JAYHAWK PIPELINE LLC

Incident Narrative

AT 05:59 12/31/12 CONTROLLER RECEIVED A HIGH SUMP ALARM AT TALOGA STATION. 06:04 CONTROLLER CONTACTED STATION OPERATOR TO HAVE HIM GO TO STATION. 06:06 SHUT DOWN MAIN LINE PUMP (P-2). STATION OPERATOR TOLD CONTROLLER ""DON'T SHUT DOWN THE BOOSTER AS LINE WILL SET UP AND WILL BE DIFFICULT TO GET MOVING AGAIN IF LOW GRAVITY OIL, COMES TO A STOP IN THE 6"" LINE. CONTROLLER AGREED AND CONTINUED PUMPING WITH BOOSTER PUMP. CONTROLLER DID NOT RECOGNIZE THERE WAS ALSO A DROP IN STATION DISCHARGE PRESSURE 13 MINUTES BEFORE HIGH SUMP ALARM RECEIVED. CONTROLLER DID NOT NOTIFY CONTROL ROOM SUPERVISOR. AT 07:00 CONTROLLER WORKING DAY SHIFT ARRIVED AND DURING SHIFT TURNOVER, SITUATION AT TALOGA STATION WAS EXPLAINED AND GONE OVER. HE TOO ACCEPTED THE DIRECTION OF THE STATION OPERATOR TO NOT SHUT DOWN THE BOOSTER OR LINE MAY BECOME PLUGGED AND CONTINUED TO RUN BOOSTER PUMP. BECAUSE OF A FLAT TIRE AND A HEAVY SNOW STATION OPERATOR DID NOT ARRIVE AT STATION UNTIL 09:10. UPON ARRIVAL HE COULD SEE OIL ON THE PUMP BUT NO WHERE ELSE AS ENTIRE STATION WAS COVERED IN A BLANKET OF HEAVY SNOW. HE IMMEDIATELY ISOLATED PUMP BY CLOSING SUCTION AND DISCHARGE VALVES OF THE PUMP TO STOP FLOW OF OIL COMING FROM THE ""STUFFING BOX"" OF PUMP P-2. STATION OPERATOR NOTIFIED RELIEF AREA FOREMAN WHO STARTED DISPATCHING PERSONELL AND EQUIPMENT TO SITE AND NOTIFIED EHS. FOREMAN NOTIFIED MAINTENANCE SUPT WHO IN TURN NOTIFIED ME. UPON INVESTIGATION THE SPILL WAS CAUSED BY THE THREADED PACKING GLAND BEING PUSHED OUT ALLOWING OIL TO FLOW INTO STUFFING BOX AND TO SUMP. IT TOOK SEVERAL HOURS TO DETERMINE THE SIZE OF THE SPILL BECAUSE OF SNOW COVER. CREW WORKED INTO THE NIGHT AND ALL THE NEXT DAY TO PICK UP FREE OIL AND ANY SATURATED SOILS FROM SITE. IN PLACE BERMS CONTAINED OIL ON SITE. CONTROLLER DID NOT RESPOND CORRECTLY TO ALARM. O&M SECTION 231.8 SUMP ALARMS: WHEN HI ALARMS ARE RECEIVED, THE CONTROLLER CALLS LOCAL PERSONNEL TO CONFIRM THAT NO MAINTENANCE OR OPERATIONS TASK HAS CAUSED THE SUMP HI ALARM. IF THE LOCAL PERSONNEL CANNOT BE CONTACTED, THE STATION IS SHUT DOWN. THE HI SUMP ALARMS MUST NOT REMAIN IN ALARM STATE. HAD THIS BEEN FOLLOWED SPILL WOULD HAVE BEEN AVOIDED OR GREATLY MINIMIZED. CAUSAL FACTORS IDENTIFIED THROUGH TAP ROOT INCIDENT INVESTIGATION: TRUCKING COMPANY HAULED IN SEVERAL LOADS OF HEATED, LOW GRAVITY, ""STONEBREAKER LEASE"" OIL EVEN THOUGH VERBAL POLICY PROHIBITS IT BEING DELIVERED TO TALOGA STATION. CONTROLLER DID NOT FOLLOW O&M FACILITY SPECIFIC PROCEDURES TO START ROLLA BOOSTER STATION IF TALOGA STATION DISCHARGE PRESSURE REACHES 750 PSI. THREADED SCREW IN TYPE PACKING RETAINING GLAND FAILED. BOOSTER PUMP WAS NOT SHUT DOWN. CONTROLLER FAILED TO RECOGNIZE AOC WHEN PRESSURE DROPPED CORRECTIVE ACTIONS BOTH CONTROLLERS INVOLVED WERE DISQUALIFIED AND RETRAINED ON THE FOLLOWING: OQ PROCEDURE 7000 PIPELINE OPERATIONS BY SCADA CONTROL DOCUMENT REVIEW, OQ PROCEDURE 7000 PIPELINE OPERATIONS BY SCADA QUIZ COMPLETION, ABNORMAL OPERATING CONDITION COMPUTER BASED TRAINING, OQ PROCEDURE 7000 PIPELINE OPERATIONS BY SCADA - REVIEW SECTIONS PERTAINING TO CONTROLLER ROLES & RESPONSIBILITIES, ACTIVATION OF ALARMS, REFERENCES TO THE O&M MANUAL, ABNORMAL OPERATING CONDITIONS, O&M MANUAL SECTION 300 ABNORMAL OPERATING CONDITIONS - REVIEW SECTIONS PERTAINING TO IDENTIFICATION AND REACTION TO AOC'S, O&M MANUAL APPENDIX A - REVIEW SECTIONS PERTAINING TO JAYHAWK PIPELINE TALOGA TO LIBERAL LINE SEGEMENT, O&M MANUAL SECTION 231.8 SUMP ALARMS - REVIEW SECTIONS PERTAINING TO HI SUMP ALARMS MUST NOT REMAIN IN ALARM STATE. BOTH CONTROLLERS WERE SUCCESSFULLY REQUALIFIED. REVIEW OF LESSONS LEARNED WITH ALL CONTROLLERS AND STATION OPERATORS. REPLACE ALL THREADED TYPE PACKING GLAND RETAINERS IN SERVICE WITH BOLT ON STYLE. REVISE O & M MANUAL, SECTION 231.8, TO INCLUDE SPECIFIC WORDING TO REQUIRE SHUT DOWN OF ALL PUMP WHEN AN EMPLOYEE IS NOT ON SITE. TRUCKING CO WILL DEVELOP A POLICY FOR OIL DELIVERY INTO TALOGA STATION AND TRAIN ALL DRIVERS ON POLICY