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NTSB Most Wanted List 2021-2022: Support Safety Through Quality Management Control

In September 2010, a natural gas pipeline ruptured in San Bruno, California that led to the release of approximately 47.6 million cubic feet of natural gas. The gas ignited, causing a fire that damaged property, people, and the environment.

More than a decade later, the San Bruno incident continues to serve as a reminder that pipeline operators need to continually improve on safety. In fact, the recently-released NTSB 2021-2022 Most Wanted List specifically cites the San Bruno incident in their recommendation for operators to “improve pipeline leak detection and mitigation efforts” to support pipeline safety.

NTSB also cited two other high-profile incidents that capture why safety improvements are needed. In August 2016, a building explosion and fire in Maryland was caused in part by the absence of leak detection by odor, among other problems. In February 2018, a natural gas-fueled explosion in Texas was caused in part by the build-up of undetected leaked gas, insufficient procedures, and an inadequate integrity management program.

What do all three events have in common? They are examples of organizational failure. This is why operators need to focus on improving their Quality Management approach to support safety. We’ll further explain how this works.

San Bruno: Lessons Learned on Consequence and Probability

A risk formula used in pipeline operations is the probability of failure multiplied by the consequences of that failure.

The probable cause of the San Bruno incident captures why leak detection safety improvement is needed across the industry from a consequence perspective. However, the probability of failure was also identified. One of the key findings in the NTSB report is that the cause of the accident was “inadequate quality assurance and quality control” over a defective piece of pipe. In other words, a lack of Quality Management.

Operators need to understand how to take a systematic approach to Quality Management to support pipeline safety. This includes focusing on how to reduce the probability of an event (leading indicators), and not just focusing on how to reduce the consequence of an event (lagging indicators).

The NTSB Most Wanted List focuses on the aftermath — or consequences — of pipeline incidents. While there are certainly important lessons learned from the aftermath, operators also need to focus on the other side of the coin to reduce the probability of an incident occurring in the first place.

This is why operators need to support the overall Quality Management of their programs and activities by proactively performing Quality Assurance (QA) and Quality Control (QC) to identify risk areas and then take action to mitigate those risks.

Focusing on Quality Management ties in with the API 1173 Recommended Practice for Pipeline Safety Management Systems (PSMS), which is the systematic application of quality management principles to support pipeline safety. Operators can reduce the probability of a failure by implementing the full Plan-Do-Check-Act cycle that is embedded in Pipeline SMS.

This includes quality management control for program documentation, implementation, and maintenance, as well as stakeholder engagement to evaluate the perceptions of safety from personnel and stakeholders.

Quality Management Control: Execute the PDCA Cycle

Operators can support safety assurance in their operation by ensuring that the right person is doing the right thing in the right way at the right time. This requires effective process management.

You need processes that capture exactly who should be doing what at what time to support each asset in your operation. This is the Plan and Do in the PDCA cycle that supports the fundamental aspects of asset safety in Pipeline SMS.

Unfortunately, many operators do not follow through with the Check and Act, which exposes them to the probability of organizational failure. Operators need to implement additional steps to ensure that they are checking whether processes were followed and then acting on the Check to fully support safety assurance.

For example, many operators perform leak detection surveys to identify potential leaks. Operators will plan the survey, execute the survey, and document that they did the survey. But, is there a process for someone in the operation to review the results, check the findings, and act on the findings? Is anything being documented? Operators need to support all of the necessary processes to determine whether their leak detection survey is optimized for safety.

Then, the results of the survey can be utilized to support continuous improvement to maintain the integrity of your program. The initial findings should capture whether leak detection processes are being followed or why certain processes are not being followed.

These findings can drive additional investigation and action to address any disparity. Over time, you should realize noticeable improvements. If not, then you need to continue seeking out how to address incomplete processes that continue to exist.

Oftentimes, this disparity continues to exist in pipeline operations because of a lack of knowledge, ability, or training for how to follow processes. This is where Stakeholder Engagement is critical to further understand where attention needs to be provided to drive improvement.

Stakeholder Engagement: Support Quality Control

Stakeholder Engagement is one of the core elements of Pipeline SMS that supports quality control. This is the Check within the PDCA cycle to gauge the perceptions of stakeholders.

Using communication tools, you can gather feedback from pipeline personnel and other stakeholders to identify areas of organizational failure, prioritize investigations, identify corrective actions, and drive toward improvements. The purpose is to ask questions that enable you to gather useful information to help uncover risk areas.

The questions should help you identify whether processes are being followed, why they might not be followed, and what is creating roadblocks for personnel and stakeholders. A sample of questions to ask includes the following:

  • Are there issues with the procedures?
    • Are they accurate? Difficult to understand?
  • Do you have enough resources?
    • Are the resources inexperienced?
  • Is our training program helpful to support your ability to perform tasks?
    • Is the training content sufficient?
  • Is the equipment that we provide you to use in the field suitable for your tasks?
    • Is the equipment suitable to meet the objective?

When you send out a questionnaire to perform this assessment, you should be looking for two types of findings. One finding is how many people actually completed the survey? This is a useful indicator of stakeholder engagement around pipeline safety. The other finding is the actual results of the survey. This will help you prioritize investigations/corrective actions and areas for improvement to support the programs and activities that you do to reduce risk.

Once the Check is performed, you can implement additional processes for follow-up checks, verification of the additional checks, and management of follow-up actions. It’s a continuous cycle (PDCA) that reduces the probability of failure, mitigates risks, and supports pipeline safety.

Utilize Tools to Support Quality Management Control

To implement a Quality Management system that improves programs and activities to reduce risk in your operation, we recommend utilizing tools that support the reduction of the probability of failure.

At P.I. Confluence, we are focused on helping operators reduce the probability of failure and address organizational failure. To support our efforts, we offer a suite of software tools to help your operation implement Plan-Do-Check-Act processes as part of Pipeline SMS and optimize stakeholder communication to determine if you are seeing desired safety results.

– ICAM (Integrated Compliance Activity Management) supports Quality Management Control. This tool can be used to:

  • Develop processes and workflow.
  • Document the survey creation, execution, and analysis.
  • Document the investigations that are driven by the results.
  • Help you circle back to see whether corrective actions worked to enhance safety performance.

– pSEc (Pipeline Stakeholder Engagement Communications) supports stakeholder engagement for Quality Control. pSEc is a Check tool that enables you to check the planning, the doing, and the acting of programs and activities to reduce risk.

  • You can check the perceptions, perspectives, and observations from stakeholders regarding potential organizational failure to support further investigation and corrective action.
  • pSEc also supports your ability to send and receive surveys, exchange information with personnel and stakeholders, and measure safety performance.

We encourage you to utilize our tools to improve the programs and activities in your operation. Through a quality management approach, you can realize incremental improvements in pipeline safety on the path to zero incidents.

– To schedule a demo of our software tools, contact us today to speak with our team. We would appreciate the opportunity to further discuss how we can help you reduce organizational failure in your operation.

 

The Check in the Plan-Do-Check-Act Cycle supports process management for pipeline safety and the reduction of organizational failure