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Recommendations
Camp Dresser & McKee Inc.
Bethune Point Wastewater Plant Explosion
Open: 23%  |  Closed: 77%

Final Report Released On: March 13, 2007

2006-3-I-FL-11

Revise CDM policies and procedures to ensure that appropriate quality control measures are applied so that designs specify appropriate materials and comply with applicable safety standards. Ensure that wastewater treatment plant design engineers are aware of the importance of proper material selection as well as the findings and recommendations of this report.


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.
 

2006-3-I-FL-12

Communicate the findings and recommendations of this report to all companies that contracted with CDM for methanol and other flammable liquid systems that were constructed with aboveground plastic pipe. Recommend replacing plastic pipe with an appropriate material in accordance with NFPA 30 and OSHA 1910.106.


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.
 

2006-3-I-FL-13

Communicate the findings and recommendations of this report to all companies that contracted with CDM for flammable liquid systems that included a flame arrester. Emphasize the importance of periodic maintenance of the flame arrester to ensure its effective performance.


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.
 

Carbide Industries
Carbide Industries Fire and Explosion
Open: 100%  |  Closed: 0%

Final Report Released On: February 07, 2013

2013-2011-5-I-KY-I-KY-3

Implement a mechanical integrity program for the electric arc furnace and cover, including preventive maintenance based on periodic inspections, and timely replacement of the furnace cover. At a minimum, the program should include factors such as leak detection and repair and refractory lining wear.  


Status: O-ARAR
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.
 

Center for Chemical Process Safety
BP America Refinery Explosion
Open: 38%  |  Closed: 62%

Final Report Released On: March 20, 2007

2005-4-I-TX-10

Issue management of change guidelines that address the safe control of the following: a. major organizational changes including mergers, acquisitions, and reorganizations; b. changes in policies and budgets; c. personnel changes; d. staffing during process startups, shutdowns and other abnormal conditions.


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.
 

Formosa Plastics Propylene Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: July 20, 2006

2006-1-I-TX-6

Incorporate guidance for vehicular traffic protection and remote equipment isolation into the next revision of the Center for Chemical Process Safety?s Guidelines for Hazard Evaluation Procedures.


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.
 

Formosa Plastics Vinyl Chloride Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: March 06, 2007

2004-10-I-IL-8

Develop guidelines for auditing chemical process safety at newly acquired facilities. Emphasize the identification of major hazards, a review of the acquired facility's previous incident history and hazard analyses, the adequacy of management safety systems, and harmonization of the acquired facility's standards and practices with those of the acquiring company.


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.
 

Improving Reactive Hazard Management
Open: 42%  |  Closed: 58%

Final Report Released On: September 17, 2002

2001-01-H-6

Publish comprehensive guidance on model reactive hazard management systems. At a minimum, ensure that these guidelines cover: · For companies engaged in chemical manufacturing: reactive hazard management, including hazard identification, hazard evaluation, management of change, inherently safer design, and adequate procedures and training. · For companies engaged primarily in the bulk storage, handling, and use of chemicals: identification and prevention of reactive hazards, including the inadvertent mixing of incompatible substances.


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

Morton International Inc. Runaway Chemical Reaction
Open: 0%  |  Closed: 100%

Final Report Released On: August 16, 2000

1998-06-I-NJ-10

Communicate the findings 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.
 

Union Carbide Corp. Nitrogen Asphyxiation Incident
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: 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.
 

Veolia Environmental Services Flammable Vapor Explosion and Fire
Open: 57%  |  Closed: 43%

Final Report Released On: July 21, 2010

2010-10-I-OH-5

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


Status: 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.
 

CertainTeed Corporation
CTA Acoustics Dust Explosion and Fire
Open: 0%  |  Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-9

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


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-10

Ensure that company design standard's applicable to facilities that handle combustible dust's incorporate good engineering practices to prevent dust explosions, such as NFPA 654.


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.
 

Chemical and Metal Industries (C&MI)
Honeywell Chemical Incidents
Open: 13%  |  Closed: 87%

Final Report Released On: August 08, 2005

2003-13-I-LA-27

Develop formal procedures for disposition of nonconforming materials received from customers. Ensure that procedures include positive identification prior to shipment.


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.
 

Improving Reactive Hazard Management
Open: 42%  |  Closed: 58%

Final Report Released On: September 17, 2002

2001-01-H-7

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


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

Chevron USA
Chevron Refinery Fire
Open: 100%  |  Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-1

At all Chevron U.S. refineries, engage a diverse team of qualified personnel to perform a documented damage mechanism hazard review. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure safeguards are in place to control hazards presented by those damage mechanisms. Analyze and incorporate into this review applicable industry best practices, Chevron Energy Technology Company findings and recommendations, and inherently safer systems to the greatest extent feasible.


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-2

At all California Chevron U.S. refineries, report leading and lagging process safety indicators, such as the action item completion status of recommendations from damage mechanism hazard reviews, to the federal, state, and local regulatory agencies that have chemical release prevention authority.


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.
 

CITGO, Inc.
CITGO Refinery Hydrofluoric Acid Release and Fire
Open: 0%  |  Closed: 100%

Date of Accident: July 19, 2009

2009-14-I-TX-1

  • Within 30 days, develop and initiate actions to ensure adequate water supply to the CITGO HF mitigation system.  Actions could include, but are not limited to, increasing onsite storage capacity, installing a permanent backup system, and developing procedures and training for water management in an emergency.
  • Every 30 days, report actions planned or completed to the Refinery Terminal Fire Company and Local Emergency Planning Committee.  Continue the 30-day periodic reporting until all planned actions are fully implemented.


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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2009-14-I-TX-2

  • Within 60 days, complete a third-party audit of all (Corpus Christi, TX and Lemont, IL) CITGO HF alkylation unit operations in the United States as recommended by API Recommended Practice 751, Safe Operation of Hydrofluoric Acid Alkylation Units, Third Edition June 2007. The selected lead auditor shall have extensive knowledge of HF hazards, HF alkylation units, and API 751. 
  • Consistent with the employee participation requirements of the Process Safety Management Standard for Highly Hazardous Chemicals (29 CFR 1910.119(c)), share all audit results and actions planned or completed to correct deficiencies in each refinery with all CITGO and contract employees whose work area includes that refinery’s alkylation unit.


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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City of Dalton
MFG Chemical Inc. Toxic Gas Release
Open: 44%  |  Closed: 56%

Final Report Released On: April 11, 2006

2004-9-I-GA-8

Establish, equip, and train a hazardous materials response team. Work with the Whitfield County Emergency Management Agency to update the Emergency Operations Plan, clearly defining the roles and responsibilities of the response team.


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.
 

2004-9-I-GA-9

Revise fire department and police department procedures and training to clearly define facility and evacuation zone access control responsibilities when hazardous chemicals are involved or suspected in an emergency.


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.
 

City of Daytona Beach
Bethune Point Wastewater Plant Explosion
Open: 23%  |  Closed: 77%

Final Report Released On: March 13, 2007

2006-3-I-FL-3

Adopt city ordinances to require departments to implement policies, practices, and procedures concerning safety and health in the workplace for city employees that are at least as effective as relevant OSHA standards. Emphasize compliance with chemical standards, including hot work procedures (OSHA Welding, Cutting, and Brazing Standard, Sections 1910.251 and 1910.252) and chemical hazard communication (OSHA Hazard Communication Standard 29 CFR 1910.1200). Implement procedures to ensure compliance with these policies, practices and procedures.


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.
 

2006-3-I-FL-4

Ensure that flammable liquid storage tanks used throughout the city comply with NFPA 30 and minimum federal standards in 29 CFR 1910.106, including appropriate piping and flame arresters.


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.
 

City of Gallatin, TN
Hoeganaes Corporation Fatal Flash Fires
Open: 85%  |  Closed: 15%

Final Report Released On: January 05, 2012

2011-4-I-TN-11

Require all facilities covered by IFC Chapter 13 (2006 edition) to conform to NFPA standards for combustible dusts including NFPA 484.


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.
 

City of Houston
Marcus Oil and Chemical Tank Explosion
Open: 0%  |  Closed: 100%

Final Report Released On: June 06, 2006

2005-2-I-TX-5

Amend the city building ordinances to require all newly installed pressure vessels to comply with the ASME Boiler and Pressure Vessel Code, Section VIII.


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.
 

2005-2-I-TX-6

Amend the city building ordinances to require pressure vessel repairs and alterations to comply with the National Board Inspection Code (NB-23).


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.
 

Colorado Division of Emergency Management Director
Xcel Energy Company Hydroelectric Tunnel Fire
Open: 55%  |  Closed: 45%

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: 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.
 

Colorado Division of Fire Safety Director
Xcel Energy Company Hydroelectric Tunnel Fire
Open: 55%  |  Closed: 45%

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: 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.
 

Colorado Public Utilities Commission
Xcel Energy Company Hydroelectric Tunnel Fire
Open: 55%  |  Closed: 45%

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: 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.
 

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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: 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.
 

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: 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.
 

PDF Document Download

 
 
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