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

Wendland 1H Well Fatal Explosion (4 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 26, 2023

2020-04-I-TX-2

Publish the following information in an appropriate document such as API RP 59 Recommended Practice for Well Control Operations:

1. A focused discussion on practices applicable to workover operations, including completed wells in underpressured reservoirs. Include well control methods applicable to workover operations, such as using continuous fluid addition, viscous fluids, bridging solids, and mechanical plugs. Also include a discussion on the well control challenges and hazards specific to workover operations;

2. Stabbing valves should not be considered as well control barriers for workover operations; and

3. Every well should be considered to have potential to flow, and therefore, should have two well control barriers, one of which should be a preventative barrier.


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.
 

PDF Document Recommendation Status Change Summary

Chesapeake Operating, LLC (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 26, 2023

2020-04-I-TX-1

Develop or revise policies incorporating the recommendations of API RP 59 regarding well planning, specifically the inclusion of well history review in conjunction with workover well control planning.


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.
 

PDF Document Recommendation Status Change Summary

Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 26, 2023

2020-04-I-TX-3

Remove the exemption for oil and gas drilling and well servicing from the Control of Hazardous Energy standard (29 CFR 1910.147) and expand its applicability to cover oil and gas production and workover operations.


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.
 

PDF Document Recommendation Status Change Summary

2020-04-I-TX-4

Promulgate a new standard with prescriptive requirements, similar to the Control of Hazardous Energy Standard, as well as a performance-based safety management system framework, similar to the OSHA Process Safety Management (PSM) Standard, that applies to the drilling, production, and servicing/workover activities surrounding onshore oil and gas wells. At a minimum, this standard should include the following:

1. Prescriptively address requirements for primary and secondary barriers for well control;

2. Detailed written drilling, production, and servicing procedures with specified steps and equipment alignment for all operations;

3. Management of change requirements (except replacements in kind) that, at a minimum, address procedures, the well plan, and equipment;

4. A risk assessment of hazards associated with the drilling, production, and servicing/workover plans;

5. A requirement to follow Recognized and Generally Accepted Good Engineering Practices (RAGAGEP);

6. Development of a Well Construction Interface Document between the operator and the drilling contractor prior to the commencement of drilling and servicing activities and an equivalent document for production and workover contractors which, at a minimum, includes a bridging document and well plans specifying barriers and how to manage them;

7. The performance and documentation of flow checks using acceptable methods at defined points during the operation for a specified duration;

8. A requirement for employee participation, similar to the Employee Participation requirement in the OSHA PSM standard;

9. A requirement for maintaining critical well information, similar to the Process Safety Information requirement in the OSHA PSM standard, which at a minimum includes well history and documented well control methods during workovers;

10. A requirement for analyzing and assessing the hazards during all phases and steps for well servicing, similar to the Process Hazard Analysis requirement in the OSHA PSM standard;

11. A requirement for developing, executing, communicating, and maintaining procedures for drilling, production, and servicing operations on a well, similar to the Operating Procedures requirement in the OSHA PSM standard; and

12. The documentation of well control plans for drilling, production, and servicing/workover operations for a well utilizing acceptable methods for monitoring the effectiveness of well control methods.


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.
 

PDF Document Recommendation Status Change Summary

West Fertilizer Explosion and Fire (19 Recommendations)
Department of Homeland Security, Federal Emergency Management Agency (FEMA) (4 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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: Closed - Exceeds Recommended Action
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

PDF Document Recommendations Status Change Summary

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: Closed - Exceeds Recommended Action
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

PDF Document Recommendations Status Change Summary

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: 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

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: 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

El Dorado Chemical Company (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendation Status Change Summary

Environmental Protection Agency (EPA) (3 Recommendations)
Open: 33% | Closed: 67%
View Investigation
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: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendation Status Change Summary

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: 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

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 - 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 Recommendation Status Change Summary

International Code Council (ICC) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
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: 50% | Closed: 50%
View Investigation
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: 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

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: 0% | Closed: 100%
View Investigation
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: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

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

PDF Document Recommendation Status Change Summary

Texas A&M Engineering Extension Services (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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: 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 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: 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 Recommendations Status Change Summary

Texas Commission on Fire Protection (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation 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: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

PDF Document Recommendation Status Change Summary

Texas Department of Insurance (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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: 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 Recommendation Status Change Summary

West Volunteer Fire Department (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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: 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 Recommendation Status Change Summary

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

Williams Olefins Plant Explosion and Fire (5 Recommendations)
American Petroleum Institute (API) (2 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: October 19, 2016

2013-3-I-LA-4

To help prevent future major incidents such as a rupture of a pressure vessel in a special operating status, strengthen API Standard 521, Pressure-relieving and Depressuring Systems, by defining the various types of equipment operating statuses. Include definitions for “standby” and “out-of-service.” Specify pressure relief requirements for each type of equipment operating status.


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.
 

2013-3-I-LA-5

To help prevent future major incidents such as pressure vessel rupture from ineffective or failed administrative controls, clarify API Standard 521, Pressure-relieving and Depressuring Systems, to require a pressure relief device for overpressure scenarios where internal vessel pressure can exceed what is allowed by the design code. Although some portions of API Standard 521 already require a pressure relief device for these scenarios, other areas, such as Section 4.4.12 Hydraulic Expansion, are not as protective. Section 4.4.12 Hydraulic Expansion (the failure mode that caused the Williams overpressure incident) permits omitting a pressure relief device and allows the exclusive use of administrative controls.


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.
 

Williams Geismer Olefins Facility (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 19, 2016

2013-3-I-LA-1

Implement a continual improvement program to improve the process safety culture at the Williams Geismar Olefins Plant. Ensure oversight of this program by a committee of Williams personnel (“committee”) that, at a minimum, includes safety and health representative(s), Williams management representative(s), and operations and maintenance workforce representative(s). Ensure the continual improvement program contains the following elements:
 
a. Process Safety Culture Assessments. Engage a process safety culture subject-matter expert, who is selected by the committee and is independent of the Geismar site, to administer a periodic process safety culture assessment that includes surveys of personnel, interviews with personnel, and document analysis. Consider the process safety culture audit guidance provided in Chapter 4 of the CCPS book Guidelines for Auditing Process Safety Management Systems as a starting point. Communicate the results of the Process Safety Culture Assessment in a report; and
 
b. Workforce Involvement. Engage the committee to (1) review and comment on the expert
report developed from the Process Safety Culture Assessments, and (2) oversee the development and effective implementation of action items to address process safety culture issues identified in the Process Safety Culture Assessment report. 
 
As a component of the process safety culture continual improvement program, include a focus on the facility’s ability to comply with its internal process safety management program requirements. Make the periodic process safety culture report available to the plant workforce. Conduct the process safety culture assessments at least once every five years.

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 Recommendations Status Change Summary

2013-3-I-LA-2

Develop and implement a permanent process safety metrics program that tracks leading and lagging process safety indicators. Consider available industry guidance, such as the guidance presented in the Center for Chemical Process Safety (CCPS) book Guidelines for Process Safety Metrics and the example metrics provided in the book’s accompanying CD. Design this metrics program to measure the effectiveness of the Williams Geismar Olefins Facility’s process safety management programs. Include the following components in this program:
 
a. Measure the effectiveness of the Williams Geismar Management of Change (MOC)
program, including evaluating whether MOCs were performed for all applicable changes,
the quality of MOC review, and the completeness of the MOC review;
 
b. Measure the effectiveness of the Williams Geismar Pre-Startup Safety Review (PSSR)
program, including the quality of the PSSR review and the completeness of the PSSR
review;
 
c. Measure the effectiveness of the Williams Geismar methods to effectively and timely
complete action items developed as a result of Process Hazard Analyses (PHAs),
Management of Change (MOC), incident investigations, audits, and safety culture
assessments; and
 
d. Measure the effectiveness of the Williams Geismar development and implementation of
operating procedures.
 
Develop a system to drive continual process safety performance improvements based upon the data identified and analysis developed as a result of implementing the permanent process safety metrics program.

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 Recommendations Status Change Summary

2013-3-I-LA-3

Develop and implement a program that demands robust and comprehensive assessments of the process safety programs at the Williams Geismar facility, at a minimum including Management of Change, Pre-Startup Safety Review, Process Hazard Analyses, and Operating Procedures. Ensure that the assessments thoroughly evaluate the effectiveness of these important safety programs. To drive continual improvement of process safety programs to meet good practice guidance, ensure these assessments result in the development and implementation of robust action items that address identified weaknesses. Engage an expert independent of the Geismar site to lead these assessments at least once every three years.


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 Recommendations Status Change Summary

Xcel Energy Company Hydroelectric Tunnel Fire (20 Recommendations)
American Public Power Association (APPA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

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

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.
 

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Governor of the State of Colorado (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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: 0% | Closed: 100%
View Investigation
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: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendations Status Change Summary

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

PDF Document Recommendation Status Change Summary

RPI Coating, Inc. (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

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: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

Society for Protective Coatings (SSPC) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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: 0% | Closed: 100%
View Investigation
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: 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 Recommendations Status Change Summary

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.
 

PDF Document Download

Xcel Energy, Inc. (5 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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: 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 Recommendations Status Change Summary

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: 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 Recommendations Status Change Summary

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: 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 Recommendations Status Change Summary

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: 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 Recommendations Status Change Summary

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: 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 Recommendations Status Change Summary