1 / 29

February 26, 2019 Des Moines, IA

Preserving Evidence Peter Katchmar Accident Investigation Division Director 2019 IOWA TQ PIPELINE SAFETY CONFERENCE. February 26, 2019 Des Moines, IA. Objectives. Thank you for what you do! Introduce PHMSA’s Accident Investigation Division Discuss Evidence Collection & Preservation

fountain
Download Presentation

February 26, 2019 Des Moines, IA

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Preserving Evidence Peter KatchmarAccident Investigation Division Director2019 IOWA TQ PIPELINE SAFETY CONFERENCE February 26, 2019 Des Moines, IA

  2. Objectives • Thank you for what you do! • Introduce PHMSA’s Accident Investigation Division • Discuss Evidence Collection & Preservation • What is a failure? • Pipeline Scene Investigation National Pipeline Incident Coordinator (NPIC) • NPIC 24 Hour toll-free: (888) 719-9033

  3. AID Contact Information • NPIC toll-free: (888) 719-9033 • PHMSAAccidentInvestigationDivision@dot.gov • Staff Mobile Numbers: • Peter Katchmar: 303-807-8458 • Chris Ruhl: 405-590-3625 • Brian Pierzina: 816-589-8293 • Darren Lemmerman: 816-807-2606 • Gery Bauman: 440-725-7043 • Julie Halliday: 202-389-2039 • Ashley Horton: 405-686-2063 • Wesley Mathews: 405-686-2073

  4. AID Activities • Review reported pipeline incidents • National Response Center • Media • Operator/State referrals • Focusing Attention on what is currently going wrong: • Daily Telephonic Report Monitoring/Dissemination (States &/Or Operators) • 30 Day Reports • Increase Pipeline Safety. • Judicious Scrutiny of all entries. • Accident Date and Time • Location Coordinates • Type of Accident • Costs • Cause • Narrative Description • Failure Investigation Reports • Prevent accidents and promote public safety through investigation, analysis and applying lessons identified/lessons learned (LI & L2). • Identifying and Disseminating failure trends.

  5. What is Evidence? • Everything about an event. • What was going on prior to the event? • What initiated the event? • Why did it happen today? • After the event. Consequences. • Physical Evidence – the Pipe? Component? • Paper Evidence – Records? • People Evidence – Interviews? Training?

  6. What is Evidence? • Official Record of what happened. • Legal – Scientific – Systematic - Repeatable • Must be uncompromised. • Must be secured. • Locked in a cage. • Under video surveillance. • Chain of Custody.

  7. What is a FAILURE? • Failures can be catastrophic events • A reportable incident or accident

  8. What Causes a FAILURE? • Whenever the carried product comes out of the carrier unintentionally • Corrosion • Natural Force • Outside Force • Pipe, Weld, or Joint Failure • Third party damage • Equipment Failure • Incorrect Operation

  9. So, What is a Failure? • Abnormal operations? or Near miss? • Regulator failure which causes an over pressurization? • …causes a RV to relieve (> 3MMCF)? • Systemic problem with equipment? • As determined by company, state, federal regulators? • Other? What do the operator’s procedures require?

  10. CFR §192.617Investigation of Failures • Each operator shall establish procedures for analyzing accidents and failures, • … including the selection of samples of the failed facility or equipment for laboratory examination, where appropriate, • … for the purpose of determining the causes of the failure and minimizing the possibility of a recurrence.

  11. Investigate To observe or study by close examination and systematic inquiry • Examination:  • to inspect closely, • to test the condition of, and • to inquire carefully • What does “CSI” stand for?

  12. Pipeline Scene Investigation • Take a forensic approach to investigating a failure, accident, or incident and follow basic root cause investigation techniques and rules • Who is your best friend on scene? … Why? • How do we cultivate relationships with these folks?

  13. Pipeline Scene Investigation • First priority – people and environmental safety! • Freeze the scene… to the extent practicable. • Don’t Just Do Something – Stand There!!!!! • Gather Appropriate Evidence: • People, • Physical, • Paper

  14. Pipeline Scene Investigation • Follow the Basics: • Use an investigation form to help prompt and remind you what to collect • Photography (Still or Video) - microphone on/off? • Document only the facts • Don’t jump to conclusions • Allow the evidence to direct the investigation • Construct a time line of the events • Document conditions at point of failure

  15. Pipeline Scene Investigation • Photograph and Diagram the Scene • Conduct a Migration Survey • Test the Facility in Place • Run tests on failed equipment as needed • Additional system tests • Retrieve or Dig up the Facility, chain of custody • Interview Witnesses

  16. Photographs without scale

  17. Photographs showing scale

  18. Map the Scene

  19. Witness Interviews • Company personnel • On site personnel • First responders • Control room • Contractor personnel • Public • Media • Emergency response personnel

  20. Plot location of Witnesses Plotting witnesses locations can help determine if they had line of site of the failure scene

  21. Gas Migration Survey • Determines where the gas came from and where it went. • Confirms that there are no additional hazardous areas (i.e. gas up against an adjacent house) • Checks for collateral damage • Everyone accounted for

  22. Gas Migration - Path of Least Resistance

  23. 90% 50% 40% 10% 0% Plot Gas Migration

  24. Recover Damaged Facility • Treat digging and recovery of equipment as if archeological dig • Take pictures and make diagrams as needed

  25. Recover Damaged Facility • Recover all pieces of failed equipment • Label all pieces • Include equipment orientation • Direction of gas flow • Follow a chain of custody for all pieces. • Maintains integrity of evidence • Protects all parties involved

  26. Recover Damaged Facility • Don’t touch That fracture surface! • Don’t clean fracture surfaces or pieces • Don’t take things apart!!! • Secure saggy pipe with a 2 X 4? • Wrap in bubble-wrap or similar product • Secure in shipping container • Have a chain of custody document

  27. Conclusion • In order to learn from failures, we play a crucial role in investigations. • Evidence collection and preservation is critical • Pipeline Scene Investigation – document, document, document… Thank you for what you do!

  28. Additional Information • PHMSA Form 11 – Pipeline Failure Investigation Report • Metallurgical Protocol www.phmsa.dot.gov/pipeline/library/forms

  29. PHMSAEmergency Contact InformationNPIC toll-free: (888) 719-9033PHMSAAccidentInvestigationDivision@dot.govInvestigate – Analyze – Prevent

More Related