COLONIAL PIPELINE CO

Incident Narrative

ON JANUARY 30, 2015, AT 07:08, A COLONIAL CONTRACTOR REPORTED SIGHTING GASOLINE ON THE GROUND IN THE LINE 1 STATION YARD. THE CONTRACTOR NOTIFIED THE LEAD TECHNICIAN WHO DIRECTED THE CONTROL ROOM OPERATOR TO SHUT DOWN THE LINE 1 DELIVERY OPERATION. AN IMMEDIATE INVESTIGATION REVEALED PRODUCT OVERFLOWING FROM A SUMP. PRODUCT WAS FILLING THE SUMP BECAUSE A PROVER VENT VALVE WAS LEFT OPEN BY A TECHNICIAN AFTER FILLING THE LINE 1 PROVER EARLIER THAT DAY. THE VALVE WAS CLOSED WHICH STOPPED THE LEAK SOURCE. INTERNAL NOTIFICATIONS WERE MADE AND PRODUCT RECOVERY ACTIVITIES BEGAN. THE GASOLINE WAS RETAINED ONSITE AND RECOVERED IN LOW LYING AREAS OF THE STATION YARD AND FROM A STORM WATER DITCH. CONTAMINATED SOILS WERE REMOVED AND PREPPED FOR TREATMENT. AN IMMEDIATE INVESTIGATION OF CONTROL ROOM ACTIVITIES LEADING UP TO THE EVENT DISCOVERED THAT A HIGH SUMP ALARM HAD BEEN RECEIVED AND ACKNOWLEDGED BY ONE OF THE CONTROL ROOM OPERATORS USING THE ""ACKNOWLEDGE ALL"" BUTTON DURING AN ANTICIPATED GROUP OF ALARMS. THE GROUP OF ALARMS WAS CAUSED BY AN UNRELATED SYSTEM STARTUP OPERATION. ACKNOWLEDGEMENT OF THE HIGH SUMP ALARM WAS NOT COMMUNICATED TO THE STATION YARD OPERATOR TO RESPOND. THE INCIDENT WAS REPORTED TO LOUISIANA DEPARTMENT OF ENVIRONMENTAL QUALITY ON 1/30/15. NO OTHER NOTIFICATION OR REPORTING THRESHOLDS WERE REACHED. AN INCIDENT ANALYSIS WAS CONDUCTED WHICH REVEALED ADDITIONAL FACTORS AFFECTING THE EVENT. THE PROVER HAD A HISTORY OF MALFUNCTIONS INCLUDING SEQUENCING FAILURES THAT RESULTED IN DAMAGE TO THE PROVER RAM. ON THE DAY OF THE EVENT, A SERIES OF FAILED PROVING OPERATIONS OCCURRED, AND DURING AN ATTEMPTED FILL, THE TECHNICIAN RECEIVED AN INDICATION THAT THE PROVER WAS ABOUT TO OPERATE OUT OF SEQUENCE AGAIN. THE TECHNICIAN STOPPED THE PROVER FILLING OPERATION AND LEFT TO CONFER WITH OTHERS ON A POSSIBLE SOLUTION. THE INCIDENT ANALYSIS IDENTIFIED THE TECHNICIAN'S PREOCCUPATION WITH PREVIOUS FAILURES AND BEING DISTRACTED BY THE PROVER OUT-OF-SEQUENCE INDICATIONS AS ONE THE BASIC CAUSES OF THE EVENT. CORRECTIVE ACTIONS WERE GENERATED DURING THE IA PROCESS INCLUDING A REVIEW OF THE PROVER FILL PROCEDURE FOR ACCURACY AND USABILITY AND A REVIEW OF THE HMI ALARM SCHEME AT THE CONTROL ROOM. THIS CONTROL ROOM REVIEW INCLUDED A REVIEW OF THE ""ACKNOWLEDGE ALL"" ALARM FUNCTION WITH THE OPERATORS AND ITS INTENDED USE. A THIRD CORRECTIVE ACTION IDENTIFIED WAS THE ADDITION OF A SECONDARY OR ""MAX-FILL"" ALARM ON ALL THE STATION SUMPS. NOTE: AT THE TIME THE INCIDENT OCCURRED, THE TECHNICIAN DID NOT HAVE HIS OPERATOR QUALIFICATION ON COLONIAL TASK 43-4 (""MANUALLY OR REMOTELY OPEN OR CLOSE VALVES OR OTHER EQUIPMENT"") BECAUSE LOCAL PERSONNEL BELIEVED THAT VALVES OPERATED ON A PROVER DID NOT FALL WITHIN THE OQ PROGRAM. SUBSEQUENTLY, LOCAL PERSONNEL WERE ADVISED THAT THIS TYPE OF VALVE FALLS UNDER COLONIAL'S OPERATOR QUALIFICATION PROGRAM AND THAT ONLY A QUALIFIED INDIVIDUAL MAY PERFORM THE TASK. THE TECHNICIAN HAS ALSO SUCCESSFULLY COMPLETED HIS TRAINING AND EVALUATION TO BECOME QUALIFIED TO OPERATE VALVES AND IS CURRENTLY QUALIFIED UNDER COLONIAL'S OQ PROGRAM.