Lessons for effective integrity management from the San Bruno pipeline rupture

In September 2010, eight members of the public were killed when a gas transmission pipeline ruptured at San Bruno, California. This article describes the causes of this serious organizational failure with a view to learning by other organizations that operate hazardous facilities. The rupture occurred when a longitudinal seam weld failed. The weld had been poorly made at the time the pipeline was fabricated and installed in 1956. The line had not been inspected or tested since that time. While the details are specific to the case at hand, organizational lessons are valid for other organizations operating complex sociotechnical systems that face the problem of sleeping or latent faults that can remain dormant for many years. This analysis focuses on the organizational arrangements that led to such ineffective integrity management, in particular how the potential for an event such as the one that occurred was systematically ignored by the operating company for many years. The key to effective management of the potential for disaster is to ensure that risk management does not become a "fantasy" but remains grounded in the reality of the dangers that the assets pose to workers, the public, and to the organization itself.