Recommendations

2020-01-I-TX-1

For all waterflood stations where the potential exists to expose workers or non-employees to H2S concentrations at or above 10 ppm, mandate the use of personal H2S detection devices as an integral part of every employee or visitor personal protective equipment (PPE) kit prior to entering the vicinity of the facility. Ensure detector use is in accordance with manufacturer specifications.

2020-01-I-TX-2

For all Aghorn facilities, develop a site-specific, formalized and comprehensive Lockout / Tagout program, to include policies, procedures, and training, to protect workers from energized equipment hazards, such as exposure to H2S. Ensure the program meets the requirements outlined in 29 CFR 1910.147 and includes energy control procedures, training, and periodic inspections.

2020-01-I-TX-3

For all waterflood stations where the potential exists to expose workers to H2S concentrations at or above 10 ppm, commission an independent and comprehensive analysis of each facility design vis-à-vis ventilation and mitigation systems to ensure that, in the event of an accidental release, workers are protected from exposure to toxic gas levels.

2020-01-I-TX-4

For all waterflood stations where the potential exists to expose workers or non-employees to H2S concentrations at or above 10 ppm, develop and demonstrate the use of a safety management program that includes a focus on protecting workers and non-employees from H2S. This program should include risk identification, assessment, mitigation, and monitoring of design, procedures, maintenance and training related to H2S. This program must be in compliance with 29 CFR 1910.1000 – Air Contaminants and 29 CFR 1910.147 – The Control of Hazardous Energy (Lockout / Tagout).

2020-01-I-TX-5

For all waterflood stations where the potential exists to expose workers to H2S concentrations at or above 10 ppm, ensure the H2S detection and alarm systems are properly maintained and configured, and develop site-specific detection and alarm programs and associated procedures based on manufacturer specifications, current codes, standards, and industry good practice guidance. The program must address installation, calibration, inspection, maintenance, training and routine operations.

2020-01-I-TX-6

For all waterflood stations where the potential exists to expose workers or non-employees within the perimeter of the facility to H2S concentrations at or above 10 ppm, ensure that the H2S detection and alarm system designs employ multiple layers of alerts unique to H2S, such as with the use of both audible and visual mediums, so that workers and non-employees within the perimeter of the facility would be alerted to a significant release. The system design must meet manufacturer specifications, current codes, standards, and industry good practice guidance.

2020-01-I-TX-7

For all waterflood stations where the potential exists to expose non-employees to H2S concentrations at or above 10 ppm, develop and implement a formal, written, site-specific security program to prevent unknown and unplanned entrance of those not employed by Aghorn, starting with a requirement for employees to lock access gates upon entering and departing the facility.

2020-01-I-TX-8

Issue a safety information product (such as a safety bulletin or safety alert) that addresses the requirements for protecting workers from hazardous air contaminants and from hazardous energy.

2020-01-I-TX-9

Develop and send a Notice to Operators to all oil and gas operators that fall under the jurisdiction of the Railroad Commission of Texas that describes the safety issues described in this report, including: 1. Nonuse of Personal H2S Detector 2. Nonperformance of Lockout / Tagout 3. Confinement of H2S Inside Pump House 4. Lack of Safety Management Program 5. Nonfunctioning H2S Detection and Alarm System 6. Deficient Site Security

2020-05-I-LA-1

Evaluate the hazards to the Bio-Lab Lake Charles facility from hurricanes and accompanying wind, rainwater, floodwater, or storm surge forces. Implement processes and safeguards for protection against those hazards, such as through:

a. Constructing new and maintaining existing buildings and structures to withstand hurricane winds and flooding, with a particular focus on those containing hazardous materials;

b. Implementing safeguards and processes to ensure hazardous chemicals are not compromised and released during extreme weather events; and

c. Following the guidance presented in the Center for Chemical Process Safety Monograph Assessment of and Planning for Natural Hazards.

2020-05-I-LA-2

Develop and implement an improved Process Hazard Analysis (PHA) action item management system. At a minimum the PHA action item management system should:

a. Ensure that each PHA action item or recommendation is assigned to an appropriate person with a deadline for initial evaluation;

b. Document and maintain the rationale if the action item or recommendation is modified or rejected; and

c. Track the status of all PHA action items or recommendations until they are resolved.

Additionally, periodic audits must be conducted on the PHA action item management system to ensure its effectiveness.

2020-05-I-LA-3

Perform process hazard analyses (PHAs) on all buildings and units processing or storing trichloroisocyanuric acid. Ensure that the PHAs are revalidated at least every five years. Also include the building design basis as process safety information for the PHA team to reference during their analysis.

2020-05-I-LA-4

Revise the Bio-Lab Lake Charles emergency response plan to require the following:

a. The site’s fire protection system is properly maintained and routinely function-tested in accordance with published industry guidance and NFPA requirements. Require in the emergency response plan that any equipment identified as nonfunctional must be repaired in a timely manner in accordance with NFPA requirements;

b. Emergency and fire protection equipment (in particular fire water pumps) must be checked regularly to ensure it is in good working order one month before the start of the U.S. hurricane season, as recommended by the Center for Chemical Process Safety Monograph Assessment of and Planning for Natural Hazards; and

c. Site personnel must be trained on the use of all emergency generators and other emergency equipment at least one month before the start of the U.S. hurricane season.

2020-05-I-LA-6

Implement the five open recommendations issued in the 2022 U.S. Government Accountability Office Report titled Chemical Accident Prevention: EPA Should Ensure Regulated Facilities Consider Risks from Climate Change, which are:

a. The U.S. Environmental Protection Agency (EPA) should provide additional compliance assistance to Risk Management Program (RMP) facilities related to risks from natural hazards and climate change;

b. The EPA should design an information system to track common deficiencies found during inspections, including any related to natural hazards and climate change, and use this information to target compliance assistance;

c. The EPA should issue regulations, guidance, or both, as appropriate, to clarify requirements and provide direction for RMP facilities on how to incorporate risks from natural hazards and climate change into their risk management programs;

d. The EPA should develop a method for inspectors to assess the sufficiency of RMP facilities’ incorporation of risks from natural hazards and climate change into risk management programs and provide related guidance and training to inspectors; and

e. The EPA should incorporate the vulnerability of RMP facilities to natural hazards and climate change as criteria when selecting facilities for inspection.

2020-05-I-LA-5

Under existing statutory or regulatory authority or through the establishment of new authority by executive or legislative action, for all existing chemical manufacturing and storage facilities that:

(1) Are located in a hurricane-prone region as defined by the International Building Code, and

(2) Manufacture or store or can inadvertently or otherwise produce (e.g., by chemical reaction) regulated substances inside equipment or building(s) built before more current wind design requirements came into effect

Require the facility operators to evaluate the hazards to their facilities from hurricanes and accompanying wind, rainwater, floodwater, or storm surge forces. Require the facility operators to implement processes and safeguards for protection against those hazards, such as through:

a. Ensuring that buildings and structures (both new and existing) can withstand hurricane winds and flooding, with a particular focus on buildings and structures containing hazardous materials;

b. Implementing safeguards and processes to ensure that hazardous chemicals are not compromised and released during extreme weather events; and/or

c. Following the guidance presented in the Center for Chemical Process Safety Monograph Assessment of and Planning for Natural Hazards.

2020-07-I-NC-3

Update all documentation, training, and orientation materials provided to contractors pertaining to hot work to reflect Evergreen Packaging’s internal definition of hot work. The materials should make clear that hot work encompasses any method of work that can serve as a source of ignition.

2020-07-I-NC-4

Develop and implement a formalized and comprehensive Simultaneous Operations (SIMOPs) program addressing planned work occurring close together in time and place to include policies, procedures, hazards reviews, hazards abatement, training, and shared communication methods, to protect employees and contract workers from the hazards posed by simultaneous operations at its facilities. At a minimum, the program should:

• Identify potential simultaneous operations

• Identify potential hazardous interactions

• Evaluate and implement necessary safeguards to allow for safe simultaneous operations

• Ensure coordination, including shared communication methods, between the simultaneous operations

• Include emergency response personnel or services in the planning and coordination of the simultaneous operations.

2020-07-I-NC-5

Develop and implement a policy that requires the involvement of emergency response personnel in planning and coordination of activities involving the use of flammable materials in confined spaces. In the policy, require that emergency response personnel be stationed directly outside the confined space in which flammable materials are used. Ensure that the emergency response personnel are appropriately trained and equipped for confined space entry, confined space rescue and fire response.

2020-07-I-NC-1

Issue a safety information product (such as a letter of interpretation) addressing the analysis and control of hazards that are not pre-existing but which result from work activities inside permit-required confined spaces. 

2020-07-I-NC-2

(Superseded by 2021-01-I-TN-R1 from the Wacker report)

Require Owner/Operators to ensure the coordination of simultaneous operations involving multiple work groups, including contractors. Include in the requirement for Owner/Operators to ensure the following activities occur:

• Identification of potential simultaneous operations

• Identification of potential hazardous interactions

• Evaluation and implementation of necessary safeguards to allow for safe simultaneous operations

• Coordination, including shared communication methods, between the simultaneous operations

• Inclusion of emergency response personnel or services in the planning and coordination of the simultaneous operations.

As necessary, seek the regulatory authority to promulgate this requirement.

2020-07-I-NC-6

Update the Universal Blastco hot work policy and employee training program to specifically identify the use of heat guns as hot work. The policy and programs should make clear that hot work encompasses any method of work that can ignite a fire and not just spark- or flame-producing work methods.

2020-07-I-NC-7

Develop a formalized troubleshooting guide and/or standard operating procedure for the usage of resin and fiberglass matting in FRP operations. The procedure should direct employees on acceptable means of addressing cold-weather resin performance.

2020-07-I-NC-8

Develop a policy and standard operating procedures for the proper use of heat guns in FRP operations. 

2021-03-I-GA-9

Develop a comprehensive standard for the safe storage, handling, and use of liquid nitrogen in stationary applications, comparable to the guidance presented in CGA G-6.5 Standard for Small Stationary Insulated Carbon Dioxide Systems. At a minimum, the standard should include:

a) requirements for and guidance on the location, the maintenance, and the functional testing of atmospheric monitoring devices;

b) requirements for visible and audible alarm indication distinct from the building’s fire alarm system and at a continuously attended location;

c) guidance on the design, function, periodic maintenance and testing, and location of room and emergency ventilation systems; and,

d) requirements for and guidance on the location of emergency shutdown devices including E-stops.

2021-03-I-GA-10

Update P-76 Hazards of Oxygen-Deficient Atmospheres. At a minimum, the updated standard should:

a) require that atmospheric monitoring systems shall be utilized with processes, equipment, and piping systems capable of producing oxygen-deficient atmospheres;

b) require that atmospheric monitoring systems provide both visible and audible alarm indication distinct from a building’s fire alarm system and at a continuously attended location;

c) require that processes, equipment, and piping systems capable of producing oxygen-deficient atmospheres shall be equipped with remotely operated emergency isolation valves (ROEIVs); and

d) include guidance on the adequate safe location of emergency stop devices. At a minimum this guidance should be harmonized with the requirements of ISO 13850 Safety of machinery – Emergency stop function – Principles for design. As necessary, augment the general guidance of ISO 13850 with guidance specific to processes, equipment, and piping using cryogenic asphyxiants and inert gases.

2021-03-I-GA-1

Include in the emergency action program provisions for proactively interacting with and informing local emergency response resources of all emergencies at the former FFG Plant 4 facility to which Gold Creek expects them to respond. At a minimum, Gold Creek should:

a) inform local emergency responders of the existence, nature, and location of hazardous substances at its facilities, including liquid nitrogen;

b) inform local emergency responders of the location of emergency-critical equipment such as bulk storage tanks, points of use, isolation valves, E-stop switches, and any other emergency equipment or systems with which emergency responders may need to interact; and,

c) provide local emergency responders with information, such as facility plot plans, engineering drawings, or other information needed to mount an effective emergency response.

2021-03-I-GA-12

Update the International Fire Code to:

a) require the use of atmospheric monitoring with cryogenic asphyxiants in accordance with industry guidance such as is contained in CGA P-76 Hazards of Oxygen-Deficient Atmospheres and CGA P-12 Safe Handling of Cryogenic Liquids in addition to CGA P-18 Standard for Bulk Inert Gas Systems; and,

b) include guidance on the adequate safe location of manual shutoff valves and devices such as emergency push buttons used to activate remotely operated emergency isolation valves (ROEIVs) in cryogenic fluid service. At a minimum this guidance should be harmonized with the requirements of ISO 13850 Safety of machinery – Emergency stop function – Principles for design.

2021-03-I-GA-2

Update the company product stewardship policy to:

a) include participation by Messer in customers’ process hazard analyses (PHAs). The policy should require that these PHAs be conducted in a manner which conforms with CCPS Guidelines for Hazard Evaluation Procedures prior to the startup of a cryogenic freezing process;

b) require verification that proper signage, in accordance with CGA P-76 Hazards of Oxygen-Deficient Atmospheres, is displayed on and/or near equipment; and,

c) require a facility and/or equipment siting review to ensure that emergency shutoff devices, including E-stops, are located such that they can be safely actuated during a release of liquid nitrogen.

2021-03-I-GA-3

Create an informational product that provides Messer customers with information on the safety issues described in this report. In this informational product, recommend that Messer customers develop and implement effective safety management systems to control asphyxiation hazards from inert gases based on the guidance published in CGA P-86 Guideline for Process Safety Management, CGA P-12 Guideline for Safe Handling of Cryogenic and Refrigerated Liquids, CGA P-18 Standard for Bulk Inert Gas Systems, and CGA P-76 Hazards of Oxygen-Deficient Atmospheres.

2021-03-I-GA-11

Update NFPA 55 Compressed Gases and Cryogenic Fluids Code to:

a) require the use of atmospheric monitoring with cryogenic asphyxiants in accordance with industry guidance such as is contained in CGA P-76 Hazards of Oxygen-Deficient Atmospheres and CGA P-12 Safe Handling of Cryogenic Liquids in addition to CGA P-18 Standard for Bulk Inert Gas Systems; and,

b) include guidance on the adequate safe location of manual shutoff valves and devices such as emergency push buttons used to activate remotely operated emergency isolation valves (ROEIVs). At a minimum this guidance should be harmonized with the requirements of ISO 13850 Safety of machinery – Emergency stop function – Principles for design.

2021-03-I-GA-4

Update the Region 4 Poultry Processing Facilities Regional Emphasis Program to explicitly cover liquid nitrogen freezing processes. At a minimum, the update should encourage practices applicable to managing the hazards of using liquid nitrogen and other cryogenic asphyxiants, including process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.

2021-03-I-GA-5

Update the Region 5 Regional Emphasis Program for Food Manufacturing Industry to explicitly cover liquid nitrogen freezing processes. At a minimum, the update should encourage practices applicable to managing the hazards of using liquid nitrogen and other cryogenic asphyxiants, including process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.

2021-03-I-GA-6

Update the Region 6 Poultry Processing Facilities Regional Emphasis Program to explicitly cover liquid nitrogen freezing processes. At a minimum, the update should encourage practices applicable to managing the hazards of using liquid nitrogen and other cryogenic asphyxiants, including process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.

2021-03-I-GA-7

Promulgate a standard specific to cryogenic asphyxiants. The purpose of this standard shall be the prevention and/or mitigation of hazards arising from the storage, use, and/or handling of these substances. The new standard shall reference applicable national consensus standards such as those published by the Compressed Gas Association and others, as appropriate. At a minimum the new standard shall:

a) Address requirements for the design, construction, and installation of process equipment storing or using cryogenic asphyxiants;

b) Require atmospheric monitoring where equipment storing or using cryogenic asphyxiants is located indoors;

c) Require emergency shutdown systems such that equipment storing or using cryogenic asphyxiants may be isolated during a release without endangerment;

d) Address requirements for employee training and hazard awareness specific to cryogenic asphyxiants;

e) Require an emergency action plan in accordance with 29 CFR 1910.38; and,

f) Address requirements for the use of process safety management elements such as process hazard analysis, management of change, procedures, and others deemed necessary through the rulemaking process to prevent and/or mitigate these hazards.

2021-03-I-GA-8

Develop and publish a Guidance Document (similar to OSHA 3912-03 Process Safety Management for Explosives and Pyrotechnics Manufacturing) for process safety management practices applicable to processes handling compressed gases and cryogenic asphyxiants, including (at a minimum) the practices highlighted in this report.

2018-02-I-WI-13

Using API’s processes to determine the appropriate safety product, develop a publicly available technical publication for the safe operation of fluid catalytic cracking (FCC) units. The document should be applicable to both new and existing units. Include the following topics at a minimum:

a) Description of typical FCC unit hazards, including air leaks into hydrocarbon systems or hydrocarbon leaks into air systems that could form a flammable mixture during transient operation (startup, shutdown, standby, and the actions required to transition between these modes). If needed, include differences between possible reactor/regenerator configurations;

b) Recommended practices for safeguards to control FCC unit hazards;

c) Recommended monitoring for process safety during FCC unit transient operations;

d) Recommended emergency operating procedures for FCC-specific scenarios;

e) PHA guidance for key FCC-specific scenarios, including transient operation;

f) Recommended FCC-specific field and board operator process safety training topics and methods;

g) Guidelines for process safety assessments of FCC units; and

h) Incorporate lessons learned from this CSB investigation and the CSB’s ExxonMobil Torrance Refinery Electrostatic Precipitator Explosion investigation throughout the document and include references in the document’s bibliography.

2018-02-I-WI-14

Modify the appropriate existing recommended practice (for example, API RP 553, Refinery Valves and Accessories for Control and Safety Instrumented Systems) to include information about the purpose, design, maintenance, and testing of additional FCC catalyst slide valve components, including the slide valve body. If an API product other than API RP 553 is modified, API RP 553 should guide the reader to that reference.

2018-02-I-WI-15

Incorporate lessons learned from the FCC Unit Explosion and Asphalt Fire at Husky Superior Refinery incident into the appropriate API products (for example, API RP 2023, Guide for Safe Storage and Handling of Heated Petroleum-Derived Asphalt Products and Crude Oil Residua, or API RP 2021, Management of Atmospheric Storage Tank Fires). At a minimum, topics shall include the flammability of heated material such as asphalt and the ignition risk of pyrophoric material inside asphalt storage tanks. Include a reference to this CSB investigation in the document’s bibliography.

2018-02-I-WI-8

For all Cenovus operated refineries with FCC units, develop and implement an FCC unit-specific PHA guidance document as part of each FCC unit’s ongoing PHA update/revalidation cycle, including the Cenovus Superior Refinery. The PHA guidance document should be updated with new industry knowledge as it becomes available (for example, from AFPM, CCPS, and API). The PHA guidance document should include a requirement to review available licensor and industry guidance for FCC unit PHA scenarios and recommended safeguards and at a minimum, include information related to transient operation safeguards listed in CSB Recommendation 2018-02-I-WI-R1.

2018-02-I-WI-9

Develop and implement a technology-specific knowledge-sharing network program across all Cenovus operated refineries, which at a minimum includes an FCC technology peer network. The peer network(s) must include engineers, operations management, and operations staff from each site that uses the technology, including the Cenovus Superior Refinery. The network(s) must meet at least annually to discuss process safety topics in the technology including:

a) Relevant incidents and near-misses at the refineries and/or in industry;
b) Refinery learnings in implementing process safety improvements;
c) Relevant industry tools, bulletins, and knowledge-sharing documents, such as those published by AFPM, CCPS, and API; and
d) Relevant updates to industry publications and standards.

2018-02-I-WI-10

Include and maintain the FCC technology licensors’ operating manuals in the process safety information packages for all FCC units, including the FCC unit at Cenovus Superior Refinery.

2018-02-I-WI-1

Establish safeguards to prevent explosions in the FCC unit during transient operation (including startup, shutdown, standby, and emergency procedures). Incorporate these safeguards into written operating procedures. At a minimum establish the following specific safeguards:

a) Implementation of the reactor steam barrier, or a similar inert gas flow, to maintain an inert barrier at an elevated pressure between the main column (containing hydrocarbon) and the regenerator (containing air);

b) Purging the main column with a non-condensable gas as needed to prevent a dangerous accumulation of oxygen in the main column overhead receiver;

c) Monitoring to ensure that there is a sufficient non-condensable gas purge of the main column to prevent a dangerous accumulation of oxygen in the main column overhead receiver (either through direct measurement of the oxygen concentration and/or through engineering calculation);

d) Monitoring of critical operating parameters for flows, pressures, pressure differences, and catalyst levels;

e) Documentation of consequences of deviating from the transient operation safe operating limits and of predetermined corrective actions; and

f) Inclusion of the above items in the appropriate FCC operator training curricula.

2018-02-I-WI-2

Based on licensor input and good industry practices, determine the appropriate point(s) in the FCC unit’s shutdown procedures to shut down all wet gas compressor(s). Incorporate this information into all FCC unit shutdown procedures and operator training material.

2018-02-I-WI-3

Develop and implement a slide valve mechanical integrity program that addresses erosion and ensures proper functioning of the slide valves during a shutdown. The program must include, at a minimum:

a) A slide valve mechanical integrity standard that defines monitoring and inspection requirements, with acceptance criteria, required for the safe operation of the FCC unit during transient operation (such as a startup, shutdown, standby, and emergency).

b) Monitoring that includes process data analysis and mechanical preventive activities to evaluate the mechanical condition of the slide valves during the operation of the FCC unit between turnarounds;

c) Quarterly presentations of process data and mechanical preventive maintenance data to refinery operations management and maintenance management to drive key decisions such as shortening the turnaround cycle and/or planning a maintenance outage;

d) During turnarounds and other potential slide valve maintenance outages, evaluate the adequacy of the slide valve mechanical integrity program for the safe operation of the FCC unit during transient operation. If the inspection demonstrates unsuccessful performance, make appropriate corrections.

During the next major FCC unit turnaround at Cenovus Superior Refinery, demonstrate that the slide valve mechanical program is adequate for the safe operation of the FCC unit during transient operation. If the inspection demonstrates unsuccessful performance, make appropriate corrections to the slide valve mechanical integrity program.

2018-02-I-WI-4

Develop emergency procedures for responding to a loss of catalyst slide valve function (for example, when it leaks excessively or fails to close on demand).

2018-02-I-WI-5

Develop guidance for analyzing operating procedures to improve transient operation hazard evaluations during PHAs. Refer to section Chapter 9.1 in the CCPS publication Guidelines for Hazard Evaluation Procedures, 3rd Ed. or an appropriate equivalent resource to develop the guidance. Incorporate the guidance into the appropriate Cenovus Superior Refinery PHA procedural documents and policies.

2018-02-I-WI-6

Develop and implement an FCC unit operator, supervisor, and manager training program based on the licensor’s guidance and on available industry guidance. Elements of the training program shall include:

a) A set of written training materials (such as a manual) consistent with the licensor’s technology information, encompassing:

i) FCC equipment;
ii) Normal operations;
iii) Transient operations (including startup, shutdown, standby, and emergency); and
iv) Case studies of industry FCC industry incidents, including ExxonMobil Torrance (2015) and this incident; and

b) Training delivery methods including:

i) Group and individual training; and
ii) Simulator training for board operators.

2018-02-I-WI-7

Incorporate lessons learned from this incident into the appropriate training materials for the Cenovus Superior Refinery Emergency Response Team. At a minimum, topics shall include the proper response to liquids potentially stored above their flash point, such as asphalt, and the ignition risk of pyrophoric material inside asphalt storage tanks.

2018-02-I-WI-12

Develop a program that prioritizes and emphasizes inspections of FCC units in refineries that operate HF alkylation units (for example, under EPA’s National Compliance Initiative called Reducing Risks of Accidental Releases at Industrial and Chemical Facilities). As part of this program, verify FCC unit safeguards that prevent explosions during transient operation (including startup, shutdown, standby, and emergency procedures). At a minimum the program will verify the following specific safeguards:

a) Implementation of the reactor steam barrier, or a similar inert gas flow, to maintain an inert barrier at an elevated pressure between the main column (containing hydrocarbon) and the regenerator (containing air);

b) Purging the main column with a non-condensable gas as needed to prevent a dangerous accumulation of oxygen in the main column overhead receiver;

c) Monitoring to ensure that there is a sufficient non-condensable gas purge of the main column to prevent a dangerous accumulation of oxygen in the main column overhead receiver (either through direct measurement of the oxygen concentration and/or through engineering calculation);

d) Monitoring of critical operating parameters for flows, pressures, pressure differences, and catalyst levels;

e) Documentation of consequences of deviating from the transient operation safe operating parameters and of predetermined corrective actions; and

f) Inclusion of the above items in the appropriate FCC operator training curricula.

This recommendation is in addition to the recommendations to EPA relating to hydrofluoric acid outlined in the CSB’s report on the 2019 fire and explosions at the Philadelphia Energy Solutions refinery. In that report, the CSB recommended (1) that the EPA prioritize inspections of refinery HF alkylation units to ensure units are complying with API good practice guidance, (2) to require petroleum refineries with HF alkylation units to evaluate inherently safer technology, and (3) to initiate prioritization and, as applicable, risk evaluation of HF under the Toxic Substances Control Act.

2018-02-I-WI-16

Participate in the API committee that develops a technical publication for the safe operation of FCC units.

2018-02-I-WI-11

Develop guidance documents for performing process hazard analysis on operating procedures to address transient operation hazards in facilities with Process Safety Management (PSM) covered processes.

2018-03-I-TX-1

Develop and implement an emergency pressure-relief system design standard to ensure that each of these safety systems will discharge to a safe location. Include a requirement to periodically evaluate the site’s emergency pressure-relief systems and make appropriate modifications to ensure that each of these systems discharge to a safe location such that material that could discharge from these safety systems will not harm people.

2018-03-I-TX-2

Implement a site-wide system to evacuate nonessential personnel during upset conditions and exclude nonessential workers from being near equipment during transient operating modes, such as startup.

2018-03-I-TX-3

Develop and implement a system requiring a periodic evaluation of the adequacy and effectiveness of any safeguard used to mitigate or otherwise lower the risk of process safety hazards. This safeguard protection analysis should be based on the requirements of Cal/OSHA’s Process Safety Management for Petroleum Refineries regulations or an appropriate equivalent methodology.

2018-03-I-TX-4

Develop and implement a policy detailing how to effectively address recommendations generated from company process safety management systems, including audits, incident investigations, management of change, and process hazard analysis that is consistent with existing OSHA guidance. Include a periodic training requirement for managers and other employees involved with evaluating and managing proposed recommendations to help ensure proposed safety improvements are effectively evaluated and appropriately implemented.

2018-03-I-TX-5

Review the Center for Chemical Process Safety guidance on recognizing catastrophic incident warning signs and then develop and implement a program for the EVAL Plant that incorporates warning signs into its safety management system.

2018-03-I-TX-6

Clarify the lower equipment design pressure of the EVAL Reactor 2 within the operator training systems, written procedures, and in the control system interface.

2018-03-I-TX-7

Develop and implement a program to ensure that the company’s EVAL Plant nightly operating instructions do not conflict with its written operating procedures. Ensure that employees use the management of change system when changes to the written operating procedures are desired. Additionally, develop and implement a written procedure and conduct training on how to perform the EVAL Reactor methanol flush operation.

2018-03-I-TX-8

Strengthen the EVAL Plant’s operator training program by 1) including the known activities, such as bringing ethylene back into the unit, upset conditions like the reactor’s High-High-Pressure alarm, and providing guidance or otherwise clarifying when nonessential personnel should be excluded from being in the unit; 2) including alarm setpoints and actions that operators should take in response to specific process alarms, such as high pressure inside an EVAL Reactor; 3) including directions on when operators should use the emergency open valve; and 4) including safe operating limits, the consequence of deviating beyond the safe operating limits, and the predetermined steps operators need to take to return the process to a safe condition.

2018-03-I-TX-9

Complete the alarm management efforts at the EVAL Plant and implement a continual program to meet or be lower than the alarm rate performance targets established in ISA 18.2.

2018-03-I-TX-10

Improve the EVAL Plant’s safety management system by 1) controlling when chilled liquid is circulated through the heat exchanger during startup; 2) enhancing recognition of liquid ethylene accumulation and response to low-temperature conditions inside an EVAL Reactor through alarms, written procedures, and operator training; 3) implementing a system to manage abnormal operating conditions effectively by, at a minimum, including appropriate technical representation, performing a hazard analysis of temporary or troubleshooting operations, and providing management oversight of any abnormal condition; 4) updating the written startup procedures to include guidance on the appropriate operator actions to take in response to process alarms; 5) using control system guidance to aid operator response to abnormal or upset conditions to keep the process within the safe operating limits; and 6) removing the physical and procedural controls used at the EVAL Plant to restrict board operators from accessing or using the emergency open valve, and updating the written procedures and operator training to provide guidance on when to open the emergency open valve.

2018-03-I-TX-11

Modify the EVAL Plant’s safe operating limits program to prevent operating under conditions that rely upon equipment design safety factors, such as the American Society of Mechanical Engineers (ASME) code material safety factors.

2018-03-I-TX-12

Acquire the services of an independent third party to perform a comprehensive assessment of its EVAL Plant’s process safety management systems. In addition to meeting the requirements outlined in Appendix B of this report, this comprehensive assessment should evaluate whether existing policies meet minimum federal process safety regulatory requirements and apply the Center for Chemical Process Safety model to verify both the suitability of these systems and their effective, consistent implementation.

2019-04-I-PA-4

Update API RP 751 Safe Operation of Hydrofluoric Acid Alkylation Units to require the following:

1. Protection of critical safeguards and associated control system components, including but not limited to wiring and cabling for control systems and primary and backup power supplies, from fire and explosion hazards, including radiant heat and flying projectiles; and
2. Installation of remotely-operated emergency isolation valves on the inlet(s) and outlet(s) of all hydrofluoric acid containing vessels, and hydrocarbon containing vessels meeting defined threshold quantities.

2019-04-I-PA-5

Revise ASTM A234 to incorporate supplementary requirements for piping used in HF service, as defined in HF supplementary requirements S9.1 through S9.7 in ASTM A106 version 19a.

2019-04-I-PA-1

Develop a program that prioritizes and emphasizes inspections of refinery HF alkylation units, for example under EPA’s National Compliance Initiative called Reducing Risks of Accidental Releases at Industrial and Chemical Facilities. As part of this program, verify that HF alkylation units are complying with API RP 751 Safe Operation of Hydrofluoric Acid Alkylation Units, including but not limited to the implementation of a special emphasis inspection program to inspect all individual carbon steel piping components and welds to identify areas of accelerated corrosion; the protection of safety-critical safeguards and associated control system components, including but not limited to wiring and cabling for control systems and primary and backup power supplies, from fire and explosion hazards including radiant heat and flying projectiles (per recommendation 2019-04-I-PA-R4); and the installation of remotely-operated emergency isolation valves on the inlet(s) and outlet(s) of all hydrofluoric acid containing vessels, and hydrocarbon containing vessels meeting defined threshold quantities (per recommendation 2019-04-I-PA-R4).

2019-04-I-PA-2

Revise 40 C.F.R. Part 68 (EPA Risk Management Plan) to require new and existing petroleum refineries with HF alkylation units to conduct a safer technology and alternatives analysis (STAA) and to evaluate the practicability of any inherently safer technology (IST) identified. Require that these evaluations are performed every 5 years as a part of an initial PHA as well as PHA revalidations.

2019-04-I-PA-3

Per the requirements in EPA Rule Procedures for Prioritization of Chemicals for Risk Evaluation Under the Toxic Substances Control Act, initiate prioritization to evaluate whether hydrofluoric acid is a High-Priority Substance for risk evaluation. If it is determined to be a High-Priority Substance, conduct a risk evaluation of hydrofluoric acid to determine whether it presents an unreasonable risk of injury to health or the environment. If it is determined to present an unreasonable risk of injury to health or the environment, apply requirements to hydrofluoric acid to the extent necessary to eliminate or significantly mitigate the risk, for example by using a methodology such as the hierarchy of controls.

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.

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.

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.

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.

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).

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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. 

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.

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. 

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.

2016-04-I-FL-6

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.

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

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.

2011-3-I-WV-3

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.

2009-3-I-VA-1 URGENT!

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.

2009-3-I-VA-2 URGENT!

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.

2009-3-I-VA-3 URGENT!

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.

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.

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.

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.

2009-3-I-VA-10

Formally recommend to all member companies the incorporation of The Fertilizer Institute tank inspection guidelines into contracts for the storage of liquid fertilizer at terminals.

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.

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.

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.

2017-08-I-TX-1

Reduce flood risk to as low as reasonably practicable (ALARP). Ensure that any safeguards for flooding meet independent layer of protection requirements.

2017-08-I-TX-2

Within 18 months, develop a policy requiring that Arkema and its subsidiaries that manufacture organic peroxides or that have processes which involve more than the threshold quantities of highly hazardous chemicals (HHC) periodically (corresponding with PHA cycle), analyze such facilities to determine whether they are at risk for extreme weather events such as hurricanes or floods.

2017-08-I-TX-3

Establish corporate requirements for its facilities that manufacture organic peroxides or that have processes which involve more than the threshold quantities of highly hazardous chemicals (HHC) to ensure that critical safeguards, such as backup power, function as intended during extreme weather events, including hurricanes or floods.

2017-08-I-TX-4

Develop broad and comprehensive guidance to help companies assess their U.S. facility risk from all types of potential extreme weather events. Guidance should address the issues identified in this report and cover actions required to prepare for extreme weather, resiliency and protection of physical infrastructure and personnel during extreme weather, as well as recovery operations following an extreme weather event, where appropriate. Include guidance for each of the following:

• Addressing common mode failures of critical safeguards or equipment that could be caused by extreme weather events, including but not limited to flooding. For flooding scenarios, sufficient independent layers of protection should be available if floodwater heights reach the facility.

• Evaluating facility susceptibility to potential extreme weather events. Relevant safety information such as flood maps should be incorporated as process safety information.

• Involving relevant professional disciplines, including engineering disciplines, to help ensure risk assessments and process hazard analyses are as robust as practicable for any given facility.

2017-08-I-TX-5

Update your emergency operations training using lessons learned from the Arkema incident to help ensure that personnel enforcing evacuation perimeters are not harmed by exposure to hazardous chemical releases. Update existing protocols and revise training curricula to include the use of analytical tools, air monitoring, and personal protective equipment, to provide appropriate protection when emergency equipment or personnel need to be moved through an evacuation zone during a hazardous materials release. Include a process for periodic refresher training.

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.

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.

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.

2007-6-I-KS-6

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.

2007-6-I-KS-7

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.

2007-6-I-KS-8

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.

2007-6-I-KS-1

Revise the "Guidance for Hazard Determination for compliance with the OSHA Hazard Communication Standard" to advise chemical manufacturers and importers that prepare MSDSs to: -Evaluate flammable liquids to determine their potential to accumulate static electricity and form ignitable vapor-air mixtures in storage tanks. -Test the conductivity of the flammable liquid and include the testing results in the MSDS.

2007-6-I-KS-2

Prior to the next revision, communicate to the Sub-Committee on the Globally Harmonized System of Classification and Labeling of Chemicals (SCEGHS) the need to amend the GHS 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)). -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.

2007-6-I-KS-9

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.

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.

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.

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.

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.

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.

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.

2008-08-I-WV-6

Establish a Hazardous Chemical Release Prevention Program to enhance the prevention of accidental releases of highly hazardous chemicals, and optimize responses in the event of their occurrence. In establishing the program, study and evaluate the possible applicability of the experience of similar programs in the country, such as those summarized in Section 5.3 of this report. As a minimum:

a. Ensure that the new program:
1. Implements an effective system of independent oversight and other services to enhance the prevention of accidental releases of highly hazardous chemicals
2. Facilitates the collaboration of multiple stakeholders in achieving common goals of chemical safety; and,
3. Increases the confidence of the community, the workforce, and the local authorities in the ability of the facility owners to prevent and respond to accidental releases of highly hazardous chemicals.

b. Define the characteristics of chemical facilities that would be covered by the new Program, such as the hazards and potential risks of their chemicals and processes, their quantities, and similar relevant factors;

c. Ensure that covered facilities develop, implement, and submit for review and approval:
1. Applicable hazard and process information and evaluations.
2. Written safety plans with appropriate descriptions of hazard controls, safety culture and human factors programs with employee participation, and consideration of the adoption of inherently safer systems to reduce risks
3. Emergency response plans; and,
4. Performance indicators addressing the prevention of incidents and chemical incidents.

d. Ensure that the program has the right to evaluate the documents submitted by the covered facilities, and to require modifications, as necessary

e. Ensure that the program has right-of-entry to covered facilities, and access to requisite information to conduct periodic audits of safety systems and investigations of chemical releases;

f. Establish a system of fees assessed on covered facilities sufficient to cover the oversight and related services to be provided to the facilities including necessary technical and administrative personnel; and,

g. Consistent with applicable law, ensure that the program provides reasonable public participation with the program staff in review of facility programs and access to:
1. The materials submitted by covered facilities (e.g., hazard evaluations, safety plans, emergency response plans);
2. The reviews conducted by program staff and the modifications triggered by those reviews;
3. Records of audits and incident investigations conducted by the program;
4. Performance indicator reports and data submitted by the facilities, and;
5. Other relevant information concerning the hazards and the control methods overseen by the program.

h. Ensure that the program will require a periodic review of the designated agency activities and issue a periodic public report of its activities and recommended action items

2008-08-I-WV-8

Work with the Kanawha and Putnam counties Emergency Response Directors to prepare and issue a revision to the Kanawha Putnam County Emergency Response Plan and Annexes to address facility emergency response and Incident Command when such functions are provided by the facility owner.

2008-08-I-WV-10

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 Process Safety Management (PSM) inspection of the complex. Coordinate with the Environmental Protection Agency, as appropriate.

2008-08-I-WV-11

Revise the Chemical National Emphasis Program and the targeting criteria to:
a. Expand the coverage to all OSHA regions,
b. Include in the targeting criteria from which potential inspections are selected all establishments that have submitted certifications of completions of actions in response to previous PSM citations;
c. Require NEP inspections to examine the status of compliance of all previously cited PSM program items for which the company has submitted certifications of completion to OSHA.

2008-08-I-WV-7

Work with the Director of the Kanawha-Charleston Health Department to ensure the successful planning, fee collection, and implementation of the Hazardous Chemical Release Prevention Program as described in Recommendation 2008-08-WV-R6, above, including the provision of services to all eligible facilities in the State.
 

2008-08-I-WV-7

Work with the Director of the Kanawha-Charleston Health Department to ensure the successful planning, fee collection, and implementation of the Hazardous Chemical Release Prevention Program as described in Recommendation 2008-08-WV-R6, above, including the provision of services to all eligible facilities in the State.
 

2008-08-I-WV-9

Revise the Fire Department Evaluation Administrative Section Matrix addressing the periodic inspection of local fire departments to include a requirement for inspectors to examine and identify the status of National Incident Management System fire department personnel training.

2001-02-I-IN-10

Communicate findings of this report to your membership.

2001-02-I-IN-10

Communicate findings of this report to your membership.

2001-02-I-IN-10 URGENT!

Communicate findings of this report to your membership.

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.

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.

2001-02-I-IN-9

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

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.

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.

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.

2001-02-I-IN-4

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

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.

2001-02-I-IN-6

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

2001-02-I-IN-10

Communicate findings of this report to your membership.

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.

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.

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.

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.

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.

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.

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.

2006-3-I-FL-9

Work with the Water Environment Federation to prepare and distribute a technical bulletin containing information on the safe receipt, storage, use, and dispensing of methanol in wastewater treatment plants. In addition, include information on basic fire and explosion prevention measures when using bulk methanol (e.g., flame arrester maintenance, hot work programs, electrical classification).

2006-3-I-FL-10

Work with the Water Environment Federation to prepare safety training materials for wastewater treatment facilities that use methanol.

2006-3-I-FL-5

Revise NFPA 30 to specifically exclude the use of thermoplastics in aboveground flammable liquid service.

2006-3-I-FL-6

Revise 29 CFR 1910.106 to specifically exclude the use of thermoplastics in above ground flammable liquid service.

2006-3-I-FL-7

Work with the Methanol Institute to prepare and distribute a technical bulletin containing information on the safe receipt, storage, use, and dispensing of methanol in wastewater treatment plants. In addition, include information on basic fire and explosion prevention measures when using bulk methanol (e.g., flame arrester maintenance, hot work programs, electrical classification).

2006-3-I-FL-8

Work with the Methanol Institute to prepare safety training materials for wastewater treatment facilities that use methanol.

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.

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.

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).

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.

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.

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.

2003-06-I-TX-12

Publish an information document for exploration and production (E&P) industry employers (including producers/shippers/offerors, motor carriers, and disposal facility operators) involved in the transportation of basic sediment and water (BS&W) and other E&P waste liquids on public highways. (2003-06-I-TX-R12): -Emphasize the importance of, and responsibility for, properly classifying and identifying flammable waste liquids. -Reference the Occupational Safety and Health Administration (OSHA) requirements for obtaining material safety data sheets (MSDS) from the shipper and the required content of DOT shipping papers. -Include specific reference to this CSB Investigation Report and the American Petroleum Institute (API) recommended practices cited in this report.

2003-06-I-TX-18

Communicate the findings and recommendations of this report to your membership. Emphasize emergency response to diesel engine overspeed caused by exposure to flammable vapor atmospheres.

2003-06-I-TX-1

Provide documentation of the potential flammability hazard of exploration and production (E&P) waste liquids-such as a material safety data sheet (MSDS)- to all employees, contract personnel, and haulers handling waste liquids generated at well sites. Emphasize that mixing condensate with basic sediment and water (BS&W) during the removal process can significantly increase the flammability hazard. The mixture in the transport container should be treated as a flammable liquid absent positive identification to the contrary.

2003-06-I-TX-2

Review and revise company gauging and waste liquid removal protocols as necessary to minimize the inadvertent removal and subsequent disposal of hydrocarbon product when removing BS&W from product storage tanks.

2003-06-I-TX-13

Issue a Safety and Health Information Bulletin on the potential flammability hazard associated with bulk transportation of oilfield exploration and production (E&P) waste liquids. Summarize OSHA requirements for proper hazard classification by the shipper and for the use of material safety data sheets (MSDS). Summarize U.S. Department of Transportation (DOT) requirements for proper hazard classification and manifesting of flammable liquids, approved container design, and periodic testing. Discuss safe handling to minimize the generation of flammable vapor and to control ignition sources from vehicle-mounted equipment and facility equipment. Discuss the need for the employer to provide all worker safety information in languages or formats that are clearly understood by all affected personnel. Summarize the requirements for proper labeling of storage tanks to clearly identify the hazard of the contents to all employees and contractors working at the well site.

2003-06-I-TX-3

Ensure that the written procedures for hazard identification require that all customers requesting loading and transportation of exploration and production (E&P) waste liquids provide written notification, such as a material safety data sheet (MSDS), listing the potential flammability hazard.

2003-06-I-TX-4

Ensure that the written procedures for safe operation of vacuum trucks incorporate applicable good practices, including techniques to minimize the possibility of exposing the diesel engine to flammable vapor, as provided in API RP-2219, Guidelines for Commercial Exploration and Production Waste Management Facilities.

2003-06-I-TX-5

Develop written operating procedures that incorporate best practices for unloading storage tank waste liquids, such that drivers accurately measure the quantity of liquid removed from the storage tank and minimize removal of product, such as flammable condensate.

2003-06-I-TX-6

Ensure that written emergency procedures address the safe response to abnormal diesel engine operation due to a flammable vapor atmosphere. Explain that the normal engine shutoff method will not function as long as flammable vapor continues to enter the intake system.

2003-06-I-TX-7

Conduct and document training for all personnel who handle waste liquids, using languages or formats that are clearly understood by all affected personnel. Address the potential flammability hazard associated with E&P waste liquids, emphasizing how the withdrawal procedure is likely to increase the flammability of the vacuum truck contents through unavoidable mixing of product and basic sediment and water (BS&W). Describe operating and emergency response to diesel engine overspeed caused by a flammable vapor atmosphere.

2003-06-I-TX-14

Require that all permitted drillers and producers identify and document (e.g., material safety data sheet [MSDS]) the potential flammability hazard of exploration and production (E&P) waste liquids. Provide the information to workers and contractors in languages clearly understood by the recipients.

2003-06-I-TX-15

Provide information (e.g., safety bulletin) to industry on the potential flammability hazard associated with basic sediment and water (BS&W) and other E&P waste liquids. Waste liquids can contain sufficient hydrocarbons to be classified as flammable liquids. The waste liquid removal method can result in removing significant quantities of flammable hydrocarbon product such that the mixture in the transport container may require classification as a flammable liquid under Occupational Safety and Health Administration (OSHA) or U.S. Department of Transportation (DOT) regulations.

2005-4-I-TX-2 URGENT!

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.

2005-4-I-TX-3 URGENT!

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.

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

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.

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.

2005-4-I-TX-1 URGENT!

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

2005-4-I-TX-20

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

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.

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.

2005-4-B-TX-2

Develop / update the written piping component installation quality control procedure to require positive material identification testing or other suitable verification or tracking process for all alloy steel piping components removed during maintenance.

2005-4-I-TX-3 URGENT!

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.

2005-4-I-TX-5

1. Implement a national emphasis program for all oil refineries that focuses on: - The hazards of blowdown drums and stacks that release flammables to the atmosphere instead of to an inherently safer disposal system such as a flare. Particular attention should be paid to blowdown drums attached to collection piping systems servicing multiple relief valves; - The need for adequately sized disposal knockout drums to safely contain discharged flammable liquid based on accurate relief valve and disposal collection piping studies 2. Urge states that administer their own OSHA plan to implement comparable emphasis programs within their respective jurisdictions.

2005-4-I-TX-8

1. Strengthen the planned comprehensive enforcement of the OSHA Process Safety Management (PSM) standard. At a minimum: a. Identify those facilities at greatest risk of a catastrophic accident by using available indicators of process safety performance and information gathered by the EPA under its Risk Management Program (RMP). b. Conduct, or have conducted, comprehensive inspections, such as those under your Program Quality Verification (PQV) program at facilities identified as presenting the greatest risk. c. Establish the capacity to conduct more comprehensive PSM inspections by hiring or developing a sufficient cadre of highly trained and experienced inspectors. d. Expand the PSM training offered to inspectors at the OSHA National Training Institute.

2005-4-I-TX-9

2. Amend the OSHA PSM standard to require that a management of change (MOC) review be conducted for organizational changes that may impact process safety including: a. major organizational changes such as mergers, acquisitions, or reorganizations; b. personnel changes, including changes in staffing levels or staff experience; and c. policy changes such as budget cutting.

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-R6b) 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.

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-R7b) 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.

2005-4-I-TX-21

Work with BP to establish a joint program that promotes reporting, investigating, and analyzing 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.

2001-03-I-GA-10

Communicate the findings of this report to your membership.

2001-03-I-GA-9

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

2009-03-I-GA-11

Communicate the findings of this report to your membership.

2001-03-I-GA-1

Examine the manufacturing businesses acquired from BP Amoco Performance Polymers and ensure that a systematic safety review procedure is developed and implemented for identifying and controlling hazards from unintended chemical reactions. Additionally, ensure that reactive hazards are identified and evaluated: - During product R&D, during conceptual design of a new process, and during detailed design of a new process. - Before changes are made to existing equipment or process chemistry. - Communicate the results of this review to the workforce.

2001-03-I-GA-2

Ensure that a program is in place at facilities acquired from BP Amoco Performance Polymers to systematically review the hazards associated with new and modified processes and equipment as operating experience accrues. Ensure that facilities correct all identified design, operation, and maintenance deficiencies. Verify that operating experience does not invalidate the design basis for equipment.

2001-03-I-GA-3

Revise the Material Safety Data Sheet (MSDS) for Amodel to warn of the hazards of accumulating large masses of molten polymer. Communicate the MSDS changes to current and past customers (who may retain inventories of this product).

2001-03-I-GA-4

Implement a program to conduct periodic management reviews of incidents and near-miss incidents. Look for trends and patterns among incidents. Address root causes and implement and track corrective measures.

2001-03-I-GA-5

Revise process safety information to include: - Information regarding the decomposition reactions of Amodel. - Design intent, basis, capacity, and limitations of equipment. - Hazards and consequences of deviations from design intent and operating limits.

2001-03-I-GA-6

Revalidate hazard analyses for the Amodel process to address: - Credible deviations from process intent and their consequences. - Hazards associated with startup and shutdown operations. - Prevention of accumulations of potentially hazardous masses of polymer.

2001-03-I-GA-7

Revise your lockout/tagout program to ensure that equipment is rendered safe prior to opening for maintenance. At a minimum, ensure that equipment opening procedures contain a stop work provision that requires higher levels of management review and approval when safe opening conditions, such as equipment depressurization, cannot be verified.

2001-03-I-GA-8

Ensure that your management of change policy applies to operational and procedural modifications.

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).

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.

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.

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.

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).

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.

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.

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.

2007-03-I-MA-9

Revise Flammable and Combustible Liquids Code (NFPA 30): - Prohibit heating flammable and combustible liquids above their flashpoints in tanks inside buildings, unless the tanks are sealed and vented to the building exterior. - 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.

2007-03-I-MA-10

Revise The Standard for the Manufacture of Organic Coatings (NFPA 35): -Define equipment specifically discussed in the standard, such as kettles and thin-down tanks. -Define the terms "open, "closed", and "sealed" and "vented." -Prohibit heating flammable and combustible liquids above their flashpoints in tanks inside buildings unless the tanks are sealed and vented to the building exterior. -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.

2007-03-I-MA-7

Pending revision of the Massachusetts Fire Safety Code (527 CMR), revise the town bylaws addressing 527 CMR 14 requirements applicable to facility licensing and annual registration to: -Require new and current product manufacturing registrants to certify in writing that the facility complies with, at a minimum, all state and local fire codes and hazardous chemical regulations as part of the annual registration renewal. -Require companies holding a license and current registration for any of the eight classes of flammable materials specified in 527 CMR 14.03 (2) to re-register the facility before increasing any chemical quantity above the registered amount or adding a different regulated chemical at the facility. Include a requirement in the approval process to solicit input from affected landowners, similar to the requirement for obtaining the original license and registration. -Revise the license and registration forms to require listing each hazardous material type and quantity, and require a separate license and permit for each of the eight classes of flammable materials specified in 527 CMR 14.03 (2) . -Require the fire department to annually inspect licensed manufacturing facilities for compliance with the fire code.

2011-5-I-KY-2

Modify the design and procedures for the electric arc furnace and related structures including the control room to comply with the NFPA standard developed per R1 of this case study.  

2011-5-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.

2011-5-I-KY-1

Establish a committee to evaluate and develop a standard that defines the safety requirements for electric arc furnaces operated with flammable materials and low oxygen atmospheres. At a minimum, establish requirements that electric arc furnaces containing flammables have: • Adequate safety instrumentation and controls to prevent explosions and overpressure events; • Mechanical integrity and inspection programs; • A documented siting analysis to ensure that control rooms and other occupied areas are adequately protected.  

2010-02-I-PR-7

2010-02-I-PR-8

2010-02-I-PR-9

2010-02-I-PR-1

2010-02-I-PR-2

2010-02-I-PR-3

2010-02-I-PR-5

2010-02-I-PR-6

2010-02-I-PR-4

2012-03-I-CA-26

Revise API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries to establish minimum requirements for preventing catastrophic rupture of low-silicon carbon steel piping.  At a minimum: 

a.       Require users to identify carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components.  These circuits have the potential to contain carbon steel components that were not manufactured to the American Society for Testing and Materials (ASTM) A106 specification and may contain less than 0.10 weight percent silicon content. 

b.      For piping circuits identified to meet the specifications detailed in 2012-03-I-CA-R26(a), require users to either (1) enact a program to inspect every component within the piping circuit once, known as 100 percent component inspection (per the requirements established pursuant to recommendation 2012-03-I-CA-R28(c)), or (2) replace the identified at-risk carbon steel piping with a steel alloy that is more resistant to sulfidation corrosion. 

c.       If low-silicon components or components with accelerated corrosion are identified in a carbon steel piping circuit meeting the specifications detailed in 2012-03-I-CA-R26(a), require designation of these components as permanent Condition Monitoring Locations (CMLs) until the piping components are replaced.

2012-03-I-CA-27

Revise API RP 571: Damage Mechanisms Affecting Fixed Equipment in the Refining Industry to:

a.       Describe the potential for increased rates of sulfidation corrosion occurring in low-silicon carbon steel in Section 4.4.2.3 Critical Factors; 

b.      Specify that sulfidation corrosion rates in carbon steel piping can be significantly faster in a few, individual piping components in section 4.4.2.5 Appearance or Morphology of Damage; and

c.       Refer the reader to the 100 percent component inspection or pipe replacement requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to recommendation 2012-03-I-CA-R26)  and API 570: Piping Inspection Code:  In-service Inspection, Rating, Repair, and Alteration of Piping Systems (pursuant to 2012-03-I-CA-R28(c)) for carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components.  

2012-03-I-CA-28

Revise API 570: Piping Inspection Code:  In-service Inspection, Rating, Repair, and Alteration of Piping Systems to:   

a.       Use terminology consistent with API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries and other API standards and recommended practices discussed in this report.  Replace the terminology “high-temperature sulfur corrosion” with “sulfidation corrosion”;

b.      Specify that sulfidation corrosion rates in carbon steel piping can be significantly faster in some individual piping components than in others;

c.       Establish a new section that details inspection requirements to identify low-silicon piping components in carbon steel circuits susceptible to sulfidation corrosion.  This section shall require users to identify carbon steel piping circuits at risk to contain low-silicon components by following the requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to 2012-03-I-CA-R26(a)) and API RP 578: Material Verification Program for New and Existing Alloy Piping Systems (pursuant to 2012-03-I-CA-R29).  At a minimum, require users to either:

                                                              i.      Inspect every component within all carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components once.  The purpose of this practice is to identify any low-silicon components that are corroding at accelerated rates.  Inspection may be performed through ultrasonic thickness measurements to establish corrosion rates for each component, destructive laboratory analysis, or other methods.  Following the inspection, require users to follow the low-silicon corrosion rate monitoring requirements established in 2012-03-I-CA-R26(c); or    

                                                            ii.      Replace the identified at-risk carbon steel piping with a steel alloy that is more resistant to sulfidation corrosion.

d.      Incorporate as a “normative reference” API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries; and

e.       Require users to follow the minimum leak response guidance establishedinAPI RP 2001: Fire Protection in Refineries, developed in response to recommendation 2012-03-I-CA-R31.

2012-03-I-CA-29

Revise API RP 578: Material Verification Program for New and Existing Alloy Piping Systems, to require users to establish and implement a program to identify carbon steel piping circuits that are susceptible to sulfidation corrosionand may contain low-silicon components.  These circuits have the potential to contain carbon steel components that were not manufactured to the American Society for Testing and Materials (ASTM) A106 specification and may contain less than 0.10 weight percent silicon content.  Refer the reader to the 100 percent component inspection or pipe replacement requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to recommendation 2012-03-I-CA-26(b))  and API 570: Piping Inspection Code:  In-service Inspection, Rating, Repair, and Alteration of Piping Systems (pursuant to 2012-03-I-CA-28(c)) for carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components.

2012-03-I-CA-30

Revise API RP 574: Inspection Practices for Piping System Components (3rd edition) to: 

a.       Incorporate as a normative reference API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries;

b.      Reference API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries when discussing that nonsilicon-killed carbon steel is susceptible to sulfidation corrosion; and

c.       In Section 9.3 Investigation of Leaks, require users to follow the leak response protocol requirements established in API RP 2001: Fire Protection in Refineries (pursuant to 2012-03-I-CA-R31).

2012-03-I-CA-31

Revise API RP 2001: Fire Protection in Refineries to require users to develop a process fluid leak response protocol specific to their own facility that must be followed when a process fluid leak is discovered.  Recommend users to incorporate the following actions into their leak response protocol: 

a.       Establish an Incident Command structure upon identification of a process fluid leak;

b.      Conduct a pre-response meeting with personnel with specific technical expertise (e.g., inspectors, operators, metallurgists, engineers, and management) and the Incident Commander to determine pressure, temperature, remaining inventory of process fluids, potential damage mechanisms that caused the leak, and worst-case leak scenario;

c.       Establish a hot zone that identifies the area of risk of exposure or injuries due to flame contact, radiant heat, or contact to hazardous materials, taking into consideration the worst-case leak scenario;

d.      Limit site access around leak location to essential personnel only;

e.       Isolate the leaking piping or vessel, or if isolation is not possible, shutdown of the unit when the leaking process fluid poses immediate danger to safety, health, or the environment—such as piping fluid that is toxic or near the autoignition temperature.

2012-03-I-CA-32

Revise ASME PCC-2-2011: Repair of Pressure Equipment and Piping to require users to follow the minimum process fluid leak response requirements established in API RP 2001: Fire Protection in Refineries, developed in response to recommendation 2012-03-I-CA-R31, before conducting process fluid leak repair.

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).

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.

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.

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.

2012-03-I-CA-25

Implement a compensation system to ensure the regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical competency at all levels of process safety regulatory oversight and policy development in Contra Cost County, California. A market analysis and benchmarking review should be periodically conducted to ensure the compensation system remains competitive with California petroleum refineries.

2012-03-I-CA-36

Revise the Industrial Safety Ordinance (ISO) regulations for petroleum refineries to require a process safety culture continuous improvement program including a written procedure for periodic process safety culture surveys across the work force. Require an oversight committee comprised of the regulator, the company, the company’s workforce and their representatives, and community representatives. This oversight committee shall:

a. Select an expert third party that will administer a periodic process safety culture survey;

b. Review and comment on the third party expert report developed from the survey;

c. Oversee the development and effective implementation of action items to effectively address identified process safety culture issues; and

d. Develop process safety culture indicators to measure major accident prevention performance.

The periodic process safety culture report shall be made available to the plant workforce.

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.

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.

2012-03-I-CA-1 URGENT!

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.

2012-03-I-CA-2 URGENT!

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.

2012-03-I-CA-33

Develop a method to assign accountability at Chevron to determine whether any whether any new Energy Technology Company (ETC) recommended program or industry best practice, such as API guidance must be followed to ensure process safety or employee personal safety.  This method shall include monitoring of these practices and guidance at a refining system level and at the refinery level.  Develop a tracking system to monitor the progress of implementing these selected practices and guidance to completion.

2012-03-I-CA-34

Develop an auditable process to be available for all recommended turnaround work items necessary to address mechanical integrity deficiencies or inspection recommendations that are denied or deferred.  This process shall provide the submitter of the denied or deferred recommendation with the option to seek further review by his or her manager, who can further elevate and discuss the recommendation with higher level management, such as the Area Business Unit Manager.  Maintain an auditable log of each of these potential turnaround work items, including the ultimate determination of approval, deferral, or rejection, justification determination, and the person or team responsible for that decision.

2012-03-I-CA-35

Develop an approval process that includes a technical review that must be implemented prior to resetting the minimum alert thickness to a lower value in the inspection database.

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.

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.

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.

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.

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.

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).

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.

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.

2012-03-I-CA-21

Based on the findings in this report, enhance and restructure California’s process safety management (PSM) regulations for petroleum refineries by including the following goal-setting attributes:

a. Require a comprehensive process hazard analysis (PHA) written by the company that includes:

i. Systematic analysis and documentation of all major hazards and safeguards, using the hierarchy of controls to identify hazards and significantly reduce risks to a goal of as low as reasonably practicable (ALARP) or similar;

ii. Documentation of the recognized methodologies, rationale and conclusions used to claim that inherently safer systems have been implemented to as low as reasonably practicable (ALARP) or similar, and that additional safeguards intended to control remaining hazards will be effective;

iii. Documented damage mechanism hazard review conducted by a diverse team of qualified personnel. This review shall be an integral part of the process hazard analysis (PHA) cycle and shall be conducted on all covered processes, piping circuits and equipment. The damage mechanism hazard review shall identify potentia process damage mechanisms and consequences of failure, and shall ensure effective safeguards are in place to prevent or control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safer design to the greatest extent feasible into this review; and

iv. 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) or similar. Include requirements for inherently safer systems analysis to be automatically triggered for all management of change (MOC) and process hazard analysis (PHA) reviews, as well as prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.

b. Require a thorough review of the comprehensive process hazard an alysis by technically competent regulatory personnel;

c. Require preventative audits and preventative inspections by the regulator to ensure the effective implementation of the comprehensive process hazard analysis (PHA);

d. Require that all safety codes, standards, employer internal procedures and recognized and generally accepted good engineering practices (RAGAGEP) used in the implementation of the regulations contain adequate minimum requirements;

e. Require mechanisms for the regulator, the refinery, and workers and their representatives to play an equal and essential role in the direction of preventing major incidents. Require an expanded role for workers in management of process safety by establishing the rights and responsibilities of workers and their representatives on health and safety-related matters, and the election of safety representatives and establishment of safety committees (with equal representation between management and labor) to serve health and safety-related functions. The elected representatives should have a legally recognized role that goes beyond consultation in activities such as the development of the comprehensive process hazard analysis, implementation of corrective actions generated from hierarchy of control analyses, management of change, incident investigation, audits, and the identification, prevention, and control of all processhazards. The regulation should provide workers and their representatives with the authority to stop work that is perceived to be unsafe until the employer resolves the matter or the regulator intervenes.  Workforce participation practices should be documented by the refinery to the regulator;

f. Require reporting of information to the public to the greatest extent feasible, such as a summary of the comprehensive process hazard analysis (PHA) which should include a list of inherently safer systems implemented; safeguards implemented for remaining hazards; standards utilized to reduce risks to As Low As Reasonably Practicable (ALARP) or similar; and process safety indicators that demonstrate the effectiveness of the safeguards and management systems;

g. Implement an approach or system that determines when new or improved industry standards and practices are needed and initiate programs and other activities, such as an advisory committee or forum, toprompt the timely development and implementation of such standards and practices; and

h. Ensure that a means of sustained funding is established to support an independent, well-funded, well-staffed, technically competent regulator.

2012-03-I-CA-22

Implement a compensation system to ensure the regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical competency at all levels of process safety regulatory oversight and policy development in California. A market analysis and benchmarking review should be periodically conducted to ensure the compensation system remains competitive with California petroleum refineries.

2012-03-I-CA-23

Work with the regulator, the petroleum refining industry, labor, and other relevant stakeholders in the state of California to develop and implement a systemthat collects, tracks, and analyzes process safety leading and lagging indicators from refineries and contractors to promote continuous safety improvements. At a minimum, this program shall:

a. Require the use of leading and lagging process safety indicators to actively monitor the effectiveness of process safety management systems and safeguards for major accident prevention. Include leading and lagging indicators that are measureable, actionable, and standardized. Require that the reported data be used for continuous process safety improvement and accident prevention;

b. Analyze data to identify trends and poor performers and publish annual reports with the data at facility and corporate levels;

c. Require companies to publicly report required indicators annually at facility and corporate levels;

d. Use process safety indicators (1) to drive continuous improvement for major accident prevention by using the data to identify industry and facility safety trends and deficiencies and (2) to determine appropriate allocation of regulator resources and inspections; and

e. Be periodically updated to incorporate new learning from world-wide industry improvements in order to drive continuous major accident safety improvements in California.

2012-03-I-CA-3

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).

2012-03-I-CA-4

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.

2012-03-I-CA-5

Ensure 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

2012-03-I-CA-17

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.

2012-03-I-CA-24

Implement or cause to be implemented a compensation system to ensure the regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical competency at all levels of process safety regulatory oversight and policy development in Richmond, California. A market analysis and benchmarking review should be periodically conducted to ensure the compensation system remains competitive with California petroleum refineries.

2012-03-I-CA-37

Revise the Richmond Industrial Safety Ordinance (RISO) regulations for petroleum refineries to require a process safety culture continuous improvement program including a written procedure for periodic process safety culture surveys across the work force. Require an oversight committee comprised of the regulator, the company, the company’s workforce and their representatives, and community representatives. This oversight committee shall:

a. Select an expert third party that will administer a periodic process safety culture survey;

b. Review and comment on the third party expert report developed from the survey;

c. Oversee the development and effective implementation of action items to effectively address identified process safety culture issues; and

d. Develop process safety culture indicators to measure major accident prevention performance.

The periodic process safety culture report shall be made available to the plant workforce.

2009-14-I-TX-1 URGENT!

• 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.

2009-14-I-TX-2 URGENT!

• 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.

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.

2006-1-H-1

(Superseded by 2017-07-I-WI-R10 from the Didion Milling Co. investigation)

Issue a standard designed to prevent combustible dust fires and explosions in general industry. Base the standard on current National Fire Protection Association (NFPA) dust explosion standards (including NFPA 654 and NFPA 484), and include at least - hazard assessment, - engineering controls, - housekeeping, - building design, - explosion protection, - operating procedures, and - worker training.

2006-1-H-2

Revise the Hazard Communication Standard (HCS) (1910.1200) to: - Clarify that the HCS covers combustible dusts, including those materials that may reasonably be anticipated to generate combustible dusts through downstream processing or handling. - Require Material Safety Data Sheets (MSDSs) to include the hazards and physical properties of combustible dusts, as well as clear information on safe handling practices and references to relevant consensus standards.

2006-1-H-3

Communicate to the United Nations Economic Commission for Europe (UNECE) the need to amend the Globally Harmonized System (GHS) to address combustible dust hazards by: - defining combustible dusts, - specifying the hazards that must be addressed in chemical information sheets, and - addressing the physical properties that must be included on a chemical information sheet pertinent to combustible dusts.

2006-1-H-4

Provide training through the OSHA Training Institute (OTI) on recognizing and preventing combustible dust explosions.

2006-1-H-5

While a standard is being developed, identify manufacturing industries at risk and develop and implement a national Special Emphasis Program (SEP) on combustible dust hazards in general industry. Include in the SEP an outreach program focused on the information in the Safety and Health Information Bulletin (SHIB), Combustible Dust in Industry: Preventing and Mitigating the Effects of Fire and Explosions.

2010-12-I-NC-1 URGENT!

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

2010-12-I-NC-2 URGENT!

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

2010-12-I-NC-2 URGENT!

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

2010-12-I-NC-1 URGENT!

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

2003-09-I-KY-19

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

2003-09-I-KY-11

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

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.

2003-09-I-KY-13

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

2003-09-I-KY-9

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

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.

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.

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.

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.

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.

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.

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.

2003-09-I-KY-7

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

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.

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.

2003-09-I-KY-20

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

2003-09-I-KY-17

Incorporate the findings and recommendations of this report in your continuing training of inspectors, plan reviewers, technical advisors, and fire marshal general inspectors who interface with facilities that may handle combustible dusts.

2003-09-I-KY-18

Identify sites that handle combustible dusts when facilities apply for new or modified construction permits, and use this information to help prioritize establishments that will be inspected by the fire marshal.

2003-09-I-KY-14

Develop and distribute an educational bulletin on the prevention of combustible dust explosions.

2003-09-I-KY-15

Enhance the training program for compliance officers regarding the recognition and prevention of combustible dust explosion hazards.

2003-09-I-KY-21

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

2003-09-I-KY-22

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

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.

2003-11-I-KY-1

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

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.

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.

2003-11-I-KY-4

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

2003-11-I-KY-5

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

2003-11-I-KY-6

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

2003-11-I-KY-8

Communicate to your members that used pressure vessels are not exempt from registration and initial inspection before being placed in service in Kentucky.

2003-11-I-KY-10

Communicate the findings of this report to your membership.

2003-11-I-KY-9

Communicate the findings of this report to your membership.

2017-07-I-WI-1

Contract a competent third party to develop a comprehensive combustible dust process safety management system, such as OSHA’s Process Safety Management standard or the requirements in the 2019 edition of NFPA 652, Standard on the Fundamentals of Combustible Dust, Chapter 8, which includes, at a minimum, the following elements:

a. Management of Change for combustible dust;

b. Process Safety Information Management;

c. Management of Audits and Inspections;

d. Fugitive Dust Management;

e. Incident Investigation;

f. Dust Hazard Analyses;

g. Management of Engineering Controls for combustible dust

h. Personal Protective Equipment; and

i. Emergency Preparedness.

2017-07-I-WI-2

Contract a competent third party to develop and implement modifications to the pneumatic conveying and dust collector ductwork systems in accordance with guidance such as NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, NFPA 652, Standard on the Fundamentals of Combustible Dust, and NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids, to include, at a minimum:

a. Ensure minimum required transport velocity is maintained throughout the system.

b. Implement a periodic inspection and testing program for pneumatic conveying and dust collector ductwork systems, following industry guidance such as NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Particulate Solids, and FM Global guidance. The program should include cleaning on a set frequency and measuring transport velocities on a routine basis to ensure proper system function.

2017-07-I-WI-3

Contract a competent third party to perform dust hazard analyses (DHAs) on all buildings and units that process combustible dust. Ensure that the DHAs are revalidated at least every five years. Implement pre-deflagration detection, deflagration venting, deflagration suppression, deflagration isolation, and deflagration pressure containment engineering controls identified in the initial and revalidation DHA in accordance with NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, NFPA 68, Standard on Explosion Protection by Deflagration Venting, NFPA 69, Standard on Explosion Prevention Systems, and NFPA 652, Standard on the Fundamentals of Combustible Dust.

2017-07-I-WI-4

Contract a competent third party to assess and implement engineering controls for the structural design and venting requirements of the reconstructed facility to ensure they meet the requirements and guidance in NFPA 68, Standard on Explosion Protection by Deflagration Venting, for adequacy of venting capacity.

2017-07-I-WI-5

Incorporate recording any paper-based process safety information into Didion’s existing electronic records management system so that the information can be reliably retained, retrieved, and analyzed in the event of a catastrophic incident.

2017-07-I-WI-6

Contract a competent third party to perform personal protective equipment hazard analyses, such as those prescribed by NFPA 2113, Standard on Selection, Care, Use, and Maintenance of Flame-Resistant Garments for Protection of Industrial Personnel Against Short-Duration Thermal Exposures from Fire, and require appropriate flame-resistant garments for all operations that handle combustible dusts during normal and upset conditions.

2017-07-I-WI-7

Contract a competent third party to update the facility emergency response plan and train all employees on updated emergency response plan. The update should include the guidance in NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, and NFPA 652, Standard on the Fundamentals of Combustible Dust, Chapter 8 and Section A.8.10.1, which includes, at a minimum, the following elements:

a. A signal or alarm system;

b. Emergency shutdown procedures; 

c. Provide instructions for when and how to trigger emergency evacuations;

d. Provide instructions for when to notify emergency responders for need of assistance;

e. Response to potential fire scenarios, such as smoldering fires inside equipment; and

f. Prevent firefighting of process fires inside equipment.

2017-07-I-WI-8

Contract a competent third party to assess and update the pre-deflagration detection and suppression engineering controls, such as those discussed in Chapter 9 of the 2019 edition of NFPA 69, Standard on Explosion Prevention Systems, for adequacy to detect and alarm employees of an emergency situation, such as a smoldering fire, and trigger an evacuation.

2017-07-I-WI-9

Contract a competent third party to develop and implement a process safety leadership and culture program, based on the guidance of the CCPS’s Guidelines for Auditing Process Safety Management Systems and Process Safety: Leadership from the Boardroom to the Frontline. The program should include, at a minimum, the following elements:

a. A process safety policy;

b. A process safety leadership and culture committee;

c. Appropriate goals for process safety;

d. A commitment to process safety culture;

e. Leading and lagging process safety metrics;

f. Process Safety Culture Assessments; and,

g. Engagement with external process safety leadership and culture experts.

2017-07-I-WI-13

Update NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, or a successor standard, to incorporate, at a minimum, the following elements:

1. Unify the requirements for performing dust hazard analyses to remove equipment exemptions and require the assessment of all processes, such as cyclones, as required in:

a. The 2019 edition of NFPA 652, Standard on the Fundamentals of Combustible Dust

b. Chapters 3, 5, and 6 of the CCPS’s Guidelines for Combustible Dust Hazard Analysis.

2. Incorporate the additional guidance for Management of Change to include but not limited to:

a. Harmonize the 2019 edition of NFPA 652, Standard on the Fundamentals of Combustible Dust, requirements for section 8.12.2.4, modifications to operating and maintenance procedures, and section 8.12.2.4, employee training requirements.

b. Chapter 3 and Appendix B of the CCPS’s Guidelines for the Management of Change for Process Safety, such as addressing temporary changes, operating and maintenance procedures, employee training, and dust testing results, to standardize MOC requirements across all industries that handle combustible dust.

3. Update the requirements for incident investigation management systems, to include but not limited to:

a. Incorporate the optional guidance of the 2019 edition of NFPA 652, Standard on the Fundamentals of Combustible Dust, as a mandatory requirement.

b. Chapters 4 and 10 of CCPS’s Guidelines for Investigating Process Safety Incidents (3rd Edition).  

2017-07-I-WI-10

Promulgate a standard for all industries that handle combustible dust, which should be based on the requirements of current NFPA combustible dust standards, including NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, NFPA 484, Standard for Combustible Metals, NFPA 652, Standard on the Fundamentals of Combustible Dust, NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids, NFPA 655, Standard for Prevention of Sulfur Fires and Explosions, NFPA 664, Standard for the Prevention of Fires and Explosions in Wood Processing and Woodworking Facilities, or a successor standard. At a minimum, the standard should include the following elements:

a. Hazard Recognition;

b. Dust Hazard Analysis;

c. Management of Change;

d. Incident Investigation;

e. Engineering Controls;

f. Building Design;

g. Fugitive Dust Management;

h. Operating Procedures;

i. Process Safety Information; 

j. External Audit Management;

k. Training;

l. Emergency Response; and

m. Personal Protective Equipment.

(Superseded the following recommendations: 2006-1-H-R1 from the Combustible Dust Hazard investigation, 2008-05-I-GA-R11 from the Imperial Sugar investigation, and 2011-04-I-TN-R1 and 2011-04-I-TN-R2 from the Hoeganaes Corporation investigation)

2017-07-I-WI-11

Following implementation of CSB Recommendation No. 2017-07-I-WI-R10, update the Grain Handling Facilities Standard to clarify grain handling facilities with combustible dust are covered by the new Combustible Dust Standard.

2017-07-I-WI-12

Develop a program to trigger follow-up inspections when hazard alert letters are issued for combustible dust hazards and there is insufficient evidence to demonstrate that those hazards have been abated.

2011-06-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.

2011-06-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."

2011-06-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.

2011-06-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.