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Recommendations
Accreditation Board for Engineering and Technology, Inc.
T2 Laboratories Inc. Reactive Chemical Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: September 15, 2009

2008-03-I-FL-3

Work with the American Institute of Chemical Engineers to add reactive hazard awareness to baccalaureate chemical engineering curricula requirements.


Status: C-ERA
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

Acetylene Service Company (ASCO)
Acetylene Service Company Gas Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: January 26, 2006

2005-3-I-NJ-1

Improve isolation on acetylene generator water lines by incorporating a double-block-and-bleed with a vent to a safe location, or other isolation means of comparable effectiveness.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

2005-3-I-NJ-2

Implement an effective Process Safety Management program, in accordance with OSHA 1910.119. Include written operating procedures and checklists that are understood by the workers responsible for using them. Train workers on the procedures and periodically confirm that they are being properly followed.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

AFL-CIO Building Trades Council
Bethlehem Steel Corporation Gas Condensate Fire
Open: 0%  |  Closed: 100%

Final Report Released On: December 06, 2001

2001-02-I-IN-10

Communicate findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Agency for Toxic Substances and Disease Registry (ATSDR)
DPC Enterprises Festus Chlorine Release
Open: 0%  |  Closed: 100%

Final Report Released On: May 01, 2003

2002-04-I-MO-17

Work with State and local agencies to address concerns about the long-term health effects of the chlorine release in Festus, Missouri, and communicate your findings to the community.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

Georgia-Pacific Corp. Hydrogen Sulfide Poisoning
Open: 0%  |  Closed: 100%

Final Report Released On: November 20, 2002

2002-01-I-AL-10

Evaluate and amend as necessary the ATSDR Medical Management Guidelines to consider the risk to responders posed by exposure to victims of high levels of hydrogen sulfide (H2S) gas. Specify procedures for adequate decontamination. Communicate the results of this activity to relevant organizations, such as the American Association of Occupational Health Nurses.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

AIB International
Imperial Sugar Company Dust Explosion and Fire
Open: 9%  |  Closed: 91%

Final Report Released On: September 24, 2009

2008-05-I-GA-6

Incorporate combustible dust hazard awareness into employee and member companies’ training programs, such as the Safety and Health Management Systems training course. Include combustible dust characteristics, especially ignition energy and minimum explosible concentration; best practices for minimizing dust accumulation, especially on elevated surfaces; and safe housekeeping practices.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2008-05-I-GA-7

Add specific combustible dust inspection requirements and metrics to the Food Contact Packaging Facility audit procedures.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Allied Terminals Inc.
Allied Terminals Fertilizer Tank Collapse
Open: 60%  |  Closed: 40%

Final Report Released On: May 26, 2009

2009-3-I-VA-1

Take immediate action to reduce the risk of a catastrophic failure of Tanks 202, 205, and 209 at the Allied Terminals Hill Street facility including but not limited to significantly reducing the maximum liquid levels ("safe fill height") based on sound engineering principles. Report the actions taken to the City of Chesapeake.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

PDF Document Download

2009-3-I-VA-2

Select and retain a qualified, independent tank engineering firm to evaluate Tanks 202, 205, and 209 and determine their fitness for continued service. The evaluation should be based on recognized and generally accepted good engineering practices, such as API 653 - Tank Inspection, Repair Alteration, and Reconstruction and API 579 - Fitness for Service.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2009-3-I-VA-3

Within 30 days, provide the report prepared by the independent tank engineering firm to the City of Chesapeake, together with a comprehensive action plan and schedule to address any identified deficiencies.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2009-3-I-VA-6

Hire a qualified independent reviewer to verify that maximum liquid levels for all tanks at Allied’s Norfolk and Chesapeake terminals meet the requirements of American Petroleum Institute Standard 653, Tank Inspection, Repair, Alteration, and Reconstruction. At a minimum, the review should verify that all requirements for welding, inspection of welds, and In-Service and Out-of-Service tank inspections are met. Make the complete review report for both terminals available to the Cities of Norfolk, Chesapeake, and Portsmouth, Virginia, as well as the Virginia Department of Environmental Quality.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2009-3-I-VA-7

Develop and implement worker safety procedures for initial filling of tanks following major modification or change-in-service. At a minimum, require the exclusion of all personnel from secondary containment during the initial filling.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Aluminum Association, Inc.
Hayes Lemmerz Dust Explosions and Fire
Open: 15%  |  Closed: 85%

Final Report Released On: September 27, 2005

2004-1-I-IN-12

Conduct research into the feasibility and design of improved explosion protection for aluminum dust collector applications, including explosion venting, isolation and suppression systems. Coordinate this research activity with the Fire Protection Research Foundation.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2004-1-I-IN-13

Communicate the findings and recommendations of this report to your members


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

American Bakers Association
Imperial Sugar Company Dust Explosion and Fire
Open: 9%  |  Closed: 91%

Final Report Released On: September 24, 2009

2008-05-I-GA-8

Actively promote improvements in combustible dust hazard awareness and control throughout the wholesale baking industry by publishing bulletins or safety guidance that address combustible dust characteristics including ignition energy, minimum explosible concentration, best practices for minimizing dust accumulation, and safe housekeeping practices.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

American Chemical Society (ACS)
Texas Tech University Chemistry Lab Explosion
Open: 100%  |  Closed: 0%

Final Report Released On: October 19, 2011

2011-5-CS-TX-2

Develop good practice guidance that identifies and describes methodologies to assess and control hazards that can be used successfully in a research laboratory.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

American Chemistry Council (ACC)
Barton Solvents Explosions and Fire
Open: 22%  |  Closed: 78%

Final Report Released On: June 26, 2008

2007-6-I-KS-4

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

BP Amoco Thermal Decomposition Incident
Open: 0%  |  Closed: 100%

Final Report Released On: May 20, 2002

2001-03-I-GA-10

Communicate the findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

CTA Acoustics Dust Explosion and Fire
Open: 0%  |  Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-19

Communicate the findings and recommendations of this report to your membership. Emphasize that dusts from phenolic resins can explode


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

First Chemical Corp. Reactive Chemical Explosion
Open: 13%  |  Closed: 87%

Final Report Released On: October 15, 2003

2003-01-I-MS-10

Amend the Technical Specifications guidelines in the Responsible Care Management System to explicitly require facilities to identify findings and lessons learned from process hazard analyses and incident investigations in one unit and apply them to other equipment that processes similar material.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-01-I-MS-11

Ensure that ACC members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility process safety programs.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-01-I-MS-12

Communicate the findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Improving Reactive Hazard Management
Open: 42%  |  Closed: 58%

Final Report Released On: September 17, 2002

2001-01-H-8

Expand the Responsible Care Process Safety Code to emphasize the need for managing reactive hazards. Ensure that: · Member companies are required to have programs to manage reactive hazards that address, at a minimum, hazard identification, hazard evaluation, management of change, inherently safer design, and adequate procedures and training. · There is a program to communicate to your membership the availability of existing tools, guidance, and initiatives to aid in identifying and evaluating reactive hazards.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2001-01-H-9

Develop and implement a program for reporting reactive incidents that includes the sharing of relevant safety knowledge and lessons learned with your membership, the public, and government to improve safety system performance and prevent future incidents.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2001-01-H-10

Work with NIST in developing and implementing a publicly available database for reactive hazard test information. Promote submissions of data by your membership.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2001-01-H-11

Communicate the findings and recommendations of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Morton International Inc. Runaway Chemical Reaction
Open: 0%  |  Closed: 100%

Final Report Released On: August 16, 2000

1998-06-I-NJ-10

Communicate the findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

American Chemistry Council Phosgene Panel
DuPont Corporation Toxic Chemical Releases
Open: 64%  |  Closed: 36%

Final Report Released On: September 20, 2011

2010-06-I-WV-11

Revise the Phosgene Safe Practice Guidelines Manual  to

  • Advise against the use of hoses for phosgene transfer that are constructed of permeable cores and materials subject to chlorides corrosion.
  • Include guidance for the immediate reporting and prompt investigation of all potential (near-miss) phosgene releases.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

American Conference of Governmental Industrial Hygienists (ACGIH)
Technic Inc. Ventilation System Explosion
Open: 57%  |  Closed: 43%

Final Report Released On: August 20, 2004

2003-08-I-RI-7

Update the preliminary steps in the chapter on exhaust system design in the next revision of the Industrial Ventilation Manual, emphasizing the need to evaluate potential incompatibilities between dusts, fumes, or vapors that are likely to be intermixed in main header ducts of a ventilation system to ensure that they do not result in fire or explosion hazards, or destructive corrosion. Reference appropriate methods for such evaluations, such as the ASTM E 2012-00 standard.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

American Forest and Paper Association (AFPA)
Georgia-Pacific Corp. Hydrogen Sulfide Poisoning
Open: 0%  |  Closed: 100%

Final Report Released On: November 20, 2002

2002-01-I-AL-13

Communicate the findings and recommendations of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

American Gas Association (AGA)
ConAgra Natural Gas Explosion and Ammonia Release
Open: 0%  |  Closed: 100%

Final Report Released On: February 04, 2010

2010-12-I-NC-1

Enact a Tentative Interim Amendment as well as permanent changes to the National Fuel Gas Code (NFPA 54/ANSI Z223.1) to require that during the purging of fuel gas piping at industrial, commercial, and public facilities: (a) Purged fuel gases shall be directly vented to a safe location outdoors, away from personnel and ignition sources 

(b) If it is not possible to vent purged gases outdoors, purging gas to the inside of a building shall be allowed only upon approval by the authority having jurisdiction of a documented risk evaluation and hazard control plan. The evaluation and plan shall establish that indoor purging is necessary and that adequate safeguards are in place such as:

     • Evacuating nonessential personnel from the vicinity of the purging;      • Providing adequate ventilation to maintain the gas concentration at an established safe level, substantially below   
     the lower explosive limit; and

     • Controlling or eliminating potential ignition sources
(c) Combustible gas detectors are used to continuously monitor the gas concentration at appropriate locations in the vicinity where purged gases are released

(d) Personnel are trained about the problems of odor fade and odor fatigue and warned against relying on odor alone for detecting releases of fuel gases


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

PDF Document Download

American Industrial Hygiene Association (AIHA)
Improving Reactive Hazard Management
Open: 42%  |  Closed: 58%

Final Report Released On: September 17, 2002

2001-01-H-24

Communicate the findings and recommendations of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Technic Inc. Ventilation System Explosion
Open: 57%  |  Closed: 43%

Final Report Released On: August 20, 2004

2003-08-I-RI-6

Revise the appendix of ANSI Z9.2, American National Standard Fundamentals Governing the Design and Operation of Local Exhaust Systems, emphasizing the need to evaluate potential incompatibilities when dusts, fumes, or vapors are intermixed in local exhaust ventilation systems with common headers to ensure that they do not result in fire or explosion hazards, or destructive corrosion. Reference appropriate methods for such evaluations, such as the ASTM E 2012-00 standard.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

American Institute of Chemical Engineers (AIChE)
T2 Laboratories Inc. Reactive Chemical Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: September 15, 2009

2008-03-I-FL-1

Work with the Accreditation Board for Engineering and Technology, Inc. to add reactive hazard awareness to baccalaureate chemical engineering curricula requirements.


Status: C-ERA
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

2008-03-I-FL-2

Inform all student members about the Process Safety Certificate Program and encourage program participation.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

American Iron and Steel Institute (AISI)
Bethlehem Steel Corporation Gas Condensate Fire
Open: 0%  |  Closed: 100%

Final Report Released On: December 06, 2001

2001-02-I-IN-10

Communicate findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

American National Standards Institute (ANSI) Z400.1 Committee
Barton Solvents Explosions and Fire
Open: 22%  |  Closed: 78%

Final Report Released On: June 26, 2008

2007-6-I-KS-3

Revise ANSI Z400.1 to advise chemical manufacturers and importers that prepare MSDSs to: -Identify and include a warning for materials that are static-accumulators and that may form ignitable vapor-air mixtures in storage tanks; -Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)); and -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Combustible Dust Hazard Investigation
Open: 33%  |  Closed: 67%

Final Report Released On: November 09, 2006

2006-1-H-6

Modify ANSI Z400.1 American National Standard for Hazardous Industrial Chemicals--Material Safety Data Sheets to recommend that MSDSs include information on: - combustible dust hazards, safe handling practices, and references to relevant fire codes in MSDS; - hazard information about the by-products of materials that may generate combustible dusts due to processing or handling; - identification of combustible dust hazards and selection of physical properties to include in MSDS.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

American Petroleum Institute (API)
Barton Solvents Explosions and Fire
Open: 22%  |  Closed: 78%

Final Report Released On: June 26, 2008

2007-6-I-KS-5

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

BLSR Operating Ltd. Vapor Cloud Fire
Open: 0%  |  Closed: 100%

Final Report Released On: September 17, 2003

2003-06-I-TX-16

Revise API RP-2219, Safe Operation of Vacuum Trucks in Petroleum Service, and API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities, to discuss the hazards of unloading potentially flammable or flammable liquids onto an open unloading area, such as a concrete pad. Recommend other alternatives for minimizing vapor generation, such as unloading of flammable liquids into a closed piping system.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-06-I-TX-17

Communicate the findings and recommendations of this report to your membership. Emphasize that basic sediment and water (BS&W) removed from crude oil and condensate storage tanks requires special handling, in addition to compliance with Occupational Safety and Health Administration (OSHA) or U.S. Department of Transportation (DOT) regulations, if it contains sufficient hydrocarbons (either residual or mixed in during the removal process) to be classified a flammable liquid as defined by each regulation.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

BP America Refinery Explosion
Open: 38%  |  Closed: 62%

Final Report Released On: March 20, 2007

2005-4-I-TX-2

In light of the findings concerning the March 23rd incident at BP's Texas City refinery, revise your Recommended Practice 752, Management of Hazards Associated with Location of Process Plant Buildings or issue a new Recommended Practice to ensure the safe placement of occupied trailers and similar temporary structures away from hazardous areas of process plants. Ensure that the new recommended practice: - Protects occupants from accident hazards such as heat, blast overpressure, and projectiles; - Establishes minimum safe distances for trailers and similar temporary structures away from hazardous areas of process plants; - Evaluates the siting of trailers under a separate methodology from permanent structures, since trailers are more susceptible to damage, are more readily relocated, and likely do not need to be placed near hazardous areas.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2005-4-I-TX-3

Issue a safety alert to your membership to take prompt action to ensure the safe placement of occupied trailers away from hazardous areas of process plants.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2005-4-I-TX-4

Revise API Recommended Practice 521, Guide for Pressure Relieving and Depressurizing Systems to ensure that the guidelines: - Identifies overfilling vessels as a potential hazard for evaluation in selecting and designing pressure relief and disposal systems; - Addresses the need to adequately size disposal drums for credible worse-case liquid relief scenarios, based on accurate relief valve and disposal collection piping studies; - Warns against the use of atmospheric blowdown drums and stacks attached to collection piping systems that receive flammable discharges from multiple relief valves and urges the use of appropriate inherently safer alternatives such as a flare system


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2005-4-I-TX-6

Work together to develop two new consensus American National Standards Institute (ANSI) standards. a. In the first standard, create performance indicators for process safety in the refinery and petrochemical industries. Ensure that the standard identifies leading and lagging indicators for nationwide public reporting as well as indicators for use at individual facilities. Include methods for the development and use of the performance indicators. (CSB2005-04-I-TX-R6A) In the development of each standard, ensure that a. the committees are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2005-4-I-TX-7

Work together to develop two new consensus American National Standards Institute (ANSI) standards. b. In the second standard, develop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. (CSB2005-04-I-TX-R7a) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Motiva Enterprises Sulfuric Acid Tank Explosion
Open: 21%  |  Closed: 79%

Final Report Released On: August 28, 2002

2001-05-I-DE-10

Work with NACE International (National Association of Corrosion Engineers) to develop API guidelines to inspect storage tanks containing fresh or spent H2SO4 at frequencies at least as often as those recommended in the latest edition of NACE Standard RP 0294-94, Design, Fabrication, and Inspection of Tanks for the Storage of Concentrated Sulfuric Acid and Oleum at Ambient Temperatures.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2001-05-I-DE-11

Revise API tank inspection standards to emphasize that storage tanks with wall or roof holes or thinning beyond minimum acceptable thickness that may contain a flammable vapor are an imminent hazard and require immediate repair or removal from service.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2001-05-I-DE-12

Ensure that API recommended practices address the inerting of flammable storage tanks, such as spent H2SO4 tanks. Include the following: - Circumstances when inerting is recommended. - Design of inerting systems, such as proper sizing of inerting equipment, appropriate inerting medium, and instrumentation, including alarms.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2001-05-I-DE-13

Communicate the findings and recommendations of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Oil Site Safety
Open: 100%  |  Closed: 0%

Final Report Released On: October 27, 2011

2011-H-1-5

Create a new standard or amend existing standards covering exploration and production facilities to:

a) Warn that storage tanks at unmanned facilities may be subject to tampering or introduction of ignition sources by members of the public, which could result in a tank explosion or other accidental release to the environment.

b) Recommend the use inherently safer storage tank design features to reduce the likelihood of explosions, including restrictions on the use of open vents for flammable hydrocarbons, flame arrestors, pressure vacuum vent valves, floating roofs, vapor recovery systems or an equivalent alternative.

c) Require security measures at least as protective as API 2610 to prevent non-employee access to flammable storage tanks at upstream E&P sites, including such measures as a full fence surrounding the tank(s) with a locked gate, hatch locks on tank manways, and barriers securely attached to tank external ladders or stairways.

d) Require that hazard signs or placards be displayed on or near tanks to identify the fire and explosion hazards using words and symbols recognizable by the general public.

e) Recommend that new or revised mineral leasing agreements include security and signage requirements as described above.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Sonat Exploration Co. Catastrophic Vessel Overpressurization
Open: 0%  |  Closed: 100%

Final Report Released On: September 21, 2000

1998-002-I-LA-4

Develop and issue recommended practice guidelines governing the safe start-up and operation of oil and gas production facilities. Ensure that the guidelines address, at a minimum, the following: project design review processes, including hazard analyses; written operating procedures; employee and contractor training; and pressure-relief requirements for all equipment exposed to pressure hazards.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

1998-002-I-LA-5

Communicate the findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Third Coast Industries Petroleum Products Facility Fire
Open: 15%  |  Closed: 85%

Final Report Released On: March 06, 2003

2009-03-I-TX-7

Communicate the findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Tosco Avon Refinery Petroleum Naphtha Fire
Open: 0%  |  Closed: 100%

Final Report Released On: March 21, 2001

1999-014-I-CA-5

Communicate the findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Valero Refinery Asphyxiation Incident
Open: 25%  |  Closed: 75%

Final Report Released On: November 02, 2006

2006-2-I-DE-6

Revise Guidelines for Safe Work in Inert Confined Spaces in the Petroleum and Petrochemical Industries (API, 2005) to clearly address the following: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Valero Refinery Propane Fire
Open: 83%  |  Closed: 17%

Final Report Released On: July 09, 2008

2007-5-I-TX-1

Issue API-recommended practices for freeze protection in oil refinery process units that include, as a minimum: -the establishment of a written program; -periodic inspections to identify freeze hazards in dead-legs or infrequently used piping and equipment where water could collect; -specific approaches to eliminate or protect against such freeze hazards; and -identification of infrequently used piping or equipment subject to freezing as a trigger for Management Of Change (MOC) reviews.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

PDF Document Download

2007-5-I-TX-2

Revise API 2218, Fireproofing Practices in Petroleum and Petrochemical Processing Plants, so that conformance with the standard addresses jet fire scenarios, and requires more protective fireproofing radii and other measures (e.g., emergency isolation valves, depressuring systems) for pipe rack support steel near process units containing highly pressurized flammables.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2007-5-I-TX-3

Revise API Recommended Practice 2001, Fire Protection in Refineries, and API 2030, Application of Fixed Water Spray Systems for Fire Protection in the Petroleum Industry, so that conformance with these recommended practices includes the design, installation, and use of ROSOVs and interlocked equipment controls to enable the safe and rapid emergency isolation of process equipment containing highly pressurized flammables.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2007-5-I-TX-4

Revise API Standard 2510, Design and Construction of LPG Installations, and API Publication 2510A, Fire-Protection Considerations for the Design and Operation of Liquefied Petroleum Gas (LPG) Storage Facilities, to address effective deluge system activation during emergencies originating in nearby process units.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

American Public Power Association (APPA)
Xcel Energy Company Hydroelectric Tunnel Fire
Open: 55%  |  Closed: 45%

Final Report Released On: August 25, 2010

2008-01-I-CO-17

Publish safety guidance addressing the hazards and controls for using hazardous materials including flammables in confined spaces and the unique hazards of penstocks. At a minimum

a. In controlling hazards in confined spaces, implement a hierarchy of controls by first attempting to eliminate hazards or substitute with a less hazardous material(s) or method(s). Examples include performing work outside of a confined space where reasonably practicable or substituting a flammable material with a non-flammable one.

b. Establish a maximum permissible percentage substantially below the LEL for safe entry and occupancy of permit-required confined spaces.

c. Recommend that confined spaces that are large, or part of a continuous system such as a penstock, always be managed as permit-required as defined in the OSHA Confined Space Standard, and that such spaces always be monitored for hazardous atmospheres both prior to entry and continuously in areas where work is being performed.

d. Ensure that evacuation plans for penstocks that have only one egress point provide for alternative escape routes or refuge chambers.

e. Provide guidance for implementing a written confined space rescue plan. Address staging and methods of rescue for each designated permit space including whether a rescue team is required to stand by outside the space. Require that confined space rescue teams be standing by at the permit spaces where the hazards pose an immediate threat to life or health, including the hazard of a potential flammable atmosphere.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

American Society for Nondestructive Testing (ASNT)
Honeywell Chemical Incidents
Open: 13%  |  Closed: 87%

Final Report Released On: August 08, 2005

2003-13-I-LA-28

Communicate the findings and recommendations from the July 20 incident to your membership. Emphasize the need to evaluate test methods for appropriateness in the given equipment.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE)
Honeywell Chemical Incidents
Open: 13%  |  Closed: 87%

Final Report Released On: August 08, 2005

2003-13-I-LA-22

Develop guidance on the effective design and maintenance of HVAC systems and other necessary control room components designed to protect employees and equipment in the event of a release of hazardous materials.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

American Society of Mechanical Engineers (ASME)
Kleen Energy Natural Gas Explosion
Open: 33%  |  Closed: 67%

Final Report Released On: June 28, 2010

2010-07-I-CT-3

Make appropriate changes to the 2012 version of Power Piping, ASME B31.1, to require the use of inherently safer fuel gas piping cleaning methodologies rather than natural gas blows. At a minimum, for the cleaning or flushing methods discussed in B31.1 paragraph 122.10, require the use of inherently safer alternatives such as air blows and pigging with air as the motive force in lieu of flammable gas.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

PDF Document Download

American Society of Safety Engineers (ASSE)
Improving Reactive Hazard Management
Open: 42%  |  Closed: 58%

Final Report Released On: September 17, 2002

2001-01-H-23

Communicate the findings and recommendations of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Valero Refinery Asphyxiation Incident
Open: 25%  |  Closed: 75%

Final Report Released On: November 02, 2006

2006-2-I-DE-7

Revise Safety Requirements for Confined Spaces, ANSI/ASSE Z117.1 to emphasize that: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Association of Iron and Steel Engineers
Bethlehem Steel Corporation Gas Condensate Fire
Open: 0%  |  Closed: 100%

Final Report Released On: December 06, 2001

2001-02-I-IN-10

Communicate findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Association of Public-Safety Communications Officials
Little General Store Propane Explosion
Open: 17%  |  Closed: 83%

Final Report Released On: September 25, 2008

2007-4-I-WV-6

Develop a guide card for propane emergencies to assist 911 operators in the collection of pertinent information on propane emergencies. The questionnaire in Section 1.9.1 in the Propane Education and Research Council's Certified Employee Training Program may be used as a model.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Association of State and Territorial Solid Waste Management Officials
Kaltech Industries Waste Mixing Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: September 30, 2003

2009-02-I-NY-11

Communicate the findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Baton Rouge Fire Department
Honeywell Chemical Incidents
Open: 13%  |  Closed: 87%

Final Report Released On: August 08, 2005

2009-13-I-LA-23

Evaluate and update as necessary community notification procedures to include timely notification of residents in the event of a chemical release. Conduct periodic refresher training with staff on the requirements in the procedures.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Bayer CropScience- Institute, West Virginia
Bayer CropScience Pesticide Waste Tank Explosion
Open: 31%  |  Closed: 69%

Final Report Released On: January 20, 2011

2008-08-I-WV-2

Review and revise, as necessary, all Bayer production unit standard operating procedures to ensure they address all operating modes (startup, normal operation, temporary operations, emergency shutdown, emergency operations, normal shutdown, and startup following a turnaround or emergency shutdown), are accurate, and approved.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2008-08-I-WV-3

Ensure that all facility fire brigade members are trained in the National Incident Management System, consistent with municipal and state emergency response agencies.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2008-08-I-WV-4

Evaluate the fenceline air monitor program against federal, state, and local regulations, and Bayer corporate policies, and upgrade and install air monitoring devices as necessary to ensure effective monitoring of potential releases of high-hazard chemicals at the perimeter of the facility.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2008-08-I-WV-5

Commission an independent human factors and ergonomics study of all Institute site PSM/RMP covered process control rooms to evaluate the human-control system interface, operator fatigue, and control system familiarity and training. Develop and implement a plan to resolve all recommendations identified in the study that includes assigned responsibilities, required corrective actions, and completion dates.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Bayer CropScience- Research Triangle Park, NC
Bayer CropScience Pesticide Waste Tank Explosion
Open: 31%  |  Closed: 69%

Final Report Released On: January 20, 2011

2008-08-I-WV-1

Revise the corporate PHA policies and procedures to require:
a. Validation of all PHA assumptions to ensure that risk analysis of each PHA scenario specifically examines the risk(s) of intentional bypassing or other nullifications of safeguards,
b. Addressing all phases of operation and special topics including those cited in chapter 9 of "Guidelines for Hazard Evaluation Procedures" (CCPS, 2008), and
c. Training all PHA facilitators on the revised policies and procedures prior to assigning the facilitator to a PHA team.
Ensure all PHAs are updated to conform to the revised procedures.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

Bethlehem Steel Corporation
Bethlehem Steel Corporation Gas Condensate Fire
Open: 0%  |  Closed: 100%

Final Report Released On: December 06, 2001

2001-02-I-IN-7

Conduct periodic audits of work authorization, line and equipment opening, deadleg management programs, and decommissioning and demolition activities at your steelmaking facilities. Share findings with the workforce.


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

2001-02-I-IN-8

Revise the Material Safety Data Sheet (MSDS) for COG condensate to highlight the potential flammability hazard. Ensure that management at your steelmaking facilities trains employees and informs contractors with regard to the potential presence of flammable liquids when working with or opening COG condensate piping and equipment.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2001-02-I-IN-9

Communicate findings of this report to the workforce and contractors at Bethlehem Steel's steelmaking facilities.


Status: C-R/S
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

Bethlehem Steel Corporation, Burns Harbor Mill
Bethlehem Steel Corporation Gas Condensate Fire
Open: 0%  |  Closed: 100%

Final Report Released On: December 06, 2001

2001-02-I-IN-1

Implement a work authorization program that requires higher levels of management review, approval, and oversight for jobs that present higher levels of risk, such as opening lines potentially containing flammable liquids where there is no low point drain.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2001-02-I-IN-2

Monitor the accumulation and flammability of COG condensate throughout the mill. Address potentially hazardous changes in condensate accumulation rates and flammability.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2001-02-I-IN-3

Survey the mill for deadlegs and implement a program for resolving the hazards. Develop guidance for plant personnel on the risks of deadlegs and their prevention. Include deadlegs in plant winterization planning.


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

2001-02-I-IN-4

Provide drains at low points in piping to allow for the safe draining of potentially flammable material.


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

2001-02-I-IN-5

Ensure that Burns Harbor and contractor employees are trained with regard to the potential presence of flammable liquids when working with or opening COG or condensate piping and equipment.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2001-02-I-IN-6

Establish procedures to ensure that insulation is replaced when removed for maintenance.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

BLSR Operating, Ltd.
BLSR Operating Ltd. Vapor Cloud Fire
Open: 0%  |  Closed: 100%

Final Report Released On: September 17, 2003

2003-06-I-TX-8

Develop a written Waste Acceptance Plan as recommended by API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities. Require the shipper or carrier to properly classify the flammability hazard of exploration and production (E&P) waste liquids. Require the hauler to provide information that identifies the flammability hazard of the material before accepting the load, such as a material safety data sheet (MSDS).


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-06-I-TX-9

Develop and implement written procedures and provide training to employees on the safe handling of all waste liquids delivered to the facility in accordance with API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities; and API RP-2219, Safe Operation of Vacuum Trucks in Petroleum Service. Include requirements for proper grounding of trucks and eliminating other sources of ignition (e.g., facility electrical equipment and smoking in unloading areas). Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-06-I-TX-10

Develop written procedures and provide training to employees on unloading all flammable or potentially flammable E&P waste liquids. Avoid unloading flammable liquids onto an open work area, such as the mud disposal and washout pad. Include alternative unloading method(s), such as using a closed piping system to minimize vapor generation. Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-06-I-TX-11

Develop written emergency procedures and provide training to employees on response to abnormal or emergency situations, including uncontrolled flammable vapor releases that can result in a fire or explosion hazard. Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Board of Supervisors, Contra Costa County, CA
Chevron Refinery Fire
Open: 100%  |  Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-6

Revise the Industrial Safety Ordinance (ISO) to require that Process Hazard Analyses include documentation of the recognized methodologies, rationale and conclusions used to claim that safeguards intended to control hazards will be effective. This process shall use established qualitative, quantitative, and/or semi-quantitative methods such as Layers of Protection Analysis (LOPA).


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2012-03-I-CA-7

Revise the Industrial Safety Ordinance (ISO) to require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2012-03-I-CA-8

Monitor and confirm the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R1 and 2012-03-I-CA-R2), so that all necessary mechanical integrity work at the Chevron Richmond Refinery is identified and recommendations are completed in a timely way.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2012-03-I-CA-16

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Borden Chemical, Inc.
CTA Acoustics Dust Explosion and Fire
Open: 0%  |  Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-11

Ensure MSDSs for phenolic resins include, at a minimum, warnings that dust from these products can be explosive.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-09-I-KY-12

Develop and distribute educational material, in addition to MSDSs, to inform customers of the explosion hazard of phenolic resin dust.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-09-I-KY-13

Communicate the findings and recommendations of this report to your customers that purchase phenolic resin.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

BP Chemicals Group
BP Amoco Thermal Decomposition Incident
Open: 0%  |  Closed: 100%

Final Report Released On: May 20, 2002

2001-03-I-GA-9

Communicate the findings of this report to your chemical and plastics manufacturing facilities in North America.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

BP Global Executive Board of Directors
BP America Refinery Explosion
Open: 38%  |  Closed: 62%

Final Report Released On: March 20, 2007

2005-4-I-TX-1

1. Commission an independent panel to assess and report on the effectiveness of BP North America's corporate oversight of safety management systems at its refineries and its corporate safety culture. Provide the panel with necessary funding, resources, and authority - including full access to relevant data, corporate records, and employee interviews - in order to conduct a thorough, independent, and credible inquiry. 2. Ensure that, at a minimum, the panel report examines and recommends any needed improvements to: Corporate safety oversight, including the safe management of refineries obtained through mergers and acquisitions; Corporate safety culture, including the degree to which: - Corporate officials exercise appropriate leadership to promote adherence to safety management systems; - Process safety is effectively incorporated into management decisionmaking at all levels; - Employees at all levels are empowered to promote improved process safety; - Process safety programs receive adequate resources and are appropriately positioned within organizational structures; Corporate and site safety management systems, specifically: - Near-miss reporting and investigation programs; - Mechanical integrity programs; - Hazard analysis programs, management-of-change programs, and up-todate operating procedures for processes with catastrophic potential; - Siting policies for occupied structures near hazardous operating units. 3. Ensure that the panel has a diverse makeup, including an external chairperson; employee representatives; and outside safety experts, such as experts in process safety; experts in corporate culture, organizational behavior, and human factors; and experts from other high-risk sectors such as aviation, space exploration, nuclear energy, and the undersea navy. 4. Ensure that the report and recommendations of the independent panel, which should be completed within 12 months, are made available to the BP workforce and to the public.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2005-4-I-TX-11

1. Appoint an additional non-executive member of the Board of Directors with specific professional expertise and experience in refinery operations and process safety. Appoint this person to be a member of the Board Ethics and Environmental Assurance Committee.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2005-4-I-TX-12

2. Ensure and monitor that senior executives implement an incident reporting program throughout your refinery organization that a. encourages the reporting of incidents without fear of retaliation; b. requires prompt corrective actions based on incident reports and recommendations, and tracks closure of action items at the refinery where the incident occurred and other affected facilities; and c. requires communication of key lessons learned to management and hourly employees as well as to the industry.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2005-4-I-TX-13

3. Ensure and monitor that senior executives use leading and lagging process safety indicators to measure and strengthen safety performance in your refineries.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

BP Texas City Refinery
BP America Refinery Explosion
Open: 38%  |  Closed: 62%

Final Report Released On: March 20, 2007

2005-4-I-TX-14

1. Evaluate your refinery process units to ensure that critical process equipment is safely designed. At a minimum, a. Ensure that distillation towers have effective instrumentation and control systems to prevent overfilling such as multiple level indicators and appropriate automatic controls. b. Configure control board displays to clearly indicate material balance for distillation towers.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2005-4-I-TX-16

3. Work with the United Steelworkers Union and Local 13-1 to establish a joint program that promotes the reporting, investigation, and analysis of incidents, near-misses, process upsets, and major plant hazards without fear of retaliation. Ensure that the program tracks recommendations to completion and shares lessons learned with the workforce.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2005-4-I-TX-15

2. Ensure that instrumentation and process equipment necessary for safe operation is properly maintained and tested. At a minimum, a. Establish an equipment database that captures the history of testing, inspections, repair, and successful work order completion. b. Analyze repair trends and adjust maintenance and testing intervals to prevent breakdowns. c. Require repair of malfunctioning process equipment prior to unit startups.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2005-4-I-TX-17

4. Improve the operator training program. At a minimum, require a. face-to-face training conducted by personnel with process-specific knowledge and experience who can assess trainee competency, and; b. training on recognizing and handling abnormal situations including the use of simulators or similar training tools.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2005-4-I-TX-18

5. Require additional board operator staffing during the startup of process units. Ensure that hazard reviews address staffing levels during abnormal conditions such as startups, shutdowns, and unit upsets.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2005-4-I-TX-19

6. Require knowledgeable supervisors or technically trained personnel to be present during especially hazardous operation phases such as unit startup.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2005-4-I-TX-20

7. Ensure that process startup procedures are updated to reflect actual process conditions.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2005-4-B-TX-1

Revise the maintenance quality control program to require positive material identification testing or another suitable material verification process for all critical service alloy steel piping components removed and reinstalled during maintenance and inform work crews of special material handling precautions.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Branham Corporation
DPC Enterprises Festus Chlorine Release
Open: 0%  |  Closed: 100%

Final Report Released On: May 01, 2003

2002-04-I-MO-11

Implement a materials verification procedure to improve quality assurance during chlorine transfer hose fabrication and shipment, such that hoses shipped to customers are readily identifiable and meet required specifications.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Brazoria County, Texas
Third Coast Industries Petroleum Products Facility Fire
Open: 15%  |  Closed: 85%

Final Report Released On: March 06, 2003

2002-03-I-TX-4

Adopt a fire code, such as the NFPA Uniform Fire Code or the ICC International Fire Code, for application in unincorporated areas.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Building and Construction Trades Department, AFL-CIO
Motiva Enterprises Sulfuric Acid Tank Explosion
Open: 21%  |  Closed: 79%

Final Report Released On: August 28, 2002

2001-05-I-DE-19

Communicate the findings and recommendations of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Building Owners and Managers Association (BOMA)
Kaltech Industries Waste Mixing Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: September 30, 2003

2002-02-I-NY-12

Communicate the findings of this report to your membership.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF)
Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire
Open: 100%  |  Closed: 0%

Final Report Released On: January 17, 2013

2013-2011-06-I-HI-I-HI-12

Effectively participate in the National Fire Protection Association’s standard development process to develop guidance on the safe disposal of fireworks, as recommended under recommendation 2011-06-I-HI-R7.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Burkes Construction, Inc.
Georgia-Pacific Corp. Hydrogen Sulfide Poisoning
Open: 0%  |  Closed: 100%

Final Report Released On: November 20, 2002

2002-01-I-AL-11

Train your employees on the specific hazards of hydrogen sulfide (H2S), including appropriate emergency response practices, in areas where Georgia-Pacific has identified this material as a hazard.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

CAI, Inc.
CAI / Arnel Chemical Plant Explosion
Open: 36%  |  Closed: 64%

Final Report Released On: May 13, 2008

2007-03-I-MA-8

Develop a written safety program to manage hazardous process operations. The program should : -Prohibit heating flammable or combustible liquids above their flashpoints in tanks inside buildings unless the tanks are sealed and vented to the building exterior. -Require safety controls to prevent overheating of flammable or combustible liquids. - Apply the process safety management program elements as contained in the American Institute of Chemical Engineers (AIChE) Center for Chemical Process Safety (CCPS) Guidelines for Implementing Process Safety Management Systems to all processes that use flammable, toxic, or reactive chemicals. -Comply with the following, as applicable: OSHA Flammable and Combustible Liquids standard (29 CFR 1910.106), OSHA Process Safety Management standard (29 CFR 1910.119), National Fire Protection Association Flammable and Combustible Liquids Code (NFPA 30), and National Fire Protection Association Standard for the Manufacture of Organic Coatings (NFPA 35).


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

California Air Quality Management Divisions
Chevron Refinery Fire
Open: 100%  |  Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-18

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

California Air Resources Board (CARB)
Sterigenics Ethylene Oxide Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: March 30, 2006

2004-11-I-CA-7

In collaboration with other state/regional agencies as necessary, such as California Occupational Safety and Health Administration, recommend to facilities that treat ethylene oxide backvent emissions with oxidizing emissions control devices to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

California Environment Protection Agency
Chevron Refinery Fire
Open: 100%  |  Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-20

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

California Occupational Safety and Health Administration (Cal/OSHA)
Sterigenics Ethylene Oxide Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: March 30, 2006

2004-11-I-CA-8

In collaboration with other state/regional agencies as necessary, such as California Environmental Protection Agency, identify the ethylene oxide sterilization facilities in California that utilize oxidizing emissions control devices and conduct inspections of those facilities (including the Sterigenics Ontario facility) in terms of the findings of this report. Ensure prompt correction of all violations identified during these inspections.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Camp Dresser & McKee Inc.
Bethune Point Wastewater Plant Explosion
Open: 23%  |  Closed: 77%

Final Report Released On: March 13, 2007

2006-3-I-FL-11

Revise CDM policies and procedures to ensure that appropriate quality control measures are applied so that designs specify appropriate materials and comply with applicable safety standards. Ensure that wastewater treatment plant design engineers are aware of the importance of proper material selection as well as the findings and recommendations of this report.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2006-3-I-FL-12

Communicate the findings and recommendations of this report to all companies that contracted with CDM for methanol and other flammable liquid systems that were constructed with aboveground plastic pipe. Recommend replacing plastic pipe with an appropriate material in accordance with NFPA 30 and OSHA 1910.106.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2006-3-I-FL-13

Communicate the findings and recommendations of this report to all companies that contracted with CDM for flammable liquid systems that included a flame arrester. Emphasize the importance of periodic maintenance of the flame arrester to ensure its effective performance.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Carbide Industries
Carbide Industries Fire and Explosion
Open: 100%  |  Closed: 0%

Final Report Released On: February 07, 2013

2013-2011-5-I-KY-I-KY-3

Implement a mechanical integrity program for the electric arc furnace and cover, including preventive maintenance based on periodic inspections, and timely replacement of the furnace cover. At a minimum, the program should include factors such as leak detection and repair and refractory lining wear.  


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

Center for Chemical Process Safety
BP America Refinery Explosion
Open: 38%  |  Closed: 62%

Final Report Released On: March 20, 2007

2005-4-I-TX-10

Issue management of change guidelines that address the safe control of the following: a. major organizational changes including mergers, acquisitions, and reorganizations; b. changes in policies and budgets; c. personnel changes; d. staffing during process startups, shutdowns and other abnormal conditions.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Formosa Plastics Propylene Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: July 20, 2006

2006-1-I-TX-6

Incorporate guidance for vehicular traffic protection and remote equipment isolation into the next revision of the Center for Chemical Process Safety?s Guidelines for Hazard Evaluation Procedures.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Formosa Plastics Vinyl Chloride Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: March 06, 2007

2004-10-I-IL-8

Develop guidelines for auditing chemical process safety at newly acquired facilities. Emphasize the identification of major hazards, a review of the acquired facility's previous incident history and hazard analyses, the adequacy of management safety systems, and harmonization of the acquired facility's standards and practices with those of the acquiring company.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Improving Reactive Hazard Management
Open: 42%  |  Closed: 58%

Final Report Released On: September 17, 2002

2001-01-H-6

Publish comprehensive guidance on model reactive hazard management systems. At a minimum, ensure that these guidelines cover: · For companies engaged in chemical manufacturing: reactive hazard management, including hazard identification, hazard evaluation, management of change, inherently safer design, and adequate procedures and training. · For companies engaged primarily in the bulk storage, handling, and use of chemicals: identification and prevention of reactive hazards, including the inadvertent mixing of incompatible substances.


Status: C-ERA
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

Morton International Inc. Runaway Chemical Reaction
Open: 0%  |  Closed: 100%

Final Report Released On: August 16, 2000

1998-06-I-NJ-10

Communicate the findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Union Carbide Corp. Nitrogen Asphyxiation Incident
Open: 0%  |  Closed: 100%

Final Report Released On: February 23, 1999

2009-05-I-LA-5

Communicate the findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Veolia Environmental Services Flammable Vapor Explosion and Fire
Open: 57%  |  Closed: 43%

Final Report Released On: July 21, 2010

2010-10-I-OH-5

Revise control room siting guidelines to reflect the diversity of characteristics that Class 1B flammable liquids can exhibit (e.g., heavy vapor, and plant areas that provide congestion and confinement).


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

CertainTeed Corporation
CTA Acoustics Dust Explosion and Fire
Open: 0%  |  Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-9

Evaluate your facilities that handle combustible dusts and ensure that good practice guidelines such as NFPA 654 are followed.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-09-I-KY-10

Ensure that company design standard's applicable to facilities that handle combustible dust's incorporate good engineering practices to prevent dust explosions, such as NFPA 654.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Chemical and Metal Industries (C&MI)
Honeywell Chemical Incidents
Open: 13%  |  Closed: 87%

Final Report Released On: August 08, 2005

2003-13-I-LA-27

Develop formal procedures for disposition of nonconforming materials received from customers. Ensure that procedures include positive identification prior to shipment.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Improving Reactive Hazard Management
Open: 42%  |  Closed: 58%

Final Report Released On: September 17, 2002

2001-01-H-7

Communicate the findings and recommendations of this report to your membership.


Status: C-ERA
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

Chevron USA
Chevron Refinery Fire
Open: 100%  |  Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-1

At all Chevron U.S. refineries, engage a diverse team of qualified personnel to perform a documented damage mechanism hazard review. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure safeguards are in place to control hazards presented by those damage mechanisms. Analyze and incorporate into this review applicable industry best practices, Chevron Energy Technology Company findings and recommendations, and inherently safer systems to the greatest extent feasible.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2012-03-I-CA-2

At all California Chevron U.S. refineries, report leading and lagging process safety indicators, such as the action item completion status of recommendations from damage mechanism hazard reviews, to the federal, state, and local regulatory agencies that have chemical release prevention authority.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

CITGO, Inc.
CITGO Refinery Hydrofluoric Acid Release and Fire
Open: 0%  |  Closed: 100%

Date of Accident: July 19, 2009

2009-14-I-TX-1

  • Within 30 days, develop and initiate actions to ensure adequate water supply to the CITGO HF mitigation system.  Actions could include, but are not limited to, increasing onsite storage capacity, installing a permanent backup system, and developing procedures and training for water management in an emergency.
  • Every 30 days, report actions planned or completed to the Refinery Terminal Fire Company and Local Emergency Planning Committee.  Continue the 30-day periodic reporting until all planned actions are fully implemented.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

PDF Document Download

2009-14-I-TX-2

  • Within 60 days, complete a third-party audit of all (Corpus Christi, TX and Lemont, IL) CITGO HF alkylation unit operations in the United States as recommended by API Recommended Practice 751, Safe Operation of Hydrofluoric Acid Alkylation Units, Third Edition June 2007. The selected lead auditor shall have extensive knowledge of HF hazards, HF alkylation units, and API 751. 
  • Consistent with the employee participation requirements of the Process Safety Management Standard for Highly Hazardous Chemicals (29 CFR 1910.119(c)), share all audit results and actions planned or completed to correct deficiencies in each refinery with all CITGO and contract employees whose work area includes that refinery’s alkylation unit.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

PDF Document Download

City of Dalton
MFG Chemical Inc. Toxic Gas Release
Open: 44%  |  Closed: 56%

Final Report Released On: April 11, 2006

2004-9-I-GA-8

Establish, equip, and train a hazardous materials response team. Work with the Whitfield County Emergency Management Agency to update the Emergency Operations Plan, clearly defining the roles and responsibilities of the response team.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-9-I-GA-9

Revise fire department and police department procedures and training to clearly define facility and evacuation zone access control responsibilities when hazardous chemicals are involved or suspected in an emergency.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

City of Daytona Beach
Bethune Point Wastewater Plant Explosion
Open: 23%  |  Closed: 77%

Final Report Released On: March 13, 2007

2006-3-I-FL-3

Adopt city ordinances to require departments to implement policies, practices, and procedures concerning safety and health in the workplace for city employees that are at least as effective as relevant OSHA standards. Emphasize compliance with chemical standards, including hot work procedures (OSHA Welding, Cutting, and Brazing Standard, Sections 1910.251 and 1910.252) and chemical hazard communication (OSHA Hazard Communication Standard 29 CFR 1910.1200). Implement procedures to ensure compliance with these policies, practices and procedures.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2006-3-I-FL-4

Ensure that flammable liquid storage tanks used throughout the city comply with NFPA 30 and minimum federal standards in 29 CFR 1910.106, including appropriate piping and flame arresters.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

City of Gallatin, TN
Hoeganaes Corporation Fatal Flash Fires
Open: 85%  |  Closed: 15%

Final Report Released On: January 05, 2012

2011-4-I-TN-11

Require all facilities covered by IFC Chapter 13 (2006 edition) to conform to NFPA standards for combustible dusts including NFPA 484.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

City of Houston
Marcus Oil and Chemical Tank Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: June 06, 2006

2005-2-I-TX-5

Amend the city building ordinances to require all newly installed pressure vessels to comply with the ASME Boiler and Pressure Vessel Code, Section VIII.


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

2005-2-I-TX-6

Amend the city building ordinances to require pressure vessel repairs and alterations to comply with the National Board Inspection Code (NB-23).


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

Colorado Division of Emergency Management Director
Xcel Energy Company Hydroelectric Tunnel Fire
Open: 55%  |  Closed: 45%

Final Report Released On: August 25, 2010

2008-01-I-CO-7

Publish a safety communication that will inform fire service and emergency planning organizations in the state about the confined space safety lessons learned from the Cabin Creek incident including
a. The need to train and certify emergency response personnel who perform technical, including confined space, rescue.

b. The importance of a written confined space rescue plan for each designated permit space that includes

i. Methods of rescue and determination of whether a rescue team is required to standby outside the space.
ii. Rescue equipment requirements and plan of action.

c. The importance of treating confined spaces with the potential for flammable atmospheres above 10 percent of the LEL as a hazard immediately dangerous to life or health that requires rescuers to be stationed directly outside the permit space and available for immediate rescue with appropriate fire-extinguishing and rescue equipment.

d. The need for confined space rescue procedures to instruct emergency responders to not enter or occupy a confined space containing a flammable atmosphere 10 percent of the LEL or greater. Personal protective equipment (PPE) will not protect rescuers from an explosion in a confined space.
 


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Colorado Division of Fire Safety Director
Xcel Energy Company Hydroelectric Tunnel Fire
Open: 55%  |  Closed: 45%

Final Report Released On: August 25, 2010

2008-01-I-CO-7

Publish a safety communication that will inform fire service and emergency planning organizations in the state about the confined space safety lessons learned from the Cabin Creek incident including
a. The need to train and certify emergency response personnel who perform technical, including confined space, rescue.

b. The importance of a written confined space rescue plan for each designated permit space that includes

i. Methods of rescue and determination of whether a rescue team is required to standby outside the space.
ii. Rescue equipment requirements and plan of action.

c. The importance of treating confined spaces with the potential for flammable atmospheres above 10 percent of the LEL as a hazard immediately dangerous to life or health that requires rescuers to be stationed directly outside the permit space and available for immediate rescue with appropriate fire-extinguishing and rescue equipment.

d. The need for confined space rescue procedures to instruct emergency responders to not enter or occupy a confined space containing a flammable atmosphere 10 percent of the LEL or greater. Personal protective equipment (PPE) will not protect rescuers from an explosion in a confined space.
 


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Colorado Public Utilities Commission
Xcel Energy Company Hydroelectric Tunnel Fire
Open: 55%  |  Closed: 45%

Final Report Released On: August 25, 2010

2008-01-I-CO-4

Revise your rules regulating electric utilities, 4 Code of Colorado Regulations 723-3, to:

a. Require regulated utilities to investigate the facts, conditions, and circumstances of all incidents resulting in death, serious injury or significant property damage as defined in Section 3204

b. Require utilities to submit a written investigation report to the Commission within one year of the incident that contains the investigation findings, root causes and recommendations for preventing future incidents that focus on needed changes to utility safety systems. All reports shall be made public.

c. Authorize the commission to issue orders addressing needed corrective actions to be taken as a result of the incident.

d. Require utilities to submit periodic reports to the Commission detailing action taken on the incident report recommendations and Commission orders. All reports shall be made the public.


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Download

2008-01-I-CO-5

Revise your rules regulating electric utilities, 4 Code of Colorado Regulations 723-3, to:

Require all regulated utilities to fully cooperate with all government safety investigations including facilitating access to witnesses, facilities, and equipment; providing copies of requested records; and responding to interrogatories and other investigative requests for information as expeditiously as possible.


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Download

2008-01-I-CO-6

Revise your rules regulating electric utilities, 4 Code of Colorado Regulations 723-3, to:

Require that competitive bidding and contractor selection rules for construction, maintenance or repair of regulated utilities include procedures for prequalifying or disqualifying contractors based on specific safety performance measures and qualifications.


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Download

Commonwealth of Kentucky
D.D. Williamson & Co. Catastrophic Vessel Failure
Open: 0%  |  Closed: 100%

Final Report Released On: March 12, 2004

2003-11-I-KY-7

Communicate to the owners of pressure vessels, mechanical contractors, engineering consulting companies, and insurance companies doing business in Kentucky that used pressure vessels are not exempt from registration and initial inspection before being placed in service in Kentucky.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Commonwealth of Massachusetts Office of Public Safety, Department of Fire Services
CAI / Arnel Chemical Plant Explosion
Open: 36%  |  Closed: 64%

Final Report Released On: May 13, 2008

2007-03-I-MA-3

Incorporate the Flammable and Combustible Liquids Code (NFPA 30) and Standard for the Manufacture of Organic Coatings (NFPA 35) into the Massachusetts Board of Fire Prevention Regulations.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2007-03-I-MA-4

Revise 527 CMR 14 to specify the maximum interval (such as annually) for local fire departments to conduct inspections of manufacturing facilities holding one or more licenses and permits to store and handle flammable materials.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2007-03-I-MA-5

Develop mandatory written inspection criteria to be used by the local fire departments when performing manufacturing facility inspections. Develop inspection training material and provide training to the local fire departments.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2007-03-I-MA-6

Revise the license and registration forms (FP-2 and FP-5) to require listing each hazardous material type and quantity. Identify the requirement that a separate license and permit are required for each of the eight classes of flammable material when the facility possesses more than the listed threshold quantity specified in 527 CMR 14.03 (2).


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Compressed Gas Association (CGA)
DuPont Corporation Toxic Chemical Releases
Open: 64%  |  Closed: 36%

Final Report Released On: September 20, 2011

2010-06-I-WV-9

Revise CGA P-1, Safe Handling of Compressed Gases in Containers, to include specific requirements for storing and handling highly toxic compressed gas, including enclosure ventilation and alarm requirements at least as protective as Section 7.9, Toxic and Highly Toxic Gases and NFPA 55, Compressed Gases and Cryogenics Fluids Code.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2010-06-I-WV-10

Revise CGA P-1, Safe Handling of Compressed Gases in Containers, to incorporate by reference CGA E-9, Standard for Flexible, PTFE-lined Pigtails for Compressed Gas Service.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

Praxair Flammable Gas Cylinder Fire
Open: 0%  |  Closed: 100%

Final Report Released On: June 15, 2006

2005-5-I-MO-1

Communicate with your members who operate gas repackaging facilities the details of this incident and the best practices for handling and storing cylinders.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2005-5-I-MO-2

Revise CGA standards for the CG-7 relief valves used in propylene service to require: 1) a greater margin between vapor pressure and relief valve set point (similar to propane); and 2) that valves be capable of multiple operations within the specified setpoint tolerance or be furnished with an indicator that alerts users that the valve has operated.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Union Carbide Corp. Nitrogen Asphyxiation Incident
Open: 0%  |  Closed: 100%

Final Report Released On: February 23, 1999

1998-05-I-LA-6

Communicate the findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Valero Refinery Asphyxiation Incident
Open: 25%  |  Closed: 75%

Final Report Released On: November 02, 2006

2006-2-I-DE-8

Issue a safety alert to address nitrogen/inert gas hazards in confined spaces. Emphasize that: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Crystal, Inc. - PMC
West Pharmaceutical Services Dust Explosion and Fire
Open: 0%  |  Closed: 100%

Final Report Released On: September 23, 2004

2003-07-I-NC-9

Modify the material safety data sheet for manufactured polyethylene antitack agents to include hazards posed by the end-use of the product.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

CTA Acoustics, Inc.
CTA Acoustics Dust Explosion and Fire
Open: 0%  |  Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-1

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Minimize surfaces where combustible dust could accumulate in the design or modification of the plant.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-09-I-KY-2

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Ensure phenolic resin-handling facilities are designed to prevent the spread of fires or explosions involving combustible dust. Options include measures such as the use of firewalls and blast-resistant construction.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-09-I-KY-3

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Prevent the unsafe accumulation and dispersion of combustible dust by frequently cleaning process areas, including locations above production lines.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-09-I-KY-4

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Minimize the dispersion of combustible dust by using appropriate dust-cleaning methods and tools.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-09-I-KY-5

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Address the dangers of combustible dust and the prevention of dust explosions in the hazard communication training program.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-09-I-KY-6

Conduct hazard assessments of ovens to ensure that fire detection and suppression systems are adequate, using good practice guidelines such as NFPA 86, Standard for Ovens and Furnaces.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-09-I-KY-7

Develop procedures to maintain safety during nonroutine operating conditions, such as the loss of oven temperature control.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-09-I-KY-8

Revise the incident investigation program to ensure that the underlying causes of incidents such as fires are identified and corrective actions implemented.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

D.D. Williamson and Co., Inc.
D.D. Williamson & Co. Catastrophic Vessel Failure
Open: 0%  |  Closed: 100%

Final Report Released On: March 12, 2004

2003-11-I-KY-1

Institute procedures to ensure that pressure vessels are designed, fabricated, and operated according to applicable codes and standards.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-11-I-KY-2

Audit all vessels at all D. D. Williamson facilities and ensure that they are: Equipped with adequate overpressure protection, as warranted. Equipped with alarms or interlocks, as warranted.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-11-I-KY-3

Implement a program to review existing equipment when it is used for new purposes and when safety devices are removed or altered.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-11-I-KY-4

Implement a hazard evaluation procedure to determine the potential for catastrophic incidents and necessary safeguards.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-11-I-KY-5

Audit manual control of process conditions, such as temperature and pressure, and determine if safeguards are needed.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-11-I-KY-6

Upgrade written operating procedures and train operators on the revised procedures.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Davison Transport, Inc.
Georgia-Pacific Corp. Hydrogen Sulfide Poisoning
Open: 0%  |  Closed: 100%

Final Report Released On: November 20, 2002

2002-01-I-AL-2

Communicate the findings and recommendations of this report to those employees who haul or handle sodium hydrosulfide


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Delaware Department of Natural Resources and Environmental Control
Motiva Enterprises Sulfuric Acid Tank Explosion
Open: 21%  |  Closed: 79%

Final Report Released On: August 28, 2002

2001-05-I-DE-2

Ensure that regulations developed for the recently enacted Jeffrey Davis Above ground Storage Tank Act require that facility management take prompt action in response to evidence of tank corrosion that presents hazards to people or the environment.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Department of Treasury - Office of Procurement Executive (OPE)
Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire
Open: 100%  |  Closed: 0%

Final Report Released On: January 17, 2013

2013-2011-06-I-HI-I-HI-2

Establish formal policy requiring that: • Solicitations for contracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, incorporate rigorous safety-related contractor selection provisions such as those provided in the DoD’s Contractor’s Safety Manual for Ammunition and Explosives, Section C1.5, “Pre-Award Safety Survey”; and • Contracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, include a provision requiring that any subcontract (regardless of tier) for the storage, handling, and disposal of explosives (including fireworks) be selected based on rigorous safety-related contractor selection provisions such as those provided in the DOD's Contractor Safety Manual for Ammunition and Explosives, Section C1.5, "Pre-Award Safety Survey."


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2013-2011-06-I-HI-I-HI-3

Establish a formal policy requiring that contracts and subcontracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, incorporate rigorous safety-related contractor oversight provisions such as those provided in the DoD’s Contractor’s Safety Manual for Ammunition and Explosives, Section C1.6, “Pre-Operational Safety Survey” and C1.7, “Post-Award Contractor Responsibilities” to provide effective oversight of subcontractors handling and disposing of explosives and hazardous materials.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2013-2011-06-I-HI-I-HI-4

When the NFPA guidance developed by the National Fire Protection Association for the safe disposal of fireworks as recommended under recommendation 2011-06-I-HI-R7 is completed, incorporate this document by reference into the formal policies established by 2011-06-I-HI-R2 and 2011-06-I-HI-R3.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

DPC Enterprises, Festus Site
DPC Enterprises Festus Chlorine Release
Open: 0%  |  Closed: 100%

Final Report Released On: May 01, 2003

2002-04-I-MO-1

Revise the mechanical integrity program: Develop and implement a quality assurance management system, such as positive materials identification, to confirm that chlorine transfer hoses (CTH) are of the appropriate materials of construction.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-2

Revise the mechanical integrity program: Implement procedures and practices to ensure the emergency shutdown (ESD) system operates properly. Include procedures to verify that the ESD valves will close to shut down the flow of chlorine.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-3

Revise the mechanical integrity program: Revise the preventive maintenance and inspection program for the chlorine transfer system to address moisture-related corrosion. Evaluate and correct any problems associated with corrosion that could potentially lead to chlorine transfer and safety system failure.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-04-I-MO-4

Revise the mechanical integrity program: Require periodic inspection of the above critical safety systems by the operations or facility manager.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-5

Revise the Emergency Response Plan: Develop procedures to clearly designate the roles and responsibilities of facility emergency response personnel, including post-incident remediation.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-6

Revise the Emergency Response Plan: Develop and implement a timetable for drills to test emergency response personnel on various levels of response, including a large uncontrolled release that could affect the public. Coordinate these drills with local emergency response authorities. Provide a copy of the revised Emergency Response Plan to the local emergency planning committee, and review the plan with the committee and the local fire department. Work with these authorities to implement an improved community emergency notification system.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-7

Revise the Emergency Response Plan: Improve accessibility of equipment required for emergency response, considering likely response scenarios.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

DPC Enterprises, L.P.
DPC Enterprises Glendale Chlorine Release
Open: 7%  |  Closed: 93%

Final Report Released On: February 28, 2007

2004-2-I-AZ-1

Establish and implement DPC corporate engineering standards that include adequate layers of protection on chlorine scrubbers at DPC facilities, including: -additional interlocks and shutdowns, such as automatically stopping chlorine flow to the scrubber upon oxidation-reduction potential alarm; -mitigation measures, such as systems to automatically add caustic to over-chlorinated scrubbers, or back-up scrubbing capability to treat emissions from over-chlorinated scrubbers; -increases in the final caustic concentration in the scrubbers to eight percent or higher to provide a substantial safety margin against over-chlorination; and -use of the site's continuous bleach manufacturing system to convert scrubber solution to saleable bleach.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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2004-2-I-AZ-2

Revise scrubber SOPs to include: -clearly described operating limits and warnings about the consequences of exceeding those limits, and -the safety and environmental hazards associated with scrubber over-chlorination.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

PDF Document Download

2004-2-I-AZ-3

Train employees on the revised SOPs and include a test to verify understanding. Periodically review operator understanding of and conformance to the scrubber SOPs.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

PDF Document Download

2004-2-I-AZ-4

Include scrubber operation in facility PHAs. Ensure that they: -include lessons learned from this incident and other DPC scrubber incidents, as well as industry experience with over-chlorination, and -consider off-site consequences when evaluating the adequacy of existing safeguards.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

PDF Document Download

2004-2-I-AZ-5

Use a qualified, independent auditor to evaluate DPC's PSM and RMP programs against best practices. Implement audit recommendations in a timely manner at all DPC chlorine repackaging sites.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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2004-2-I-AZ-6

Implement a recognized safety management system, including third party verification and certification, to achieve documented continuous improvement in safety performance at Glendale and the other DPC chlorine repackaging sites.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

PDF Document Download

DuPont Belle Plant
DuPont Corporation Toxic Chemical Releases
Open: 64%  |  Closed: 36%

Final Report Released On: September 20, 2011

2010-06-I-WV-3

Improve the existing maintenance management by

  • Supplementing the computerized system with sufficient redundancy to ensure tracking and timely scheduling of preventive maintenance for all PSM-critical equipment.
  • Conducting Management-of-Change (MOC) reviews for all changes to preventive maintenance orders for all PSM-critical equipment in the computerized maintenance management system.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2010-06-I-WV-4

Revise the facility emergency response protocol to require that a responsible and accountable DuPont employee always be available (all shifts, all days) to provide timely and accurate information to the Kanawha County Emergency Ambulance Authority (KCEAA) and Metro 9-1-1 dispatchers.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2010-06-I-WV-5

Revise the near-miss reporting and investigation policy and implement a program that includes the following at a minimum:

  • Ensures employee participation in reporting, investigating, analyzing, and recommending corrective actions as appropriate for all near-misses and disruptions of normal operations.
  • Develops and encourages use of an anonymous electronic and/or hard copy near-miss reporting process for all DuPont Belle site employees.
  • Establishes roles and responsibilities for ownership, management, execution, and resolution of recommendations from incident or near-miss investigations at the DuPont Belle facility.
  • Ensures that the near-miss investigation program requires prompt investigations, as appropriate, and that results are promptly circulated to well-suited recipients throughout the DuPont Corp.
  • Ensures that this program is operational at all times (e.g. nights, weekends, and holiday shifts).

 


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

DuPont-First Chemical Pascagoula Facility
First Chemical Corp. Reactive Chemical Explosion
Open: 13%  |  Closed: 87%

Final Report Released On: October 15, 2003

2003-01-I-MS-2

Establish a program for conducting process hazard analyses of processes involving reactive materials.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-01-I-MS-3

Evaluate the need for layers of protection and install appropriate safeguards, such as alarms and interlocks, to reduce the likelihood of a runaway reaction and catastrophic release of material.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-01-I-MS-4

Review and revise as necessary procedures for units that process highly energetic material, effectively communicate the updated procedures, and train workers appropriately. Revised procedures should include: Specific steps for isolation of energy sources. Warnings and cautions concerning process chemicals and consequences of deviations from operating limits. Critical operating limits and guidance when the limits are exceeded. Instruction on how to perform a shutdown for all foreseeable causes, to ensure proper isolation, and to continue monitoring critical parameters (such as temperature) while the column is shut down; in addition, review conditions under which material must be deinventoried (such as during extended shutdowns).


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-01-I-MS-5

Conduct a facility-wide survey of pressure vessels to ensure that all equipment that processes reactive materials has appropriate overpressure protection.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-01-I-MS-6

Identify equipment critical to safe operation of processes containing reactive materials. Upgrade the maintenance program and establish inspection schedules to ensure the integrity of such equipment.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-01-I-MS-7

Survey and take appropriate action to ensure that buildings occupied by plant personnel are of adequate construction and are located so as to protect people inside in the event of an explosion in equipment processing reactive materials.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

DX Group
DPC Enterprises Festus Chlorine Release
Open: 0%  |  Closed: 100%

Final Report Released On: May 01, 2003

2002-04-I-MO-8

In light of the findings of this report, conduct periodic audits of the safety management systems involved in this incident, such as mechanical integrity, emergency response, and material quality assurance. Ensure that the audit recommendations are tracked and implemented. Share findings and recommendations with the work force at your repackaging facilities.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-9

To improve supervision of day-to-day operations, revise your corporate safety management training program on chlorine repackaging operations. Emphasize safety critical systems, including verification of safety system performance.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-04-I-MO-10

Communicate the findings and recommendations of this report to all DPC facilities.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

E. I. du Pont de Nemours and Company
DuPont Corporation Toxic Chemical Releases
Open: 64%  |  Closed: 36%

Final Report Released On: September 20, 2011

2010-06-I-WV-6

Revise safeguards for phosgene handling at all DuPont facilities by

  • Requiring that all indoor phosgene production and storage areas, as defined in NFPA 55, have secondary enclosures, mechanical ventilation systems, emergency phosgene scrubbers, and automated audible alarms, which are, at a minimum, consistent with the standards of NFPA 55 for highly toxic gases.
  • Prohibiting the use of hoses with permeable cores and materials susceptible to chlorides corrosion for phosgene transfer.
  • Conducting annual phosgene hazard awareness training for all employees who handle phosgene, including the hazards associated with thermal expansion of entrapped liquid phosgene in piping and equipment.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2010-06-I-WV-7

Review all DuPont units that produce and handle phosgene that, at a minimum, observe and document site-specific practices for engineering controls, construction materials, PPE, procedures, maintenance, emergency response, and release detection and alarms, and use information from external sources to develop and implement consistent company-wide policies for the safe production and handling of phosgene.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2010-06-I-WV-8

For each DuPont facility that uses, but does not manufacture, phosgene onsite:

  • Conduct a risk assessment of manufacturing phosgene onsite against the current configuration.
  • Communicate the findings of each assessment to compile recommendations applicable to all DuPont phosgene delivery systems.
  • Implement these recommendations.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2010-06-I-WV-12

Commission an audit in consultation with operations personnel to establish and identify the conditions that cause nuisance alarms at all DuPont facilities. Establish and implement a corporate alarm management program as part of the DuPont PSM Program, including measures to prevent nuisance alarms and other malfunctions in those systems. Include initial and refresher training as an integral part of this effort.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2010-06-I-WV-13

Revise the DuPont PSM standard to require confirmation that all safety alarms/interlocks are in proper working order (e.g., not in an active alarm state) prior to the start-up of all Higher-Hazard Process facilities.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2010-06-I-WV-14

Reevaluate and clarify the DuPont corporate MOC policies to ensure that staff can properly identify and use the distinctions between subtle and full changes and train appropriate personnel how to properly apply the distinctions on any changes in the policy.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

E. I. DuPont De Nemours Co. Fatal Hotwork Explosion
Open: 100%  |  Closed: 0%

Final Report Released On: April 19, 2012

2011-01-I-NY-1

Develop and enforce corporate-directed policies and procedures which will require all DuPont facilities to audit their hot work permitting systems prior to initiating hot work to ensure that:

  • All potential explosion hazards associated with hot work activities are identified and mitigated
  • All relevant forms required for permits are completed in accordance with corporate policies and industry standards (including NFPA 326 and NFPA 51B)
  • Appropriate DuPont personnel officially approve hot work permits, by signature or equivalent, consistent with DuPont policies


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2011-01-I-NY-2

Revise corporate policies and procedures to require that all process piping, or similar connections to tanks or vessels be positively isolated, (using closed valves, blind flanges or pancake blanks) and the equipment appropriately vented before authorizing any hot work.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2011-01-I-NY-3

Revise corporate policies and procedures to require that the atmosphere inside the container be monitored for flammable vapor prior to performing any welding, cutting, or grinding on the container surface.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2011-01-I-NY-4

Revise corporate policies and procedures to require air monitoring for flammable vapor inside the container for the duration of the hot work consistent with industry standards (NFPA 326, NFPA 51B). Create a policy for determining criteria for requiring continuous or periodic testing for the duration of hot work.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

First Chemical Corp. Reactive Chemical Explosion
Open: 13%  |  Closed: 87%

Final Report Released On: October 15, 2003

2003-01-I-MS-1

Conduct audits to ensure that the First Chemical Pascagoula facility addresses the issues detailed below. Communicate results of these audits to the workforce.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

East Baton Rouge Parish Office of Homeland Security and Emergency
Honeywell Chemical Incidents
Open: 13%  |  Closed: 87%

Final Report Released On: August 08, 2005

2003-13-I-LA-24

Conduct an awareness campaign to educate residents on the proper response during a chemical release. Include instructions on the way residents (including those outside the affected area) can obtain information during an emergency.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

El Paso Production Company
Sonat Exploration Co. Catastrophic Vessel Overpressurization
Open: 0%  |  Closed: 100%

Final Report Released On: September 21, 2000

1998-002-I-LA-1

Institute a formal engineering design review process for all oil and gas production facilities,following good engineering practices and including analyses of process hazards.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

1998-002-I-LA-2

Implement a program to ensure that all oil and gas production equipment that is potentially subject to overpressurization is equipped with adequate pressure-relief systems, and audit compliance with the program.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

1998-002-I-LA-3

Develop written operating procedures for oil and gas production facilities and implement programs to ensure that all workers, including contract employees, are trained in the use of the procedures. Ensure the procedures address, at a minimum, purging and start-up operations and provide information on process-related hazards.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Electric Power Research Institute (EPRI)
Kleen Energy Natural Gas Explosion
Open: 33%  |  Closed: 67%

Final Report Released On: June 28, 2010

2010-01-I-CT-18

Work with the six turbine manufacturers identified in this document – General Electric, Siemens, Solar, Mitsubishi Power Systems, Pratt & Whitney, and Rolls-Royce – to publish technical guidance addressing the safe cleaning of fuel gas piping supplying gas turbines. At minimum:

a. For cleaning methodology, require the use of inherently safer alternatives such as air blows and pigging with air in lieu of flammable gas.

b. Provide comprehensive technical guidance on inherently safer methods for cleaning fuel gas piping, such as the use of air or pigging with air.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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Environmental Protection Agency (EPA)
Allied Terminals Fertilizer Tank Collapse
Open: 60%  |  Closed: 40%

Final Report Released On: May 26, 2009

2009-3-I-VA-4

Revise and reissue the Chemical Emergency Preparedness and Prevention Office Rupture Hazard from Liquid Storage Tanks Chemical Safety Alert. At a minimum, revise the alert to: 1) Include the Allied Terminals tank failure, 2) Discuss the increased rupture hazard during first fill or hydrostatic testing, and 3) List The Fertilizer Institute fertilizer tank inspection guidelines in the reference section.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Bayer CropScience Pesticide Waste Tank Explosion
Open: 31%  |  Closed: 69%

Final Report Released On: January 20, 2011

2008-08-I-WV-12

In light of the findings of this report and the serious potential hazards to workers and the public from chemicals used and stored at the Bayer Institute site (such as phosgene, MIC, and methomyl), conduct a comprehensive Risk Management Program (RMP) inspection of the complex. Coordinate with the Occupational Safety and Health Administration, as appropriate.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

Chevron Refinery Fire
Open: 100%  |  Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-15

Jointly plan and conduct inspections with Cal/OSHA, California EPA and other state and local regulatory agencies with chemical accident prevention responsibilities to monitor the effective implementation of the damage mechanism hazard review and disclosure requirements under 2012-03-I-CA-R9 and R10 above.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2012-03-I-CA-19

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire
Open: 100%  |  Closed: 0%

Final Report Released On: January 17, 2013

2013-2011-06-I-HI-I-HI-9

Revise the Resource Conservation and Recovery Act (RCRA) Subtitle C regulations to require a permitting process with rigorous safety reviews to replace the use of emergency permits under 40 CFR §270.61 for the disposal of explosive hazardous materials, including fireworks. At a minimum, the new process should require the use of best available technology, safe disposal methodologies, as well as safety management practices, such as those required by OSHA’s Process Safety Management Standard (PSM), 29 CFR §1910.119 (e.g., hazard analysis and control, management of change).


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2013-2011-06-I-HI-I-HI-10

Until recommendation 2011-06-I-HI-R9 can be implemented, develop and issue a policy guidance document to provide a regulatory process with rigorous safety reviews to replace the use of emergency permits under 40 CFR §270.61 for the disposal of explosive hazardous materials, including fireworks. At a minimum, the new process should require the use of best available technology, safe disposal methodologies, as well as safety management practices, such as those required by OSHA’s Process Safety Management Standard (PSM), 29 CFR §1910.119 (e.g., hazard analysis and control, management of change). Ensure its effective communication to all EPA regional administrators, state environmental agencies, and organizations within the fireworks industry


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2013-2011-06-I-HI-I-HI-11

Effectively participate in the National Fire Protection Association’s standard development process to develop guidance on the safe and environmentally sound disposal of fireworks, as recommended under recommendation 2011-06-I-HI-R7. Status


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

EQ Hazardous Waste Plant Explosions and Fire
Open: 0%  |  Closed: 100%

Final Report Released On: April 16, 2008

2007-1-I-NC-1

Ensure that the emergency response planning required for permitted hazardous waste treatment, storage, and disposal facilities (40 CFR 264.37) includes providing written information to state and local emergency response officials on the type, approximate quantities, and locations of materials within the facility (similar to reporting requirements of the Emergency Planning and Community Right-to-Know Act). Additionally, ensure that permit holders periodically update this information throughout the ten-year permit period.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Formosa Plastics Vinyl Chloride Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: March 06, 2007

2004-10-I-IL-7

Ensure that the EPA's Enforcement Alert concerning PVC facilities includes the causes and lessons learned from this investigation. Emphasize the importance of analyzing human factors and the need to implement adequate safeguards to minimize the likelihood and consequences of human error that could result in catastrophic incidents.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Improving Reactive Hazard Management
Open: 42%  |  Closed: 58%

Final Report Released On: September 17, 2002

2001-01-H-3

Revise the Accidental Release Prevention Requirements, 40 CFR 68, to explicitly cover catastrophic reactive hazards that have the potential to seriously impact the public, including those resulting from self-reactive chemicals and combinations of chemicals and process-specific conditions. Take into account the recommendations of this report to OSHA on reactive hazard coverage. Seek congressional authority if necessary to amend the regulation.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2009-01-H-4

Modify the accident reporting requirements in RMP* Info to define and record reactive incidents. Consider adding the term "reactive incident" to the four existing "release events" in EPA's current 5-year accident reporting requirements (Gas Release, Liquid Spill/Evaporation, Fire, and Explosion). Structure this information collection to allow EPA and its stakeholders to identify and focus resources on industry sectors that experienced the incidents; chemicals and processes involved; and impact on the public, the workforce, and the environment.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Morton International Inc. Runaway Chemical Reaction
Open: 0%  |  Closed: 100%

Final Report Released On: August 16, 2000

1998-06-I-NJ-9

Participate in a hazard investigation of reactive chemical process safety conducted by the CSB. The objectives of the special investigation will include: Determine the frequency and severity of reactive chemical incidents. Examine how industry, OSHA, and EPA are currently addressing reactive chemical hazards. Determine the differences, if any, between large/medium/small companies with regard to reactive chemical policies, practices, in-house reactivity research, testing, and process engineering. Analyze the effectiveness of industry and OSHA use of the National Fire Protection Association Reactivity Rating system for process safety management purposes. Develop recommendations for reducing the number and severity of reactive chemical incidents.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

1998-06-I-NJ-8

Issue joint guidelines on good practices for handling reactive chemical process hazards. Ensure that these guidelines, at a minimum, address the following issues: The evaluation of reactive hazards and the consequences of reasonably foreseeable and worst-case deviations from normal operations. The importance of reporting and investigating deviations from normal operations. The determination of proper design for pressure relief capability, emergency cooling process controls, alarms, and safety interlocks, as well as other good-practice design features for handling reactive substances. The appropriate use of chemical screening techniques such as differential scanning calorimetry.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Oil Site Safety
Open: 100%  |  Closed: 0%

Final Report Released On: October 27, 2011

2011-H-1-1

Publish a safety alert directed to owners and operators of exploration and production facilities with flammable storage tanks, advising them of their general duty clause responsibilities for accident prevention under the Clean Air Act. At a minimum, the safety alert should:

a. Warn that storage tanks at unmanned facilities may be subject to tampering or introduction of ignition sources by members of the public, which could result in a tank explosion or other accidental release to the environment

b. Recommend the use of inherently safer storage tank design features to reduce the likelihood of explosions, including restrictions on the use of open vents for flammable hydrocarbons, flame arrestors, pressure vacuum vent valves, floating roofs, vapor recovery systems or an equivalent alternative.

c. Describe sufficient security measures to prevent non-employee access to flammable storage tanks, including such measures as a full fence surrounding the tank with locked gate, hatch locks on tank manways, and barriers securely attached to tank external ladders or stairways

d. Recommend that hazard signs or placards be displayed on or near tanks to identify the fire and
explosion hazards using words and symbols recognizable by the general public


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Sterigenics Ethylene Oxide Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: March 30, 2006

2004-11-I-CA-16

Communicate the findings and recommendations of this report to the states that require EO backvent emissions treatment. Emphasize the need for facilities to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Environmental Technology Council
EQ Hazardous Waste Plant Explosions and Fire
Open: 0%  |  Closed: 100%

Final Report Released On: April 16, 2008

2007-1-I-NC-2

Superseded by 2009-10-I-OH-R6
Petition the National Fire Protection Association, following the guidelines of their "Codes and Standards Development Process" (http://www.nfpa.org/index.asp), to develop a fire protection standard (occupancy standard) specific to hazardous waste treatment, storage, and disposal facilities. This standard should address fire prevention, detection, control, and suppression requirements.


Status: C-R/S
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

2007-1-I-NC-3

Superseded by 2009-10-I-OH-R7
Develop standardized guidance for the handling and storage of hazardous waste to reduce the likelihood of releases and fires at hazardous waste treatment, storage, and disposal facilities.


Status: C-R/S
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

Veolia Environmental Services Flammable Vapor Explosion and Fire
Open: 57%  |  Closed: 43%

Final Report Released On: July 21, 2010

2010-10-I-OH-6

Supersedes 2007-01-I-NC-R2
Petition the National Fire Protection Association, following the guidelines of their "Codes and Standards Development Process" (www.nfpa.org), to develop an occupancy standard specific to hazardous waste treatment, storage, and disposal facilities. The purpose of the standard would be to prescribe technical requirements for the safety to life and property from fire, explosion, and release; and to minimize the resulting damage from a fire, explosion, and release.
At a minimum, but not limited to, the standard should address:
• Hazard Identification
• Chemical Fire and Release Protection and Prevention
• Facility and Systems Design
• Employee Training and Procedures
• Inspection and Maintenance


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2010-10-I-OH-7

Supersedes 2007-01-I-NC-R3
Develop and issue standardized guidance for the processing, handling and storage of hazardous waste to reduce the likelihood of fires, explosions, and releases at hazardous waste treatment storage and disposal facilities. Include the incident findings, consequences, conclusions, and recommendations from the CSB investigations of the Environmental Quality facility and the Veolia ES Technical Solutions.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

Ethylene Oxide Sterilization Association (EOSA)
Sterigenics Ethylene Oxide Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: March 30, 2006

2004-11-I-CA-14

Coordinate with NIOSH to revise and reissue Appendix C of the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically, remove the portion of paragraph D that states, "[t]he accuracy, reliability, resolution, and availability of current ethylene oxide measurement devices is questionable."


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-11-I-CA-15

Conduct outreach to communicate the findings and recommendations of this report, and the contents of the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities, to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Federal Aquisition Regulatory (FAR) Council
Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire
Open: 100%  |  Closed: 0%

Final Report Released On: January 17, 2013

2013-2011-06-I-HI-I-HI-1

Establish an additional contractor responsibility determination requirement under Subpart 9.104-1 of the Federal Acquisition Regulation (FAR) addressing contractor safety performance. The analysis under this requirement should focus on incident prevention, and environmental and system safety. At a minimum, the language should specifically require the review of a prospective contractor’s: • Environmental and safety programs; • Safety record and incident history; • Ability to use safe methods for any work involving hazardous materials (including explosives); and • Suitable training and qualifications for the personnel involved in the work including prior relevant safety experience.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Ferrellgas
Little General Store Propane Explosion
Open: 17%  |  Closed: 83%

Final Report Released On: September 25, 2008

2007-4-I-WV-12

Establish and implement a comprehensive safety management system that includes at a minimum: -An auditing program developed in accordance with generally accepted methodologies to monitor the performance and effectiveness of safety management systems and personnel at all levels; -An inspection program that uses NFPA 58 as a guide to systematically inspect all customer propane systems and identify all deficiencies; -A means of tracking audits and inspections and identified deficiencies; -A means of tracking corrective actions; -A means of collecting and using audit and inspection data for trend analysis and organizational learning; -A means of periodically reporting audit and inspection trends to the Board of Directors and Managing Board, and; -A provision for periodic safety management system audits conducted by a third party competent in the requirements of NFPA 58.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Fire Protection Research Foundation
Hayes Lemmerz Dust Explosions and Fire
Open: 15%  |  Closed: 85%

Final Report Released On: September 27, 2005

2004-1-I-IN-11

Conduct research into the feasibility and design of improved explosion protection for aluminum dust collector applications, including explosion venting, isolation and suppression systems. Coordinate this research activity with the Aluminum Association, Inc.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

Fire Service Institute of Iowa State University
Herrig Brothers Farm Propane Tank Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: June 23, 1999

1998-007-I-IA-7

Ensure that fire fighter training materials address proper response procedures for BLEVEs.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

FM Global
CTA Acoustics Dust Explosion and Fire
Open: 0%  |  Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-16

Incorporate the findings and recommendations of this report in your training of employees who conduct inspections at facilities that may handle combustible dusts.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Formosa Plastics USA
Formosa Plastics Propylene Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: July 20, 2006

2006-1-I-TX-1

Revise policies and procedures for process hazard analysis and pre-startup safety review to more fully evaluate vehicle impact hazards, passive fire protection, and catastrophic releases.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2006-1-I-TX-2

Require flame resistant clothing for workers in units at the Point Comfort complex where there is a risk of flash fires.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Formosa Plastics Vinyl Chloride Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: March 06, 2007

2004-10-I-IL-1

Review the design and operation of FPC USA manufacturing facilities and implement policies and procedures to ensure that: -Site-wide policies are implemented to address necessary steps and approval levels required to bypass safety interlocks and other critical safety systems. -Chemical processes are designed to minimize the likelihood and consequences of human error that could result in a catastrophic release. -Safety impacts of staffing changes are evaluated. -Risks identified during hazard analyses and near-miss and incident investigations are characterized, prioritized, and that corrective actions are taken promptly. -High-risk hazards are evaluated using layers of protection analysis (LOPA) techniques and that appropriate safeguards are installed to reduce the likelihood of a catastrophic release of material. -All credible consequences are considered in near-miss investigations. -Emergency procedures clearly characterize emergency scenarios, address responsibilities and duties of responders, describe evacuation procedures, and ensure adequate training. Ensure that periodic drills are conducted. -The siting of offices for administrative and support personnel is evaluated to ensure the safety of personnel should an explosion or catastrophic release occur.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-10-I-IL-2

Conduct periodic audits of each FPC USA PVC manufacturing facility for implementation of the items in Recommendation R1. Develop written findings and recommendations. Track and promptly implement corrective actions arising from the audit. Share audit findings with the workforce at the facilities and the FPC USA Board of Directors.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-10-I-IL-3

Design and implement a program requiring audits of newly acquired facilities that address the issues highlighted in this report. Document, track, and promptly address recommended actions arising from the audits.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-10-I-IL-4

Communicate the contents of this report to all employees of FPC USA PVC facilities.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Gallatin Fire Department
Hoeganaes Corporation Fatal Flash Fires
Open: 85%  |  Closed: 15%

Final Report Released On: January 05, 2012

2011-4-I-TN-12

Ensure that all industrial facilities in the City of Gallatin are inspected periodically against the International Fire Code. All facility inspections shall be documented.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2011-4-I-TN-13

Implement a program to ensure that fire inspectors and response personnel are trained to recognize and address combustible dust hazards.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

General Court of the Commonwealth of Massachusetts
CAI / Arnel Chemical Plant Explosion
Open: 36%  |  Closed: 64%

Final Report Released On: May 13, 2008

2007-03-I-MA-1

Revise the General Laws of Massachusetts addressing flammable materials licensing and registration: - As part of the annual registration renewal, require new and existing product manufacturing registrants to submit written certification to local governments stating that the facility complies with, at a minimum, all state and local fire codes and hazardous chemical regulations. -Require all companies holding a license and current registration to apply for an amended license and re-register the facility before increasing any flammable material quantity above the licensed amount or adding a different regulated chemical. Include a requirement in the approval process to solicit input from affected landowners, similar to the requirement for obtaining the original license and registration.


Status: C-ERA
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

2007-03-I-MA-2

Amend the General Laws of Massachusetts to require the Office of the State Fire Marshal to audit local governments for compliance with the flammable materials licensing regulation and audit fire departments for compliance with permit issuance and inspection of manufacturing facilities licensed to store and handle flammable liquids and solids. The audits should be conducted at least once every five years.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

General Electric (GE)
Kleen Energy Natural Gas Explosion
Open: 33%  |  Closed: 67%

Final Report Released On: June 28, 2010

2010-07-I-CT-4

Provide to your customers:

a. Comprehensive technical guidance on inherently safer methods for cleaning fuel gas piping, such as the use of air or pigging with air.

b. Comprehensive Cleaning Force Ratio (CFR) guidelines, specifying both the upper and lower limits required to obtain satisfactory cleaning for the fuel gas piping for purposes of the warranties of the turbines.

c. Warnings against the use of fuel gas to clean pipes.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

PDF Document Download

2010-01-I-CT-10

Work with the Electric Power Research Institute to publish technical guidance addressing the safe cleaning of fuel gas piping supplying gas turbines. At minimum:

a. For cleaning methodology, require the use of inherently safer alternatives such as air blows and pigging with air in lieu of flammable gas.

b. Provide technical guidance for the safe and effective use of alternative methods for cleaning such as air and pigging with air.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

PDF Document Download

Georgia Pacific Corporation
Georgia-Pacific Corp. Hydrogen Sulfide Poisoning
Open: 0%  |  Closed: 100%

Final Report Released On: November 20, 2002

2002-01-I-AL-1

Conduct periodic safety audits of Georgia-Pacific pulp and paper mills in light of the findings of this report. At a minimum, ensure that management systems are in place at the mills to: Evaluate process sewers where chemicals may collect and interact, and identify potential hazardous reaction scenarios to determine if safeguards are in place to decrease the likelihood or consequences of such interactions. Take into account sewer system connections and the ability to prevent inadvertent mixing of materials that could react to create a hazardous condition.


Status: C-ERA
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

2002-01-I-AL-2

Conduct periodic safety audits of Georgia-Pacific pulp and paper mills in light of the findings of this report. At a minimum, ensure that management systems are in place at the mills to: Identify areas of the mill where hydrogen sulfide (H2S) could be present or generated, and institute safeguards (including warning devices) to limit personnel exposure. Require that personnel working in the area are trained to recognize the presence of H2S and respond appropriately. Update emergency response plans for such areas to include procedures for decontaminating personnel exposed to toxic gas.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-01-I-AL-3

Conduct periodic safety audits of Georgia-Pacific pulp and paper mills in light of the findings of this report. At a minimum, ensure that management systems are in place at the mills to: Apply good engineering and process safety principles to process sewer systems. For instance, ensure that hazard reviews and management of change (MOC) analyses are completed when additions or changes are made where chemicals could collect and react in process sewers. (Such principles may be found in publications from the Center for Chemical Process Safety [CCPS].)


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-01-I-AL-4

Communicate the findings and recommendations of this report to the workforce and contractors at all Georgia-Pacific pulp and paper mills.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Georgia Pacific Naheola Mill
Georgia-Pacific Corp. Hydrogen Sulfide Poisoning
Open: 0%  |  Closed: 100%

Final Report Released On: November 20, 2002

2002-01-I-AL-5

Evaluate mill process sewer systems where chemicals may collect and react to identify potential hazardous reaction scenarios to determine if safeguards are in place to decrease the likelihood or consequences of such interactions. Evaluate sewer connections and ensure that materials that could react to create a hazardous condition are not inadvertently mixed, and that adequate mitigation measures are in place if such mixing does occur.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-01-I-AL-6

Establish programs to comply with recommendations from manufacturers of sodium hydrosulfide (NaSH) regarding its handling, such as preventing it from entering sewers because of the potential for acidic conditions.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-01-I-AL-7

Establish programs to require the proper design and maintenance of manway seals on closed sewers where hazardous materials are present.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2002-01-I-AL-8

Identify areas of the plant where hydrogen sulfide (H2S) could be present or generated, and institute safeguards (including warning devices) to limit personnel exposure. Institute a plan and procedures for dealing with potential H2S releases in these areas, and require that anyone who may be present is adequately trained on appropriate emergency response practices, including attempting rescue. Require contractors working in these areas to train their employees on the specific hazards of H2S, including appropriate emergency response practices.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2009-01-I-AL-9

Update the Naheola mill emergency response plan to include procedures for decontaminating personnel who are brought to the first-aid station. Include specific instructions for decontaminating personnel exposed to H2S so that they do not pose a secondary exposure threat to medical personnel.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Glendale Fire Department
DPC Enterprises Glendale Chlorine Release
Open: 7%  |  Closed: 93%

Final Report Released On: February 28, 2007

2004-2-I-AZ-7

Work with the Glendale Police Department to integrate them into the incident command structure during hazardous material incidents, and address communications issues, such as radio interoperability, to ensure the timely transmission of critical safety information to responding officers.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-2-I-AZ-8

Conduct hazardous materials exercises with the Glendale Police Department to identify and resolve police/fire integration issues. Coordinate exercise planning with the Arizona Division of Emergency Management Exercise Officer and with the Maricopa County LEPC. Schedule periodic hazardous materials incident drills to ensure safe and effective responses to future hazardous materials incidents.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Glendale Police Department
DPC Enterprises Glendale Chlorine Release
Open: 7%  |  Closed: 93%

Final Report Released On: February 28, 2007

2004-2-I-AZ-9

Work with the Glendale Fire Department to integrate the Glendale Police Department into the command structure during hazardous material incidents, and address communications issues, such as radio interoperability, to ensure the timely transmission of critical safety information to responding officers.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-2-I-AZ-10

Ensure that police officers responding to hazardous material incidents are briefed on specific incident conditions, and are equipped with and trained on the proper use, capabilities, and limitations of appropriate protective equipment.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-2-I-AZ-11

Ensure that police officers receive hazardous materials - operations level training, and annual hazardous materials and air purifying respirator (APR) refresher training.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-2-I-AZ-12

Conduct exercises with the Glendale Fire Department to identify and resolve police/fire integration issues. Coordinate exercise planning with the Arizona Division of Emergency Management Exercise Officer and with the Maricopa County LEPC. Schedule periodic hazardous materials incident drills to ensure safe and effective responses to future hazardous materials incidents.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Govenor and Legislature of the Commonwealth of Virginia
Allied Terminals Fertilizer Tank Collapse
Open: 60%  |  Closed: 40%

Final Report Released On: May 26, 2009

2009-3-I-VA-5

Require state regulation of 100,000-gallon and larger fertilizer storage tanks (which presently are located solely along and in the area of the Elizabeth River) or authorize local jurisdictions to regulate these tanks. The regulations should: 1) Address design, construction, maintenance, and inspection of 100,000-gallon and larger liquid fertilizer storage tanks, and 2) Incorporate generally recognized and accepted good engineering practice.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

Governor and Legislature of the State of California
Chevron Refinery Fire
Open: 100%  |  Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-9

Revise the California Code of Regulations, Title 8, Section 5189, Process Safety Management of Acutely Hazardous Materials, to require improvements to mechanical integrity and process hazard analysis programs for all California oil refineries. These improvements shall include engaging a diverse team of qualified personnel to perform a documented damage mechanism hazard review. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure safeguards are in place to control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safety systems to the greatest extent feasible into this review.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2012-03-I-CA-10

For all California oil refineries, identify and require the reporting of leading and lagging process safety indicators, such as the action item completion status of recommendations from damage mechanism hazard reviews, to state and local regulatory agencies that have chemical release prevention authority. These indicators shall be used to ensure that requirements described in 2012-03-I-CA-R9 are effective at improving mechanical integrity and process hazard analysis performance at all California oil refineries and preventing major chemical incidents.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2012-03-I-CA-11

Establish a multi-agency process safety regulatory program for all California oil refineries to improve the public accountability, transparency, and performance of chemical accident prevention and mechanical integrity programs. This program shall:

  1. Establish a system to report to the regulator the recognized methodologies, findings, conclusions and corrective actions related to refinery mechanical integrity inspection and repair work arising from Process Hazard Analyses, California oil refinery turnarounds and maintenance-related shutdowns;
  2. Require reporting of information such as damage mechanism hazard reviews, notice of upcoming maintenance-related shutdowns, records related to proposed and completed mechanical integrity work lists, and the technical rationale for any delay in work proposed but not yet completed;
  3. Establish procedures for greater workforce and public participation including the public reporting of information; and
  4. Provide mechanisms for federal, state and local agency operational coordination, sharing of data (including safety indicator data), and joint accident prevention activities. The California Department of Industrial Relations will be designated as the lead state agency for establishing a repository of joint investigative and inspection data, coordinating the sharing of data and joint accident prevention activities.

Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2012-03-I-CA-12

Require that Process Hazard Analyses required under California Code of Regulations, Title 8, Section 5189 Section (e) include documentation of the recognized methodologies, rationale and conclusions used to claim that safeguards intended to control hazards will be effective. This process shall use established qualitative, quantitative, and/or semi-quantitative methods such as Layers of Protection Analysis (LOPA).


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2012-03-I-CA-13

Require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new process, process unit rebuilds, significant process repairs and in the development of corrective actions from incident investigation recommendations.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2012-03-I-CA-14

Monitor and confirm the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R9 and 2012-03-I-CA-R10), so that all necessary mechanical integrity work at all California Chevron Refineries is identified and recommendations are completed in a timely way.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Governor and Legislature of the State of Connecticut
Kleen Energy Natural Gas Explosion
Open: 33%  |  Closed: 67%

Final Report Released On: June 28, 2010

2010-01-I-CT-16

Enact legislation applicable to power plants in the state that prohibits the use of flammable gas that is released to the atmosphere to clean fuel gas piping.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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2010-01-I-CT-17

Adopt the current version of NFPA 54 as amended pursuant to 2010-01-I-CT-R2.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

PDF Document Download

Governor and Legislature of the State of Florida
Bethune Point Wastewater Plant Explosion
Open: 23%  |  Closed: 77%

Final Report Released On: March 13, 2007

2006-3-I-FL-1

Enact legislation requiring state agencies and each political subdivision (i.e. counties and municipalities) of Florida to implement policies, practices, procedures, including chemical hazards covering the workplace health and safety of Florida public employees that are at least as effective as OSHA. Establish and fund a mechanism to ensure compliance with these standards. Consider legislation providing coverage of Florida public employees under an occupational safety and health program in accordance with Section 18(b) of the Occupational Safety and Health Act of 1970, and Code of Federal Regulations 29 CFR 1956.1.


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

2006-3-I-FL-2

Develop and fund a workplace safety and health consultation program for Florida public employees similar to the private sector program currently administered by the Florida Safety Consultation Program at the University of South Florida.


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

Governor and Legislature of the State of West Virginia
Little General Store Propane Explosion
Open: 17%  |  Closed: 83%

Final Report Released On: September 25, 2008

2007-4-I-WV-1

Require training and qualification of individuals who operate bulk propane plants, dispense and deliver propane, install and service propane systems, and install propane appliances. The training and qualification requirements should be comparable to those of existing propane industry programs such as the Certified Employee Training Program.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Governor of the State of Colorado
Xcel Energy Company Hydroelectric Tunnel Fire
Open: 55%  |  Closed: 45%

Final Report Released On: August 25, 2010

2008-01-I-CO-3

Implement, through the Division of Fire Safety, an accredited firefighter certification program for technical rescue that encompasses appropriate specialty areas including confined space rescue.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Governor of the State of Georgia
MFG Chemical Inc. Toxic Gas Release
Open: 44%  |  Closed: 56%

Final Report Released On: April 11, 2006

2004-9-I-GA-12

Clearly designate and define the roles of the agencies responsible for ensuring compliance with all sections of the SARA Title III (Emergency Planning and Community Right-to-Know Act) including review of Local Emergency Response Plans and accompanying attachments, such as standard operating procedures.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-9-I-GA-13

Designate a responsible agency and develop a system that will encourage and assist local authorities to obtain and use Risk Management Plans for those facilities that are required to develop this information to aid in the development of the site-specific emergency response plans.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

GP Chemical
MFG Chemical Inc. Toxic Gas Release
Open: 44%  |  Closed: 56%

Final Report Released On: April 11, 2006

2004-9-I-GA-5

Implement written procedures for tolling agreements using resources such as the CCPS book Process Safety in Outsourced Manufacturing Operations. Ensure that tolling agreements provide for: - Direct GPC involvement in new process development, including the detailed process hazard analysis and emergency planning, - Active participation in the first production run, as appropriate.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Hayes Lemmerz International, Huntington, Indiana
Hayes Lemmerz Dust Explosions and Fire
Open: 15%  |  Closed: 85%

Final Report Released On: September 27, 2005

2004-1-I-IN-1

Develop and implement a means of handling and processing aluminum chips that minimizes the risk of dust explosions. Refer to: 1. The Aluminum Association Pamphlet F-1, Guidelines for Handling Aluminum Fines Generated During Various Aluminum Fabricating Operations. 2. NFPA 484, Standard for Combustible Metals, Metal Powders, and Metal Dusts.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

2004-1-I-IN-2

Implement a program to provide regular training for all facility employees on the fire and explosion hazards of aluminum dust.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

2004-1-I-IN-3

Develop and implement policies and procedures for conducting engineering, hazard, and management of change (MOC) reviews of plant projects and modifications to support systems such as chip processing. In particular, ensure that a hazard analysis is conducted during the design phase, as well as during the engineering and construction phases, and when changes are made to the system.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

2004-1-I-IN-4

Implement a program to conduct management reviews of incidents and near-miss incidents, including duct fires and dust flashes. Apply this program to all plant areas, including support areas such as chip processing. Address the root causes of the incidents and near-misses and implement and track corrective measures.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

2004-1-I-IN-5

Develop and implement written operating procedures for chip processing and train all affected employees. Ensure that procedures address maintenance and housekeeping.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

Hayes-Lemmerz International (HLI)
Hayes Lemmerz Dust Explosions and Fire
Open: 15%  |  Closed: 85%

Final Report Released On: September 27, 2005

2004-1-I-IN-6

Conduct regular audits of all North American facilities that produce, process, or handle aluminum chips or dust, in light of the findings of this report. Emphasize engineering, hazard, and MOC reviews and compliance with NFPA-484. Ensure that: audits are documented and contain findings and recommendations, audit findings are shared with the work force at the facility, and audit recommendations are tracked and implemented.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

2004-1-I-IN-7

Communicate the findings and recommendations of this report to the work force at Hayes and other HLI facilities with similar operations.


Status: C-NLA
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

Herring Brothers Farm
Herrig Brothers Farm Propane Tank Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: June 23, 1999

1998-007-I-IA-1

Install protection (i.e., fencing or barricades) to protect aboveground propane pipes from possible damage from vehicles.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

1998-007-I-IA-2

Install properly sized propane outlet piping from excess flow valves.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

HMT Inspection, Inc.
Allied Terminals Fertilizer Tank Collapse
Open: 60%  |  Closed: 40%

Final Report Released On: May 26, 2009

2009-3-I-VA-8

Implement The Fertilizer Institute’s inspection guidelines as part of tank inspector training and inspection procedures for fertilizer tank inspection.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2009-3-I-VA-9

Revise company procedures to require tank inspectors to verify that radiography required as part of the calculation for a maximum liquid level has been performed.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Hoeganaes Corporation
Hoeganaes Corporation Fatal Flash Fires
Open: 85%  |  Closed: 15%

Final Report Released On: January 05, 2012

2011-4-I-TN-6

Conduct periodic independent audits of the Hoeganaes Gallatin facility for compliance with the following NFPA standards, using knowledgeable experts, and implement all recommended corrective actions:

  • NFPA 484, Standard for Combustible Metals, Metal Powders, and Metal Dusts
  • NFPA 499, Recommended Practice for the Classification of Combustible Dusts and of Hazardous Locations for Electrical Installations in Chemical Process Areas
  • NFPA 497, Recommended Practice for the Classification of Flammable Liquids, Gases, or Vapors and of Hazardous (Classified) Locations for Electrical Installations in Chemical Process Areas
  • NFPA 2, Hydrogen Technologies Code
  • NFPA 2113, Standard on Selection, Care, Use, and Maintenance of Flame-Resistant Garments for Protection of Industrial Personnel Against Flash Fire


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2011-4-I-TN-7

Develop training materials that address combustible dust and plant-specific metal dust hazards and train all employees and contractors. Require periodic (e.g., annual) refresher training for all employees and contractors.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2011-4-I-TN-8

Implement a preventive maintenance program and leak detection and leak mitigation procedures for all flammable gas piping and gas processing equipment.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2011-4-I-TN-9

Develop and implement a near-miss reporting and investigation policy that includes the following at a minimum:

  • Ensure facility-wide worker participation in reporting all near-miss events and operational disruptions (such as significant iron powder accumulations, smoldering fires, or unsafe conditions or practices) that could result in worker injury.
  • Ensure that the near-miss reporting program requires prompt investigations, as appropriate, and that results are promptly circulated throughout the Hoeganaes Corporation.
  • Establish roles and responsibilities for the management, execution, and resolution of all recommendations from near-miss investigations
  • Ensure the near-miss program is operational at all times (e.g. nights, weekends, holiday shifts).


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Honeywell Baton Rouge Facility
Honeywell Chemical Incidents
Open: 13%  |  Closed: 87%

Final Report Released On: August 08, 2005

2003-13-I-LA-1

Revise inspection and testing procedures to include effective methods for detecting and preventing leaks in coolers that use chlorine. These procedures should include the use of appropriate NDT methods.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-2

Analyze layers of protection installed to prevent possible consequences of failure of heat exchangers that use chlorine, and implement corrective actions as appropriate. Examples of additional measures include installing monitors on the coolant stream to detect the presence of chlorine, and determining the feasibility of operating the coolant stream at a pressure high enough to prevent the entry of chlorine in the event of a leak.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-3

To address ongoing issues regarding layers of protection and leaks in heat exchangers, revise procedures for performing process hazard analyses for equipment that contains hazardous materials such as chlorine to, at a minimum: - Require an evaluation of the effects of leaks in heat exchangers.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-4

To address ongoing issues regarding layers of protection and leaks in heat exchangers, revise procedures for performing process hazard analyses for equipment that contains hazardous materials such as chlorine to, at a minimum: - Consider the layers of protection necessary to prevent a catastrophic incident and require recommendations to be implemented when existing protection is inadequate.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-5

Revise the incident investigation procedure to ensure that odors inside positive pressure control rooms are investigated, the causes identified, and the appropriate corrective actions implemented. Address causes of the releases as well as entry of the material into the building.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-6

Survey units that handle chlorine, and evaluate the effectiveness of shutdown systems for detecting and preventing the release of chlorine. At a minimum, ensure that shutdown systems and procedures are integrated to stop all potential sources of chlorine.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-7

Conduct training to emphasize that MOC evaluations must consider whether emergency shutdown procedures need to be changed when there are changes in material inventory.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-8

Conduct a hazard analysis (such as a job safety analysis) in the ton-cylinder area, incorporate appropriate findings into unit operating procedures, and train personnel accordingly.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-9

Revise plant procedures on receiving cylinders to require that weights be recorded on incoming materials and suspicious materials be isolated so that hazardous materials are handled appropriately.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-10

Revise the personal protective equipment matrix to include requirements for specific activities, such as draining HF equipment. Refer to the HFIPI guidelines as appropriate.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-11

Develop and implement a program for the identification and management of hazards in nonroutine situations. Ensure that this program covers the following: - Situations where employees are unable to follow standard operating procedures, such as properly purging equipment.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-12

Develop and implement a program for the identification and management of hazards in nonroutine situations. Ensure that this program covers the following: - Circumstances where there is no specific formal procedure for handling a highly hazardous chemical.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-13

Develop and implement a program for the identification and management of hazards in nonroutine situations. Ensure that this program covers the following: - Operations following an emergency shutdown.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Honeywell International, Inc.
Honeywell Chemical Incidents
Open: 13%  |  Closed: 87%

Final Report Released On: August 08, 2005

2003-13-I-LA-14

Develop and implement corporate standards to ensure positive pressure control rooms, including the HVAC systems, are designed and maintained to prevent the short-term entry of hazardous materials. Implement corporate standard changes at the Baton Rouge facility, and other Honeywell facilities as appropriate.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-15

Develop and implement procedures for positively identifying material rejected by contractors such as C&MI so that hazardous materials are handled appropriately.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2003-13-I-LA-16

Develop and implement corporate standards for safely handling hydrogen fluoride.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-17

In light of the findings of this investigation report, conduct a comprehensive audit of fluorine-based manufacturing facilities in your Specialty Materials group facilities. Ensure that the audit addresses: Thoroughness of hazard analysis and adequacy of safeguards.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-18

In light of the findings of this investigation report, conduct a comprehensive audit of fluorine-based manufacturing facilities in your Specialty Materials group facilities. Ensure that the audit addresses: Recognition and management of nonroutine situations.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-19

In light of the findings of this investigation report, conduct a comprehensive audit of fluorine-based manufacturing facilities in your Specialty Materials group facilities. Ensure that the audit addresses: Adherence to standard operating procedures.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-20

In light of the findings of this investigation report, conduct a comprehensive audit of fluorine-based manufacturing facilities in your Specialty Materials group facilities. Implement the recommendations from the audit and communicate the findings to the work force.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2003-13-I-LA-21

Communicate the findings and recommendations of this report to your employees at fluorine-based manufacturing facilities in your Specialty Materials group.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Hydrogen Fluoride Industry Practices Institute (HFIPI)
Honeywell Chemical Incidents
Open: 13%  |  Closed: 87%

Final Report Released On: August 08, 2005

2003-13-I-LA-25

Conduct a survey of members to determine best industry practices for HF handling activities, such as draining equipment, use of open systems, and nonroutine work. Develop best practices guidance as appropriate and communicate it to your members.


Status: O-ARAR
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2003-13-I-LA-26

Communicate the findings and recommendations from the August 13 incident to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

ICC International Fuel Gas Code Committee Chair
ConAgra Natural Gas Explosion and Ammonia Release
Open: 0%  |  Closed: 100%

Final Report Released On: February 04, 2010

2010-12-I-NC-2

Incorporate the revised gas purging provisions of the National Fuel Gas Code, consistent with CSB recommendation 2009-12-I-NC-R1, into the International Fuel Gas Code


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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Imperial Sugar Company
Imperial Sugar Company Dust Explosion and Fire
Open: 9%  |  Closed: 91%

Final Report Released On: September 24, 2009

2008-05-I-GA-1

Apply the following standards to the design and operation of the new Port Wentworth facility:

  • NFPA 61: Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities
  • NFPA 499: Recommended Practice for the Classification of Combustible Dusts and Hazardous (Classified) Locations for Electrical Installations in Chemical Process Areas.
  • NFPA 654:Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. 
  • NFPA Handbook, Electrical Installations in Hazardous Locations. 
  • NFPA 70 Article 500:Hazardous (Classified) Locations.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2008-05-I-GA-2

Conduct a comprehensive review of all existing Imperial Sugar Company sugar manufacturing facilities against the standards listed in recommendation R1 and implement identified corrective actions.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2008-05-I-GA-3

Implement a corporate-wide comprehensive housekeeping program to control combustible dust accumulation that will ensure sugar dust, cornstarch dust, or other combustible dust does not accumulate to hazardous quantities on overhead horizontal surfaces, packing equipment, and floors.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2008-05-I-GA-4

Develop training materials that address combustible dust hazards and train all employees and contractors at all Imperial Sugar Company facilities. Require periodic (e.g., annual) refresher training for all employees and contractors.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2008-05-I-GA-5

Improve the emergency evacuation policies and procedures at the Port Wentworth facility; specifically,

  • Install an emergency alert (alarm) system in the facility, and
  • Require routine emergency evacuation drills and critiques.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Independant Lubricant Manufacturers Association (ILMA)
Third Coast Industries Petroleum Products Facility Fire
Open: 15%  |  Closed: 85%

Final Report Released On: March 06, 2003

2002-03-I-TX-6

Communicate the findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Indiana Department of Homeland Security
Hayes Lemmerz Dust Explosions and Fire
Open: 15%  |  Closed: 85%

Final Report Released On: September 27, 2005

2004-1-I-IN-10

Provide training for fire inspectors in Indiana jurisdictions on the recognition and prevention of aluminum dust explosion hazards.


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

Indiana Occupational Safety and Health Administration
Hayes Lemmerz Dust Explosions and Fire
Open: 15%  |  Closed: 85%

Final Report Released On: September 27, 2005

2004-1-I-IN-9

Develop and distribute an educational bulletin on the prevention of metal dust explosions.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Institute of Clean Air Companies (ICAC)
Sterigenics Ethylene Oxide Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: March 30, 2006

2004-11-I-CA-17

Communicate the findings and recommendations of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Institute of Makers of Explosives (IME)
Sierra Chemical Co. High Explosives Accident
Open: 0%  |  Closed: 100%

Final Report Released On: September 23, 1998

1998-001-I-NV-11

Develop and disseminate process and safety training guidelines for personnel involved in the manufacture of explosives that include methods for the demonstration and maintenance of proficiency.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

1998-001-I-NV-12

Distribute the CSB report on the incident at Sierra to IME member companies.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

1998-001-I-NV-13

Develop safety guidelines for the screening of reclaimed explosive materials.


Status: C-ERA
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

International Association of Fire Fighters (IAFF)
Improving Reactive Hazard Management
Open: 42%  |  Closed: 58%

Final Report Released On: September 17, 2002

2001-01-H-18

Communicate the findings and recommendations of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Third Coast Industries Petroleum Products Facility Fire
Open: 15%  |  Closed: 85%

Final Report Released On: March 06, 2003

2002-03-I-TX-10

Communicate the findings of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

International Brotherhood of Electrical Workers (IBEW)
Georgia-Pacific Corp. Hydrogen Sulfide Poisoning
Open: 0%  |  Closed: 100%

Final Report Released On: November 20, 2002

2002-01-I-AL-14

Communicate the findings and recommendations of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

International Brotherhood of Teamsters Local #5
Honeywell Chemical Incidents
Open: 13%  |  Closed: 87%

Final Report Released On: August 08, 2005

2003-13-I-LA-29

Work with Honeywell to communicate the findings and recommendations of this report to your members employed at the Honeywell Baton Rouge Facility.


Status: C-UA/NRR
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

International Code Council (ICC)
CAI / Arnel Chemical Plant Explosion
Open: 36%  |  Closed: 64%

Final Report Released On: May 13, 2008

2007-03-I-MA-11

Revise the International Fire Code: Chapter 20: - Specifically include "printing inks" in the definition of "organic coating." - Define equipment specifically discussed in the standard, such as open and closed kettles. - Require heated tanks and vessels containing flammable and combustible liquids to have equipment to prevent overheating, such as: devices to stop the heating process if the temperature exceeds the safe operating limits; devices to stop the heating process if the flammable vapor control equipment malfunctions (e.g., building ventilation system or heated tank vent); and a heating medium that is unable to heat the tank above safe operating temperatures. Chapters 20, 27, and 34: -Define "open", "closed", and "sealed and vented" process tanks. -Define "non-listed" process tanks. -Prohibit heating flammable and combustible liquids above their flashpoints in tanks inside buildings unless the tanks are sealed and vented to the building exterior.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

ConAgra Natural Gas Explosion and Ammonia Release
Open: 0%  |  Closed: 100%

Final Report Released On: February 04, 2010

2010-12-I-NC-2

Incorporate the revised gas purging provisions of the National Fuel Gas Code, consistent with CSB recommendation 2009-12-I-NC-R1, into the International Fuel Gas Code


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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CTA Acoustics Dust Explosion and Fire
Open: 0%  |  Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-20

Communicate the findings and recommendations of this report to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Hayes Lemmerz Dust Explosions and Fire
Open: 15%  |  Closed: 85%

Final Report Released On: September 27, 2005

2004-1-I-IN-20

Communicate findings, recommendations and sections applicable to fire codes and standards to your membership.


Status: C-AA
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Hoeganaes Corporation Fatal Flash Fires
Open: 85%  |  Closed: 15%

Final Report Released On: January 05, 2012

2011-4-I-TN-4

Revise IFC Chapter 22 Combustible Dust Producing Operations; Section 2204.1 Standards, to require mandatory compliance and enforcement with the detailed requirements of the NFPA standards cited in the chapter, including NFPA 484.


Status: O-ARE/AR
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Third Coast Industries Petroleum Products Facility Fire
Open: 15%  |  Closed: 85%

Final Report Released On: March 06, 2003

2002-03-I-TX-3

Revise the International Fire Code to address the following issues: