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Investigators found that an operator's shift-change procedure required specific information to be exchanged and required no record that it had been. The line near Marshall, Michigan ruptured at 5:58 p.m. on July 25, 2010. The control center never identified the rupture on its own, and the release was reported at 11:17 the following morning by an employee of a different company who had seen oil in a creek.1 The National Transportation Safety Board adopted its report on July 10, 2012. It recorded that the operator "had a procedure that required specific information to be exchanged during shift changes, but no formal documentation or written record of the exchanged information was required."1

One rule reaches the contents of a handover, and one does not

Control room management is regulated on both the gas and the hazardous liquid side. An operator must have and follow written control room management procedures, which cover a method of recording controller shift changes and any hand-over of responsibility between controllers.2 Both parts require procedures for when a different controller assumes responsibility, including the content of information to be exchanged.2

The two rules part company there. The hazardous liquid section directs operators to implement section 5 of an incorporated industry practice.3 The gas section carries no such reference, so a gas operator writing a handover procedure decides for itself what belongs in the exchange. The requirement is identical and the drafting problem is not.

A regulation that dictates what a procedure must specify

One paragraph of the emergency plan rule now names the contents of a document. Each operator develops written rupture identification procedures to evaluate and identify whether a notification of potential rupture is an actual rupture event or a non-rupture event.4 Those procedures must, at a minimum, specify the sources of information, operational factors, and other criteria that operator personnel use to evaluate a notification of potential rupture and identify an actual rupture.4

Sources of information, operational factors, and criteria are three headings supplied by the rule itself. Most recordkeeping requirements name a document and stop. This one names the minimum contents of the procedure whose absence the Marshall investigation had made visible.

The manual absorbs the procedures written elsewhere

Each operator prepares and follows, for each pipeline, a manual of written procedures for operations, maintenance, and emergency response.5 It is reviewed and updated at intervals not exceeding 15 months but at least once each calendar year. Twelve items belong in it where applicable, among them making construction records, maps, and operating history available to appropriate operating personnel.5

The twelfth is easy to read past. It requires implementing the applicable control room management procedures required by the control room section.5 The handover procedure is therefore a component of the manual rather than a free-standing document, and it inherits the manual's review interval.

Somebody decides which portion a supervisor receives

The rule on furnishing emergency procedures is narrower than it first reads. An operator furnishes its supervisors who are responsible for emergency action a copy of that portion of the latest edition of the emergency procedures as necessary for compliance with those procedures.4 What the supervisor receives is not the procedures but a portion of them, selected by somebody. Whether that portion still makes sense without the paragraphs around it is a question about writing, and nothing in the rule assigns it to anyone.

Records kept for the useful life of the pipeline

Integrity management records are maintained for the useful life of the pipeline, across nine categories.6 One covers documents supporting the threat identification and risk assessment. Another covers documents supporting any decision, analysis, and process used to implement and evaluate each element of the baseline assessment plan and the integrity management program.6 The schedule prioritizing conditions found during an assessment is kept with the technical justifications for that schedule.6

A technical justification is prose, and its retention period is measured against the asset rather than against a fixed number of years. A separate rule keeps two filings about one event joined: where information arrives after an incident report is submitted, the supplemental report carries a clear reference by date to the original.7 Without that sentence the file holds two documents about one event.

What the agency has said makes a record adequate

PHMSA has published a three-part test, in the narrower setting of records establishing maximum allowable operating pressure and maximum operating pressure. Traceable records can be clearly linked to original information about a pipeline segment or facility. Verifiable records are those in which information is confirmed by other complementary, but separate, documentation. Complete records are finalized as evidenced by a signature, a date, or another appropriate marking.8 Those three words describe qualities of a document rather than of the data inside it, which is why an operator can hold the right information and still fail the test.

The operator decides, the manual records

We do not write procedures, set an operating pressure, classify a threat, or decide what an incident report should say. Operators, their engineers, and their regulators do that. Our part is whether the document says what those people decided. We check that a term defined in one section of a manual carries that meaning in the next. We check that a step referenced in an emergency procedure exists in the procedure it names, and that a revision date on a cover page matches the revision recorded inside. Documents arrive in confidence and stay that way.

The extract given to supervisors is the document with no owner. A manual has an author and a review interval. A portion of a manual, selected to fit a role, has neither of those and is remade every time the manual changes.

References

  1. National Transportation Safety Board, "Enbridge Incorporated Hazardous Liquid Pipeline Rupture and Release, Marshall, Michigan, July 25, 2010," Pipeline Accident Report NTSB/PAR-12/01, adopted July 10, 2012. https://www.ntsb.gov/investigations/AccidentReports/Reports/PAR1201.pdf
  2. National Archives and Records Administration, Code of Federal Regulations, 49 CFR 192.631, "Control room management." https://www.ecfr.gov/current/title-49/subtitle-B/chapter-I/subchapter-D/part-192/subpart-L/section-192.631
  3. National Archives and Records Administration, Code of Federal Regulations, 49 CFR 195.446, "Control room management." https://www.ecfr.gov/current/title-49/subtitle-B/chapter-I/subchapter-D/part-195/subpart-F/section-195.446
  4. National Archives and Records Administration, Code of Federal Regulations, 49 CFR 192.615, "Emergency plans." https://www.ecfr.gov/current/title-49/subtitle-B/chapter-I/subchapter-D/part-192/subpart-L/section-192.615
  5. National Archives and Records Administration, Code of Federal Regulations, 49 CFR 192.605, "Procedural manual for operations, maintenance, and emergencies." https://www.ecfr.gov/current/title-49/subtitle-B/chapter-I/subchapter-D/part-192/subpart-L/section-192.605
  6. National Archives and Records Administration, Code of Federal Regulations, 49 CFR 192.947, "What records must an operator keep?" https://www.ecfr.gov/current/title-49/subtitle-B/chapter-I/subchapter-D/part-192/subpart-O/section-192.947
  7. National Archives and Records Administration, Code of Federal Regulations, 49 CFR 191.15, "Incident report." https://www.ecfr.gov/current/title-49/subtitle-B/chapter-I/subchapter-D/part-191/section-191.15
  8. Pipeline and Hazardous Materials Safety Administration, "Pipeline Safety: Verification of Records," Advisory Bulletin ADB-2012-06, Docket No. PHMSA-2012-0068, 77 FR 26822, May 7, 2012. https://www.federalregister.gov/documents/2012/05/07/2012-10866/pipeline-safety-verification-of-records

A worked example: Controller Shift Turnover Record

Control room shift turnover log entry

Federal rules require a method of recording controller shift changes, and require the procedures to cover the content of information to be exchanged. They do not say what that content is on the natural gas side. Investigators at Marshall, Michigan found an operator whose procedure required an exchange and required no record of it. The entry below shows the difference between a log that records that a handover happened and one that transfers what the next controller needs.

Before

Turnover 0700. Line 4 was doing something odd overnight, we had some alarms but Dave thinks it's column separation, same as last week. Pressure is a bit low at Salt Creek. Pigging still going on. Nothing else to report, handed over to day shift.

After

Shift turnover, 0700, 14 March. Outgoing controller A. Reyes to incoming controller J. Okafor.

Line 4. Three low-suction alarms, at 0212, 0244 and 0331. Outgoing controller assessed these as column separation. The assessment was not confirmed and was not evaluated against the rupture identification procedure.

Salt Creek. Discharge pressure 612 psig at 0655, against a normal operating range of 640 to 680 psig.

In-line inspection tool. Launched 0430, still in the line, last reported position milepost 118.

Open items carried to the incoming controller. Confirm or rule out column separation on Line 4 before any change of state. Confirm tool position before any pressure change.

What changed, and why

WasNowReason
Line 4 was doing something odd overnightThree low-suction alarms, at 0212, 0244 and 0331The entry records what the instruments showed and when, so a later reader can place the events in sequence. An impression cannot be checked against anything.
Dave thinks it's column separationOutgoing controller assessed these as column separation. The assessment was not confirmedThe assessment is labeled as an assessment and its status is stated. A first name identifies nobody to a reader outside the shift.
Pressure is a bit low at Salt CreekDischarge pressure 612 psig at 0655, against a normal operating range of 640 to 680 psigA comparative word is replaced by the reading and by the range it is being compared against, so the incoming controller is not asked to supply either.
Pigging still going onLaunched 0430, still in the line, last reported position milepost 118The position and elapsed time are recorded. As written, the original leaves the incoming controller to find both somewhere else.
Nothing else to reportOpen items carried to the incoming controllerA closing that asserts nothing is outstanding is replaced by one that names what is, which is the part of a handover a written record exists to carry.

Final specimen (PDF, 4 KB) Marked-up specimen (PDF, 5 KB)

Specimen prepared by EditFast for illustration only. Not a real document, record or filing. Any resemblance to an actual organization, person or record is unintended. Not legal, regulatory, clinical or professional advice.

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