The CSB issues safety recommendations to prevent the recurrence or reduce the likelihood or consequences of similar incidents or hazards in the future. Recommendations are issued to a variety of parties, including government entities, safety organizations, trade unions, trade associations, corporations, emergency response organizations, educational institutions, and public interest groups. Recommendations are published in CSB reports and are closed only by vote of the Board. The CSB tracks all recommendations and communicates regularly with recommendations recipients to ensure that the recommended corrective actions are implemented. For more information, see Frequently Asked Questions about CSB recommendations.
2020-02-I-TX-4
Revise the Butadiene Product Stewardship Guidance Manual to include guidance on identifying and controlling or eliminating dead legs in high-purity butadiene service. Specifically, provide guidance on the potential for dead legs to be formed when equipment, such as primary or spare pumps, is out of service. In the Manual, also provide guidance on method(s) to identify dead legs that could be formed when equipment, such as primary or spare pumps, is temporarily or permanently out of service. Recommend actions to mitigate, control, and prevent hazardous popcorn polymer buildup in these in-process or temporary dead legs, such as through monitoring, use of inhibitor(s), or conducting maintenance activities to minimize the presence of dead legs. Status: Open - Awaiting Response or Evaluation/Approval of Response
Revise the Butadiene Product Stewardship Guidance Manual to include guidance on identifying and controlling or eliminating dead legs in high-purity butadiene service. Specifically, provide guidance on the potential for dead legs to be formed when equipment, such as primary or spare pumps, is out of service. In the Manual, also provide guidance on method(s) to identify dead legs that could be formed when equipment, such as primary or spare pumps, is temporarily or permanently out of service. Recommend actions to mitigate, control, and prevent hazardous popcorn polymer buildup in these in-process or temporary dead legs, such as through monitoring, use of inhibitor(s), or conducting maintenance activities to minimize the presence of dead legs.
2020-02-I-TX-5
Revise the Butadiene Product Stewardship Guidance Manual to provide guidance on a methodology to help identify what should be considered excessive or dangerous amounts of popcorn polymer in a unit. Provide mitigation strategies that describe the actions that owner/operators should take during those polymer excursions to control or eliminate the popcorn polymer to reduce the likelihood of popcorn polymer-induced process loss of containment. Status: Open - Awaiting Response or Evaluation/Approval of Response
Revise the Butadiene Product Stewardship Guidance Manual to provide guidance on a methodology to help identify what should be considered excessive or dangerous amounts of popcorn polymer in a unit. Provide mitigation strategies that describe the actions that owner/operators should take during those polymer excursions to control or eliminate the popcorn polymer to reduce the likelihood of popcorn polymer-induced process loss of containment.
2020-02-I-TX-1
For all TPC PNO terminal operations in high-purity butadiene service (e.g., greater than 80 percent butadiene concentration), develop and implement a program to identify and control, or eliminate, dead legs. At a minimum, the program must require: a) a comprehensive review of equipment configurations in high-purity butadiene service using both Piping and Instrumentation Diagrams (P&IDs) and field evaluations to identify all permanent dead legs. Implement a process to identify changes in operating conditions in high-purity butadiene service that could result in the formation of temporary or new permanent dead legs, such as when primary or spare pumps are temporarily or permanently out of service. Ensure this review is conducted at least every five years; b) evaluation and implementation of design strategies, where practical, to prevent dead legs in areas susceptible to popcorn polymer formation; c) mitigation, control, or prevention of hazardous popcorn polymer buildup in all identified dead legs in high-purity butadiene service, such as through increased monitoring, flushing of equipment, use of inhibitor(s), or planning maintenance activities to minimize the amount of time that a temporary dead leg is present; and d) periodic continual auditing (at a minimum annually) by TPC PNO management to ensure that the process is being implemented. Status: Closed - Acceptable Action
For all TPC PNO terminal operations in high-purity butadiene service (e.g., greater than 80 percent butadiene concentration), develop and implement a program to identify and control, or eliminate, dead legs. At a minimum, the program must require:
a) a comprehensive review of equipment configurations in high-purity butadiene service using both Piping and Instrumentation Diagrams (P&IDs) and field evaluations to identify all permanent dead legs. Implement a process to identify changes in operating conditions in high-purity butadiene service that could result in the formation of temporary or new permanent dead legs, such as when primary or spare pumps are temporarily or permanently out of service. Ensure this review is conducted at least every five years;
b) evaluation and implementation of design strategies, where practical, to prevent dead legs in areas susceptible to popcorn polymer formation;
c) mitigation, control, or prevention of hazardous popcorn polymer buildup in all identified dead legs in high-purity butadiene service, such as through increased monitoring, flushing of equipment, use of inhibitor(s), or planning maintenance activities to minimize the amount of time that a temporary dead leg is present; and
d) periodic continual auditing (at a minimum annually) by TPC PNO management to ensure that the process is being implemented.
2020-02-I-TX-2
For all TPC PNO terminal operations, passivate all storage vessels, fixed equipment, and associated piping systems in high-purity butadiene service consistent with industry good practice guidance. Status: Closed - Acceptable Action
For all TPC PNO terminal operations, passivate all storage vessels, fixed equipment, and associated piping systems in high-purity butadiene service consistent with industry good practice guidance.
2020-02-I-TX-3
At the TPC PNO facility, incorporate the recording of any paper-based process performance information into TPC PNO’s existing electronic records management system so that the information can be reliably retained, retrieved, and analyzed in the event of a catastrophic incident. At a minimum, those records shall include Dead Leg Inspection check sheets, Spare Pump Rotation check sheets, and handwritten logs documenting the performance of all critical process instrumentation (e.g., the oxygen analyzer). Status: Closed - Acceptable Action
At the TPC PNO facility, incorporate the recording of any paper-based process performance information into TPC PNO’s existing electronic records management system so that the information can be reliably retained, retrieved, and analyzed in the event of a catastrophic incident. At a minimum, those records shall include Dead Leg Inspection check sheets, Spare Pump Rotation check sheets, and handwritten logs documenting the performance of all critical process instrumentation (e.g., the oxygen analyzer).
2021-04-I-OH-6
Develop specific design, construction, and alteration guidance for low-pressure process vessels in flammable and other highly hazardous chemicals service not exceeding an internal pressure of 15 psig in API 510 Pressure Vessel Inspection Code, API RP 572 Inspection Practices for Pressure Vessels, and/or other appropriate products. At a minimum, include guidance for: (i) determining and documenting the low-pressure vessel’s design pressure (such as through a data sheet and a nameplate affixed to the vessel); (ii) determining when or if all or parts of the ASME Boiler and Pressure Vessel Code should be applied; (iii) acceptable alternative engineering methods, if applicable; and, (iv) alteration requirements, such as design assessments, inspections, and pressure testing. Status: Open - Awaiting Response or Evaluation/Approval of Response
Develop specific design, construction, and alteration guidance for low-pressure process vessels in flammable and other highly hazardous chemicals service not exceeding an internal pressure of 15 psig in API 510 Pressure Vessel Inspection Code, API RP 572 Inspection Practices for Pressure Vessels, and/or other appropriate products. At a minimum, include guidance for:
(i) determining and documenting the low-pressure vessel’s design pressure (such as through a data sheet and a nameplate affixed to the vessel);
(ii) determining when or if all or parts of the ASME Boiler and Pressure Vessel Code should be applied;
(iii) acceptable alternative engineering methods, if applicable; and,
(iv) alteration requirements, such as design assessments, inspections, and pressure testing.
2021-04-I-OH-7
Assist API in developing design, construction, and alteration guidance for low-pressure vessels in flammable and other highly hazardous chemicals service not exceeding an internal pressure of 15 psig. If any new design and construction guidance is specifically developed for pressure vessels in flammable and other highly hazardous chemicals service not exceeding an internal pressure of 15 psig, reference the design and construction guidance in the Section VIII, Division 1 of the ASME Boiler and Pressure Vessel Code (BPVC). Status: Open - Awaiting Response or Evaluation/Approval of Response
Assist API in developing design, construction, and alteration guidance for low-pressure vessels in flammable and other highly hazardous chemicals service not exceeding an internal pressure of 15 psig. If any new design and construction guidance is specifically developed for pressure vessels in flammable and other highly hazardous chemicals service not exceeding an internal pressure of 15 psig, reference the design and construction guidance in the Section VIII, Division 1 of the ASME Boiler and Pressure Vessel Code (BPVC).
2021-04-I-OH-1
Update mechanical integrity procedures for all process vessels in highly hazardous chemicals service, including pressure vessels not exceeding 15 psig, to adopt alteration guidance in API 510 Pressure Vessel Inspection Code or Part 3 of the National Board Inspection Code. Status: Open - Awaiting Response or Evaluation/Approval of Response
Update mechanical integrity procedures for all process vessels in highly hazardous chemicals service, including pressure vessels not exceeding 15 psig, to adopt alteration guidance in API 510 Pressure Vessel Inspection Code or Part 3 of the National Board Inspection Code.
2021-04-I-OH-2
Assess and document applicable design, construction, and alteration standards for all pressure vessels in highly hazardous chemicals service in new resin plant designs, including pressure vessels not exceeding 15 psig. At a minimum, adopt PIP VESLP001 Low-Pressure, Welded Vessel Specification as design and construction guidance for pressure vessels not exceeding 15 psig. Implement a program to assess the pressure vessels against updated applicable recognized and generally accepted good engineering practices, such as those published by API, ASME, PIP, and other organizations, at least once every five years, and address the gaps identified. Develop and implement written procedures to document and maintain records of (i) all inspections of, (ii) all alterations to, and (iii) all maintenance and repairs on all pressure vessels in highly hazardous chemicals service. Status: Open - Awaiting Response or Evaluation/Approval of Response
Assess and document applicable design, construction, and alteration standards for all pressure vessels in highly hazardous chemicals service in new resin plant designs, including pressure vessels not exceeding 15 psig. At a minimum, adopt PIP VESLP001 Low-Pressure, Welded Vessel Specification as design and construction guidance for pressure vessels not exceeding 15 psig. Implement a program to assess the pressure vessels against updated applicable recognized and generally accepted good engineering practices, such as those published by API, ASME, PIP, and other organizations, at least once every five years, and address the gaps identified. Develop and implement written procedures to document and maintain records of (i) all inspections of, (ii) all alterations to, and (iii) all maintenance and repairs on all pressure vessels in highly hazardous chemicals service.
2021-04-I-OH-3
Demonstrate the use of prevention through design using the hierarchy of controls in future resin plant designs. Specifically, prioritize inherently safer design and engineering controls to prevent process safety events. Refer to sources such as Safety Instrumented Systems: A Life-Cycle Approach by P. Gruhn and S. Lucchini, Human Error in Process Plant Design and Operations – A Practitioner’s Guide by J. Robert Taylor, Guidelines for Preventing Human Error in Process Safety by the Center for Chemical Process Safety (CCPS), Guidelines for Inherently Safer Chemical Processes – A Life Cycle Approach by the CCPS, and Guidelines for Risk Based Process Safety by the CCPS for guidance. Demonstration could include documentation of conceptual design safety reviews, hazard analysis and risk assessments of detailed project designs, and a plan to address the recommendations to control the hazards. Status: Open - Awaiting Response or Evaluation/Approval of Response
Demonstrate the use of prevention through design using the hierarchy of controls in future resin plant designs. Specifically, prioritize inherently safer design and engineering controls to prevent process safety events. Refer to sources such as Safety Instrumented Systems: A Life-Cycle Approach by P. Gruhn and S. Lucchini, Human Error in Process Plant Design and Operations – A Practitioner’s Guide by J. Robert Taylor, Guidelines for Preventing Human Error in Process Safety by the Center for Chemical Process Safety (CCPS), Guidelines for Inherently Safer Chemical Processes – A Life Cycle Approach by the CCPS, and Guidelines for Risk Based Process Safety by the CCPS for guidance. Demonstration could include documentation of conceptual design safety reviews, hazard analysis and risk assessments of detailed project designs, and a plan to address the recommendations to control the hazards.
2021-04-I-OH-4
Identify and document all equipment that could release flammable materials and install LEL detectors in accordance with sources and guidance such as Guidelines for Engineering Design for Process Safety by the Center for Chemical Process Safety and Explosion Hazards in the Process Industries by Rolf K. Eckhoff. Ensure that detection of hazardous conditions automatically triggers both visual and audible alarms to alert plant personnel of the hazard. Develop and implement employee training on actions to take, such as prompt evacuation, when such alarms are activated. Status: Open - Awaiting Response or Evaluation/Approval of Response
Identify and document all equipment that could release flammable materials and install LEL detectors in accordance with sources and guidance such as Guidelines for Engineering Design for Process Safety by the Center for Chemical Process Safety and Explosion Hazards in the Process Industries by Rolf K. Eckhoff. Ensure that detection of hazardous conditions automatically triggers both visual and audible alarms to alert plant personnel of the hazard. Develop and implement employee training on actions to take, such as prompt evacuation, when such alarms are activated.
2021-04-I-OH-5
Develop and implement requirements for personnel to wear flame-resistant uniforms in all operating areas that process flammable chemicals. Update employee training material to include the requirement for and purpose of PPE use. Status: Open - Awaiting Response or Evaluation/Approval of Response
Develop and implement requirements for personnel to wear flame-resistant uniforms in all operating areas that process flammable chemicals. Update employee training material to include the requirement for and purpose of PPE use.
2019-03-I-IL-1
Develop hazardous gas detection and alarm programs and associated procedures based on manufacturer specifications, current codes, standards, and industry good practice guidance, for all hazardous gases that could be released near workers, including hydrogen. The program must address proper installation, calibration, inspection, maintenance, training, and routine operations. Ensure such hazardous gas detection and alarm systems are functional at all times. Status: Closed - Acceptable Action
Develop hazardous gas detection and alarm programs and associated procedures based on manufacturer specifications, current codes, standards, and industry good practice guidance, for all hazardous gases that could be released near workers, including hydrogen. The program must address proper installation, calibration, inspection, maintenance, training, and routine operations. Ensure such hazardous gas detection and alarm systems are functional at all times.
2019-03-I-IL-2
Establish a safety management system that addresses process safety at the AB Specialty Waukegan, Illinois facility. Include in that system elements recommended in industry guidance publications, including Center for Chemical Process Safety (CCPS) publications Guidelines for Risk Based Process Safety and Guidelines for Implementing Process Safety Management. Status: Closed - Acceptable Action
Establish a safety management system that addresses process safety at the AB Specialty Waukegan, Illinois facility. Include in that system elements recommended in industry guidance publications, including Center for Chemical Process Safety (CCPS) publications Guidelines for Risk Based Process Safety and Guidelines for Implementing Process Safety Management.
2019-03-I-IL-3
Incorporate into operations and activities at AB Specialty the specific elements recommended in CCPS’s Essential Practices for Managing Chemical Reactivity Hazards, which are: 1. Put into place a system to manage chemical reactivity hazards 2. Collect reactivity hazard information 3. Identify chemical reactivity hazards 4. Test for chemical reactivity 5. Assess chemical reactivity risks 6. Identify and implement process controls and risk management options 7. Document chemical reactivity risks and management decisions 8. Communicate and train on chemical reactivity hazards 9. Investigate chemical reactivity incidents 10. Review, audit, manage change in, and improve hazard management practices and programs. Status: Closed - Acceptable Action
Incorporate into operations and activities at AB Specialty the specific elements recommended in CCPS’s Essential Practices for Managing Chemical Reactivity Hazards, which are:
1. Put into place a system to manage chemical reactivity hazards
2. Collect reactivity hazard information
3. Identify chemical reactivity hazards
4. Test for chemical reactivity
5. Assess chemical reactivity risks
6. Identify and implement process controls and risk management options
7. Document chemical reactivity risks and management decisions
8. Communicate and train on chemical reactivity hazards
9. Investigate chemical reactivity incidents
10. Review, audit, manage change in, and improve hazard management practices and programs.
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: Closed - No Longer Applicable
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.
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: Closed - No Longer Applicable
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.
2005-3-I-NJ-5
Update the OSHA 1910.102 Acetylene Standard (a. Cylinders, b. Piped Systems, and c. Generators and filling cylinders) to remove the existing references to unavailable and obsolete Compressed Gas Association Pamphlets (CGA G-1-1966, G 1.3-1959, G 1.4-1966). As an alternative, consider incorporating by reference NFPA 51A Standard for Acetylene Cylinder Charging Plants. Status: Closed - Acceptable Action
Update the OSHA 1910.102 Acetylene Standard (a. Cylinders, b. Piped Systems, and c. Generators and filling cylinders) to remove the existing references to unavailable and obsolete Compressed Gas Association Pamphlets (CGA G-1-1966, G 1.3-1959, G 1.4-1966). As an alternative, consider incorporating by reference NFPA 51A Standard for Acetylene Cylinder Charging Plants.
2005-3-I-NJ-3
Immediately inform existing acetylene generator users that the check valve did not prevent acetylene gas backflow in this incident. Recommend interim actions be taken to ensure that Rexarc check valves in service on acetylene production equipment will operate reliably. Status: Closed - Acceptable Action
Immediately inform existing acetylene generator users that the check valve did not prevent acetylene gas backflow in this incident. Recommend interim actions be taken to ensure that Rexarc check valves in service on acetylene production equipment will operate reliably.
2005-3-I-NJ-4
Replace check valves of this or similar design supplied by Rexarc with valves that will perform more reliably in recycle water service. Status: Closed - Acceptable Action
Replace check valves of this or similar design supplied by Rexarc with valves that will perform more reliably in recycle water service.
2016-04-I-FL-5
Provide effective warning about nitrous oxide decomposition hazards Modify nitrous oxide pump product literature to include warnings about nitrous oxide decomposition hazards, illustrated by examples from historical incidents, and refer users to this CSB investigation report for additional information. Status: Closed - Acceptable Action
Provide effective warning about nitrous oxide decomposition hazards
Modify nitrous oxide pump product literature to include warnings about nitrous oxide decomposition hazards, illustrated by examples from historical incidents, and refer users to this CSB investigation report for additional information.
2016-04-I-FL-1
The goal of 2016-04-I-FL-R1 is to prevent all nitrous oxide explosions at its facilities, while preventing harm to workers and the public. Following the August 28, 2016, incident, the company began a comprehensive initiative to review its nitrous oxide production facilities, trucking fleet, and cylinder-filling operations. The scope of the ongoing Air Liquide initiative is shown in Table 1. Complete the development and implementation of the company’s nitrous oxide business process safety initiative as shown in Table 1, consistent with the findings, conclusions, and recommendations contained in this report. Status: Closed - Exceeds Recommended Action
The goal of 2016-04-I-FL-R1 is to prevent all nitrous oxide explosions at its facilities, while preventing harm to workers and the public.
Following the August 28, 2016, incident, the company began a comprehensive initiative to review its nitrous oxide production facilities, trucking fleet, and cylinder-filling operations. The scope of the ongoing Air Liquide initiative is shown in Table 1.
Complete the development and implementation of the company’s nitrous oxide business process safety initiative as shown in Table 1, consistent with the findings, conclusions, and recommendations contained in this report.
2016-04-I-FL-2
Safety Management System for Nitrous Oxide Manufacturing Develop and implement a safety management system standard for nitrous oxide manufacturing, to manage known process safety hazards, including nitrous oxide decomposition, which includes appropriate elements based on chemical industry good practice guidance, such as CCPS Guidelines for Risk Based Process Safety, Essential Practices for Managing Chemical Reactivity Hazards, and Guidelines for Implementing Process Safety Management. Status: Closed - Exceeds Recommended Action
Safety Management System for Nitrous Oxide Manufacturing
Develop and implement a safety management system standard for nitrous oxide manufacturing, to manage known process safety hazards, including nitrous oxide decomposition, which includes appropriate elements based on chemical industry good practice guidance, such as CCPS Guidelines for Risk Based Process Safety, Essential Practices for Managing Chemical Reactivity Hazards, and Guidelines for Implementing Process Safety Management.
2016-04-I-FL-3
Ensure Effective Flame Arrestor Design Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to require testing of safety devices, such as strainers used as flame arrestors, for applications where a safety device is used to quench a nitrous oxide decomposition reaction. To ensure that these safety devices meet the intended purpose, the user should test the safety device by simulating conditions of use. In addition, require users to document the required performance standard or test protocol followed. Status: Closed - Acceptable Alternative Action
Ensure Effective Flame Arrestor Design
Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to require testing of safety devices, such as strainers used as flame arrestors, for applications where a safety device is used to quench a nitrous oxide decomposition reaction. To ensure that these safety devices meet the intended purpose, the user should test the safety device by simulating conditions of use. In addition, require users to document the required performance standard or test protocol followed.
2016-04-I-FL-4
Require Pump Run-Dry Safety Interlocks Apply ISA-84 Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to reference and require applying International Society of Automation (ISA) standard ISA-84, Functional Safety: Safety Instrumented Systems for the Process Industry Sector to safety interlocks such as the nitrous oxide pump “run-dry” shutdown. Status: Closed - Acceptable Action
Require Pump Run-Dry Safety Interlocks Apply ISA-84
Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to reference and require applying International Society of Automation (ISA) standard ISA-84, Functional Safety: Safety Instrumented Systems for the Process Industry Sector to safety interlocks such as the nitrous oxide pump “run-dry” shutdown.
2016-04-I-FL-6
2011-3-I-WV-1
For all new and existing equipment and operations at AL Solutions facilities that process combustible dusts or powders, apply the following chapters of NFPA 484-2012, Standard for Combustible Metals: Chapter 12, Titanium Chapter 13, Zirconium Chapter 15, Fire Prevention, Fire Protection, and Emergency Response Chapter 16, Combustible Metal Recycling Facilities Status: Closed - Unacceptable Action/No Response Received
For all new and existing equipment and operations at AL Solutions facilities that process combustible dusts or powders, apply the following chapters of NFPA 484-2012, Standard for Combustible Metals:
2011-3-I-WV-2
Develop training materials that address combustible dust hazards and plant-specific metal dust hazards and then train all employees and contractors. Require periodic (e.g., annual) refresher training for all employees and contractors. Status: Closed - Unacceptable Action/No Response Received
Develop training materials that address combustible dust hazards and plant-specific metal dust hazards and then train all employees and contractors. Require periodic (e.g., annual) refresher training for all employees and contractors.
2011-3-I-WV-3
Prohibit the use of sprinkler systems and water deluge systems in all buildings that process or store combustible metals. Status: Closed - Unacceptable Action/No Response Received
Prohibit the use of sprinkler systems and water deluge systems in all buildings that process or store combustible metals.
2011-3-I-WV-4
Conduct a process hazard analysis as defined in NFPA 484-2012, Section 12.2.5, and submit a copy to the local fire department or the enforcing authority for the fire code. Status: Closed - Unacceptable Action/No Response Received
Conduct a process hazard analysis as defined in NFPA 484-2012, Section 12.2.5, and submit a copy to the local fire department or the enforcing authority for the fire code.