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Valero Refinery Asphyxiation Incident (8 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: November 02, 2006

2006-2-I-DE-6

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


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

American Society of Safety Engineers (ASSE) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: November 02, 2006

2006-2-I-DE-7

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


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

Compressed Gas Association (CGA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-8

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


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

Matrix Service Industrial Contractors, Inc. (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-5

Conduct confined space control and inert gas purge procedure refresher training for all affected personnel. Emphasize: - The requirements to maintain posted warnings at all access points to confined space temporary openings. - The need to maintain posted warnings, barricades, and access controls as required by the client. - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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

Valero Delaware City Refinery (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-1

Conduct safe work permit refresher training for all permit-preparers and approvers and affected refinery personnel and contractors. Emphasize: - All proposed work requires a jobsite visit by the requestor and a unit operator to identify special precautions, equipment status, and personal safety equipment requirements. - The conditions for marking the "nitrogen purge or inerted" (Yes/No/NA) status box. - The permit must clearly identify all hazards and special personal protective equipment requirements. - "Fresh Air" work restrictions apply to "Set up only" permits whenever an IDLH atmosphere is suspected or known to be present in the work area.


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

2006-2-I-DE-2

Conduct confined space control and inert gas purge procedure refresher training for all affected refinery personnel and contractors. Emphasize: - The requirements to maintain posted warnings at all access points to confined space temporary openings. - The requirements to maintain posted warnings, barricades, and access control log at equipment during purging. - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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

Valero Energy Corporation (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-3

Audit work permit procedures and nitrogen purge safety procedures at each Valero U.S. refinery. Determine if issues identified in this Case Study are occurring elsewhere. Implement corrective action, including training, where necessary.


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

2006-2-I-DE-4

Require Valero U.S. refineries to revise and conduct nitrogen hazards awareness training. Emphasize: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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

Valero Refinery Propane Fire (12 Recommendations)
American Petroleum Institute (API) (4 Recommendations)
Open: 75% | Closed: 25%

Final Report Released On: July 09, 2008

2007-5-I-TX-1

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


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

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2007-5-I-TX-2

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


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

2007-5-I-TX-3

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


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

2007-5-I-TX-4

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


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

United Steelworkers of America (USWA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 09, 2008

2007-5-I-TX-10

Work together to benchmark effective PHA methods and practices and implement improvements to the McKee Refinery PHA program, including: -involving the workforce in PHA preparation, performance, and follow-up; -training participants; -conducting PHA quality control checks; and -following up on recommendations for timely implementation and appropriate close-out.


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

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USW Local 13-487 (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 09, 2008

2007-5-I-TX-10

Work together to benchmark effective PHA methods and practices and implement improvements to the McKee Refinery PHA program, including: -involving the workforce in PHA preparation, performance, and follow-up; -training participants; -conducting PHA quality control checks; and -following up on recommendations for timely implementation and appropriate close-out.


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

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Valero Energy Corporation (5 Recommendations)
Open: 60% | Closed: 40%

Final Report Released On: July 09, 2008

2007-5-I-TX-5

Identify all processes in this and other refineries where Valero's mandatory Emergency Isolation Valve standard is applicable, and ensure that Remotely Operable Shut-off Valves (ROSOVs) are installed to control large accidental releases of flammable materials.


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

2007-5-I-TX-6

Establish corporate requirements for written freeze protection programs at Valero refineries subject to freezing temperatures, including identification, mitigation, MOC, and audit requirements.


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

2007-5-I-TX-7

Revise Valero standards, including Fire Proofing Specifications, to require evaluation of jet fire scenarios and, as a minimum, ensure more protective fireproofing for pipe rack support steel near process units containing highly pressurized flammables.


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

2007-5-I-TX-8

Audit PHA performance at its refineries to ensure adherence to company standards and good practice guidelines.


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

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2007-5-I-TX-9

Implement Valero's strategic plan to replace chlorine used as a biocide in cooling water treatment with inherently safer materials, such as sodium hypochlorite, at all refineries.


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

Valero McKee Refinery (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 09, 2008

2007-5-I-TX-10

Work together to benchmark effective PHA methods and practices and implement improvements to the McKee Refinery PHA program, including: -involving the workforce in PHA preparation, performance, and follow-up; -training participants; -conducting PHA quality control checks; and -following up on recommendations for timely implementation and appropriate close-out.


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

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Veolia Environmental Services Flammable Vapor Explosion and Fire (7 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 21, 2010

2010-10-I-OH-5

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


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

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Environmental Technology Council (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 21, 2010

2010-10-I-OH-6

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


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

2010-10-I-OH-7

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


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

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 21, 2010

2010-10-I-OH-4

Revise NFPA 30, Chapter 17, to include a section requiring a written engineering analysis to determine the safe separation distance for occupied buildings, control rooms, and operating areas. The analysis must be acceptable to the authority having jurisdiction.


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

Veolia ES Technical Solutions (3 Recommendations)
Open: 33% | Closed: 67%

Final Report Released On: July 21, 2010

2010-10-I-OH-1

During the rebuild of the plant, revise policy to restrict occupancy of non-essential personnel in buildings in close proximity to operating plants.


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

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2010-10-I-OH-2

During the rebuild, design and install a closed relief system and develop a policy for safe venting (e.g., use of a flare) for relief systems to the atmosphere.


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

2010-10-I-OH-3

Conduct a process hazard analysis on all OSHA Process Safety Management covered processes to ensure all buildings and structures at the West Carrollton facility are located and designed in accordance with electrical classification and spacing as defined in NFPA 70.


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

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West Pharmaceutical Services Dust Explosion and Fire (9 Recommendations)
Crystal, Inc. - PMC (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 23, 2004

2003-07-I-NC-9

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


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

North Carolina Building Code Council (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 23, 2004

2003-07-I-NC-7

Amend Chapter 13, Section 1304, of the International Fire Code (as adopted by the North Carolina Fire Code) to make compliance with NFPA 654, Standard for the Prevention of Fire and Dust Explosions From the Manufacturing, Processing, and Handling of Combustible Particulate Solids, mandatory.


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

North Carolina Code Officials Qualification Board (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 23, 2004

2003-07-I-NC-8

Incorporate the provisions of NFPA 654, Standard for the Prevention of Fire and Dust Explosions From the Manufacturing, Processing, and Handling of Combustible Particulate Solids, into the training program for State and local building and fire code officials.


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

North Carolina Department of Labor, Occupational Safety and Health Division (NCOSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 23, 2004

2003-07-I-NC-6

Identify the manufacturing industries at risk for combustible dust explosions, and develop and conduct an outreach program on combustible dust hazards.


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

West Pharmaceutical Services, Inc. (5 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 23, 2004

2003-07-I-NC-1

Revise policies and procedures for new material safety reviews. In particular: Use the most recent versions of material safety data sheets (MSDSs) and other technical hazard information. Fully identify the hazardous characteristics of new materials, including relevant physical and chemical properties, to ensure that those characteristics are incorporated into safety practices, as appropriate. Include an engineering element that identifies and addresses the potential safety implications of new materials on manufacturing processes.


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

2003-07-I-NC-2

Develop and implement policies and procedures for safety reviews of engineering projects. In particular: Address the hazards of individual materials and equipment? and their effect on entire processes and facilities. Consider hazards during the conceptual design phase, as well as during engineering and construction phases. Cover all phases of the project, including engineering and construction performed by outside firms. Identify and consider applicable codes and standards in the design.


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

2003-07-I-NC-3

Identify West manufacturing facilities that use combustible dusts. Ensure that they incorporate applicable safety precautions described in NFPA 654, Standard for the Prevention of Fire and Dust Explosions From the Manufacturing, Processing, and Handling of Combustible Particulate Solids. In particular: Ensure that penetrations of partitions, floors, walls, and ceilings are sealed dust-tight. Ensure that spaces inaccessible to housekeeping are sealed to prevent dust accumulation.


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

2003-07-I-NC-4

Improve hazard communication programs so that the hazards of combustible dust are clearly identified and communicated to the workforce. In particular, ensure that the most current MSDSs are in use and that employees receive training on the revised/updated information.


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

2003-07-I-NC-5

Communicate the findings and recommendations of this report to the West Pharmaceutical Services, Inc., workforce.


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

Xcel Energy Company Hydroelectric Tunnel Fire (20 Recommendations)
American Public Power Association (APPA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: August 25, 2010

2008-01-I-CO-17

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

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

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

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

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

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


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

Colorado Division of Emergency Management Director (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-7

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

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

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

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

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


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

Colorado Division of Fire Safety Director (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-7

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

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

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

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

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


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

Colorado Public Utilities Commission (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-4

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

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

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

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

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


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

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2008-01-I-CO-5

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

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


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

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2008-01-I-CO-6

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

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


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

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Governor of the State of Colorado (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-3

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


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

Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: August 25, 2010

2008-01-I-CO-1

Amend the OSHA Permit-Required Confined Spaces Rule for general industry (29 CFR 1910.146) to establish a maximum permissible percentage substantially below the lower explosive limit (LEL) for safe entry and occupancy in permit-required confined spaces.


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

2008-01-I-CO-2

Publish a “Safety and Health Information Bulletin” addressing the hazards and controls when using flammable materials in confined spaces that includes actionable guidance regarding:
 
a. The importance of implementing a hierarchy of controls to address hazards in a confined space that first seeks to eliminate hazards or substitute with a less hazardous material(s) or method(s). Examples include performing work outside of a confined space where reasonably practicable or substituting a flammable material with a non-flammable one.

b. The necessity of establishing a maximum permissible percentage substantially below the lower explosive limit (LEL) for safe entry and occupancy of permit required confined spaces.

c. The need to comprehensively control all potential ignition sources and continuously monitor the confined space at appropriate locations and elevations when work activities involve the use of flammable materials or where flammable atmospheres may be created.

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

e. The requirement that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Such spaces need to be monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working.


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

RPI Coating, Inc. (3 Recommendations)
Open: 67% | Closed: 33%

Final Report Released On: August 25, 2010

2008-01-I-CO-13

Revise your confined space entry program and practices. At a minimum

a. Require continuous monitoring for flammable atmospheres at appropriate locations and elevations within a confined space where work activities involve the use of flammables or where flammable atmospheres may be created.

b. Prohibit entry or require evacuation of a confined space if the atmospheric concentration of flammable vapors is 10 percent of the LEL or higher.

c. Ensure that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Ensure that such spaces are monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working.

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

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


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

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2008-01-I-CO-14

Based on the findings and conclusions of this report, hire a certified safety professional to conduct periodic safety audits at your worksites. At a minimum, assess safety training, confined space safety, safe handling of flammables, emergency response, rescue, and fire prevention.


Status: Open - Unacceptable Response
Open - Unacceptable Response (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

2008-01-I-CO-15

Ensure that all journeyman painters have received safety training equivalent in content to that covered in the Joint Apprenticeship program. At a minimum, address confined space safety, safe handling of flammables, emergency response and rescue, and fire prevention.


Status: Open - Unacceptable Response
Open - Unacceptable Response (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

Society for Protective Coatings (SSPC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-16

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

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

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

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

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

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


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

Southern California Painting and Drywall Industries Joint Apprenticeship and Training Committee (2 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: August 25, 2010

2008-01-I-CO-18

Require that all journeyman painters who are employees and/or members have received safety training equivalent in content to that covered in the Joint Apprenticeship program. At a minimum, address confined space safety, safe handling of flammables, emergency response and rescue, and fire prevention.


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

2008-01-I-CO-19

Include a safety knowledge and skills component to your journeyman and apprentice evaluation criteria.


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

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Xcel Energy, Inc. (5 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: August 25, 2010

2008-01-I-CO-8

Revise your policies for solicitation and procurement of construction services to

a. Ensure that requests for proposals (RFPs) and selection processes include criteria and procedures for prequalifying or disqualifying contractors based on specific safety performance measures and qualifications.

b. Implement written verification procedures for the safety information and documentation submitted by contractors during the bidding and selection process.


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

2008-01-I-CO-9

Revise your contractor safety policies to require a comprehensive review and evaluation of contractor safety policies and procedures such as the permit-required confined space program and safety performance of contractors working in confined spaces to ensure that any bidding contractor meets or exceeds Xcel Energy safety requirements.


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

2008-01-I-CO-10

Conduct periodic safety audits of contractor selection and oversight at your power-generating facilities to ensure adherence to corporate contractor procurement and safety policies.


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

2008-01-I-CO-11

Report key findings, causes and recommendations of the CSB report to Xcel shareholders so that the owners of Xcel are fully informed of the report contents and how Xcel intends to prevent a similar accident in the future.


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

2008-01-I-CO-12

Revise your confined space entry program and practices. At a minimum

a. Require continuous monitoring for flammable atmospheres at appropriate locations and elevations within a confined space where work activities involve the use of flammables or where flammable atmospheres may be created.

b. Prohibit entry or require evacuation of a confined space if the atmospheric concentration of flammable vapors is 10 percent of the LEL or higher.

c. Ensure that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Ensure that such spaces are monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working.

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

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


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

 
 
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