during excavation separated at a compression coupling about 5 feet from the north wall of John T. Gross Towers, an 8-story retirement home. The escaping gas flowed underground toward Gross Towers, passed through openings in the building foundation, entered the mechanical room through the floor vents, and migrated to other floors.

A resident smelled the gas, as did a workman onsite, who told his foreman. The foreman called the gas company and the housing authority, then had other employees locate and shut off the gas line valve inside the towers. But at 6:58 p.m., the built-up natural gas in the building ignited and exploded; a second explosion followed 5 minutes later. The accident killed one person and injured 66—and it could have been much worse. Many residents were not in the building on the early summer evening of the disaster.

A humble EFV could have shut off the gas flow into Gross Towers. After the explosion, the NTSB recommended that PHMSA’s predecessor agency require that all gas distribution operators inform all customers of the availability of EFVs. After many years, the agency did so. Meanwhile, fatal accidents continued—all potentially preventable with EFVs.

Then, in 1998, the NTSB was called to the site of an explosion and fire at a single-family home in South Riding, Virginia.

A man, woman, and their two children were spending their first night together in their new home. The family retired at about 10:30—the children to the upper level of the house, and, because not all of their furniture had arrived, the parents to the first-floor study. Shortly after midnight, the house exploded and was engulfed in flames. The children were thrown out of the house and onto the lawn, suffering minor injuries. The parents fell into the basement as the first floor collapsed. The father was able to crawl to safety, badly burned; the mother did not escape and died as a result of her injuries.

Again, an EFV could have prevented the tragedy.

Following this accident, the NTSB recommended that PHMSA require EFVs in all new and renewed gas service lines, regardless of customer classification, when operating conditions were compatible with readily available valves. PHMSA first required only that single-family homeowners be notified of the availability of the valve and be allowed to pay for it themselves. Then, in 2009, PHMSA changed the rule, requiring EFVs to be installed on almost all new and renewed service pipelines to single family homes.[1] Finally, on October 14, 2016, PHMSA expanded the safety requirement to include most new and renewed service pipelines for multi-residential and commercial applications, closing one chapter in EFV history—and with it, an outstanding NTSB recommendation.

My first NTSB supervisor is no longer with us, but even years ago, he could imagine the broad use of EFVs that he did not live to see. Sometimes it takes a long time to normalize safety. Too often, it takes a highly visible accident—or several of them—to draw attention to a problem. Solutions often come a little bit at a time, or a long time afterward, without any fanfare.

But for now, and well into the future, for many businesses and homes nationwide, if a service line fails, nothing will happen. These homes and businesses are a little safer today because PHMSA and the gas industry acted on NTSB’s EFV recommendations.

 

Charles Koval is a Petroleum Engineer and Pipeline Specialist in the NTSB Office of Railroad, Pipeline and Hazardous Materials.

 

[1] The service line does not need an EFV if it: 1. does not operate at or above 10 psig all year, 2. has previously had contaminates, 3. could interfere with necessary operation or maintenance activities, or 4. is not commercially available to the operator.

Don’t Press the Envelope

By Mike Folkerts

Loss of control in flight—when a pilot fails to maintain or regain control of an aircraft—is the leading cause of general aviation fatalities. From 2011 to 2015, nearly half of all fatal fixed-wing accidents in the United States involved pilots losing control of their aircraft, resulting in 819 fatalities. Far too many NTSB investigations have shown how a loss of aircraft attitude control is often preceded by the loss of a pilot’s mental attitude control.

April 27, 2013, Piper PA-28R-180 airplane crash near Norfolk, Nebraska.
April 27, 2013, Piper PA-28R-180 airplane crash near Norfolk, Nebraska.

In the fatal accidents that I have investigated, this loss of mental control seems to be a conscious decision by the pilot to “press the envelope”—a term made famous in the 1983 film The Right Stuff, an adaptation of Tom Wolfe’s best‑selling book about the military test pilots who became Project Mercury astronauts. As the United States sought to achieve supersonic flight and put a human on the moon, these test pilots pressed the envelope, pushing the boundaries of both aircraft and human performance. Their efforts were based on national objectives and security, and many of these aviators paid the ultimate price in that pursuit.

Unfortunately, in far too many general aviation accidents, pilots choose to press the envelope for relatively minor (and often selfish) reasons, like “pressing the weather” to get home for dinner, flying at low altitude or maneuvering aggressively for an extra boost of adrenaline, or “pressing a known aircraft issue” to get a job done. Although a “git-r-done” attitude is certainly commendable, pilots too often forget to trust the little voice inside that warns them to steer clear of unwarranted risks, or they fail to guard against the temptation to make extreme efforts to please or impress others. General aviation flying very rarely requires the need to press the envelope, and pressing far too often ends in a tragic loss of control.

The NTSB is so concerned with this phenomenon that, for the last 3 years, we have placed “Prevent Loss of Control in Flight in General Aviation” on our Most Wanted List of transportation safety improvements to help bring attention to the issue. Last week, NTSB Board Member Earl Weener even attended the Sun ‘n Fun International Fly-In—one of the world’s largest general aviation enthusiasts’ training events—to talk to pilots about the dangers of losing control.

Whatever a pilot’s motivation may be for wanting to press the envelope, in general aviation, it’s not worth risking loss of control. Never underestimate the connection between mental attitude and aircraft attitude.

Mike Folkerts is an aviation safety investigator in the NTSB Office of Aviation Safety.

 

NTSB: 50 Years of Asking “Why?”

By Acting Chairman Robert L. Sumwalt

NTSB 50th Anniversary commemerative emblemFifty years ago, on April 1, 1967, the National Transportation Safety Board (NTSB) came into existence, helping to fulfill President Lyndon B. Johnson’s pledge to ensure the safety of Americans on land, sea, and air.

In 1966, Johnson recommended the creation of a single Department of Transportation (DOT), bringing together the functions of many far-flung agencies. He also urged

…that there be created under the Secretary of Transportation a National Transportation Safety Board independent of the operating units of the Department. The sole function of this Board will be the safety of our travelers. It will review investigations of accidents to seek their causes. It will determine compliance with safety standards. It will examine the adequacy of the safety standards themselves… I consider the functions of this Board so important that I am requesting authority from Congress to name five Presidential appointees as its members.

. . .

No function of the new agency—no responsibility of its Secretary—will be more important than safety.

Indeed, between March 2, 1966, and the NTSB’s birth the following year, there was a spate of disastrous commercial aviation crashes, either on US soil or involving US-built aircraft, together taking the lives of hundreds of passengers. This was not extremely unusual for this era; sometimes multiple fatal aviation accidents happened during the same month.

At the same time, the roads were full of automobiles that could never be sold under today’s safety standards. Most cars had no seat belts, and those that did generally had them in the front seat only. Air bags and child safety seats had not made their way into production. Drunk driving laws and enforcement were permissive, and even with far fewer cars on the roads, there were far more crash deaths.

Before the NTSB, major accidents in aviation were investigated by a section of the Civil Aeronautics Board, or CAB. Accidents in other modes of transportation might be investigated by a special subcommittee or jury, but there was no agency to coordinate these efforts or to collect the various findings and analyze them.

The written testimony of government officials in favor of creating the NTSB put it this way: “There is no single official in the entire Government who is in a position to identify, study, and propose solutions to transportation problems.”

The NTSB was established to ask “why?” when an accident happened, and to ask “why not?” Why not improve regulations, training, or a certain aspect of the vehicle or the environment? Even in its infancy, NTSB reports included, as they do today, recommendations to prevent future accidents, often pointing industry and regulators toward a safer future. Although action on NTSB recommendations is purely voluntary, more than 80% of our recommendations are acted upon favorably.

However, like the CAB investigators of its immediate predecessor in aviation, the NTSB initially was part of a larger agency that also concerned itself with operations and regulations. Although NTSB independence has been spelled out since its inception, the Board still came under the purview of the Secretary of Transportation. This arrangement put the NTSB in the position of investigating actions of its own parent agency and its constituent modal administrations. In 1974, Congress passed the Independent Safety Board Act of 1974, which, effective April 1, 1975, made the NTSB independent of the DOT, removing any concern that the regulator was, effectively, investigating itself.

Since our inception, we can point to numerous improvements that the NTSB has recommended as the result of accident and crash investigations in aviation, marine, highway, railroad, and pipeline transportation. The NTSB’s work throughout our 50-year history is responsible for the transformational improvements that make transportation safer for all of us today. But, by design, we can only take partial credit for any such improvement. We have no authority to regulate: only to recommend.

So, in celebrating our 50th anniversary, we also celebrate those who read our investigations and recommendations, agreed with us, and made the improvements happen, as well as those who made things not happen. Together, we avoided preventable accidents. We saved lives that didn’t have to be lost in the first place. We kept property intact that did not have to be damaged, and prevented injuries that didn’t need to be sustained (and the medical costs and loss of productivity that go with them).

The transportation industry is focused on a future with zero accidents. The men and women of the NTSB are committed to this vision and will continue to investigate accidents and to make recommendations that will help future generations enjoy an era free from transportation accidents.

As new technologies and transportation fields come into existence—from autonomous vehicles to commercial space launches, and beyond—we look forward to the next 50 years of transportation safety improvements.

Women of the NTSB

By Robert L. Sumwalt

As Women’s History Month draws to a close, we at the NTSB reflect on the thousands of women who have made a profound impact on transportation—at the NTSB and in the public, private, and nonprofit sectors. The contributions women have made to advance transportation safety, currently and throughout America’s history, are immeasurable and indispensable.

This weekend will mark the 50th anniversary of the NTSB opening its doors, and women have played key roles in the agency since its inception. In 1969, Isabel Burgess was nominated to be the first female Board member. In 1974, Mary Wallace (“Wally”) Funk became the first woman given the official title of Air Safety Investigator at the Board. Throughout the NTSB’s history, there have been seven female Board Members and three female Chairmen of the Board. Kay Bailey (later Kay Bailey Hutchison), once Vice Chairman of the Board, went on to become a US senator from Texas, where she served as the ranking member on the Senate Commerce, Science, and Transportation Committee. On a personal note, I had the pleasure of serving with our former Chairman, Debbie Hersman, who is now president and CEO of the National Safety Council.

Today, women make up 40% of the staff at the NTSB. There are 22 women working specifically on aviation safety issues. Nineteen women are in leadership roles as Member, directors, deputy directors, and supervisors.

The number of great accomplishments achieved by women at the NTSB and in the transportation industry is too great to attempt to tally. Women have been essential fibers in the fabric of the NTSB since day one, and they continue to make essential contributions. In addition to the women included in our administrative, human resources, and other support teams, the women who serve the NTSB as accident investigators, technical writers and editors, recommendation specialists, safety advocates, transportation disaster assistance specialists, recorder specialists, chemists, attorneys, and engineers ensure that the mission of this agency is fulfilled, day in and day out.

This month, and every month, the NTSB honors women in transportation and all the contributions they have made—and will continue to make—both within and outside the agency.

Teens and Drowsy Driving

Teens and Drowsy Driving

By Dr. Jana PriceTeenager sleeping after prepare for Exam at the Home. Focus on the Clock

Sleepiness while driving can have serious consequences. The NTSB has investigated numerous crashes in which driver drowsiness played a role. Today marks the first anniversary of one of those crashes.

On March 20, 2016, four teens were traveling home from a weekend trip to South Padre Island, Texas. At about 1:57 pm, the driver lost control of the car, crossed the center median, entered the opposing lanes of traffic, and collided with a truck-tractor semitrailer. The driver was seriously injured and her three friends died. The Board determined that that the driver’s loss of control was due to inattention resulting from her fatigue.

NTSB investigators learned that, in the 24 hours before the crash, the driver had very little opportunity for sleep—only about 5 hours on the morning of the crash.

According to the CDC, motor vehicle crashes are the leading cause of death for teens in the United States, and recent AAA Foundation for Traffic Safety research shows that one in five fatal crashes involves a drowsy driver. Other research shows that drivers aged 16 to 24 are at the greatest risk of being involved in a drowsy driving crash.

In a recent AAA Foundation study, many drivers who understood the risks of drowsy driving admitted they had, nonetheless, driven while fatigued. Specifically, the AAA survey found that 96 percent of drivers see drowsy driving as a serious threat and a completely unacceptable behavior; however, among that same group, 3 in 10 admitted to driving when they were so tired that they had a hard time keeping their eyes open.

Lack of sleep slows reaction time and makes us more susceptible to forgetting or overlooking important tasks. A few seconds is all it takes to drift out of the lane or to miss a stopped vehicle ahead.

Although it’s not always possible to predict when you will become drowsy behind the wheel, there are several steps you can take to help avoid this risk. Today, to call attention to the risk posed by driving drowsy, the NTSB is releasing a new Safety Alert, Drowsy Driving Among Young Drivers.

Jana Price, PhD, is a Senior Human Performance Investigator in NTSB’s Office of Highway Safety.

Act to End Deadly Distractions

By Robert L. Sumwalt

Every year, more than 3,000 people are killed—and 100 times more than that are injured—in accidents caused by distracted drivers. Whether the distraction is due to a driver using a hand-held personal electronic device or engaging in a wide range of other activities that take a driver’s attention off the road, the number of crashes, injuries, and fatalities resulting from distraction is on the rise. It will take a concerted effort by lawmakers, law enforcers, and transportation safety advocates to end this deadly trend.

Save the date card for the "Act to End Deadly Distractions" eventThis year marks the ninth time that the NTSB has included “eliminate distractions while driving” on its Most Wanted List (MWL) of transportation safety improvements. Although it’s not a new issue, ending deadly distractions in all modes of transportation is again on our signature priority list because it is one of the most critical issues facing the traveling public today.

More must be done to raise awareness about this issue, which has appeared on the MWL for far too long. To that end, the NTSB, in partnership with StopDistractions.org, will host a roundtable, titled “Act to End Deadly Distractions”—its second such event in 25 months aimed at shedding light on the issue of distracted driving and focusing on practical and measurable solutions to this growing problem. This upcoming roundtable will build off the momentum from our first distraction roundtable in March 2015, and will examine existing public policy and laws in several states that have reduced the number of crashes attributed to distraction. Our panel of participants will highlight ways that advocates and community influencers can work with law enforcement to continue to ensure distracted driving laws are enforced consistently. And, perhaps most importantly, victims’ families will speak about how they’ve been affected by these preventable crashes.

I have the pleasure of hosting this year’s event, which will be held on Wednesday, April 26, 2017, from 9:00 a.m. to 4:00 p.m. in the NTSB Conference Center in Washington, DC. More details can be found at the Act to End Deadly Distractions Roundtable webpage. The roundtable is open to the public and will be live streamed on the Web.

April is Distracted Driving Awareness Month and May is Global Youth Traffic Safety Month; this roundtable comes at the perfect time to raise awareness and spur action toward eliminating distraction.

One fatality due to a distracted driver is one too many. We know what it will take to eliminate these tragedies, and we are confident that the upcoming roundtable will be a step that direction.

The Black Box

Bella Dinh-Zarr, PhD, MPH, Vice Chairman

The famous “black box.”

Mosaic image of data recorders for the Most Wanted List issue are Expand Recorder Use to Enhance SafetyReporters always ask us about it during high-profile aviation and rail investigations. After the sinking of the El Faro cargo ship during Hurricane Joaquin, the news media closely followed the recovery of the voyage data recorder, which was located in about 15,000 feet of water.

The black box, which is usually orange with reflective tape to make it easier to locate in wreckage, can be critical to our investigations at the NTSB. These devices can withstand enormous impact forces, intense temperatures, and the extreme pressures of ocean depths. Recorders capture a range of useful data, from crewmembers’ actions and conversations to vehicle parameters. We use these data to help identify the cause of an accident and to make recommendations to prevent such accidents from happening in the future. Industry can also use this information to make transportation safer.

We analyze recorder information in all modes of transportation. We transcribe audio from cockpit voice recorders and extract information from flight data recorders on aircraft. We review voyage data recorders that provide ship data, bridge audio, and radar images on vessels. We assess information from event recorders and forward- and inward-facing video recorders on trains. We analyze a variety of recorders and cameras that provide performance information on highway vehicles. No matter what type of recorder we encounter, we are required by law to protect the information obtained for our investigations.

Although the NTSB uses recorders to learn from one tragedy to prevent future ones, industry and operators can install recorders and develop programs to learn lessons from normal operations.

The NTSB urges the transportation industry to install recorders in their vehicles, vessels, trains, and aircraft, and to assess the data collected from them to prevent accidents and assess operator performance. Industry can use information from data, audio, and video recorders to identify issues of operational weakness or noncompliance with procedures. Airlines use the data they gather in everyday line operations through flight operational quality assurance (FOQA) programs to prevent accidents from occurring in the first place. Although most large aircraft are already required to have flight data and cockpit voice recorders, we have also recommended that they have cockpit video recording systems, and we have recommended that certain small aircraft that are not required to have recorders be required to carry recording devices that capture data. For smaller aircraft, recorders can provide crucial accident data, and they can also be a vital part of flight data management programs.

We appreciate the special value of data from video recorders, and that’s why many of our recent recommendations to regulators and operators propose that video recorders be installed to capture operator and crew behavior. Currently, investigators have no access to the visual information from an accident sequence. Although we can piece together key events in an airplane accident from cockpit audio and flight data, with video we have access to nonverbal communications and cockpit instrument manipulation. In fact, our NTSB scientists have even written software that reads needle positions and creates valuable data tables based on cockpit images! Reconstructing the accident sequence without video evidence requires additional time and effort—possibly delaying critical safety improvements.

What can be learned when inward-facing video is available? The answer is apparent from our 2014 investigation of the mid-air breakup of SpaceShipTwo during a test flight. SpaceShipTwo was equipped with data recorders, including video recorders to document the flight test. Because of those video images, the NTSB was able to identify quickly (by the second day of the on-scene investigation) that the co-pilot moved a lever at an inappropriate time, which ultimately resulted in the crash.

It is indisputable that we can make transportation safer by using information obtained from recorders. That’s why “Expand Recorder Use to Enhance Safety” is on the NTSB’s Most Wanted List of transportation safety improvements. And that’s why we urge transportation operators to install this important safety technology as soon as possible.

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