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Recommendations

The CSB issues safety recommendations to prevent the recurrence or reduce the likelihood or consequences of similar incidents or hazards in the future. Recommendations are issued to a variety of parties, including government entities, safety organizations, trade unions, trade associations, corporations, emergency response organizations, educational institutions, and public interest groups. Recommendations are published in CSB reports and are closed only by vote of the Board. The CSB tracks all recommendations and communicates regularly with recommendations recipients to ensure that the recommended corrective actions are implemented.

For more information, see Frequently Asked Questions about CSB recommendations.


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Recommendations Status:
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Recommendations
Union Carbide Corp. Nitrogen Asphyxiation Incident (6 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 23, 1999

2009-05-I-LA-5

Communicate the findings of this report to your membership.


Status: 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.
 

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

Final Report Released On: February 23, 1999

1998-05-I-LA-6

Communicate the findings of this report to your membership.


Status: 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.
 

National Institute for Occupational Safety and Health (NIOSH) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 23, 1999

1998-05-I-LA-3

Conduct a study concerning the appropriateness and feasibility of odorizing nitrogen in order to warn personnel of the presence of nitrogen when it is used in confined spaces.


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) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 23, 1999

1998-05-I-LA-4

Issue a safety alert that addresses the hazards and provides safety guidelines for the use of temporary enclosures that are erected around equipment containing hazardous substances.


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.
 

Union Carbide Taft Plant (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 23, 1999

1998-05-I-LA-1

Post signs containing the warning "Danger, Confined Space: Do Not Enter Without Authorization" or similar wording at potential entryways when tanks, vessels, pipes, or other similar chemical industry equipment are opened. When nitrogen is added to a confined space, post an additional sign that warns personnel of the potential nitrogen hazard.


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.
 

1998-05-I-LA-2

Ensure that the plant safety program addresses the control of hazards created by erecting temporary enclosures around equipment that may trap a dangerous atmosphere in the enclosure if the equipment leaks or vents hazardous material.


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.
 

Universal Form Clamp Co. Explosion and Fire (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 10, 2007

2006-8-I-IL-1

Amend 1910.106 Flammable and Combustible Liquids to require facilities that handle flammable and combustible liquids to implement the requirements of 1910.38 Emergency Action Plans.


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.
 

2006-8-I-IL-2

Amend 1910.38 Emergency Action Plans to require employers to conduct practice evacuation drills at least annually, but more frequently if necessary to ensure employees are prepared for emergencies.


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.
 

US Ink Fire (9 Recommendations)
New Jersey Department of Community Affairs (3 Recommendations)
Open: 67% | Closed: 33%

Final Report Released On: January 15, 2015

2013-01-I-NJ-3

Revise the exemption for “manufacturing, production, and process equipment” under the New Jersey Uniform Construction Code (N.J.A.C 5:23-2.2) to require that equipment involved in processing, handling, or conveying combustible dust comply with the design and operating requirements of the current edition of the International Building Code.


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.
 

PDF Document Status Change Summary

2013-01-I-NJ-4

Develop and implement training for local code officials on the National Fire Protection Association (NFPA) standards referenced in the New Jersey adoption of the International Building Code (IBC) for occupancies with a high hazard classification (Group H); specifically, include training on equipment that handles combustible dust and the hazards involved.


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.
 

PDF Document Status Change Summary

2013-01-I-NJ-5

Promulgate a regulation that requires all occupancies handling hazardous materials to inform the local enforcement agency of any type of construction or installation of equipment at an industrial or manufacturing facility. Also require local enforcement agencies to evaluate the information to determine whether a construction permit is required.


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.
 

Occupational Safety and Health Administration (OSHA) (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 15, 2015

2013-01-I-NJ-1

Add North American Industry Classification System (NAICS) Code 325910, Printing Ink Manufacturing, to the list of industries in Appendix D-1 or Appendix D-2 of Combustible Dust National Emphasis Program (NEP), Directive CPL 03-00-008.


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.
 

2013-01-I-NJ-2

Communicate with all OSHA Area Offices to encourage appropriate application of the following existing provisions of the Combustible Dust NEP, Directive CPL 03-00-008:

  • Paragraph IX, Section A2, indicates that area offices may add to their Combustible Dust NEP establishment lists those facilities in their jurisdictions with a Standard Industrial Classification System code, NAICS code, or both (other than those listed in Appendices D-1 and D-2 of the Combustible Dust NEP directive) if those facilities have a known pattern of combustible dust hazards.
  • Paragraph IX, Section B4, indicates that if a fatality or catastrophe investigation is performed at a facility because of a combustible dust deflagration or explosion, the inspector shall use the guidelines in Fatality/Catastrophe Investigation Procedures, Directive CPL 02-00-137, and in the Combustible Dust NEP, Directive CPL 03-00-008.

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.
 

2006-1-H-1 REITERATED!

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.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (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.
 

PDF Document Download

US Ink/Sun Chemical Corporation (3 Recommendations)
Open: 33% | Closed: 67%

Final Report Released On: January 15, 2015

2013-01-I-NJ-6

At the US Ink East Rutherford facility, install automatic fire alarm systems consistent with NFPA 72 (the National Fire Alarm Code) in manufacturing areas (such as mixing) where heat generation could occur.


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.
 

PDF Document Status Change Summary

2013-01-I-NJ-7

Revise the Capital Appropriations/Asset Request (CAR) form procedure for new installations and modifications to existing equipment to require at a minimum the following:

  • Process hazard analysis (PHA)
  • Management of change (MOC)
  • Review of engineering drawings for permits
  • Safety management of contractors
  • Training of plant operators based on applicable dust collection system guidelines and standards, including NFPA 91 and NFPA 654.

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.
 

2013-01-I-NJ-8

Develop and implement a management of organizational change protocol to allow for the transfer of knowledge and information to new personnel, at a minimum including initial or refresher training in the following:

  • Safety and health procedures
  • Lessons learned from previous incidents
  • Technical information for equipment
  • Routine plant operations.

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.
 

PDF Document Status Change Summary

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: 25% | Closed: 75%

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.
 

PDF Document Download

2007-5-I-TX-2

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


Status: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendation Status Change Summary

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: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendations Status Change Summary

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.
 

PDF Document Download

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.
 

PDF Document Download

Valero Energy Corporation (5 Recommendations)
Open: 20% | Closed: 80%

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: 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.
 

PDF Document Recommendation Status Change Summary

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: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Status Change Summary

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.
 

PDF Document Download

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.
 

PDF Document Download

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

2009-10-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.
 

PDF Document Download

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

Final Report Released On: July 21, 2010

2009-10-I-OH-6

Supersedes 2007-01-I-NC-R2, issued pursuant to EQ Hazardous Waste Plant Explosions and Fire

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.
 

2009-10-I-OH-7

Supersedes 2007-01-I-NC-R3, issued pursuant to EQ Hazardous Waste Plant Explosions and Fire

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: 0% | Closed: 100%

Final Report Released On: July 21, 2010

2009-10-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: 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.
 

PDF Document Recommendation Status Change Summary

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

Final Report Released On: July 21, 2010

2009-10-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.
 

PDF Document Download

2009-10-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.
 

2009-10-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.
 

PDF Document Download

West Fertilizer Explosion and Fire (19 Recommendations)
Department of Homeland Security, Federal Emergency Management Agency (FEMA) (4 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2016

2013-02-I-TX-7

Through a new or existing program and in conjunction with training partners, create and implement a competitive funding mechanism to provide training to regional, state, and local career and volunteer fire departments on how to respond to fire and explosion incidents at facilities that store fertilizer grade ammonium nitrate (FGAN).  Continue to use available funding to ensure training effectiveness.


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.
 

2013-02-I-TX-8

During the proposal review process for the program, ensure that the FGAN training includes multiple delivery methods to enable a broad reach.  Training should allow for instructor-led, web-based, and train-the-trainer courses; initial orientation; and refresher training.  Training also should accommodate both resident and mobile capabilities to facilitate flexible delivery.
Objectives of the selected training course should address the following:
a. Previous FGAN fire and explosion incidents, incorporating lessons learned

b. Hazards posed by other materials and chemicals stored near FGAN, including FGAN incompatibility with those materials and chemicals

c. Pre-incident planning for fires involving FGAN d. On-scene emergency response and decision-making requirements for FGAN fires, including risk assessment, scene size-up, and situational awareness

e. National Incident Management System and Incident Command System.


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.
 

2013-02-I-TX-9

Assist training partners to develop and provide continual oversight for an FGAN training program.  In addition, evaluate the training curriculum to confirm that it adequately meets course objectives as well as the details of recommendation 2013-02-I-TX R8.


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.
 

2013-02-I-TX-10

Develop an outreach program that notifies regional, state, and local fire departments about available FGAN training opportunities.  The program should include the following:

a. Guidance for fire departments on how to identify FGAN hazards within their communities by engaging State Emergency Response Commissions and Local Emergency Planning Committees

b. Details on how to obtain FGAN training by submitting a proposal in response to the funding opportunity

c. Information on training partners and programs that provide FGAN training.


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.
 

El Dorado Chemical Company (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2016

2013-02-I-TX-19

For all distributors and bulk retail sites (i.e., customers) that receive fertilizer grade ammonium nitrate (FGAN) manufactured by El Dorado Chemical Company (EDC) for storage, shipment, and sale:

a. Encourage customers to conduct internal monitoring and auditing (in accordance with recent industry standards and guidelines) in locations where FGAN will be stored or used.  Communicate that such internal monitoring and auditing may be conducted through established product safety programs, including ResponsibleAg.

b. Develop a process to establish mutual product stewardship expectations for the downstream chain of customers.  Communicate expectations to existing customers, and to new customers before their first shipment of FGAN.  Include the following components:

i. For all FGAN sold to distributors, encourage distributors to provide Safety Data Sheets and FGAN safety guidance to their customers and bulk retail sites to which FGAN is sold or shipped

ii. For all EDC bulk retailers and non-EDC bulk retailers that store and sell FGAN, encourage bulk retailers to address, such as through certification checklists, the following:

• Written procedures for the safe handling of FGAN, including employee training

• Emergency response plans to be sent to Local Emergency Planning Committees and local fire departments

• Tier II Chemical Inventory Report submissions.


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.
 

Environmental Protection Agency (EPA) (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2016

2013-02-I-TX-1

Develop a guidance document on Emergency Planning and Community Right-to-Know Act (EPCRA) requirements that is issued annually to State Emergency Response Commissions(SERCs) and Local Emergency Planning Committees (LEPCs) and ensure that the guidance focuses on the following:

a. Explains which chemicals are exempt and which must be reported.

b. Describes how emergency responders should use Tier I and Tier II inventory reports and Safety Data Sheets, such as in safety training, practice drills, and for emergency planning.

c. Includes comprehensive LEPC planning requirements, with an emphasis on annual training exercises and drills for local emergency response agencies.


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.
 

2013-02-I-TX-2

Develop a general guidance document on the agricultural exemption under EPCRA Section311(e)(5) and its associated regulation, 40 CFR 370.13(c)(3), to clarify that fertilizer facilities that store or blend fertilizer are covered under EPCRA.  Communicate to the fertilizer industry publication of this guidance document as well as the intention of Section 311(e)(5).


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.
 

2013-02-I-TX-3

Revise the Risk Management Program rule to include fertilizer grade ammonium nitrate (FGAN) at an appropriate threshold quantity on the List of Regulated Substances.

a. Ensure that the calculation for the offsite consequence analysis considers the unique explosive characteristics of FGAN explosions to determine the endpoint for explosive effects and overpressure levels.  Examples of such analyses include that adopted by the 2014 Fire Protection Research Foundation report, “Separation Distances in NFPA Codes and Standards,” Great Britain’s Health and Safety Executive, and other technical guidance.

b. Develop Risk Management Program rule guidance document(s) for regulated FGAN facilities.


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.
 

International Code Council (ICC) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2016

2013-02-I-TX-6

In a subsequent edition of the International Fire Code, develop a chapter or a separate section under Chapter 50 (“Hazardous Materials”) or Chapter 63 (“Oxidizers, Oxidizing Gases and Oxidizing Cryogenic Fluids”) that includes the following requirements for the storage and handling of ammonium nitrate (AN):

a. Require automatic fire detection and suppression systems in existing buildings constructed of combustible materials

b. Provide ventilation requirements in accordance with the International Mechanical Code to prevent the accumulation of off-gases produced during AN decomposition

c. Provide smoke and heat vents to remove heat from AN during fire situations

d. Establish minimum safe separation distances between AN and combustible materials to avoid contamination in the event of fire.

e. Prohibit the use of combustible materials of construction.


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.
 

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

Final Report Released On: January 28, 2016

2013-02-I-TX-4

Develop and issue a Regional Emphasis Program for Section (i) of the Explosives and Blasting Agent standard, 29 CFR 1910.109(i), in appropriate regions (such as Regions IV, VI, and VII) where fertilizer grade ammonium nitrate (FGAN) facilities similar to the West Fertilizer Company facility are prevalent.  Establish a minimum number of emphasis program inspections per region for each fiscal year.  Work with regional offices to communicate information about the emphasis program to potential inspection recipients. 


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.
 

2013-02-I-TX-5

Implement one of the following two regulatory changes, either option (a) or (b) below, to address

FGAN hazards:
a. Add FGAN to the OSHA Process Safety Management (PSM) standard List of Highly Hazardous Chemicals, Toxics and Reactives in 29 CFR 1910.119, Appendix A, and establish an appropriate threshold quantity.  Identify National Fire Protection Association (NFPA) 400 as a source of Recognized and Generally Accepted Good Engineering Practices (RAGAGEP) for PSM-covered FGAN equipment and processes.
b. Revise the OSHA Explosives and Blasting Agents standard, 29 CFR 1910.109, to ensure that the title, scope, or both make(s) clear that the standard applies to facilities that store bulk quantities of FGAN.  Revise 1910.109(i), “Storage of Ammonium Nitrate,” to include requirements similar to those in NFPA 400, Hazardous Materials Code (2016

Edition), Chapter 11.  Ensure the following elements are considered:
i. For new construction, prohibit combustible materials of construction for FGAN facilities and FGAN bins. For existing facilities, establish a phase-in requirement for the replacement of wooden bins with bins made of noncombustible materials of construction within a reasonable time period (e.g., 3 to 5 years from the date standard revisions are enacted), based on feedback from the fertilizer industry.

ii. Require automatic fire sprinkler systems and fire detection systems for indoor FGAN storage areas.

iii. Define adequate ventilation for FGAN for indoor storage areas.

iv. Require all FGAN storage areas to be isolated from the storage of combustible, flammable, and other contaminating materials.

v. Establish separation distances between FGAN storage areas and other hazardous chemicals, processes, and facility boundaries.


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.
 

State Firefighters' and Fire Marshals' Association of Texas (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2016

2013-02-I-TX-13

Develop a fertilizer grade ammonium nitrate (FGAN) training certification program for fire departments that either have FGAN facilities in their jurisdictions or respond as mutual aid to other jurisdictions with FGAN facilities.  The certification program should include multiple delivery methods to enable a broad reach.  The certification program should allow for instructor-led, web-based, and train-the-trainer courses; initial orientation; and refresher training.  The training also should accommodate both resident and mobile capabilities to facilitate flexibility in delivery.

The criteria for the certification program should address the following:

a. Previous FGAN fire and explosion incidents, incorporating lessons learned

b. Hazards posed by other materials and chemicals stored near FGAN, including FGAN incompatibility with those materials and chemicals

c. Pre-incident planning for fires involving FGAN

d. On-scene emergency response and decision-making requirements for FGAN fires, including risk assessment, scene size-up, and situational awareness

e. National Incident Management System and Incident Command System.


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.
 

2013-02-I-TX-14

Develop an outreach component for the training certification program that notifies regional, state, and local fire departments with FGAN facilities in their jurisdictions about the training certification opportunities available for FGAN.  Ensure that the following items are included in the development of this program:

a. Guidance for fire departments on how to identify FGAN hazards within their communities by engaging State Emergency Response Commissions and Local Emergency Planning Committees

b. Encouragement for members in jurisdictions with FGAN facilities to become certified in FGAN training

c. Information on training partners and programs that provide FGAN training.


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.
 

Texas A&M Engineering Extension Services (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2016

2013-02-I-TX-15

Develop and administer a hazardous materials training module for career and volunteer fire departments that addresses fertilizer grade ammonium nitrate (FGAN) and other hazardous materials or chemicals that could pose new specialized hazards.  Ensure that the training includes multiple delivery methods to enable a broad reach.  The training should allow for instructor-led, web-based, and train-the-trainer courses; initial orientation; and refresher training.  The training also should accommodate both resident and mobile capabilities to facilitate flexibility in delivery.

Objectives of the training course should address the following:

a. How to respond to industrial fires involving FGAN and other hazardous materials or chemicals that could pose new specialized hazards to responding firefighters

b. Previous FGAN fire and explosion incidents, incorporating lessons learned

c. Hazards posed by other materials and chemicals stored near the FGAN, including FGAN incompatibility with those materials and chemicals

d. Pre-incident planning for fires involving FGAN and other hazardous materials or chemicals that could pose new specialized hazards to responding firefighters

e. On-scene emergency response and decision-making requirements for FGAN fires, including risk assessment, scene size-up, and situational awareness

f. National Incident Management System and Incident Command System.


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.
 

PDF Document Recommendations Status Change Summary

2013-02-I-TX-16

Develop an outreach program that notifies state, regional, and local fire departments about available FGAN training opportunities.  The program should include the following elements:

a. Guidance for fire departments on how to identify FGAN and other recognized hazards associated with other hazardous materials or chemicals within their communities by engaging with State Emergency Response Commissions and Local Emergency Planning Committees

b. Promotion of use of the hazardous materials training module with TEEX training partners.


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.
 

Texas Commission on Fire Protection (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2016

2013-02-I-TX-11

Develop minimum standards for course curricula to include hazard awareness of fertilizer grade ammonium nitrate (FGAN) for those fire departments that either have FGAN facilities in their jurisdictions or respond as mutual aid to other jurisdictions with FGAN facilities.  In addition, develop a training program specific to FGAN.

Objectives of the program’s training course should address the following:

a. Previous FGAN fire and explosion incidents, incorporating lessons learned

b. Hazards posed by other materials and chemicals stored near FGAN, including FGAN incompatibility with those materials and chemicals

c. Pre-incident planning for fires involving FGAN

d. On-scene emergency response and decision-making requirements for FGAN fires, including risk assessment, scene size-up, and situational awareness

e. National Incident Management System and Incident Command System.


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.
 

PDF Document Recommendations Status Change Summary

2013-02-I-TX-12

Implement outreach to regional, state, and local fire departments that either have FGAN facilities in their jurisdictions or respond as mutual aid to jurisdictions with FGAN facilities, informing them about the new FGAN training certification requirements and opportunities to receive training.  Include the following in the outreach:

a. Guidance for fire departments on how to identify FGAN hazards within their communities by engaging  State Emergency Response Commissions and Local Emergency Planning Committees

b. Encouragement for fire departments in jurisdictions with FGAN facilities to become certified in FGAN training.


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.
 

PDF Document Recommendations Status Change Summary

Texas Department of Insurance (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2016

2013-02-I-TX-17

For companies that provide insurance to agricultural facilities storing bulk fertilizer grade ammonium nitrate (FGAN) in Texas, including surplus lines insurers and Texas-registered risk retention groups, develop and issue guidance to assist in underwriting risk and conducting annual loss control surveys.  Guidance should include the following:

a. Combustible materials of construction for facilities and bins storing FGAN

b. Storage of combustible materials near FGAN piles

c. Adequate ventilation for indoor FGAN storage areas

d. Automatic sprinklers and smoke detection systems for indoor FGAN storage areas

e. Separation distances between FGAN and other hazardous materials onsite

f. Potential for offsite consequences from a fire or explosion, including the proximity of FGAN facilities to nearby residences, schools, hospitals, and other community structures.

Provide references in the guidance document to existing materials from the following sources or to other equivalent guidance:

a. National Fire Protection Association (NFPA), NFPA 400, Hazardous Materials Code, 2016 Edition, Chapter 11, “Ammonium Nitrate”

b. FM Global, “Property Loss Prevention Data Sheet 7-89”

c. U.S. Environmental Protection Agency, Occupational Safety and Health Administration, and Bureau of Alcohol, Tobacco, Firearms and Explosives; “Chemical Advisory: Safe Storage, Handling, and Management of Solid Ammonium Nitrate Prills”

d. TDI, “Best Practices for the Storage of Ammonium Nitrate”

e. National Fire Protection Research Foundation, “Separation Distances and NFPA Codes and Standards.”


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.
 

West Volunteer Fire Department (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2016

2013-02-I-TX-18

Develop standard operating procedures for pre-incident planning for facilities that store or handle hazardous materials such as fertilizer grade ammonium nitrate (FGAN).


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.
 

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.
 

PDF Document Download

2008-01-I-CO-5

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

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


Status: 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.
 

PDF Document Download

2008-01-I-CO-6

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

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


Status: 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.
 

PDF Document Download

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.
 

PDF Document Download

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/No Response Received
Open - Unacceptable Response/No Response Received (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/No Response Received
Open - Unacceptable Response/No Response Received (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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