Pipeline Accident Report

Rupture of Piney Point Oil Pipeline

and Release of Fuel Oil

Near Chalk Point, Maryland

April 7, 2000

National 

Transportation 

Safety Board

Washington, D.C.

A

A

N TION

L TRA SPOR

ATIO

N

B OARD

SAF E T Y

N

T

E PLURIBUS UNUM 

NTSB/PAR-02/01

PB2002-916501

Pipeline Accident Report

Rupture of Piney Point Oil Pipeline 

and Release of Fuel Oil 

Near Chalk Point, Maryland

April 7, 2000

NTSB/PAR-02/01

PB2002-916501 National Transportation Safety Board

Notation 7285A 490 LíEnfant Plaza, S.W.

Adopted July 23, 2002 Washington, D.C. 20594
National Transportation Safety Board. 2002. Rupture of Piney Point Oil Pipeline and Release of Fuel

Oil Near Chalk Point, Maryland, April 7, 2000. Pipeline Accident Report NTSB/PAR-02/01.

Washington, DC.

Abstract: On the morning of April 7, 2000, the Piney Point Oil Pipeline system, which was owned by the

Potomac Electric Power Company, experienced a pipe failure at the Chalk Point Generating Station in

southeastern Prince Georgeís County, Maryland. The release was not discovered and addressed by the

contract operating company, Support Terminal Services, Inc., until the late afternoon. Approximately

140,400 gallons of fuel oil were released into the surrounding wetlands and Swanson Creek and,

subsequently, the Patuxent River as a result of the accident. No injuries were caused by the accident, which

cost approximately $71 million for environmental response and clean-up operations.

The safety issues discussed in this report are the sufficiency of the evaluation procedures for pipe wrinkles;

the efficiency of the leak notification procedures; and the effectiveness of the incident command.

As a result of its investigation, the National Transportation Safety Board issued safety recommendations to

the Research and Special Programs Administration and the Environmental Protection Agency.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2002-916501 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Pipeline Accident Report

Contents

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Accident Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Actions Taken After Pipeline Shutdown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Response to Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Notifying Authorities and Containing Spill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Response to Escape From Containment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Postaccident Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Piney Point Oil Pipeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Pipeline Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Pipeline Maps and Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Pepco Oil Spill Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Office of Pipeline Safety Postaccident Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Pipeline Safety Actions Since Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Incident Command System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Postaccident Assessments of Chalk Point Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

November 2000 Safety Board Hearing on Pipeline Safety . . . . . . . . . . . . . . . . . . . . . . 35

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Pipeline In-line Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Evaluation of Pipe Wrinkles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Leak Detection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Leak-related Notifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Inaccurate National Response Center Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Limited Involvement of Local Response Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Incident Command . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Contents iv Pipeline Accident Report

Appendixes

A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

B: Initial Incident Timeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

C: Significant Events From Leak Recognition to Loss of Containment . . . . . . . . . . . . . . 53

D: Significant Environmental Response and Clean-up Events . . . . . . . . . . . . . . . . . . . . . . 54
v Pipeline Accident Report

Acronyms and Abbreviations

API -- American Petroleum Institute

CFR -- Code of Federal Regulations

EPA -- Environmental Protection Agency

Mirant -- Mirant Piney Point, LLP

Pepco -- Potomac Electric Power Company

RSPA -- Research and Special Programs Administration

SCADA -- supervisory control and data acquisition

ST Services -- Support Terminal Services, Inc.
vi Pipeline Accident Report

Executive Summary

On the morning of April 7, 2000, the Piney Point Oil Pipeline system, which was

owned by the Potomac Electric Power Company, experienced a pipe failure at the Chalk

Point Generating Station in southeastern Prince Georgeís County, Maryland. The release

was not discovered and addressed by the contract operating company, Support Terminal

Services, Inc., until the late afternoon. Approximately 140,400 gallons of fuel oil were

released into the surrounding wetlands and Swanson Creek and, subsequently, the

Patuxent River as a result of the accident. No injuries were caused by the accident, which

cost approximately $71 million for environmental response and clean-up operations.

The National Transportation Safety Board determines that the probable cause of

the April 7, 2000, Piney Point Oil Pipeline accident at the Potomac Electric Power

Companyís Chalk Point, Maryland, generating station was a fracture in a buckle in the

pipe that was undiscovered because the data from an in-line inspection tool were

interpreted inaccurately as representing a T-piece. Contributing to the magnitude of the

fuel oil release were inadequate operating procedures and practices for monitoring the

flow of fuel oil through the pipeline to ensure timely leak detection.

This report discusses the following major safety issues:

ï The sufficiency of the evaluation procedures for pipe wrinkles;

ï The efficiency of the leak notification procedures; and,

ï The effectiveness of the incident command.

In addition to these issues, the Safety Boardís investigation addressed the leak

detection procedures used on the Piney Point Oil Pipeline and the analysis of the pipeline

in-line inspection results.

As a result of its investigation of this accident, the Safety Board makes safety

recommendations to the Research and Special Programs Administration and the

Environmental Protection Agency. 
1 Pipeline Accident Report

Factual Information

Accident Synopsis

On the morning of April 7, 2000, the Piney Point Oil Pipeline system, which was

owned by the Potomac Electric Power Company (Pepco), experienced a pipe failure at the

Chalk Point Generating Station in southeastern Prince Georgeís County, Maryland. (See

figure 1 for a map showing the location of the Chalk Point Generating Station and the spill

site.) The release was not discovered and addressed by the contract operating company,

Support Terminal Services, Inc., (ST Services) until the late afternoon. Approximately

140,400 gallons1 of fuel oil were released into the surrounding wetlands and Swanson

Creek and, subsequently, the Patuxent River as a result of the accident. No injuries were

caused by the accident, which cost approximately $71 million for environmental response

and clean-up operations.

The Accident

At the time of the accident, Pepco was the owner of the Piney Point Oil Pipeline

system. ST Services, a limited partnership of the Kaneb Pipe Line Company, operated the

pipeline and performed certain maintenance functions according to the terms of its

contract with Pepco.2 The pipeline was used to deliver heated No. 6 fuel oil from Piney

Point Terminal, in Maryland, through an intermediate station at Ryceville, Maryland, to

Pepcoís power generating stations at either Chalk Point or Morgantown, Maryland. (See

figure 2.)

On April 7, 2000, a pigging operation was being conducted on the pipeline to

prepare the Chalk Point Station to Ryceville Station segment of the pipeline for an in-line

inspection. The pipeline from the Chalk Point Station to the Ryceville Station was started

in the reverse direction of normal flow with flushing oil3

 in the system. (See figure 3 for a

schematic of the pipeline.) Employees calculated the amount of oil in the Chalk Point

flushing oil tank and the Ryceville receiving tank before the operation began. As the

operation proceeded, they obtained tank level data that would typically be used to

determine how much oil had been pumped from Chalk Point and how much had been

received by Ryceville.

1 Pipeline operators typically quantify their product using barrels rather than gallons. There are

42 gallons in a barrel.

2 In December 2000, Pepco sold some of its facilities, including the Piney Point Oil Pipeline and the

Chalk Point Generating Station, to Southern Energy, Inc., of Atlanta, Georgia. Southern Energy later became

Mirant Mid-Atlantic of Atlanta, Georgia. Currently, Mirant Piney Point, LLP, (Mirant) is the pipeline owner

and operator.

3 Flushing oil is a mixture of No. 2 and No. 6 fuel oil. No. 6 fuel oil is a thick, black petroleum liquid

that may become solid at cooler temperatures. No. 2 fuel oil is a light, refined petroleum product similar to

diesel fuel.
Factual Information 2 Pipeline Accident Report

Figure 1. Map of accident site.

Rt 301

Benedict Route 231

Patuxent

River

PEPCO - Chalk Point

Generating Station

CHARLES

COUNTY

PRINCE GEORGE'S

COUNTY

CALVERT

Swanson Creek COUNTY

ST. MARY'S

COUNTY

N

Major Roads

MARYLAND

Oil Spill Site
Factual Information 3 Pipeline Accident Report

At 0715 eastern daylight time, ST Services employees (see figure 4) at the Chalk

Point Station started pumping and launched a cleaning pig. Before this operation began,

the estimated tank level that would indicate completion of the pigging process was

calculated for Chalk Point. The first pig was initially estimated to arrive at the Ryceville

Station 7 hours after it had been launched. Before launching the cleaning pig, the ST

Services Chalk Point operator walked through the tank and pipe manifold area and

measured the actual level4

 of the flushing oil tank. Within 15 to 25 minutes, a sizing pig5

was launched to follow the cleaning pig.

The ST Services Chalk Point operator measured the first tank level at 0910. He

passed this information on to the crew at Ryceville, who had the tank volume conversion

tables that were used to determine the volume in the tank and calculate the oil flow rate.

The first tank gauge was read at Ryceville shortly after the crew arrived, about 0837. The 

Figure 2. Locations of Piney Point Oil Pipeline Stations.

4 An operator obtains precise tank level measurements by climbing to the top of a tank carrying a

weighted tape, which is used to determine the liquid level in the tank.

5 The sizing pig was constructed to 90 percent of the pipelineís internal diameter to verify that the

pipeline did not have any internal restrictions that could damage or restrict the passage of an ultrasonic

inspection tool.

301

Waldorf

La Plata

Wicomico River

Hughesville

301

301

5

234

231

5

5

235

234 235

5

Potomac River

Patuxent River

4

4

Valley Lee

5

Leonardtown

Mechanicsville

Newburg

Morgantown

Station Ryceville

Station

Chalk Point

Station

Piney Point

Station

Oil

Spill

Site

PEPCO 

Piney Point 

Oil Pipeline
Figure 3. Piney Point Pipeline schematic. Morgantown Chalk P

Wicomico River Swanson Creek 12" Pipeline 12" Pipeline Valve Pit #2 16" Pipeline Valve Pit #1 Leak Site ST Services Terminal Piney Point Water Crossing- nitrogen operated valves Manual isolation Valve TankLegend PEPCO - Piney Point Oil Pipeline Ryceville Transfer Station Fuel Oil Pump Transfer Station Flushing Oil Tank #6 Oil Tank 

Flushing Oil Tank 

Tank Tank Fuel Oil Pump Transfer Station Piney Point Transfer Station
Figure 4. Selective organizational chart for ST Services. Positions cited in accident narrative are in boldface and This chart was developed by the Safety Board for informational purposes. It is not intended to cover the full range positions.) ST Services Senior Vice President, Mid-Atlantic Region Traffic A

Operators (10 positions) PINEY POINT SHIFT SUPERVISO

(function as PINEY POINT PIPELINE CONT

Plant Mechanics (function as CHALK POINT AND RYCEVILLE OPERATORS) Maintenance Workers- Relief Operators MAINTENANCE FOREMAN ASSISTANT TERMINAL MANAGER Administrative Director of Operations, East Coast Terminal Manager
Factual Information 6 Pipeline Accident Report

ST Services Ryceville operator determined that about 1,500 barrels (63,000 gallons) had

been transferred into the Ryceville tank since the pumping started. The ST Services

Ryceville operator kept some notes during the pumping but did not record the time and

tank level information in the station log.

Tank levels were taken at Chalk Point to be used to check the flow rate from the

facility at about 2-hour intervals for most of the pumping operation. The ST Services

Ryceville operator said he read the tank gauge at Ryceville, the receiving station, about

every 1 1/2 hours to determine the volume of product in the Ryceville tank. The operating

personnel did not provide tank volumes to the ST Services Chalk Point operator, and they

did not calculate the line balance6 periodically during the pigging operation. Further, they

did not communicate the tank level information to the ST Services Piney Point pipeline

controller7 when it was obtained.

At 1119, another tank level measurement was made at Chalk Point, and the ST

Services Chalk Point operator passed the information on to the ST Services Ryceville

operator. A few minutes before 1200, the ST Services Chalk Point operator told Ryceville

that the pumping was going well and that the cleaning pig would arrive early, between

1300 and 1330. At the same time, the ST Services Chalk Point operator asked Ryceville

what it was getting for volume received, as he had not had any confirmation on the

product pumped from his station to Ryceville. Ryceville told him the station was working

on it. As a normal check-in, the ST Services Chalk Point operator also called the ST

Services Piney Point pipeline controller to inform him that he was at the station and that

things were going fine.

The next Chalk Point tank level measurement was taken at 1220 and reported to

Ryceville and Piney Point. The ST Services Chalk Point operator stood by the Chalk Point

pump starting about 1250 and was prepared to shut it down whenever he received a call

from Ryceville stating that the cleaning pig had arrived. The tank gauge was checked at

Ryceville about 1300, but no information on the volume received was calculated or

reported to the ST Services Chalk Point operator or the ST Services Piney Point pipeline

controller. The ST Services Ryceville operator went outside to the Ryceville pipe manifold

about 1300 to await the cleaning pigís arrival. About 1412, the ST Services Chalk Point

operator decided to double-check the Chalk Point tank level because the pig had not

arrived at Ryceville.

About 1430, the Chalk Point pump started cavitating8 due to a low-pressure

condition at the pump inlet, because the level of product in the tank was not providing

sufficient pressure for the pump to run properly. About the same time, the ST Services

Ryceville operator noticed that Rycevilleís meter noise suddenly stopped, indicating no

6 Line balance is the difference between the volume of product pumped at the origin and the volume

received at the destination. It is used for determining whether the pipeline operation is being conducted

within certain limits in order to identify a possible leak.

7 The ST Services Piney Point shift supervisors served as the pipeline controllers.

8 Cavitation is an internal pump condition created by the sudden formation and collapse of bubbles in

a liquid, which makes a characteristic sound.
Factual Information 7 Pipeline Accident Report

product flow. The ST Services Chalk Point operator kept the pump operating by partially

closing the pump outlet valve in an effort to avoid internal damage to the pump.

The ST Services Chalk Point operator talked to the ST Services maintenance

foreman at Ryceville and was told that the meter noise had stopped and no pig had arrived.

The ST Services Chalk Point operator was then directed to close the valve as much as

possible to maintain product flow. The ST Services Chalk Point operator had not taken a

recent tank level measurement but was now ordered by the ST Services maintenance

foreman to determine the Chalk Point tank level. The ST Services Ryceville operator was

also directed to measure the Ryceville tank level so that the volume pumped could be

compared with the volume received. The ST Services assistant terminal manager was

notified about the situation, and he confirmed the need for an immediate tank level

measurement of the pumping and receiving tanks.

The ST Services Chalk Point operator and the ST Services assistant terminal

manager had a phone conversation about 1440 and reviewed the situation. The ST

Services assistant terminal manager instructed the ST Services Chalk Point operator to

double-check which valves were closed to confirm that the No. 6 fuel system was isolated

from the flushing oil system.

Tank levels were acquired for Chalk Point and Ryceville. The ST Services

Ryceville operator, using the tank volume tables, calculated that enough oil had been

pumped for the pigs to have reached the Ryceville Station. He said he thought that

something was wrong because Ryceville did not receive all the oil pumped from Chalk

Point.

The ST Services assistant terminal manager later said that at the time he believed

that the tank volume discrepancy had been caused by a valve that was improperly aligned

(open to another tank) or leaking (product leaking through a valve to another tank) and

that flushing oil was being transferred to the No. 6 fuel oil tank. He then directed ST

Services employees to make a number of checks to confirm that the correct valves were

open, to obtain a reading of the No. 6 fuel oil meters at Chalk Point, and to measure the

tanks at Piney Point. The ST Services assistant terminal manager had the ST Services

Piney Point pipeline controller perform the line balance calculations, with the result that

3,088.7 barrels (129,725 gallons) could not be accounted for.

By 1534, after receiving the additional information he had requested, the ST

Services assistant terminal manager stated that the discrepancies could not be explained

by tank inventory data. He had ruled out the possibility of the missing oil being anywhere

it should be. During a phone call, the ST Services Chalk Point operator told the ST

Services assistant terminal manager that the requested check had confirmed the isolation

of the flushing oil system from the No. 6 fuel oil. The ST Services assistant terminal

manager told the ST Services Chalk Point operator to shut the Chalk Point pump down. At

1538, the ST Services Chalk Point operator shut down the pump. The ST Services

assistant terminal manager stated that he paged his Pepco pipeline contact, the Pepco

Chalk Point general supervisor for fuel and ash, three times using a ì911 codeî to indicate

the urgent need for a response. (See figure 5 for an organizational chart of Pepco

personnel involved in the accident.)
Figure 5. Selective and simplified organization chart for Pepco Generation Organization, intended onshow the basic organizational relationships between the major positions cited in the accident narrativecited in the narrative are in boldface and all capitals. (Note: This chart was developed by the Safety Binformational purposes. It is not intended to cover the full range of Pepco Generation Organization po

ENVIRONMENTAL 

COORDINATOR 

(also QUALIFIED INDIVIDUAL)

SENIOR 

ENVIRONMENTAL 

COORDINATOR 

Environmental Services 

Manager

Division Manager

Generation Ea

CHALK POIN

GENERATIN

STATION MANA

Fuels and Business

Planning 

Bulk Power

Management

Engineering and 

Maintenance Services Environmental 

GENERAL SUPERVIS

FOR FUEL AND ASH

GENERAL SUPERVISOR 

FOR OPERATIONS

Maintenance Fuel and As

and Planning Operations Station Engineering

ENGINEERING 

SUPERVISOR 

PEPCO Generation Organization

Vice President

CHALK POINT SHIFT 

SUPERVISOR 

CHALK POINT CONTROL ROOM 

OPERATIONS SUPERVISOR 
Factual Information 9 Pipeline Accident Report

Actions Taken After Pipeline Shutdown

The ST Services assistant terminal manager told the ST Services Chalk Point

operator that he had pumped about 8,900 barrels (373,800 gallons) and that Ryceville had

received about 5,900 barrels (247,800 gallons). The ST Services assistant terminal

manager then directed the ST Services Chalk Point operator to check the No. 1 valve pit

area at Swanson Creek for a leak and to look across the creek at the No. 2 valve pit for

signs of a leak. (Valve pit No. 1 is on the north side of Swanson Creek, between the creek

and the Chalk Point Station.) The ST Services Chalk Point operator also obtained the

closing tank level for the Chalk Point flushing oil tank.

The ST Services Chalk Point operator made the visual checks by 1545 and

reported that he saw no sign of an oil leak at the creek. Next, the ST Services Chalk Point

operator was directed to check all roads that the pipeline crossed back to Ryceville for an

oil leak. He called the Chalk Point Operations Center and stated that he was finished

pumping and that the pigs had not been received at Ryceville, indicating there was a

problem with the pipeline. He said he told the Chalk Point Operations Center that he was

checking road crossings and would contact the center if he noticed a leak or some other

problem.

At 1550, the ST Services assistant terminal manager called a Pepco Washington,

D.C., headquarters oil procurement employee who confirmed the pager number for the

Pepco Chalk Point general supervisor for fuel and ash. The contact also provided the

Pepco engineering supervisorís phone number, because the Pepco engineering supervisor

might be able to locate other contacts needed by the ST Services assistant terminal

manager.

The ST Services assistant terminal manager contacted the Pepco engineering

supervisor, who advised him that the Pepco Chalk Point general supervisor for fuel and

ash was on vacation. The ST Services assistant terminal manager told him the details of

the 3,000-barrel line balance discrepancy and was advised to call the Pepco Chalk Point

general supervisor for operations. The ST Services assistant terminal manager also stated

that ST Services personnel were checking the levels of the flushing oil and No. 6 fuel oil

tanks at Chalk Point, Morgantown, and Piney Point to determine the location of a 3,000-

barrel line balance discrepancy. The ST Services assistant terminal manager indicated that

similar discrepancies had occurred in the past due to valve misalignment or valves not

being fully closed, which allowed oil to be inadvertently directed into one of the other oil

storage tanks in the system.

The Pepco engineering supervisor said that about 1620, he called the Pepco Chalk

Point general supervisor for operations and informed him of a 2,000- to 3,000-barrel line

balance discrepancy, which the Pepco Chalk Point general supervisor for operations noted

in his log as a discrepancy of 2,000 barrels. The Pepco Chalk Point general supervisor for

operations also noted in his log that ST Services personnel had initiated a ground

inspection and were checking the pipeline at road crossings. At 1643, the Pepco Chalk

Point general supervisor for operations ordered a patrol flight of the pipeline right-of-way.
Factual Information 10 Pipeline Accident Report

Response to Accident

Notifying Authorities and Containing Spill

April 7. About 1800 or shortly thereafter, the Pepco Chalk Point general supervisor

for operations called the on-duty Pepco environmental coordinator, who was the

designated Pepco qualified individual,9

 at home to discuss the pipeline line balance

shortage. He told the Pepco qualified individual what was being done at the pipeline,

including the tank level measurement discrepancy found when oil had been pumped back

to Ryceville. The Pepco Chalk Point general supervisor for operations also said that he

had ordered a pipeline patrol flight.

At 1802, the ST Services assistant terminal manager learned that during the

pipeline patrol plane flight, an oil release from the Piney Point Oil Pipeline had been

spotted in the Swanson Creek wetlands area. By 1807, the ST Services assistant terminal

manager had put the Chalk Point pipeline emergency response plan into effect by

contacting the Pepco qualified individual and an oil spill clean-up contractor. This plan

listed the criteria for notification of local response agencies as ìfire, explosion, personal

injury or release or significant threat of release off-site.î Local response agencies were not

notified. The ST Services assistant terminal manager called Piney Point to summon ST

Services employees to assist at Chalk Point. (See appendix B for a timeline indicating

significant developments as the leak occurred and was identified.)

The Pepco qualified individual called the Pepco Chalk Point general supervisor for

operations back and reported that the pipeline patrol flight had found an oil spill. The

Pepco Chalk Point general supervisor for operations then notified the Chalk Point control

room of the pipeline release.

The Pepco Chalk Point general supervisor for operations sent the Pepco Chalk

Point shift supervisor to the pipeline crossing at Swanson Creek to assess the situation.

During this period, the Pepco Chalk Point general supervisor for operations reviewed the

three Pepco spill response plans for the area to ensure that all emergency response

requirements were being met.10 Because each plan had a somewhat different purpose and

focus and the general supervisor for operations did not know the exact location of the

(underground) spill, he did not know which plan applied to this accident. Consequently, he

attempted to notify all response personnel identified in all three plans.

9 As indicated under 49 Code of Federal Regulations (CFR) Part 194, the qualified individual is a

company representative available on a 24-hour basis with full authority to: activate personnel and contract

with required oil spill removal organization(s); activate personnel and equipment maintained by the

operator; act as liaison with the on-scene coordinator; and obligate funds needed to carry out all required or

directed oil response activities.

10 The three plans were 1) the Pepco Oil Spill Emergency Response Plan for the Ryceville Pumping

Station and Pipeline, 2) the Pepco Oil Spill Emergency Response Plan for the Chalk Point Generating

Station, and 3) the Pepco Spill Prevention, Control, and Emergency Response Plan for the Chalk Point

Generating Station.
Factual Information 11 Pipeline Accident Report

About 1817, the Pepco Chalk Point shift supervisor called the Pepco Chalk Point

general supervisor for operations and reported that he would deploy an oil spill boom to

contain the oil in Swanson Creek.

At 1822, the ST Services assistant terminal manager asked the Pepco Chalk Point

control room operations supervisor to notify Federal and State agencies about the release,

as required by the oil spill response plan for the Chalk Point Generating Station. About

1827, the Pepco Chalk Point general supervisor for operations called the headquarters

Pepco senior environmental coordinator at home and discussed the oil spill, so that the

Pepco senior environmental coordinator could notify the National Response Center.11

Between 1830 and 1835, the Pepco qualified individual met the Pepco Chalk Point

shift supervisor (who had been to the leak site) at the Chalk Point plant building and asked

the shift supervisor how much oil had spilled. When the Pepco Chalk Point shift

supervisor responded that he was not sure, the Pepco qualified individual pressed him for

some number because, he said, he believed that he would have to report a spill quantity

when he called the responsible authorities. The Pepco qualified individual stated that,

when pressed, the Pepco Chalk Point shift supervisor said, ì1,000 gallons, 2,000 gallons,

[expletive] mess; tell them what you want.î

They reported together to the office of the Pepco Chalk Point general supervisor

for operations about 1835, during his continuing telephone conversation with the Pepco

senior environmental coordinator. The Pepco qualified individual told the Pepco Chalk

Point general supervisor for operations that the estimated size of the spill was 1,000 to

2,000 gallons. The Pepco senior environmental coordinator later told investigators that

during their phone conversation, he and the Pepco Chalk Point general supervisor for

operations discussed that the ìbest guessî estimate of the release was 1,000 to

2,000 gallons. He stated that he and the Pepco Chalk Point general supervisor for

operations agreed to report a release of 2,000 gallons to the National Response Center.

The Pepco senior environmental coordinator stated that the Pepco Chalk Point general

supervisor for operations did not discuss the ST Services tank level readings with him.

Shortly thereafter, the Pepco senior environmental coordinator called the Pepco

qualified individual for more information about the release. The Pepco qualified

individual confirmed the oil spill location and stated that booms were being placed in the

wetlands. Based on the information they had, the Pepco senior environmental coordinator

and the Pepco qualified individual decided to report the estimated spill volume as

2,000 gallons. They agreed to split the reporting task, with the Pepco senior environmental

coordinator reporting to the National Response Center and the Pepco qualified individual

reporting to the Maryland Department of the Environment.

11 The National Response Center serves as the communications hub of the National Response System,

which is the Federal Governmentís mechanism for providing emergency responses to discharges of oil and

releases of chemicals. The National Response Center receives reports of all reportable oil and hazardous

substance releases anywhere in the United States and its territories. The National Response Center then

distributes incident reports to predetermined Government agencies based on National Response Center

incident classification guidelines.
Factual Information 12 Pipeline Accident Report

Around 1840, the Pepco Chalk Point general supervisor for operations received a

call from the ST Services assistant terminal manager, who advised him that the ST

Services tank level readings were 3,000 barrels (126,000 gallons) short, that the spill

covered 3 to 4 acres in the wetlands at Swanson Creek, and that he had activated an oil

spill contractor. He also said that ST Services personnel would be arriving in about

15 minutes to close the pipeline valve between Swanson Creek and the Ryceville Station.

The notes made by the Pepco Chalk Point general supervisor for operations at this time

recorded the figure of ì3,000 barrelsî and that a 3- to 4-acre area was affected by the

release.

At 1845, the Pepco qualified individual called the Maryland Department of the

Environment to report the release. At 1850, the Pepco qualified individual called the

Pepco Chalk Point general supervisor for operations and told him that he had reported a

2,000-gallon release to the Maryland Department of the Environment.

About 1850, the Pepco senior environmental coordinator called the National

Response Center and reported a 2,000-gallon No. 2 fuel oil release from a pipeline at the

Pepco Chalk Point Generating Station, on the border of the facility property where the

pipeline crosses Swanson Creek. The Pepco senior environmental coordinator stated that

he understood from people at the plant that most or all of the release was in the creek. The

Pepco senior environmental coordinator also reported that the incident was discovered at

1817 on Friday, April 7, and that a clean up and an investigation into the cause of the

accident were underway. The Pepco senior environmental coordinator indicated that

Pepco had booms in the creek, that materials to absorb oil were being used, and that cleanup contractors had been activated. He reported that he was not aware of any injuries or

evacuations. The National Response Center watch officer designated the release

notification as Incident Report No. 525411 and, lacking information on the exact source of

the leak, inaccurately classified it as a fixed (power plant) facility incident rather than a

pipeline-type incident. The National Response Center officer sent notifications to the

agencies on the fixed facility distribution list.12 Following the Pepco senior environmental

coordinatorís notification of the National Response Center, the Pepco qualified individual

notified the U.S. Coast Guard Marine Safety Office in Baltimore, Maryland.

By 1850, the Pepco spill response teams had completed the initial deployment of

more than 1 mile of floating boom in the wetland area on the north side of Swanson Creek

and at the mouth of Swanson Creek on the Patuxent River.

About 1911, the National Response Center notified Environmental Protection

Agency (EPA) Region III (Philadelphia) of the accident by fax.13 About 1930, the on-call

EPA Federal On-Scene Coordinator for Region III contacted the Prince Georgeís County

Fire Department requesting directions to the site and was advised that Prince Georgeís

County had not been notified of the spill.

12 The National Response Center maintains a number of distribution lists. The Office of Pipeline Safety

was on the pipeline accident distribution list but not the fixed facility accident distribution list.

13 The EPA responds to spills in the inland areas of the United States, and the Coast Guard responds to

spills in U.S. coastal and inland waterways.
Factual Information 13 Pipeline Accident Report

The EPA Federal On-Scene Coordinator contacted the Pepco senior environmental

coordinator and advised him to call the Prince Georgeís County Communication Center

and provide the spill information. The Pepco senior environmental coordinator contacted

the Prince Georgeís County Communications Center and advised the center that

ì2,000 gallons of No. 2 fuel oil was released and county fire response was not necessary.î

The communications center informed the countyís hazardous materials coordinator about

the spill, and the hazardous materials coordinator arrived at the accident site within

15 minutes to assess the situation.

About 2015, the Pepco qualified individual stated that when he returned to the

Chalk Point command center, he learned from the information blackboard that the

estimated spill volume was 3,000 barrels (126,000 gallons), rather than 2,000 gallons. The

Pepco qualified individual stated that he advised Maryland Department of the

Environment and Coast Guard representatives, following their arrival on the scene about

2030, that the spill was ìcloser to 3,000 barrels in quantity.î Shortly afterwards, this

information was relayed to the Coast Guard Baltimore office and the State emergency

response duty officer. At 2035, the responders from the Maryland Department of the

Environment called their emergency response duty officer and advised him that the

updated release amount was 3,000 barrels.

Between 2030 and 2100, outside response personnel (including spill response

contractors, key Pepco responders, and State and Federal personnel) began arriving with

additional boom and boom deployment boats to augment those that Pepco already had at

the site. Around 2050, ST Services and other contractors working under Pepcoís direction

began evacuating oil from the pipeline between the closed No. 1 river pit valve and the

Chalk Point Pump Station.

Shortly after 2100, members of Pepcoís engineering and maintenance services

group confirmed a 3,000-barrel release, based on calculations using the tank level

readings that ST Services used. The Pepco senior environmental coordinator stated that,

when he arrived at the Chalk Point command center about 2130, he learned from the

information blackboard that the release volume was estimated to be 3,000 barrels

(126,000 gallons). The Pepco senior environmental coordinator stated that even though he

had notified several agencies earlier of the 2,000-gallon amount, he did not revise the

2,000-gallon notification because he believed representatives of all the agencies he had

notified were on-scene or in contact with each other.

Around 2300, Pepco conducted a command post briefing, during which

participants reviewed the boom placement and the need to augment the boom Pepco had

already deployed to contain the oil. They agreed for the night to place booms to direct the

oil to a point accessible to a vacuum truck. The command post briefing also covered plans

for deploying additional boom at 0600 on April 8, before the anticipated tide change.

During the remainder of the night, Coast Guard Baltimore office representatives and the

Maryland Department of the Environment on-scene coordinator worked with Pepco and

its spill response contractors to contain the spill and prepare collection efforts.
Factual Information 14 Pipeline Accident Report

April 8. Shortly after 0115, a member of the Prince Georgeís County Hazardous

Materials Team contacted the National Response Center watch officer and advised the

watch officer to update the Coast Guard Baltimore office about the accident status. He

also asked the watch officer whether the Chalk Point event constituted a transportationrelated incident requiring notification of the U.S. Department of Transportationís Office of

Pipeline Safety. Subsequently, the National Response Center determined that the accident

was a pipeline incident rather than a fixed facility incident and distributed the original

incident report, containing the 2,000-gallon spill estimate, to its pipeline notification list,

including the Office of Pipeline Safety and the Safety Board.

Around 0250, the Coast Guard Federal on-scene representative arrived at the

accident site to coordinate Federal, State, and local efforts. The Coast Guard

representative provided Pepco with a copy of the Baltimore Area Contingency Plan and

discussed with Pepco representatives the possibility of pre-staging booms at

environmentally sensitive creeks identified under the area contingency plan. After

assessing the spill location, the Coast Guard representative notified the Coast Guard

Baltimore office that the spill was located above the Benedict Bridge on Highway 231.

According to the Baltimore Area Contingency Plan, Benedict Bridge marks the

jurisdictional dividing line between the Coast Guard Baltimore office and the EPAís

Region III. Had the spill passed under Benedict Bridge, it would have been considered

within the Coast Guardís geographic jurisdiction.

Around 0330, the Coast Guard Baltimore office notified EPA Region III that the

spill was in the EPAís geographic jurisdiction and that Coast Guard personnel were

responding. Several hours later, when the Coast Guard representative on-scene was able to

view the wetlands area in daylight, he updated the Coast Guard Baltimore office. Shortly

after 0530, the Coast Guard Baltimore office advised the EPA Federal On-Scene

Coordinator that although the Coast Guard had personnel on the scene, the EPA should

take the lead for the spill, because the spill was contained in the wetlands and it had

significantly contaminated the wetlands area, including the local wildlife, with oil.

Shortly after 0600, the EPA Federal On-Scene Coordinator deployed from

Philadelphia with an EPA technical support contractor. Around 1015, the EPA Federal OnScene Coordinator arrived at the site and assumed responsibility from the Coast Guard for

directing the clean-up activity. Soon afterwards, the EPA Federal On-Scene Coordinator

learned for the first time that the quantity of oil released was actually 3,000 barrels, rather

than 2,000 gallons, of a mixture of No. 2 and No. 6 fuel oil. About 1100, the EPA Federal

On-Scene Coordinator held an organizational meeting with representatives of all the

parties, including Pepco, Pepcoís three spill response contractors,14 the Maryland

Department of the Environment, the Coast Guard, and the U.S. Fish and Wildlife Service.

At the meeting, those attending agreed that:

14 The contractors were A&A Environmental Services, Wood Chuck Enterprise, and Clean Harbors

(standby contactor).
Factual Information 15 Pipeline Accident Report

ï The Unified Command (the EPA, the Maryland Department of the

Environment, and Pepco) would direct the management of the response

effort.15

ï The responders would continue with the existing boom placement. The

containment and clean-up efforts appeared to be effective, and there was no

apparent threat to public health.

ï Because of the large amount of free product in the wetlands, the primary

emphasis should be on collection of oil in advance of a storm expected by early

evening.

ï With the spill contained in the wetlands, the Unified Command would release

the standby contractor, Clean Harbors.

The weather forecasts changed throughout the afternoon. Earlier forecasts tended

to indicate the approach of a relatively weak storm, but the weather reports became more

threatening as the day progressed. Around 1600, and with the expected approach of severe

winds and heavy rains, the EPA and the Maryland Department of the Environment

surveyed Pepcoís site response activities and revised the storm plan so that additional

collection resources were placed at the secondary containment points and outer booms.

During the early stages of the response, Pepco deployed about 300 of its own

employees and spill response contractors to assist with the oil recovery efforts. (See

figure 6.) Pepco response personnel were on rotating 8-hour shifts. The EPA Federal OnScene Coordinator noted that those coming on shift typically were not briefed before or

after arriving at the scene. Little information was shared between shifts of employees.

Pepco response officials stated that they often were not included in the meetings

conducted by the EPA Federal On-Scene Coordinator. In some cases, they could not attend

such meetings because it was physically impossible; the space provided for the meetings

was inadequate to accommodate all those wishing to attend. Pepco indicated that because

of these problems with the meetings, some of the orders of the Unified Command were not

clearly communicated to its personnel.16 At the same time, some meeting attendees were

not essential to the response effort.

15 A Unified Command is an element within the Incident Command System that represents the key

organizations responding to the incident. Under the National Contingency Plan, the Unified Command

typically consists of the Federal On-Scene Coordinator, the State on-scene coordinator, and the incident

commander of the responsible party.

16 From a letter, dated August 3, 2000, from Pepcoís incident commander for the Chalk Point response

to the EPA Federal On-Scene Coordinator for the response concerning lessons learned from the emergency

response to the Chalk Point oil spill.
Factual Information 16 Pipeline Accident Report

Because Pepcoís qualified individual changed with every 8-hour shift, the Pepco

qualified individual did not provide continuity of response and often had to check with

other Pepco officials before providing assistance requested by the EPA Federal On-Scene

Coordinator. In her postaccident description of events, the EPA Federal On-Scene

Coordinator cited the frequent changing of Pepcoís qualified individual and stated that it

led to ìepisodes of miscommunication and unclear lines of authority during the initial key

dates of the response.î17

During the first 24 hours of the spill response, three sets of booms had been

deployed, and the oil spill was contained in about 5 acres of wetlands. However, during

the evening of April 8, the weather deteriorated, and conditions included winds in excess

of 50 mph and strong rain showers. Because of the heavy rains and high wind gusts, the

outer booms were breached about 2030, releasing a significant amount of oil into the

Patuxent River. (See figure 7 for an aerial photo of two plumes of oil in Swanson Creek,

moving toward the Patuxent River.) During the night, Pepcoís spill response contractors

attempted to deploy additional personnel and equipment, but the weather made it unsafe

for workers to be in the wetlands area or on the river, so they could not be deployed. (See

appendix C for a listing of the significant events between the recognition of the leak and

the loss of oil containment.)

Figure 6. Response personnel working on wooden mats in the marsh.

17 Environmental Protection Agency, After-Action Report for Emergency Response at the Swanson

Creek Oil Spill Site, Aquasco, Maryland, Prince Georgeís, Charles, Calvert, and St. Maryís Counties 7 April

2000 to 16 May 2000, p. 30.
Factual Information 17 Pipeline Accident Report

Response to Escape From Containment

After the storm caused the oil to escape containment on the evening of April 8, the

Unified Command attempted, primarily using Pepco contractor resources, to reestablish

control over the spill. The efforts were unsuccessful until the Unified Command 1)

obtained additional personnel to implement an Incident Command System structure on

April 11, and 2) obtained additional marine response equipment for oil recovery. Between

April 8 and 12, the oil plume spread approximately 17 miles (linear) downstream,

affecting approximately 40 miles of shoreline, including several environmentally sensitive

and populated creeks in Calvert and St. Maryís Counties. (See figure 8 for creek boom

locations and spread of spill.) The major events that took place during the response to the

oilís escape from containment are provided below.

April 9. In the early daylight hours of April 9, an oil plume was observed traveling

in a straight line from the mouth of Swanson Creek across the Patuxent River towards

Calvert County. At 0745, the EPA Federal On-Scene Coordinator contacted the Baltimore

office of the Coast Guard to state that the containment had failed and to ask the Coast

Guard to identify potential Federal resources with marine capabilities. The Coast Guard

directed the EPA Federal On-Scene Coordinator to several possible sources of assistance

(Patuxent Naval Air Base, etc.) in the vicinity. Shortly thereafter, Pepco informed the EPA

Federal On-Scene Coordinator that it was having difficulty obtaining the necessary

contractor resources with marine capabilities, particularly the waterborne skimmers and

skimming vessels needed to respond effectively.

Figure 7. Aerial photo of Swanson Creek area taken on April 10, 2000

showing two plumes of oil moving with the creek flow towards the 

Patuxent River after containment was lost.
Factual Information 18 Pipeline Accident Report

As the morning progressed, Pepcoís contractors were deployed in an effort to

corral the moving oil plume on the river with booms before it could affect the Calvert

County shoreline. The effort was unsuccessful.

By mid-afternoon, the EPA Federal On-Scene Coordinator, other EPA officials on

the scene, the Maryland Department of the Environment on-scene coordinator, and a U.S.

Department of the Interior representative had met and agreed that the spill represented a

substantial threat to public health and the environment. As a result, the EPA contracted

with the Marine Spill Response Corporation, an environmental spill response contractor,

to provide on-water response services and personnel.18

At 2100, another meeting was held, during which the protective booming of the

environmentally sensitive Hunting, Indian, and Trent Hall Creeks, all of which fed into the

Patuxent River, was given a high priority. As a result, it was decided to continue contractor

response efforts through the night.

April 10. Around 1200, the EPA Federal On-Scene Coordinator and the Maryland

Department of the Environment on-scene coordinator toured the accident site with the

Figure 8. Spill site map showing creek boom placements and range of 

oil spill.

18 The Marine Spill Response Corporation is a not-for-profit organization that is funded by member

companies. It allows only the Federal Government or member companies to hire it to respond to spills

involving releases greater than 1,200 barrels. Pepco was not a member company.

Trent Hall 

Creek

Indian Creek

Patuxent River

Washington 

Creek Battle Creek

Hunting Creek

Swanson Creek

CALVERT COUNTY

CHARLES

COUNTY

PRINCE

GEORGE’S 

COUNTY

ST. MARY’S 

COUNTY

Spill

Site

Spill

1 mile

Barrier Booms

Oil Spill

231 2

4

5 6

235

Chalk Point
Factual Information 19 Pipeline Accident Report

Pepco qualified individual and expressed concern that 1) Pepcoís spill response

contractors had not completed booming the threatened creeks according to plans, 2) the

contractors were making ineffective use of the available response resources, and 3) the

reports being provided to the Unified Command by Pepco about the progress of the

response effort were inaccurate. In recognition of the problems, at 1430, the EPA Federal

On-Scene Coordinator asked Coast Guard on-site personnel to develop an Incident

Command System structure for the response, under her direction. About the same time,

the EPA Federal On-Scene Coordinator strongly advised Pepco that it had to greatly

increase its logistical support for and control over the response contractors and that a spill

management contractor was needed.

At the 2100 staff meeting, the EPA Federal On-Scene Coordinator stressed the

need to deploy protective boom around the creeks. She directed Pepco to immediately

deploy protective booms at Hunting, Indian, and Trent Hall Creeks. At 2200, the EPA

Federal On-Scene Coordinator requested that the Coast Guard provide 25 employees by

0600 on April 11 to staff the Incident Command System structure that was being

developed.

April 11. By 0300, the booming of the creeks had not been completed. The EPA

Federal On-Scene Coordinator again directed Pepco to protectively boom the creeks. At

0715, an overflight of the affected area showed that no boom had been installed to protect

the creeks and that Trent Hall and Indian Creeks both showed evidence of significant oil

contamination.

At the 0900 meeting, Pepco indicated that it was attempting to bring additional

contractor resources to the scene. The EPA Federal On-Scene Coordinator, in recognition

of the ìcontinued failure of the Pepco contractors to carry out direction from the Unified

Command,î19 began preparing to have additional Federal environmental responders

participate in the Incident Command System structure.

The Coast Guard Captain of the Port of Baltimore arrived on the scene about 1100,

with additional personnel to staff the Incident Command System structure that had been

developed since the previous day. Organizational functions were split into four sectionsó

operations, planning, logistics, and financeóand Unified Command officials managed

each section. All field operations were carried out under the direction of the operations

section. The newly arriving Coast Guard personnel were designated to monitor the field

operations being conducted by Pepcoís contractors to ensure that work was completed in a

timely and efficient fashion.

The EPA Federal On-Scene Coordinator again asked Pepco to hire a spill

management team to manage its contractors and the spill response. Pepco subsequently

stated that a firm had been contracted to provide logistic management support and keep

track of the contractor and equipment resources at the site.

19 Environmental Protection Agency, After-Action Report for Emergency Response at the Swanson

Creek Oil Spill Site, Aquasco, Maryland, Prince Georgeís, Charles, Calvert, and St. Maryís Counties,

7 April 2000 to 16 May 2000. Appendix A, Incident Chronology, p. A-9.
Factual Information 20 Pipeline Accident Report

During the remainder of the day, protective booming was provided for Hunting

Creek, and protective boom was pre-staged for deployment on April 12 for four more

creeks.

April 12 and Afterwards. Once the Incident Command System structure was

implemented, recovery operations were conducted and monitored around the clock with

day and night crews. Protective booms were provided for threatened creeks on April 12

and 13. Eventually, more than 1,000 contract workers were hired to assist with the cleanup operations.

Restrictions on boating were imposed, and the Maryland Department of the

Environment issued a precautionary advisory on the harvest and consumption of fish and

crabs from the contaminated areas on the Patuxent River. A rehabilitation center for

wildlife was established for oiled animals.

By April 13, Marine Spill Response Corporation skimmers had completed the

collection of free oil in the main body of the Patuxent River. Free oil continued to be

collected through April 16 in several affected creeks in St. Maryís County. During the last

few days of April 2000, the Unified Command developed a long-term site remediation

plan addressing oil removal from the wetlands, soil treatment, site decontamination, and

demobilization. On May 16, 2000, the Unified Command declared the emergency

response phase over. (See appendix D for a timeline of the significant developments in the

environmental response effort.)

Damage

Total environmental clean-up costs were approximately $71 million.

On April 24, 2000, the Maryland Department of the Environment lifted the

advisories it had issued earlier against the harvest and consumption of products from the

Patuxent River. Based on laboratory analyses of crab, fish, and shellfish samples, the

Maryland Department of the Environment determined that eating these river products

would not pose a significant potential for adverse human health effects. In addition, the

Maryland Department of the Environment stated that it had determined that no permanent

damage had been done to fishing resources as a result of the spill.

Personnel Information

The ST Services Chalk Point operator on the day of the accident was a plant

mechanic with over 7 yearsí experience on the Piney Point Oil Pipeline. His duties

included repairing pumps, valves, and construction equipment and being an equipment

and pipeline operator when required. He reported to the ST Services maintenance

foreman.
Factual Information 21 Pipeline Accident Report

The ST Services Ryceville operator on the day of the accident was a plant

mechanic with 7 yearsí experience on the Piney Point Oil Pipeline. His duties included

repairing pumps, valves, and construction equipment and being an equipment and pipeline

operator when required. He reported to the ST Services maintenance foreman.

The ST Services maintenance foreman had over 3 yearsí experience on the Piney

Point Oil Pipeline. His duties included supervising five employees in terminal and

pipeline operations and maintenance. He reported to the ST Services assistant terminal

manager.

The ST Services assistant terminal manager started working at the Piney Point

Terminal in 1973 in various positions, which included carrying out pipeline operations and

maintenance responsibilities for the previous terminal owner. He had approximately

5 yearsí experience with ST Services as an assistant terminal manager with

responsibilities for the Piney Point Terminal and the Piney Point Oil Pipeline. He reported

to the Piney Point Terminal manager.

Postaccident Examination

The April 7, 2000, pipeline rupture occurred at the Chalk Point Generating Station

in southeastern Prince Georgeís County. At this location, the pipeline was on Pepco

property and passed through wetlands adjacent to Swanson Creek, a tributary to the

Patuxent River. The release point was 127 feet north of valve pit No. 1 on Pepco property.

The pipe at the failure area was 12 3/4-inch-diameter, 0.203-inch wall thickness,

American Petroleum Institute (API) 5L grade X42 electric resistance weld steel pipe,

installed with 1-inch polyurethane thermal insulation and a 170-mill polyethylene jacket

exterior coating. The pipe was insulated and coated before the field bend at this location

was made during the pipelineís installation.

The pipeline was buried about 3 1/2 feet deep at the rupture location. The rupture

area was excavated a few days after the failure. When the pipeline was exposed, the

profile of a buckle could be seen through the pipe coating. (See figure 9.) When the pipe

coating was removed, a crack in the circumferential direction was visible.

In a postaccident communication from Pepco to Safety Board staff, Pepco stated it

had reviewed the recorded pressure information, the size of the pipeline crack, and the

pipeline operating conditions at the time of the accident and determined that, to release the

estimated 129,000 gallons of product spilled, the pipe failure had to have occurred at least

5 hours before the Chalk Point pump began cavitating at 1430 on April 7, 2000. A

subsequent communication from Mirant (current operator of the pipeline)20 to Safety

Board staff noted that the failure had probably occurred during the startup of the Chalk

20 Pepco sold the Piney Point Oil Pipeline and the Chalk Point Generating Station in December 2000.

Mirant subsequently became the pipeline owner and operator.
Factual Information 22 Pipeline Accident Report

Point pump, about 0715, when pipeline pressure was at its highest. Mirant also indicated

that the final estimated release quantity was about 3,343 barrels (140,400 gallons).

Tests and Research

A 53-inch-long section of pipeline taken from the scene was examined at the

Safety Board laboratory. The pipe was bent and contained an outward-protruding buckle

on the inside radius of the bend. The angle of the bend in which the buckle was formed

was determined to be in the 5- to 6-degree range. The buckle extended around 270 degrees

of the pipe circumference, from approximately the 10 oíclock to the 7 oíclock position.

(See figure 10.) The pipe was deformed into a slightly elliptical shape. The buckle area

contained an open crack at the crown of the buckle, which extended from approximately

the 2 oíclock to the 4 oíclock position. The maximum height of the buckle was

approximately 1 inch at the 3 oíclock position on the inside of the bend. The crack was

6 1/2-inches long by 3/8-inch wide at its widest portion. (See figure 11.) No external

corrosion was noted on the pipe section when it was examined under a microscope.

The interior surface of the pipe in the area of the buckle peak contained a number

of shallow secondary cracks. All the cracks were circumferentially oriented, confined to

the permanently deformed area of the pipe (approximately 1/4 inch from the buckle apex),

had blunt tips, and were filled with corrosion products. Some of these cracks exhibited

slight branching. The appearance of these cracks was typical of corrosion fatigue cracking

in low carbon steels, resulting from exposure to high stress amplitudes.

Figure 9. Indication of the buckle (Arrows show buckle location).
Factual Information 23 Pipeline Accident Report

Figure 10. Inside view of the buckle in the removed section of pipe.

Figure 11. 6 1/2-inch-long, 3/8-inch-wide crack, 

with coating system shown at the left edge of photo.
Factual Information 24 Pipeline Accident Report

A scanning electron microscope examination revealed five well-defined fracture

zones. Figure 12 illustrates the fracture surface profile of the failure. Bracket ìaî starts at

the interior surface of the pipe, showing a fracture from corrosion fatigue. Brackets ìb,î

ìc,î and ìdî show the crack propagation planes changing from 45 degrees from the

surface of the pipe to roughly perpendicular, showing both tensile overstress and fatigue

propagation, and contain no evidence of corrosion. Bracket ìeî shows the crack

propagation changing to a 45-degree shear plane. The final separation zone adjacent to the

exterior surface of the pipe reveals dimpled features typical of ductile overstress fractures.

Piney Point Oil Pipeline

Pipeline Information

The Piney Point Oil Pipeline was constructed for the Steuart Petroleum Company

in 1971 and 1972 and put in service in 1973. Pepco purchased the pipeline in 1976. In

1995, ST Services purchased the Piney Point Terminal facility from Steuart Petroleum,

and ST Services operated the pipeline for Pepco with former Steuart Petroleum personnel.

Fuel oil was delivered to the Piney Point Terminal by marine vessels and then

transported from the terminal by the Piney Point Oil Pipeline. The 51.5-mile-long pipeline

system was composed of 12-inch and 16-inch-diameter pipeline segments that were used

Figure 12. Fracture surface profile of failure.
Factual Information 25 Pipeline Accident Report

to transport heated fuel oil from the Piney Point Terminal, via the intermediate Ryceville

Station, to generating stations at Chalk Point and Morgantown. The pipeline segment from

Ryceville to Chalk Point was approximately 11 miles long. The oil was heated to make it

flow more easily, and the system operated up to approximately 160° F.

1995 In-line Inspection. The Ryceville to Chalk Point segment of the Piney Point

Oil Pipeline was internally inspected in November 1995 with a geometry tool and an inline magnetic flux leakage tool. After receiving the inspection reports in January 1996,

Pepco exposed the pipeline and examined corrosion anomalies at 29 locations in spring

1996. The data from the magnetic flux inspection did not correlate well with field

measurements for either wall loss data or odometer readings. Pepcoís Pipeline Working

Group recommended that an additional in-line inspection be conducted in 1997 using

ultrasonic inspection tool technology.

1997 Pipetronix In-line Inspection. Pepco contracted with the ultrasonic in-line

inspection contractor Pipetronix21 to conduct a pipeline inspection on August 16, 1997.

Before conducting its ultrasonic inspection tool survey, Pipetronix subcontracted for an inline caliper tool22 survey, which was completed on August 11, 1997. Pipetronix had the

caliper tool run to confirm that there were no physical obstructions in the pipeline that

would prevent passage of the ultrasonic inspection tool.

On August 16, 1997, Pipetronix examined the segment of the Piney Point Oil

Pipeline from Ryceville to Chalk Point with an ultrasonic inspection tool. Pepco required

that Pipetronix prepare a final report for the inspection that would include a complete,

written survey report for the pipeline. The report would provide the pipeline operator data,

including all types of corrosion, gouging, pipeline fittings (such as T-pieces,23 valves,

etc.), girth welds, wall thickness changes, special features (such as externally welded

patches, insulating flanges, etc.), and differentiation between internal and external

corrosion (for general surface corrosion, pitting, and channeling).24

According to the contract, Pipetronix was to use a multi-step process to identify

and interpret each feature in the pipeline, as follows:

1. Field check of the data at random locations immediately after the tool run is

completed,

2. Search of the data by automatic computer programs to detect girth welds, pipe

installations, defects (internal and external), markers, and other features,

21 On November 25, 1999, Pipeline Integrity International Ltd. acquired the Pipetronix Group. The

subsidiary PII North America, Inc., now controls those assets that belonged to Pipetronix in the United

States.

22 A caliper tool is an in-line inspection device used to determine the geometrical condition of the pipe,

including the size and location of abnormalities.

23 A T-piece is normally a tee pipe-fitting welded into a pipeline, although alternatively, a T-piece may

be made by welding a pipe stub to a pipeline and drilling a hole into the pipeline.

24 National Association of Corrosion Engineers Standard RP0102-2002, Recommended Practice InLine Inspection of Pipelines, table 1, lists the types of in-line inspection tools and inspection purposes.
Factual Information 26 Pipeline Accident Report

3. Computer generation, with relevant input from the interpreter, of a features list,

4. Interpretation by the interpreter of each feature found in the search phase.

The completed pipeline features list was to contain all features recorded in the tool

run and present the results of the interpretation in condensed form. The report noted that

data collected during the tool run were systematically evaluated according to criteria

defined in the contract between Pipetronix and Pepco. Pipetronix performed this

evaluation in five phases:

ï Phase 1: Handover of data from the workshop (integration within the

management of the department, handover meeting, familiarizing of the project

leader);

ï Phase 2: Preparation of the interpretation;

ï Phase 3: Main interpretation (automatic interpretation, manual interpretation,

feature list editing, quality check);

ï Phase 4: Summarizing of the results (handover of the features list to the client,

discussion of the results for the final report, documenting of the features,

completion of the final report, quality check);

ï Phase 5: Project completion, including forwarding the final report to Pepco.

After the August 1997 Pipetronix inspection, the pipeline segment from Ryceville

to Chalk Point was excavated and exposed in 12 places in fall 1997. The pipeline was

inspected and repaired at locations indicated by the ultrasonic inspection to have the

deepest and most severe corrosion. At these locations, Pepco determined that the

Pipetronix in-line inspection data correlated relatively well with the field measurements

made of the pipe-wall thickness using an ultrasonic testing instrument. However, Pepco

found that some locations had more severe corrosion than had been indicated by the

ultrasonic inspection.

Pipetronix provided the results of the inspection of the Ryceville to Chalk Point

segment of pipeline to Pepco in a final report dated January 20, 1998. The final report

included general information about the ultrasonic inspection tool used, the ultrasonic

measuring method, the design of the tool, the benefits and limitations of the tool, the

survey procedures, the procedures for evaluating the collected data, and a detailed table of

pipeline features.

Pipetronixís interpretation of the tool data was included in an appendix to the final

report entitled ìFeatures List.î The report identified and located by station number various

pipeline features, including external metal loss, internal metal loss, laminations, flanges,

field bends, weld-o-lets, hot bends, dents, sleeves, markers, girth welds, valves, and Tpieces. Pepco used Pipetronixís in-line inspection report to establish the baseline

conditions of the pipeline and to conduct its excavation and field inspection program.
Factual Information 27 Pipeline Accident Report

Excluding various aboveground features at the pig launcher and receiver, the

Pipetronix features list identified three T-pieces in the pipeline. Two T-pieces were

approximately 1,519 feet apart, one on each side of Swanson Creek, at odometer stations

51887.20 and 53406.10. The third identified T-piece, which was actually the buckle that

failed on April 7, 2000, was identified as being located at odometer station 53526.55.

After conducting a postaccident review of the inspection log for the August 1997

in-line inspection, Pipetronix determined that its analyst had inaccurately interpreted the

log indication at odometer station 53526.55 as a T-piece. At the time of the in-line

inspection, Pipetronixís software reference library did not include a standard image of an

outward protruding buckle, such as the one at odometer station 53526.55. Pipetronix

acknowledged that, based on its knowledge at the time, the feature should have been

interpreted as an ìunknown.î25

Before the April 7, 2000, accident, Pepco had authorized another ultrasonic

pipeline inspection to be conducted by Pipetronix in April 2000. At the time of the

accident, Pepco was cleaning the pipeline to prepare it for this upcoming in-line inspection

to take place later in April 2000.

Operations

The pipeline was operated manually for startup and shutdown.26 The Ryceville

Station was normally left unattended after initial system startup when no pump was

operating at Ryceville. Pipeline operating data were not periodically transmitted to the

Piney Point Terminal. The pipeline monitoring system transmitted pipeline pressure,

temperature, and flow rate alarms to Piney Point. The pipeline alarms were displayed on

the computer screen at the Piney Point Terminal, and audible alarms alerted the ST

Services operator on duty to pipeline operating conditions that were outside

predetermined limits. Using his computer terminal, the ST Services shift supervisorís

operating practice while serving as the pipeline controller was to verify the system alarm

status, as well as pressure, temperature, and flow rate information, once each 8-hour shift.

The alarm data were stored at each station for 30 days and could be printed locally at each

station if a data review was desired. The pipeline computer monitoring system provided

the operations data it was designed to gather during No. 6 fuel oil transfers.

Pepcoís Piney Point Oil Pipeline Manual required that during a No. 6 fuel oil

transfer, the ST Services pipeline controller had to conduct a daily recording of meter

readings and to communicate daily with Pepco operations personnel to ascertain the

delivered quantity, flow rate, available tank capacity, and estimated time of operation

completion. The Pepco manual further required that the ST Services pipeline controller

25 A postaccident Office of Pipeline Safety report that evaluated the 1997 Pipetronix survey found that

the ultrasonic inspection tool provided good characterization of the pipelineís physical elements, such as the

valves, tees, bends, fittings, and points of deformation. The report also found that the tool recorded an

indication of a buckle at the location of odometer station 53526.55, but the Pipetronix analyst

mischaracterized the indication as a T-piece.

26 The pipeline was operated on an as-needed basis when a No. 6 fuel oil transfer was required for a

generating station.
Factual Information 28 Pipeline Accident Report

record the pipeline pressure, temperature, and flow rate at Piney Point at 4-hour intervals

during a No. 6 fuel oil transfer.

The ST Services pipeline controller did not continuously monitor pipeline

operating conditions. The ST Services pipeline controller could receive a call from the

system that a pipeline operating parameter was out of allowable tolerance, and he could

then access the monitoring system to determine the nature of the alarm.

Pipeline flushing was performed at the end of each No. 6 fuel oil transfer.27 Piping

alignments for pigging operations were set up similarly to a flushing operation, although

there were obvious differences in routing the product through the pig traps. The product

did not flow through the meter at the Chalk Point Station during a flushing operation or

during the pigging operation on the day of the accident. In addition, the meters and

pressure-sensing points at the Chalk Point Station were not in the oil flow path, and the

temperature-sensing equipment was not in the direct oil flow path to the Ryceville Station.

The pipeline monitoring system was not capable of monitoring pipeline operating

conditions because of the meter location and the locations of the sensing points. Pipeline

shift supervisors and operators had no predetermined line balance limits to follow to

assess pumped and delivered product volumes during flushing or pigging operations.

Pepcoís Piney Point Oil Pipeline Manual did not require any pipeline operations

personnel to perform periodic line balance calculations during a flushing or pigging

operation, nor did they do so.

The abnormal operating condition procedures described in section 7.4,

paragraph 5.2, of Pepcoís Piney Point Oil Pipeline Manual required the ST Services

terminal duty operator or pipeline operator mechanic to report any abnormal fuel oil

system operating condition that was indicated by 1) an alarm condition on the pipeline

monitoring system, 2) a visual indication of a local pressure or level indication, 3) an

abnormal system operating indication from the Pepco generating station senior power

plant operator, 4) or the One-Call system. Paragraph 5.3 provides an example of an

abnormal system operating condition, which it termed an:

Increase, decrease or an alarm differential in the fuel oil system pressure or flow

rate outside of normal steady state operating conditions as indicated by a

computer monitoring alarm condition or a local pressure instrumentation.

Pipeline Maps and Records

The original Piney Point Oil Pipeline alignment sheets and as-built drawings were

destroyed in a fire before Pepco purchased the pipeline in 1976. Title 49 CFR 195.404

requires operators to have maps and records that include at least the following

information: 1) the location and identification of breakout tanks, pump stations, scraper

and sphere facilities, pipeline valves, cathodically protected facilities, facilities in an

immediate response area not equipped to fail safe, facility rights-of-way, and overpressure

safety devices; 2) all crossings of public roads, railroads, rivers, buried utilities, and

27 Flushing is the process of pumping flushing oil in the reverse direction of normal flow in the pipeline

to displace the No. 6 fuel oil from the pipeline before it cools to the point that it cannot be pumped.
Factual Information 29 Pipeline Accident Report

foreign pipelines; 3) the maximum operating pressure of each pipeline; and 4) the

diameter, grade, type, and nominal wall thickness of all pipe. During 1993 and 1994,

Pepco had pipeline alignment maps made based on aerial photography and created

drawings for aboveground piping of Piney Point Oil Pipeline facilities.

Meteorological Information

At mid-afternoon, on April 7, 2000, Reagan Washington National Airport (about

40 miles northwest of the accident scene) recorded a maximum wind speed of about

19 mph. The temperature was 77° F, and the sky was overcast. By mid-afternoon on

April 8, 2000, wind gusts of about 50 mph were recorded at the airport. Conditions were

rainy, and the temperature was approximately 57° F. During the evening of April 8, rains

in excess of 1 inch and winds over 50 mph were experienced in the Chalk Point area.

Pepco Oil Spill Preparedness

Under 49 CFR 194.101, pipeline operators are required to submit a spill response

plan to the Research and Special Programs Administration (RSPA) for review and

approval. Pepco had provided such a plan to RSPA. According to the regulation, the plan

must address a response to a worst-case discharge and the threat from such a discharge. It

must also include procedures for conducting drills, including identifying the types of drills

to be conducted and their schedules. Appendix A to Part 194 provides recommendations

concerning the topics that the response plan must address. Under section 7, concerning

drill procedures, it is recommended that drills be conducted on the following topics at the

following frequencies:

ï Quarterly drills on emergency procedures and notifications of qualified

individuals for manned pipelines;

ï Quarterly drills involving emergency actions by assigned operating or

maintenance personnel and notifications of qualified individuals for unmanned

pipelines;

ï Annual tabletop exercises involving the shore-based management team;

ï A drill once every 3 years that exercises the entire response plan for each

response zone of the pipeline system.

In September 1996, a tabletop exercise was conducted at Chalk Point under the

direction of RSPAís Office of Pipeline Safety, with the participation of the Coast Guard.

The response exercise involved a hypothetical spill at the Pepco Morgantown facility of

800 barrels of No. 6 fuel oil into the Wicomico River. This was a coastal inland waterway

release scenario, within the Coast Guardís jurisdiction. (The EPA did not participate in the

drill.) The Office of Pipeline Safety sponsored the tabletop exercise to assess Pepcoís

pipeline emergency preparedness under the National Preparedness for Response Exercise
Factual Information 30 Pipeline Accident Report

Program and the Oil Pollution Act of 1990. Specifically, the objectives of the tabletop

exercise were to:

Validate the emergency response plans and procedures of Pepco, and to enhance

participantsí knowledge of the appropriate plan and procedures (e.g. Facility

Response Plan, Area Contingency Plan, State Contingency Plan, etc.)[28]

In the review that followed the exercise, Pepco received the following

recommendations addressing incident management:

The Pepco FRP [Facility Response Plan] should be revised to reflect how Pepco

intends to direct response and resolve spill-related issues jointly with local, state,

and federal responders. Additional training on the roles and responsibilities

involved in these assignments should reinforce the policies of the oil spill

contingency plan. The training should include all potential response groups if

possible, to assist each group in clarifying its role in response operations and as a

part of the unified system. The SMT [Spill Management Team] should ensure that

other Pepco personnel potentially involved in response operations are also trained

in their roles. New personnel assignment to perform the functions of the Incident

Command System, revisions of their roles and responsibilities, and a description

of how these will interact with the local, state and federal responders in the unified

system should be reflected in the FRP.[29]

According to Pepco,30 Revision No. 3 (dated March 13, 1997) of the Oil Spill

Emergency Response Plan for the Ryceville Pumping Station and Pipeline incorporated

the above comments. On August 26, 1997, Pepco submitted Revision No. 3 of the plan to

the Office of Pipeline Safety, which, on October 27, 1997, completed review of the

revised plan. The Office of Pipeline Safety stated that the revised plan adequately

addressed the response planning recommendations made by the Office of Pipeline Safety

based on the drill results.

Between January 1999 and April 7, 2000, at least five notification drills were

conducted for the Piney Point Oil Pipeline. Equipment deployment drills were conducted

in July and November 1999.

Postaccident Actions

Office of Pipeline Safety Postaccident Requirements

An April 12, 2000, Office of Pipeline Safety corrective action order stated that

Pepco must not operate the Piney Point Oil Pipeline until the company:

28 Pepco Spill Management Team Tabletop Exercise Report, September 1996, prepared by the

Corporate Response Group, Inc., for RSPAís Office of Pipeline Safety.

29 Pepco Spill Management Team Tabletop Exercise Report.

30 Summary of Changes: Ryceville Facility Response Plan ñRevision 3a, dated May 4, 1998.
Factual Information 31 Pipeline Accident Report

1. Develops adequate repair procedures,

2. Reviews and addresses procedures for leak detection,

3. Develops a plan with corrective measures to address leak factors including:

ïReview existing instrumentation and improve manual line balance,

ïDevelop and implement a training program for operations personnel,

ïProvide specific procedures and training for pipeline-system monitoring,

ïReview qualifications of operations personnel, and

ïProvide classroom and practical training exercises for the above training

items.

In an amended corrective action order issued on May 4, 2000, the Office of

Pipeline Safety further required Pepco to:

1. [Conduct] Hydrostatic test[s] for integrity of pipe segment from Swanson

Creek to Chalk Point,

2. Review previous internal inspection, make needed repairs, and plan future

inspections,

3. Implement operations procedures for line monitoring during pigging activities,

4. Review and update schematic drawings.

Pipeline Safety Actions Since Accident

Since the accident, Pepco began and Mirant continued (after its purchase of the

Piney Point Oil Pipeline) to make improvements to comply with, and in some cases

exceed, the Office of Pipeline Safetyís corrective action orders. Mirant prepared an

integrity study to assess the risks posed by pipe wrinkles,31 to establish acceptance criteria

for pipe wrinkles, and to remove all those wrinkles or defects not satisfying the acceptance

criteria. Mirant also developed additional pipeline repair procedures. After all inspections

and replacements were completed, the entire pipeline system was hydrostatically tested.

The transport temperature for No. 6 fuel oil was reduced temporarily from 160° F to

125° F until the influence of heat on pipeline movement could be studied.

Mirant installed supervisory control and data acquisition (SCADA) systems32 with

software-based leak detection and radar tank gauges with remote reading capability on all

Piney Point Oil Pipeline tanks, and the entire set of operations and maintenance

procedures was rewritten. In support of this pipeline integrity focus, two different smart

31 A wrinkle is a smooth wave deflection of the pipe wall and may have a single inward or outward

deflection or may include a sinusoidal waveform with both inward and outward displacements.

32 Pipeline controllers use SCADA systems to remotely monitor and control movement through

pipelines. With a SCADA system, controllers can monitor flow rates and pressures along the lines and

control valves and pumps to adjust the flow at pump stations and locations throughout the pipeline system.
Factual Information 32 Pipeline Accident Report

pig technologies (ultrasonic and deformation inertial) were employed to inspect the entire

pipeline system in May 2001. Mirant indicated that the evaluations were intended to

provide a substantial new baseline for maintaining pipeline integrity, in addition to

restoring pipeline activities.

Mirant has put in place a new diversified pipeline management team that has

indicated it intends to continue to use industry-recognized pipeline consultants. This team

intends to prepare and manage a long-term integrity plan for the pipeline, consistent with

the integrity management rule in Federal pipeline safety regulations. Mirant has employed

its own pipeline operating personnel, which, Mirant states, have been trained in the new

procedures and equipment. Mirant has implemented an internal audit process that it says

will provide further assurance that all current regulatory and industry best practices are

maintained.

In accordance with the requirements at 49 CFR 194.101, Mirant submitted to

RSPA in December 2001 a spill response plan dated May 2001. RSPA approved the plan

on April 30, 2002. Mirant developed its facility emergency spill response plans with the

assistance of industry experts. During the first 6 months of 2001, three revisions were

made to the Oil Spill Emergency Response Plan for the Ryceville Pumping Station and

Pipeline. Specifically, these changes addressed ownership and nomenclature adjustments,

as well as additional revisions intended to clarify and simplify the plan. On July 27, 2001,

Mirant published Response Strategies for Southern Maryland. Based on ìoperational

experience gained during the Swanson Creek oil spill response and studies,î the manual

was intended to provide tactical response information for use as a pre-planning document

for response managers and crews. The manual identified key control points along and off

the pipeline corridor where response actions might be taken should a release occur. One of

the main elements in the manual was a site summary sheet for each of the primary control

point locations. The summary sheets were prepared with map and chart references with

global positioning system location data, location and general access instructions, general

release/flow paths, information concerning receiving water bodies and selected sensitive

features, and response protocols and tactics. Shortly after the manual was published,

Mirant personnel met with the members of the Local Emergency Planning Committee,

which represents the local public response agencies of the four surrounding counties, to

familiarize them with the implementation of the manual.

In 2001, Mirant conducted 11 drills concerning spill response (2 deployment drills,

5 tabletop drills, and 4 qualified individual notification drills). As of June 1, 2002, Mirant

had conducted four spill response drills (one deployment, one tabletop, and two qualified

individual notification) in 2002.
Factual Information 33 Pipeline Accident Report

Other Information

Incident Command System

The Incident Command System concept was developed as a consequence of fires

that destroyed significant environmental assets in 1970 in Southern California. Agencies

recognized that they needed a system that allowed them to work together effectively and

efficiently when conducting responses to the broadest range of emergencies, including

incidents involving threats to lives, property, and the environment. A multi-agency task

force subsequently developed the Incident Command System.

The system consists of procedures for controlling personnel, facilities, equipment,

and communications during an incident response. It is designed to be used from the time

an incident occurs until response operations are completed. The Incident Command

System structure has five major functional areasócommand, operations, planning,

logistics, and financeóbut the structure is flexible and can be accommodated to the

specific needs of each response. Consequently, it can be used for any type or size of

incident. It provides a framework under which agencies may communicate and function

using uniform terminology and operating procedures.

The system is widely used by Federal, State, and local responders. Since the

development of the Incident Command System concept, Incident Command System

structures have been used at hundreds of incidents with general success. In February 1996,

the Coast Guard officially adopted the National Interagency Incident Management System

Incident Command System and has developed various training modules for it.

In an April 24, 2001, letter to the Safety Board, the EPA Federal On-Scene

Coordinator for the Chalk Point accident stated that:

EPA currently has no formal policy on the use of Incident Command

System/Unified Command. The National Response Teamís Technical Assistance

document has been distributed to all EPA on-scene coordinator[s], and EPA

headquarters has encouraged the inclusion of the Incident Command

System/Unified Command into their Area Contingency Plans (ACP). However,

EPAís Regions have been provided the flexibility, consistent with the National

Response Teamís Technical Assistance Document, to adopt response management

structures that use an Incident Command System that may be consistent with

National Interagency Incident Management System [NIIMS]. The Region III

Inland Area Contingency Plan calls for a Unified Incident Command System that

is not based on NIIMS.

EPA has provided no written guidance to its regions on the use of Incident

Command System/Unified Command beyond that provided in the National Response

Team Technical Assistance Document Incident Command System/Unified Commandó

Managing Responses to Oil Discharges and Hazardous Substance Releases under the

National Contingency Plan. The National Response Team, with the Regional Response

Teams, constitutes the Federal component of the National Response System. The National

Response Team and Regional Response Teams are made up of 16 Federal departments and
Factual Information 34 Pipeline Accident Report

agencies. The EPA chairs the National Response Team, and the Coast Guard serves as

Vice Chair.

The EPAís Office of Emergency and Remedial Response is developing an EPA

policy position on the Incident Command System.

Postaccident Assessments of Chalk Point Response

EPA Federal On-Scene Coordinator. In her postaccident report on the Chalk

Point response,33 the EPA Federal On-Scene Coordinator made numerous findings

concerning a wide range of areas in which the response could have been improved and

made suggestions to improve future responses. She acknowledged that the lack of a

National Interagency Incident Management System-based Incident Command System

structure hindered the establishment of resource tracking and accountability as the Chalk

Point incident progressed. She also stated that because local responders were not included

in the immediate response, their capabilities were not effectively used to disseminate

information to the community or to coordinate response efforts.

Regional Response Team. In its April 5, 2001, report on the Chalk Point

accident response,34 the Regional Response Team review committee found that there

appeared to have been no effective response management system, especially early in the

incident. The committee considered that the task-oriented management structure

originally used was not conducive to managing the rapid expansion of a major oil spill.

The committee added that, although each incident is different, major oil spills have

predictable elements that can be managed more effectively via Incident Command/Unified

Command systems. As a result, the Regional Response Team review committee

recommended that, in future incidents, the Incident Command/Unified Command system

be immediately activated at the spill site to ensure that authority and responsibility are

clearly assigned. Further, the Regional Response Team stated that the EPA should develop

a guidance document on how to set up and run Incident Command/Unified Command

systems, train all Federal On-Scene Coordinators in Incident Command/Unified Command

systems, and consider augmenting the Federal On-Scene Coordinator with an Incident

Command System/Unified Command management team.

Coast Guard. In his August 25, 2001, letter addressing lessons learned from the

Chalk Point accident response, the Chief of Marine Safety for the Fifth Coast Guard

District indicated that the significant delay in establishing an Incident Command System

contributed to a fragmented and ineffective response. He further stated:

The Coast Guard has adopted the Incident Command System (ICS) as its

emergency response process. We have found ICS to be a very effective spill

management tool; particularly as the system is used by most State and Local

response entities as well.

33 Environmental Protection Agency, After-Action Report for Emergency Response at the Swanson

Creek Oil Spill Site, Aquasco, Maryland, Prince Georgeís, Charles, Calvert, and St. Maryís Counties 7 April

2000 to 16 May 2000.

34 Swanson Preparedness and Response Review: Swanson Creek Marsh Oil Spill ñ April 2000, Final

Report, dated April 5, 2001.
Factual Information 35 Pipeline Accident Report

He noted that, although it appeared that the oil was well-contained in the wetlands

early in the response, other factors were at play (wind, predicted storm, etc.) that might

have led experienced response managers to recognize the precarious nature of the

situation. He indicated that responders conducting overflights or other assessment

activities should have analyzed the gathered information more accurately and realized that

the oil was liable to break out of containment and enter the Patuxent River.

He further found that the limited involvement of the local response community had

a negative effect on the response effort. He indicated that local responders play a major

role in site safety, provide local information needed by responders from other areas, and

can help to establish the Unified Command and Incident Command System structures as

soon as they arrive on the scene.

November 2000 Safety Board Hearing on Pipeline Safety

On November 15 and 16, 2000, the Safety Board held a pipeline safety hearing

that focused on pipeline inspection, integrity verification, and leak detection and response.

Participating in the meeting were representatives of Federal agencies, including the Safety

Board, RSPA, and the Office of Pipeline Safety; the pipeline industry, including pipeline

operators, in-line pipeline inspection services, and integrity assessment consultants; and

academia and research institutes.35

In addition to addressing a wide range of other pipeline safety issues, pipeline

industry representatives stressed the need for pipeline leak detection systems to have

accurate pipeline instrumentation located at sensing sites. During the hearing, the RSPA

Administrator stated that, to increase their efficiency, leak detection systems must be less

dependent on the human pipeline controller. Hearing testimony also indicated that many

leaks could be detected in a matter of minutes with a computational pipeline monitoring

system, which would reduce the reliance of pipeline system operating parameters on

human input.

35 For additional information on the presentations made during the November 2000 pipeline safety

hearing, see the Web link at <http://www.ntsb.gov/events/2000/pipeline_hearing/default.htm>.
36 Pipeline Accident Report

Analysis

The Accident

About 0715 on April 7, 2000, employees of Pepcoís contractor, ST Services,

launched a cleaning pig in flushing oil from Pepcoís Chalk Point Station toward Ryceville

Station on the Piney Point Oil Pipeline. For the next several hours, periodic tank levels

were taken for the Chalk Point (origin) and the Ryceville (destination) Stationsí flushing

oil tanks, but tank volumes were not calculated from the tank level readings and evaluated

for line balance as the pumping operation proceeded. Because the pumping was

progressing faster than expected, ST Services personnel operating the pipeline expected

the cleaning pig to arrive at the Ryceville Station between about 1300 and 1330, but it did

not. The ST Services Chalk Point operator became concerned and double-checked the

tank level about 1412 because the pig had not arrived at Ryceville, and the Chalk Point

pump began cavitating at 1430. About the same time, the flow of oil stopped at the

Ryceville Station.

By 1440, pipeline personnel had initiated the acquisition of current tank level

measurements for line balance calculations at both stations and the checking of the Chalk

Point manifold for misaligned valves. By 1534, they had calculated that Ryceville had not

received 3,089 barrels (129,738 gallons) of the oil that had been pumped from Chalk

Point. At 1538, pipeline operating personnel shut down the pipeline and initiated surface

inspections at locations where the pipeline crosses roads and Swanson Creek to look for

an oil leak. By 1802, a pipeline aerial patrol, which had been launched earlier at the

direction of the Pepco Chalk Point general supervisor for operations, had reported sighting

a pipeline leak in the wetlands near Swanson Creek, not far from the Chalk Point Station.

Postaccident calculations performed by the Piney Point Oil Pipeline owners, which

were based on review of the recorded pipeline pressure information, the operating

conditions at the time of the accident, the size of the crack, and the amount of product

spilled, indicated that the pipe failure occurred before 0930 on April 7, 2000, probably

when the Chalk Point pump was started, about 0715, and the pipeline pressure was at its

highest level. The Safety Board reviewed this analysis and found it credible.

The pipeline ruptured at a wrinkle in a section of pipe that had been field-bent

during initial construction of the pipeline in 1971 and 1972. The deformation, or wrinkle,

that failed was a single outward deflection of the pipe wall, commonly described as a

buckle. After the pipeline was placed in service, forces imposed on the deformed area of

the bend, including the normal operating pressure and thermal cycles in the pipeline,

caused repeated straining and eventual cracking until the pipe at the deformed area failed.
Analysis 37 Pipeline Accident Report

Pipeline In-line Inspection

Although in-line inspections were not mandated, Pepco maintained a program

under which it periodically had in-line inspections conducted on the Piney Point Oil

Pipeline to help ensure pipeline integrity. Pipetronix, an ultrasonic in-line inspection

contractor, had conducted the last inspection of the pipeline before the accident on

August 16, 1997. When the April 7, 2000, accident occurred, Pepco was preparing the

Piney Point Oil Pipeline for another in-line inspection.

In accordance with its contract with Pepco for the August 1997 in-line inspection,

Pipetronix examined the segment of the Piney Point Oil Pipeline from Ryceville to Chalk

Point to identify corrosion, gouging, pipeline fittings, girth welds, wall thickness changes,

special features, and differentiation between internal and external corrosion. Pipetronix

interpreted and checked the ultrasonic tool data from the inspection using computer-based

systems and manual review by its technicians. The Pipetronix report to Pepco concerning

the in-line inspection results and Pipetronixís interpretation of the results included an

appendix that identified and located various pipeline features by station number.

Pipetronixís interpretation of the ultrasonic tool data contained a significant

inaccuracy for the feature at odometer station 53526.55. This feature, which was found

after the accident to be a buckle but was inaccurately interpreted by the Pipetronix analyst

as a T-piece, failed and resulted in the leak on April 7, 2000. Based on interpretation of the

data available to Pipetronix at the time of the inspection, the Pipetronix analyst should

have interpreted the feature as an ìunknownî because it did not match the signal

characteristic for a T-piece. Had Pepco been notified that the feature was an unknown, it

might have attempted to determine the featureís true characteristics, through excavation or

other means. Therefore, the Safety Board concludes that because Pipetronix incorrectly

interpreted the results of its ultrasonic tool data for the pipeline feature at odometer station

53526.55, Pepco was not alerted to the need for additional evaluation of the pipe at the

location where it subsequently ruptured. After the accident, Pipetronix updated its

reference library and training materials to include the signal characteristics of the outward

protruding buckle that failed in this accident.

Evaluation of Pipe Wrinkles

After the accident, RSPA required Mirant (which became the pipelineís owner

some months after the accident) to prepare an integrity study of the Piney Point Oil

Pipeline before it would allow the pipeline to be returned to service. Data from the 1997

in-line inspection of the pipeline were compared to the actual geometry of various

wrinkles in pipeline bends, obtained after excavating the most severe wrinkles and

determining the geometry by field measurements. After correlation between the in-line

inspection data and the field measurements was completed, the 1997 in-line inspection

data were used as the basis for the evaluation of wrinkles that had not been excavated and

inspected. An analysis was performed to determine if identified wrinkles needed to be

removed. As a result of this work, Mirant developed quantitative acceptance criteria for
Analysis 38 Pipeline Accident Report

pipe wrinkles remaining in the pipeline. RSPA accepted the analysis that indicated that

some wrinkles could remain in the pipeline, and RSPA allowed the pipeline to return to

service.

Field bends containing wrinkles were installed in pipelines before the hazardous

liquid pipeline safety regulations went into effect in 1970. Since then, pipeline regulations

have prohibited the installation of pipe containing wrinkle bends during pipeline

construction.36 However, pipe wrinkles that were not discovered during the construction

inspection process or that formed sometime after construction are still periodically found

in pipelines.

According to RSPAís pipeline integrity management rule, when an in-line

inspection tool is selected by a pipeline operator to assess the condition of the pipeline, it

must be ìcapable of detecting corrosion and deformation anomalies including dents,

gouges, and groovesî in high-consequence areas.37 The regulation states that ìan operator

must evaluate all anomalies and repair those anomalies that could reduce a pipelineís

integrity.î38 Although the language in this regulation does not specifically designate

wrinkles as a category of deformation anomaly, when questioned by Safety Board staff,

RSPA officials indicated that the regulation applies to wrinkles.

Wrinkles can sometimes be identified through the use of in-line inspection tools.

However, operators do not have nationally recognized quantitative criteria with which to

assess the effect of a specific wrinkle characteristic on a pipe or to determine whether a

pipeline can be safely operated while it contains some wrinkles. Therefore, the Safety

Board concludes that because pipeline operators have no nationally recognized criteria

with which to evaluate pipe wrinkles, they may not be effectively determining whether

pipe containing wrinkles should be allowed to remain in service. The Safety Board

believes that RSPA should establish quantitative criteria, based on engineering

evaluations, for determining whether a wrinkle may be allowed to remain in a pipeline.

Leak Detection

After the Chalk Point leak began, sometime before 0930 on April 7, 2000, it was

hours before those operating the Piney Point Oil Pipeline recognized that a line balance

shortage, which might indicate a leak, was developing. The leak might have been

recognized much sooner if more systematic leak detection procedures and practices had

been in place and used.

During normal deliveries of No. 6 fuel oil to the Chalk Point Generating Station,

Pepcoís automated pipeline monitoring system was designed to provide alarms for

pressure, temperature, and flow rate to the pipeline controller for operating conditions

36 49 CFR 195.212.

37 49 CFR 195.452(c)(1)(i)(A).

38 49 CFR 195.452(h)(1).
Analysis 39 Pipeline Accident Report

outside of predetermined limits. During the pigging operation on the day of the accident,

however, the meters and pressure-sensing points at Chalk Point were not in the flushing

oilís flow path, and the temperature-sensing equipment was not in the direct flow path to

Ryceville. Thus, Pepcoís automated pipeline monitoring and leak detection system on the

Piney Point Oil Pipeline did not alert the ST Services personnel to the developing

problem.

With respect to manual monitoring of the pipeline, ST Services did not require its

personnel to perform line balance calculations while conducting either normal pipeline or

pigging operations, nor did the procedures in Pepcoís Piney Point Oil Pipeline Manual

include such requirements. Although ST Services personnel took tank level measurements

at both the Chalk Point and Ryceville Stations throughout the morning of April 7, they did

not use this information to evaluate whether product had been lost from the pipeline.

Based on the speed of the pigging operation and his previous experience, the ST Services

Chalk Point operator updated the estimated cleaning pig arrival time at the Ryceville

Station from about 1415 to between 1300 and 1330. Even when the pig failed to arrive

during this period, ST Services personnel still did not evaluate the tank level information

to check the line balance. It was not until the Chalk Point pump began cavitating and the

flow of oil stopped at the Ryceville Station, about 1430, that ST Services personnel

recognized a problem. Between 1440 and 1534, using tank level measurements for line

balance calculations, they determined that Ryceville had not received 3,089 barrels of the

oil that had been pumped from Chalk Point, and they shut the pipeline down at 1538.

On April 7, 2000, therefore, Pepcoís procedures, as provided in the Piney Point Oil

Pipeline Manual, were inadequate because they did not require ST Services personnel to

conduct line balancing during pigging operations, and ST Servicesí practices were

inadequate because they did not include effective line balancing during the pigging

operation. Although some manual tank levels were obtained throughout the day, they were

not evaluated. Had line balance been determined on a timely basis, the line balance

discrepancy would likely have been discovered within about an hour of its occurrence.

The Safety Board concludes that the absence of effective pipeline monitoring procedures

and practices, including periodic line balancing, delayed the discovery of the fuel oil

shortage on April 7, 2000, which delayed the pipeline shutdown and allowed more oil to

leak from the pipeline.

As a result of a pipeline accident in North Blenheim, New York,39 the Safety Board

issued Safety Recommendation P-91-1 to RSPA. It read:

39 National Transportation Safety Board, Liquid Propane Pipeline Rupture and Fire, Texas Eastern

Products Pipeline Company, North Blenheim, New York, March 13, 1990, Pipeline Accident Report

NTSB/PAR-91/01 (Washington, DC: NTSB, 1991).
Analysis 40 Pipeline Accident Report

P-91-1

Define the operating parameters that must be monitored by pipeline operators to

detect abnormal operations and establish performance standards that must be met

by pipeline monitoring systems installed to detect and locate leaks.

Safety Recommendation P-91-1 is classified ìOpenóUnacceptable Response.î

RSPA, in its 1991 and 1992 responses to the recommendation, indicated that it

intended to conduct a study of SCADA systems. In response to a 1997 follow-up status

inquiry from the Safety Board, RSPA indicated that it would soon issue rulemaking

concerning leak detection standards.

In 1998, RSPA incorporated parts of an industry standard for leak detection, API

Standard 1130, Computational Pipeline Monitoring, in its hazardous liquid pipeline safety

regulations. In 49 CFR Part 195, computational pipeline monitoring is defined as a

ìsoftware-based monitoring tool that alerts the pipeline dispatcher of a possible pipeline

operating anomaly that may be indicative of a commodity release.î Title 49 CFR 195.134,

which is the safety regulation requiring the use of API Standard 1130 for design, applies

when operators are replacing a component of an existing computational pipeline

monitoring system or installing a new computational pipeline monitoring system on a

pipeline; the regulation does not require that such systems be installed.

Since the April 2000 accident, Pepco initiated, and Mirant completed, the

installation of a new SCADA system that meets API Standard 1130, and a pipeline

controller will continuously monitor it. This system includes additional instrumentation,

sensors, and controls, as well as a computer model that uses current pipeline operating

conditions. The system continuously calculates line balances to enable early detection and

warning, and it allows the pipeline controller to initiate remote shutdown. Mirant now

operates the pipeline with its own employees, and the pipeline controller is engaged in

active analysis and monitoring of pipeline operations. Mirant has revised the operating

procedures so that the pipeline controller initiates an immediate shutdown when a flow

shortage outside of predetermined limits is indicated by its new SCADA-based leak

detection system.

At a Safety Board pipeline safety hearing held in November 2000, panelists

discussed various types of automated monitoring systems that make leak detection

possible within a matter of minutes. In contrast, manual line balancing relies on

acquisition of data by pipeline operators. Manual computation and evaluation are then

required to develop the pipeline operating data. The manual process requires more time to

complete than an automated system, and the input data are more susceptible to human

error than data obtained and used by an automated monitoring system.

On December 1, 2000, RSPA issued a new regulation at 49 CFR 195.452,

requiring hazardous liquid operators with 500 or more miles of pipeline to provide

pipeline integrity management. On January 16, 2002, RSPA amended the regulation to

include operators that own or operate less than 500 miles of regulated hazardous liquid
Analysis 41 Pipeline Accident Report

pipelines. The regulation requires that operators have a ìmeans to detectî leaks on their

pipeline systems in high-consequence areas, but it does not specify what constitutes

adequate means to detect leaks.

RSPA officials met with Safety Board staff on May 16, 2002. In response to Safety

Board staff questions about how RSPA will enforce the new leak detection requirements,

RSPA officials indicated that they are developing specific criteria for defining adequate

leak detection measures and that the criteria will be posted and enforced.40 The Safety

Board supports this effort and encourages RSPA to expedite the development of the

criteria and, as part of the process, to consider increased system automation to ensure

timely leak detection.

Leak-related Notifications

Once the ST Services pipeline operators confirmed that they had a leak, they began

to initiate an emergency response. The emergency response was affected by several

communications breakdowns. Pepco did not provide accurate information about the

volume of the Chalk Point oil release to public agencies, nor did Pepco ensure that its

internal information exchanges were effectively coordinated. The failures left responders

with inadequate information with which to evaluate the threat posed by the release.

In the case of the Chalk Point accident, the response of deploying booms initially

contained the oil spill, despite failures to effectively notify responders about the scope of

the accident and to inform local response agencies early in the response effort. However,

in future incidents involving pipeline leaks, such notification errors could cause

responders to fail to respond with the resources needed to deal with a release, which could

have negative consequences.

Inaccurate National Response Center Notification

Between 1538, when the pipeline was shut down, and 1850, when the National

Response Center received notification of the Chalk Point spill, miscommunications and

the creation of a release estimate lacking any factual basis took place among the various

Pepco officials managing the release. By the time they shut down the pipeline, ST

Services personnel were aware that they had a line balance discrepancy of about

3,000 barrels (126,000 gallons). Sometime before 1620, the ST Services assistant terminal

manager told the Pepco engineering supervisor that the line balance discrepancy was

about 3,000 barrels. The Pepco engineering supervisor informed the Pepco Chalk Point

general supervisor for operations about the discrepancy at 1620, stating that it was about

2,000 to 3,000 barrels. At this time, the Pepco Chalk Point general supervisor for

operations noted in his log that there was a discrepancy of 2,000 barrels.

40 In addition, RSPA is soliciting research proposals to advance leak detection technologies by

improving leak detection timeliness and accuracy and by developing improved means of detecting small

pipeline leaks.
Analysis 42 Pipeline Accident Report

About 1827, a still more significant error took place concerning the estimation of

the size of the spill. The Pepco Chalk Point shift supervisor told the Pepco qualified

individual (when pressed to provide an estimate) that the amount of the spill was ì1,000

gallons, 2,000 gallons, [expletive] mess, tell them what you want.î This unfounded

estimate was reported to the Pepco Chalk Point general supervisor for operations, who, in

consultation with the Pepco senior environmental coordinator during a phone

conversation, agreed to report a release of 2,000 gallons to the National Response Center

and the Maryland Department of the Environment. About 1840, ST Services provided

additional confirmation to the Pepco Chalk Point general supervisor that the line balance

shortage was approximately 3,000 barrels (126,000 gallons). About 1850, the Pepco

senior environmental coordinator called the National Response Center and reported a

2,000-gallon No. 2 fuel oil release from a pipeline at Pepcoís Chalk Point Generating

Station, even though the Pepco Chalk Point general supervisor had updated information

that the line balance shortage was actually about 3,000 barrels (126,000 gallons).

By 2015, the estimated release amount of 3,000 barrels (126,000 gallons) had been

posted on the Chalk Point command center information blackboard. Shortly after 2100,

the Pepco engineering group confirmed with line balance calculations that the amount of

flushing oil involved in the release was 3,089 barrels (129,738 gallons).

Pepco officials could have updated the National Response Center when they

learned that the information they had initially reported was inaccurate, but they did not.

The Pepco senior environmental coordinator learned within 2 hours that the 2,000-gallon

release estimate he had given the National Response Center did not approach the true

magnitude of the release, but neither he nor any other Pepco manager updated the report.

When asked why he never updated the National Response Center, the Pepco senior

environmental coordinator said he believed that by 2130 on April 7, representatives of all

the notified agencies were on the scene or were in contact with each other. In fact, the EPA

Federal On-Scene Coordinator was not advised of the revised spill estimate until she

arrived at Chalk Point at 1015 on April 8, about 13 hours after Pepco had confirmation

that the likely size of the spill was 3,089 barrels (129,738 gallons). Thus, those oil spill

responders who received notification from the National Response Center were not

informed of the significant size of the product release and the spillís potential impact on

the environment until they arrived on the scene.

During the May 16, 2002, meeting between RSPA officials and Safety Board staff,

RSPA officials stated that National Response Center notification reports are intended to

provide responders, as quickly as possible, the information they need to activate

appropriate resources to control, mitigate, and/or clean up a product spill. Emergency

responders, as well as accident investigators, rely on the information provided by the

National Response Center when preparing their response efforts. Inaccurate or incomplete

information can hamper these activities. For instance, if the initial information reported

erroneously indicates that the release is minor, some Government responders needed on

the scene to carry out containment or mitigation efforts may decide not to respond to the

accident. And if they do respond, they may not bring sufficient resources to manage the

spill. For those Government agencies that send personnel to the accident, the National
Analysis 43 Pipeline Accident Report

Response Center report may be the only information that the responders have before

arriving on the scene. The more complete the information is, the better prepared

Government responders will be to react to the particular circumstances of the accident.

In addition to the Chalk Point accident, the Safety Board is aware of other cases in

which pipeline owners or operators reporting an incident to the National Response Center

did not update their initial reports when more comprehensive and accurate information

became available.41 The Safety Board concludes that because pipeline owners and

operators sometimes do not update their initial reports to the National Response Center,

the notifications provided to emergency responders may not always contain the complete

and accurate information needed to develop an effective incident response. Therefore, the

Safety Board believes that RSPA should require pipeline owners and operators to provide

follow-up telephone updates to the National Response Center when they discover that the

information they initially reported contains significant errors or when they identify

significant new information directly related to the reporting criteria.

Limited Involvement of Local Response Agencies

Pepco considered that, under the Chalk Point oil spill response plan, the release did

not meet the criteria for notification of local response agencies, which were ìfire,

explosion, personal injury or release or significant threat of release off-site.î Although the

accident might not have immediately met these specific criteria, Pepco should have

realized that the Chalk Point leak, due to its proximity to Swanson Creek, which fed into

the Patuxent River, had the potential for a significant off-site release. However, Pepco did

not contact local response agencies, including the Prince Georgeís County Fire

Department. As a result, the resources of the local response agencies were not utilized as

soon as possible.

In her postaccident review, the EPA Federal On-Scene Coordinator stated that she

believed the exclusion of local responders from the initial response (having been notified

only once State responders were already on-scene) had a negative impact on the response

operations, particularly with respect to the dissemination of information to the community

and the ability to coordinate response efforts. In addition, the Chief of Marine Safety for

the Fifth Coast Guard District stated, in an August 25, 2000, letter addressing lessons

learned from the Chalk Point accident, that the local responders are needed to ensure the

safety of the site, share local knowledge with the spill management team, and mobilize

essential resources to the scene.

Mirant, the current owner of the Piney Point Oil Pipeline, has significantly revised

the oil spill response procedures for the pipeline. In April 2002, RSPA approved Mirantís

oil spill response plan. After the Chalk Point accident, the Oil Spill Emergency Response

Plan for the Ryceville Pumping Station and Pipeline was revised to improve and clarify it.

41 A March 30, 1998, accident in Sandy Springs, Georgia, that was originally reported to the National

Response Center as a release of 150 gallons of gasoline was later found to be a release of over 15,800

gallons. An August 20, 2001, accident in Jackson County, Oklahoma, that was initially reported to the

National Response Center as a release of 8,400 gallons of crude oil was later found to be a release of about

126,000 gallons.
Analysis 44 Pipeline Accident Report

Further, on July 27, 2001, Mirant published the manual Response Strategies for Southern

Maryland, which was based on ìoperational experience gained during the Swanson Creek

oil spill response and studies.î42 The Safety Board notes that Mirant personnel met with

the members of the Local Emergency Planning Committee, which represents the local

public response agencies of the four surrounding counties, to familiarize the members

with the implementation of the manual. In the less than 2 years since Mirant became the

owner of the pipeline, it has conducted at least 15 drills concerning elements of effective

spill response, and some of the drills have involved local response agencies. The Safety

Board notes these Mirant efforts to provide prompt involvement of local response

agencies in any future emergencies.

Incident Command

The Safety Board found that the lack of effective incident command had a negative

effect on the emergency response to the Chalk Point release. ST Services, Pepco, and spill

recovery contractors on the scene on April 7 and 8, 2000, were initially successful in

deploying a boom system that contained the leading edge of the spill. On the night of

April 8, however, with the arrival of a severe storm that included heavy rains and 50-mph

winds, the boom containment system was overwhelmed. The spill escaped containment

and ultimately traveled an estimated 17 miles (linear) downstream and oiled 40 miles of

shoreline in Prince Georgeís, Charles, Calvert, and St. Maryís Counties. Responders were

unable to effectively mitigate the environmental impact of the oilís entry into the Patuxent

River, due in part to incident management and oversight deficiencies.

The EPA Federal On-Scene Coordinator arrived on the scene at 1015 on April 8

and began attempting to coordinate the Unified Command without establishing an

Incident Command System. Instead, she relied on a project management structure that

gave the responsible party, Pepco, primary responsibility for directing and monitoring the

activities of response contractors. Throughout April 8, the Unified Commandís efforts

were focused on containing the spill within the Swanson Creek wetlands area. Pepcoís

contractors conducted the booming operation based on the directions they received from

Pepco officials, who received their orders from the Unified Command.

Management problems were evident even at this early stage. The Pepco officials

working with the contractors were on rotating 8-hour shifts, and those personnel going

off-duty sometimes did not fully discuss response developments and necessary tasks with

those coming on-duty. This lack of continuity caused problems with task and status

communication and coordination. Instances of miscommunication and problems with

unclear lines of authority occurred. Important meetings were not attended by all necessary

personnel, and Pepco contractors sometimes did not fully understand the tasks they were

42 The manual is intended to provide tactical information for use as a pre-planning document for

response managers and crews. It identifies key control points along and off the pipeline corridor where

response actions may be taken should a release occur. The manual also includes a summary sheet for each of

the primary control point locations.
Analysis 45 Pipeline Accident Report

assigned. The EPA Federal On-Scene Coordinator also did not have extensive Federal

response resources to draw upon at this time.

A storm was predicted for that evening, and the Unified Command and the EPA

Federal On-Scene Coordinator ordered, and Pepcoís contractors took, reasonable

precautions to maintain the containment they had achieved in the Swanson Creek

wetlands area. However, the storm was more severe than had been anticipated, and the

outer booms at the Patuxent River were breached about 2030, releasing a significant

amount of oil into the river.

For the next 2 days (April 9 and 10), the Unified Command, under the direction of

the EPA Federal On-Scene Coordinator, attempted to mount an effective response to the

oil spillís escape into the river. Significant resource and organizational problems arose

immediately. Pepco had difficulty obtaining contractor resources that could carry out

marine operations, and the EPA Federal On-Scene Coordinator encountered similar

problems when she attempted to augment the response effort with Federal resources. Even

more importantly, the contractors hired by Pepco were not completing urgent assigned

tasks, and the delays in the response effort were not being promptly and accurately

reported to the Unified Command. The EPA Federal On-Scene Coordinator stated that in

the 2 days following the escape of the oil into the river, the Unified Command repeatedly

directed Pepco to ensure that several environmentally sensitive creeks leading into the

river were protectively boomed. According to the EPA Federal On-scene Coordinator,

Pepco repeatedly indicated that appropriate action was being taken and that the booms

would be placed as soon as possible. As of April 11, no booms had been deployed to

protect the creeks, and two creeks showed evidence of oil contamination.

To address the coordination and communication problems and the contractorsí

inability to complete assigned tasks, the EPA Federal On-Scene Coordinator decided that

an Incident Command System structure had to be implemented. Such a system is designed

to provide more direct Federal control over response activities, a quicker response to spill

developments, greater access to a wider range of resources, and better responder

coordination. Consequently, she requested at 1430 on April 10 that Coast Guard officials

assisting on scene develop such a structure. She also urged Pepco to hire a spill

management contractor to improve the logistics of its contractorsí efforts.

On the morning of April 11, the Coast Guard Captain of the Port of Baltimore

arrived with additional personnel to staff the Incident Command System structure that had

been developed. The new personnel were deployed to monitor the field operations being

conducted by Pepcoís contractors to ensure that work was completed as directed. Almost

immediately, with the marshalling of the additional personnel and equipment, the

effectiveness of the recovery operations improved. Protective booms were provided for

the threatened creeks on April 12 and 13. Within days, marine-specialist responders

finished collecting the free oil in the main body of the Patuxent River, and they were able

to concentrate their efforts on oil collection from the affected creeks and other

environmental mediation projects.
Analysis 46 Pipeline Accident Report

In their postaccident assessments of the Chalk Point accident, both the Coast

Guard and the Regional Response Team review committee concluded that the response

would have benefited from earlier use of an Incident Command System as the incidentís

coordination and management structure. In fact, the Regional Response Team review

committee recommended that the EPA develop a manual on how to use Incident

Command System/Unified Command structures and train all Federal On-Scene

Coordinators in Incident Command System/Unified Command principles. In her own

assessment of the response, the EPA Federal On-Scene Coordinator acknowledged that the

decision not to implement an Incident Command System structure immediately upon her

arrival at the accident scene ultimately had a detrimental effect on the response effort.

Once the oil escaped from containment in the wetlands and the situation became

more complex and difficult to resolve, the short-term project management approach could

not achieve results with the speed and efficiency needed to avoid a serious environmental

impact. The Incident Command System has proven its effectiveness in incidents covering

a wide range of transportation modes, and it has usually improved the management of a

complex incident response effort, such as the one that evolved from the Chalk Point oil

leak. Once the structure was applied at Chalk Point, response efforts soon became more

efficient and successful. The Safety Board concludes that, because it did not initially put a

fully implemented Incident Command System in place, the Unified Command was for

several days unable to mobilize and control an effective response to the loss of oil

containment that took place on the evening of April 8, 2000.

The Safety Board has previously recognized the benefits an Incident Command

System structure may provide during a pipeline spill response effort. As a result of its

investigation of the October 1994 pipeline failures on the San Jacinto River near Houston,

Texas,43 the Safety Board determined that implementing the Unified/Incident Command

structure and operational principles in the National Response Teamís technical assistance

document addressing Incident Command System/Unified Command enhances the overall

preparedness for responding to oil spills. Consequently, the Safety Board recommended

that the National Response Team:

I-96-2

Motivate National Response Team agencies to integrate into their area

contingency plans the command and control principles contained in Technical

Assistance Document Incident Command System/Unified Command and

encourage them to train all personnel assigned management responsibilities in

those principles.

In a January 17, 2001, response to Safety Recommendation I-96-2, the National

Response Team stated that it was working on methods to ensure that all member agencies

have integrated into their area contingency plans the principles contained in the Technical

43 National Transportation Safety Board, Evaluation of Pipeline Failures During Flooding and of Spill

Response Actions, San Jacinto River Near Houston, Texas, October 1994, Pipeline Special Investigation

Report NTSB/SIR-96/04 (Washington, DC: NTSB, 1996).
Analysis 47 Pipeline Accident Report

Assistance Document Incident Command System/Unified CommandóManaging

Responses to Oil Discharges and Hazardous Substance Releases under the National

Contingency Plan, as requested. The Safety Board classified Safety Recommendation I96-2 ìOpenñAcceptable Response,î pending notification that the action is complete.

The National Response Team is made up of 16 Federal departments and agencies.

The EPA is the permanent Chair of the National Response Team. Since the San Jacinto

accident, the EPA has distributed the Technical Assistance Document Incident Command

System/Unified CommandóManaging Responses to Oil Discharges and Hazardous

Substance Releases under the National Contingency Plan to all EPA on-scene

coordinators, and EPA headquarters has encouraged its regional coordinators to

incorporate the guidance from the document in their area contingency plans. Nevertheless,

an EPA official stated in an April 24, 2001, postaccident letter to the Safety Board that

ìEPA currently has no formal policy on the use of Incident Command System/Unified

Command.î The EPA has not mandated that all its regions use the Incident Command

System. Although the EPAís Office of Emergency and Remedial Response is developing

an EPA policy position on the Incident Command System, the Safety Board is concerned

that no final EPA Incident Command System policy, the development of which began in

1996 in response to lessons learned during the 1994 San Jacinto pipeline accident, has

been completed.

The lack of incident command during the Chalk Point emergency response

indicates that the EPA needs to make a greater commitment to incorporating Incident

Command System principles in its response procedures and to training its people more

effectively about the benefits provided by the use of the system. Therefore, to ensure that

the necessity of an effective Incident Command System is understood by EPA responders,

the Safety Board believes that the EPA should require all its regions to integrate the

principles contained in the National Response Teamís Technical Assistance Document

Incident Command System/Unified CommandóManaging Responses to Oil Discharges

and Hazardous Substance Releases under the National Contingency Plan in their area

contingency plans and require the regions to train all personnel who are assigned

responsibility to implement the plans according to those principles.
48 Pipeline Accident Report

Conclusions

Findings

1. Because Pipetronix incorrectly interpreted the results of its ultrasonic tool data for the

pipeline feature at odometer station 53526.55, the Potomac Electric Power Company

was not alerted to the need for additional evaluation of the pipe at the location where

it subsequently ruptured.

2. Because pipeline operators have no nationally recognized criteria with which to

evaluate pipe wrinkles, they may not be effectively determining whether pipe

containing wrinkles should be allowed to remain in service.

3. The absence of effective pipeline monitoring procedures and practices, including

periodic line balancing, delayed the discovery of the fuel oil shortage on April 7,

2000, which delayed the pipeline shutdown and allowed more oil to leak from the

pipeline.

4. Because pipeline owners and operators sometimes do not update their initial reports

to the National Response Center, the notifications provided to emergency responders

may not always contain the complete and accurate information needed to develop an

effective incident response.

5. Because it did not initially put a fully implemented Incident Command System in

place, the Unified Command was for several days unable to mobilize and control an

effective response to the loss of oil containment that took place on the evening of

April 8, 2000.

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the April 7, 2000, Piney Point Oil Pipeline accident at the Potomac Electric Power

Companyís Chalk Point, Maryland, generating station was a fracture in a buckle in the

pipe that was undiscovered because the data from an in-line inspection tool were

interpreted inaccurately as representing a T-piece. Contributing to the magnitude of the

fuel oil release were inadequate operating procedures and practices for monitoring the

flow of fuel oil through the pipeline to ensure timely leak detection.
49 Pipeline Accident Report

Recommendations

As a result of its investigation, the National Transportation Safety Board makes the

following safety recommendations:

To the Research and Special Programs Administration:

Establish quantitative criteria, based on engineering evaluations, for

determining whether a wrinkle may be allowed to remain in a pipeline. (P02-01)

Require pipeline owners and operators to provide follow-up telephone

updates to the National Response Center when they discover that the

information they initially reported contains significant errors or when they

identify significant new information directly related to the reporting

criteria. (P-02-02)

To the Environmental Protection Agency:

Require all your regions to integrate the principles contained in the

National Response Teamís Technical Assistance Document Incident

Command System/Unified CommandóManaging Responses to Oil

Discharges and Hazardous Substance Releases under the National

Contingency Plan in their area contingency plans and require the regions to

train all personnel who are assigned responsibility to implement the plans

according to those principles. (P-02-03)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARION C. BLAKEY

Chairman

CAROL J. CARMODY

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member 

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

Adopted: July 23, 2002

51 Pipeline Accident Report

Appendix A

Investigation

The National Transportation Safety Board was informed on April 8, 2000, by the

National Response Center of a fuel oil release from a pipeline that had occurred on

April 7, 2000, at Pepcoís Chalk Point Generating Station near Aquasco, Maryland. The

Safety Board launched an investigative team from Washington, D.C., on April 8, 2000,

that comprised operations and emergency response investigators.

No public hearing took place on the accident, and no formal depositions were

taken.

Parties to the investigation were Pepco; Support Terminal Services, Inc.; Mirant

Piney Point, LLP; and the Office of Pipeline Safety.
52 Pipeline Accident Report

Appendix B

Initial Incident Timeline

Day Time Events

April 7, 2000 0715 Cleaning pig is launched from Chalk Point Station to Ryceville 

Station.

0830-1400 Tank level gauges are taken (but not used to compute line 

balance) at Chalk Point and Ryceville.

1430 Chalk Point pump begins cavitating. Meter noise and oil flow stops 

at Ryceville Station.

1440-1534 Pepco and ST Services personnel determine that, based on tank 

level gauge calculations, Ryceville did not receive all oil pumped 

from Chalk Point. Shortfall of 3,089 barrels is estimated.

1538 Chalk Point pump is shut down.

1550 ST Services assistant terminal manager begins trying to report 

problems to Pepco officials.

1620 Pepco Chalk Point general supervisor for operations is told of line 

balance discrepancy of 2,000 to 3,000 barrels and notes shortfall 

quantity as ì2,000 barrels.î

1643 Pepco Chalk Point general supervisor for operations orders flight 

to locate leak site.

1802 Report from pipeline patrol plane indicates leak at Swanson 

Creek.

1807 Chalk Point emergency plan is put into effect.
53 Pipeline Accident Report

Appendix C

Significant Events From Leak Recognition 

to Loss of Containment

Day Time Events

April 7, 

2000

1835 Pepco Chalk Point shift supervisor, when pressed, estimates release size 

at 1,000 to 2,000 gallons. 

1840 ST Services assistant terminal manager confirms in his conversation with 

Pepco Chalk Point general supervisor for operations that line balance 

discrepancy is about 3,000 barrels.

1850 Pepco senior environmental coordinator reports 2,000-gallon release to 

the National Response Center.

1850 Pepco spill response teams deploy floating boom in Swanson Creek 

wetlands area.

2015 Pepco Chalk Point command center information board indicates spill 

volume of 3,000 barrels.

2030-2100 State and Coast Guard responders begin arriving at site.

2100 Pepco engineering group confirms 3,000-barrel release figure based on 

tank level calculations.

2300 Pepco conducts first command post briefing. 

April 8, 

2000

0250 Coast Guard Federal on-scene representative arrives.

0330-0530 Coast Guard notifies EPA that incident is in the EPAís geographic 

jurisdiction and that it will relinquish lead for incident response to EPA 

Federal On-Scene Coordinator.

0600 EPA Federal On-Scene Coordinator leaves Philadelphia.

1015 EPA Federal On-Scene Coordinator arrives at accident site and learns 

that spill volume is 3,000 barrels. 

1600 Unified Command revises storm plan due to worsening weather 

forecasts.

2030 Outer booms at the Patuxent River are breached.
54 Pipeline Accident Report

Appendix D

Significant Environmental Response and Clean-up Events

Day Time Events

April 9, 2000 Before 

0700

Oil plume is seen moving from Swanson Creek across the Patuxent 

River.

0745 EPA Federal On-Scene Coordinator contacts the Coast Guard 

seeking aid in locating marine response resources.

0800-

2000

Pepco contractors attempt to corral the oil plume in the river; they 

are unsuccessful.

2100 EPA Federal On-Scene Coordinator orders Pepco to arrange 

protective booming of threatened creeks.

April 10, 2000 1200 EPA Federal On-Scene Coordinator and Maryland Department of the 

Environment tell Pepco that the response is not adequate; that the 

contractors are not being used successfully; and that Pepcoís 

progress reports have not reflected the actual status of the response.

1430 EPA Federal On-Scene Coordinator asks on-scene Coast Guard 

personnel to develop an Incident Command System.

2100 EPA Federal On-Scene Coordinator again orders Pepco to boom the 

creeks.

April 11, 2000 0300-

0715

EPA Federal On-Scene Coordinator again orders Pepco to boom the 

creeks. Contamination is seen at two creeks.

1100 Coast Guard representatives arrive on the scene and establish 

Incident Command System.

1100-on Pepco hires contract firm to manage its response. Incident 

Command System begins to operate. First creek is boomed; booms 

are pre-staged at four more creeks.

April 12-13, 2000 --- All creeks are boomed. Free oil collection from the Patuxent River is 

completed.

April 16, 2000 --- Oil collection from creeks is completed.

May 16, 2000 --- Emergency response phase is declared over.