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.
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: Closed - Acceptable Action
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.
2002-01-I-AL-13
Communicate the findings and recommendations of this report to your membership. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to your membership.
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: Closed - Acceptable Action
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.
2002-01-I-AL-2
Communicate the findings and recommendations of this report to those employees who haul or handle sodium hydrosulfide Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to those employees who haul or handle sodium hydrosulfide
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: Closed - Exceeds Recommended Action
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.
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: Closed - Acceptable Action
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.
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: Closed - Acceptable Action
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].)
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: Closed - Acceptable Action
Communicate the findings and recommendations of this report to the workforce and contractors at all Georgia-Pacific pulp and paper mills.
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: Closed - Acceptable Action
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.
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: Closed - Acceptable Action
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.
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: Closed - Acceptable Action
Establish programs to require the proper design and maintenance of manway seals on closed sewers where hazardous materials are present.
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: Closed - Acceptable Action
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.
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: Closed - Acceptable Action
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.
2002-01-I-AL-14
2009-01-I-AL-15
2009-01-I-AL-16
Communicate the findings and recommendations of this report to your membership. Status: Closed - No Longer Applicable
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: Closed - Unacceptable Action/No Response Received
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.
2004-1-I-IN-13
Communicate the findings and recommendations of this report to your members Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to your members
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: Closed - Reconsidered/Superseded
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.
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: Closed - No Longer Applicable
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.
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: Closed - No Longer Applicable
Communicate the findings and recommendations of this report to the work force at Hayes and other HLI facilities with similar operations.
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: Closed - No Longer Applicable
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.
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: Closed - No Longer Applicable
Implement a program to provide regular training for all facility employees on the fire and explosion hazards of aluminum dust.
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: Closed - No Longer Applicable
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.
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: Closed - No Longer Applicable
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.
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: Closed - No Longer Applicable
Develop and implement written operating procedures for chip processing and train all affected employees. Ensure that procedures address maintenance and housekeeping.
2004-1-I-IN-10
Provide training for fire inspectors in Indiana jurisdictions on the recognition and prevention of aluminum dust explosion hazards. Status: Closed - Unacceptable Action/No Response Received
Provide training for fire inspectors in Indiana jurisdictions on the recognition and prevention of aluminum dust explosion hazards.
2004-1-I-IN-9
Develop and distribute an educational bulletin on the prevention of metal dust explosions. Status: Closed - Acceptable Action
Develop and distribute an educational bulletin on the prevention of metal dust explosions.
2004-1-I-IN-20
Communicate findings, recommendations and sections applicable to fire codes and standards to your membership. Status: Closed - Acceptable Action
Communicate findings, recommendations and sections applicable to fire codes and standards to your membership.
2004-1-I-IN-16
Communicate the findings and recommendations of this report to your membership who work in facilities with similar combustible dust hazards. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to your membership who work in facilities with similar combustible dust hazards.
2004-1-I-IN-18
2004-1-I-IN-19
2004-1-I-IN-15
2004-1-I-IN-8
Communicate the findings and recommendations of this investigation to owners/operators of facilities to which Premelt supplies similar aluminum chip-melting systems. Include in your communication specific information that the chip drying process liberates small particles of aluminum, and that such particles may be explosive. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this investigation to owners/operators of facilities to which Premelt supplies similar aluminum chip-melting systems. Include in your communication specific information that the chip drying process liberates small particles of aluminum, and that such particles may be explosive.
2004-1-I-IN-14
2004-1-I-IN-17
1998-007-I-IA-7
Ensure that fire fighter training materials address proper response procedures for BLEVEs. Status: Closed - Acceptable Action
Ensure that fire fighter training materials address proper response procedures for BLEVEs.
1998-007-I-IA-1
Install protection (i.e., fencing or barricades) to protect aboveground propane pipes from possible damage from vehicles. Status: Closed - Acceptable Action
Install protection (i.e., fencing or barricades) to protect aboveground propane pipes from possible damage from vehicles.
1998-007-I-IA-2
Install properly sized propane outlet piping from excess flow valves. Status: Closed - Acceptable Action
Install properly sized propane outlet piping from excess flow valves.
1998-007-I-IA-3
Develop a program to ensure implementation of the requirements of the National Fire Protection Association's NFPA-58 Standard for the Storage and Handling of Liquefied Petroleum Gases, as adopted by Iowa law. Ensure that this program includes, at a minimum the following element: Designation by regulation of the party (such as a facility owner or installer) who is responsible for submitting planned construction or modification documents to the State Fire Marshall. Status: Closed - Acceptable Action
Develop a program to ensure implementation of the requirements of the National Fire Protection Association's NFPA-58 Standard for the Storage and Handling of Liquefied Petroleum Gases, as adopted by Iowa law. Ensure that this program includes, at a minimum the following element: Designation by regulation of the party (such as a facility owner or installer) who is responsible for submitting planned construction or modification documents to the State Fire Marshall.
1998-007-I-IA-4
Develop a program to ensure implementation of the requirements of the National Fire Protection Association's NFPA-58 Standard for the Storage and Handling of Liquefied Petroleum Gases, as adopted by Iowa law. Ensure that this program includes, at a minimum, the following elements: · Procedures for approving the plans for new or modified installations Status: Closed - Acceptable Action
Develop a program to ensure implementation of the requirements of the National Fire Protection Association's NFPA-58 Standard for the Storage and Handling of Liquefied Petroleum Gases, as adopted by Iowa law. Ensure that this program includes, at a minimum, the following elements: · Procedures for approving the plans for new or modified installations
1998-007-I-IA-5
Develop a program to ensure implementation of the requirements of the National Fire Protection Association's NFPA-58 Standard for the Storage and Handling of Liquefied Petroleum Gases, as adopted by Iowa law. Ensure that this program includes, at a minimum, the following elements: Procedures governing the issuance and posting of permits authorizing the use of equipment Status: Closed - Acceptable Action
Develop a program to ensure implementation of the requirements of the National Fire Protection Association's NFPA-58 Standard for the Storage and Handling of Liquefied Petroleum Gases, as adopted by Iowa law. Ensure that this program includes, at a minimum, the following elements: Procedures governing the issuance and posting of permits authorizing the use of equipment
1998-007-I-IA-6
Develop a program to ensure implementation of the requirements of the National Fire Protection Association's NFPA-58 Standard for the Storage and Handling of Liquefied Petroleum Gases, as adopted by Iowa law. Ensure that this program includes, at a minimum, the following elements: · On-site inspections of new, modified, and existing propane and other Liquefied Petroleum Gas storage facilities that are covered by Iowa state law. Status: Closed - Unacceptable Action/No Response Received
Develop a program to ensure implementation of the requirements of the National Fire Protection Association's NFPA-58 Standard for the Storage and Handling of Liquefied Petroleum Gases, as adopted by Iowa law. Ensure that this program includes, at a minimum, the following elements: · On-site inspections of new, modified, and existing propane and other Liquefied Petroleum Gas storage facilities that are covered by Iowa state law.
1998-007-I-IA-8
Ensure that fire fighter-training materials address proper response procedures for BLEVEs. Status: Closed - Acceptable Action
Ensure that fire fighter-training materials address proper response procedures for BLEVEs.
1998-007-I-IA-9
Distribute the CSB findings and recommendations in this report to NPGA members. Status: Closed - Acceptable Action
Distribute the CSB findings and recommendations in this report to NPGA members.
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: Closed - Unacceptable Action/No Response Received
Require all facilities covered by IFC Chapter 13 (2006 edition) to conform to NFPA standards for combustible dusts including NFPA 484.
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: Closed - Acceptable Action
Ensure that all industrial facilities in the City of Gallatin are inspected periodically against the International Fire Code. All facility inspections shall be documented.
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: Closed - Acceptable Action
Implement a program to ensure that fire inspectors and response personnel are trained to recognize and address combustible dust hazards.
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: Closed - Unacceptable Action/No Response Received
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:
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: Closed - Unacceptable Action/No Response Received
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.
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: Closed - Unacceptable Action/No Response Received
Implement a preventive maintenance program and leak detection and leak mitigation procedures for all flammable gas piping and gas processing equipment.
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: Closed - Unacceptable Action/No Response Received
Develop and implement a near-miss reporting and investigation policy that includes the following at a minimum:
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: Closed - Acceptable Action
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.
2011-4-I-TN-10
Communicate the findings of this report to all your members, e.g. through a safety article in an upcoming monthly newsletter. Status: Closed - Acceptable Action
Communicate the findings of this report to all your members, e.g. through a safety article in an upcoming monthly newsletter.
2011-4-I-TN-1
(Superseded by 2017-07-I-WI-R10 from the Didion Milling Co. investigation) Ensure that the forthcoming OSHA Combustible Dust Standard includes coverage for combustible metal dusts including iron and steel powders. Status: Closed - Reconsidered/Superseded
(Superseded by 2017-07-I-WI-R10 from the Didion Milling Co. investigation)
Ensure that the forthcoming OSHA Combustible Dust Standard includes coverage for combustible metal dusts including iron and steel powders.
2011-4-I-TN-2
(Superseded by 2017-07-I-WI-R10 from the Didion Milling Co. investigation) Develop and publish a proposed combustible dust standard for general industry within one year of the approval of this case study. Status: Closed - Reconsidered/Superseded
Develop and publish a proposed combustible dust standard for general industry within one year of the approval of this case study.
2011-4-I-TN-3
Revise the Combustible Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities nationwide under these codes to inform them of the hazards of combustible metal dusts and NEP coverage. Status: Closed - Acceptable Alternative Action
Revise the Combustible Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities nationwide under these codes to inform them of the hazards of combustible metal dusts and NEP coverage.
2011-4-I-TN-5
Revise the state-adopted Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities statewide under these codes to inform them of the hazards of combustible metal dusts and NEP coverage. Status: Closed - Acceptable Action
Revise the state-adopted Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities statewide under these codes to inform them of the hazards of combustible metal dusts and NEP coverage.