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Recommendations
Board of Supervisors, Contra Costa County, CA
Chevron Refinery Fire
Open: 100%  |  Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-6

Revise the Industrial Safety Ordinance (ISO) to require that Process Hazard Analyses include documentation of the recognized methodologies, rationale and conclusions used to claim that safeguards intended to control hazards will be effective. This process shall use established qualitative, quantitative, and/or semi-quantitative methods such as Layers of Protection Analysis (LOPA).


Status: O-ARE/AR
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.
 

2012-03-I-CA-7

Revise the Industrial Safety Ordinance (ISO) to require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.


Status: O-ARE/AR
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.
 

2012-03-I-CA-8

Monitor and confirm the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R1 and 2012-03-I-CA-R2), so that all necessary mechanical integrity work at the Chevron Richmond Refinery is identified and recommendations are completed in a timely way.


Status: O-ARE/AR
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.
 

2012-03-I-CA-16

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.


Status: O-ARE/AR
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.
 

Borden Chemical, Inc.
CTA Acoustics Dust Explosion and Fire
Open: 0%  |  Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-11

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


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

2003-09-I-KY-12

Develop and distribute educational material, in addition to MSDSs, to inform customers of the explosion hazard of phenolic resin dust.


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

2003-09-I-KY-13

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


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

BP Chemicals Group
BP Amoco Thermal Decomposition Incident
Open: 0%  |  Closed: 100%

Final Report Released On: May 20, 2002

2001-03-I-GA-9

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


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

BP Global Executive Board of Directors
BP America Refinery Explosion
Open: 38%  |  Closed: 62%

Final Report Released On: March 20, 2007

2005-4-I-TX-1

1. Commission an independent panel to assess and report on the effectiveness of BP North America's corporate oversight of safety management systems at its refineries and its corporate safety culture. Provide the panel with necessary funding, resources, and authority - including full access to relevant data, corporate records, and employee interviews - in order to conduct a thorough, independent, and credible inquiry. 2. Ensure that, at a minimum, the panel report examines and recommends any needed improvements to: Corporate safety oversight, including the safe management of refineries obtained through mergers and acquisitions; Corporate safety culture, including the degree to which: - Corporate officials exercise appropriate leadership to promote adherence to safety management systems; - Process safety is effectively incorporated into management decisionmaking at all levels; - Employees at all levels are empowered to promote improved process safety; - Process safety programs receive adequate resources and are appropriately positioned within organizational structures; Corporate and site safety management systems, specifically: - Near-miss reporting and investigation programs; - Mechanical integrity programs; - Hazard analysis programs, management-of-change programs, and up-todate operating procedures for processes with catastrophic potential; - Siting policies for occupied structures near hazardous operating units. 3. Ensure that the panel has a diverse makeup, including an external chairperson; employee representatives; and outside safety experts, such as experts in process safety; experts in corporate culture, organizational behavior, and human factors; and experts from other high-risk sectors such as aviation, space exploration, nuclear energy, and the undersea navy. 4. Ensure that the report and recommendations of the independent panel, which should be completed within 12 months, are made available to the BP workforce and to the public.


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

2005-4-I-TX-11

1. Appoint an additional non-executive member of the Board of Directors with specific professional expertise and experience in refinery operations and process safety. Appoint this person to be a member of the Board Ethics and Environmental Assurance Committee.


Status: O-ARE/AR
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.
 

2005-4-I-TX-12

2. Ensure and monitor that senior executives implement an incident reporting program throughout your refinery organization that a. encourages the reporting of incidents without fear of retaliation; b. requires prompt corrective actions based on incident reports and recommendations, and tracks closure of action items at the refinery where the incident occurred and other affected facilities; and c. requires communication of key lessons learned to management and hourly employees as well as to the industry.


Status: O-ARE/AR
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.
 

2005-4-I-TX-13

3. Ensure and monitor that senior executives use leading and lagging process safety indicators to measure and strengthen safety performance in your refineries.


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

BP Texas City Refinery
BP America Refinery Explosion
Open: 38%  |  Closed: 62%

Final Report Released On: March 20, 2007

2005-4-I-TX-14

1. Evaluate your refinery process units to ensure that critical process equipment is safely designed. At a minimum, a. Ensure that distillation towers have effective instrumentation and control systems to prevent overfilling such as multiple level indicators and appropriate automatic controls. b. Configure control board displays to clearly indicate material balance for distillation towers.


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

2005-4-I-TX-16

3. Work with the United Steelworkers Union and Local 13-1 to establish a joint program that promotes the reporting, investigation, and analysis of incidents, near-misses, process upsets, and major plant hazards without fear of retaliation. Ensure that the program tracks recommendations to completion and shares lessons learned with the workforce.


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

2005-4-I-TX-15

2. Ensure that instrumentation and process equipment necessary for safe operation is properly maintained and tested. At a minimum, a. Establish an equipment database that captures the history of testing, inspections, repair, and successful work order completion. b. Analyze repair trends and adjust maintenance and testing intervals to prevent breakdowns. c. Require repair of malfunctioning process equipment prior to unit startups.


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

2005-4-I-TX-17

4. Improve the operator training program. At a minimum, require a. face-to-face training conducted by personnel with process-specific knowledge and experience who can assess trainee competency, and; b. training on recognizing and handling abnormal situations including the use of simulators or similar training tools.


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

2005-4-I-TX-18

5. Require additional board operator staffing during the startup of process units. Ensure that hazard reviews address staffing levels during abnormal conditions such as startups, shutdowns, and unit upsets.


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

2005-4-I-TX-19

6. Require knowledgeable supervisors or technically trained personnel to be present during especially hazardous operation phases such as unit startup.


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

2005-4-I-TX-20

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


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

2005-4-B-TX-1

Revise the maintenance quality control program to require positive material identification testing or another suitable material verification process for all critical service alloy steel piping components removed and reinstalled during maintenance and inform work crews of special material handling precautions.


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

Branham Corporation
DPC Enterprises Festus Chlorine Release
Open: 0%  |  Closed: 100%

Final Report Released On: May 01, 2003

2002-04-I-MO-11

Implement a materials verification procedure to improve quality assurance during chlorine transfer hose fabrication and shipment, such that hoses shipped to customers are readily identifiable and meet required specifications.


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

Brazoria County, Texas
Third Coast Industries Petroleum Products Facility Fire
Open: 15%  |  Closed: 85%

Final Report Released On: March 06, 2003

2002-03-I-TX-4

Adopt a fire code, such as the NFPA Uniform Fire Code or the ICC International Fire Code, for application in unincorporated areas.


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

Building and Construction Trades Department, AFL-CIO
Motiva Enterprises Sulfuric Acid Tank Explosion
Open: 21%  |  Closed: 79%

Final Report Released On: August 28, 2002

2001-05-I-DE-19

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


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

Building Owners and Managers Association (BOMA)
Kaltech Industries Waste Mixing Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: September 30, 2003

2002-02-I-NY-12

Communicate the findings of this report to your membership.


Status: C-NLA
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).
 

Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF)
Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire
Open: 100%  |  Closed: 0%

Final Report Released On: January 17, 2013

2013-2011-06-I-HI-I-HI-12

Effectively participate in the National Fire Protection Association’s standard development process to develop guidance on the safe disposal of fireworks, as recommended under recommendation 2011-06-I-HI-R7.


Status: O-ARE/AR
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.
 

Burkes Construction, Inc.
Georgia-Pacific Corp. Hydrogen Sulfide Poisoning
Open: 0%  |  Closed: 100%

Final Report Released On: November 20, 2002

2002-01-I-AL-11

Train your employees on the specific hazards of hydrogen sulfide (H2S), including appropriate emergency response practices, in areas where Georgia-Pacific has identified this material as a hazard.


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

CAI, Inc.
CAI / Arnel Chemical Plant Explosion
Open: 36%  |  Closed: 64%

Final Report Released On: May 13, 2008

2007-03-I-MA-8

Develop a written safety program to manage hazardous process operations. The program should : -Prohibit heating flammable or combustible liquids above their flashpoints in tanks inside buildings unless the tanks are sealed and vented to the building exterior. -Require safety controls to prevent overheating of flammable or combustible liquids. - Apply the process safety management program elements as contained in the American Institute of Chemical Engineers (AIChE) Center for Chemical Process Safety (CCPS) Guidelines for Implementing Process Safety Management Systems to all processes that use flammable, toxic, or reactive chemicals. -Comply with the following, as applicable: OSHA Flammable and Combustible Liquids standard (29 CFR 1910.106), OSHA Process Safety Management standard (29 CFR 1910.119), National Fire Protection Association Flammable and Combustible Liquids Code (NFPA 30), and National Fire Protection Association Standard for the Manufacture of Organic Coatings (NFPA 35).


Status: C-UA/NRR
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.
 

California Air Quality Management Divisions
Chevron Refinery Fire
Open: 100%  |  Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-18

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.


Status: O-ARE/AR
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.
 

California Air Resources Board (CARB)
Sterigenics Ethylene Oxide Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: March 30, 2006

2004-11-I-CA-7

In collaboration with other state/regional agencies as necessary, such as California Occupational Safety and Health Administration, recommend to facilities that treat ethylene oxide backvent emissions with oxidizing emissions control devices to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices.


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

California Environment Protection Agency
Chevron Refinery Fire
Open: 100%  |  Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-20

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.


Status: O-ARE/AR
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.
 

California Occupational Safety and Health Administration (Cal/OSHA)
Sterigenics Ethylene Oxide Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: March 30, 2006

2004-11-I-CA-8

In collaboration with other state/regional agencies as necessary, such as California Environmental Protection Agency, identify the ethylene oxide sterilization facilities in California that utilize oxidizing emissions control devices and conduct inspections of those facilities (including the Sterigenics Ontario facility) in terms of the findings of this report. Ensure prompt correction of all violations identified during these inspections.


Status: C-AA
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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