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E. I. du Pont de Nemours and Company
DuPont Corporation Toxic Chemical Releases
Open: 64%  |  Closed: 36%
View Investigation
Final Report Released On: September 20, 2011

2010-06-I-WV-6

Revise safeguards for phosgene handling at all DuPont facilities by

  • Requiring that all indoor phosgene production and storage areas, as defined in NFPA 55, have secondary enclosures, mechanical ventilation systems, emergency phosgene scrubbers, and automated audible alarms, which are, at a minimum, consistent with the standards of NFPA 55 for highly toxic gases.
  • Prohibiting the use of hoses with permeable cores and materials susceptible to chlorides corrosion for phosgene transfer.
  • Conducting annual phosgene hazard awareness training for all employees who handle phosgene, including the hazards associated with thermal expansion of entrapped liquid phosgene in piping and equipment.


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.
 

2010-06-I-WV-7

Review all DuPont units that produce and handle phosgene that, at a minimum, observe and document site-specific practices for engineering controls, construction materials, PPE, procedures, maintenance, emergency response, and release detection and alarms, and use information from external sources to develop and implement consistent company-wide policies for the safe production and handling of phosgene.


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.
 

2010-06-I-WV-8

For each DuPont facility that uses, but does not manufacture, phosgene onsite:

  • Conduct a risk assessment of manufacturing phosgene onsite against the current configuration.
  • Communicate the findings of each assessment to compile recommendations applicable to all DuPont phosgene delivery systems.
  • Implement these recommendations.


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.
 

2010-06-I-WV-12

Commission an audit in consultation with operations personnel to establish and identify the conditions that cause nuisance alarms at all DuPont facilities. Establish and implement a corporate alarm management program as part of the DuPont PSM Program, including measures to prevent nuisance alarms and other malfunctions in those systems. Include initial and refresher training as an integral part of this effort.


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.
 

2010-06-I-WV-13

Revise the DuPont PSM standard to require confirmation that all safety alarms/interlocks are in proper working order (e.g., not in an active alarm state) prior to the start-up of all Higher-Hazard Process facilities.


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.
 

2010-06-I-WV-14

Reevaluate and clarify the DuPont corporate MOC policies to ensure that staff can properly identify and use the distinctions between subtle and full changes and train appropriate personnel how to properly apply the distinctions on any changes in the policy.


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.
 

E. I. DuPont De Nemours Co. Fatal Hotwork Explosion
Open: 100%  |  Closed: 0%
View Investigation
Final Report Released On: April 19, 2012

2011-01-I-NY-1

Develop and enforce corporate-directed policies and procedures which will require all DuPont facilities to audit their hot work permitting systems prior to initiating hot work to ensure that:

  • All potential explosion hazards associated with hot work activities are identified and mitigated
  • All relevant forms required for permits are completed in accordance with corporate policies and industry standards (including NFPA 326 and NFPA 51B)
  • Appropriate DuPont personnel officially approve hot work permits, by signature or equivalent, consistent with DuPont policies


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.
 

2011-01-I-NY-2

Revise corporate policies and procedures to require that all process piping, or similar connections to tanks or vessels be positively isolated, (using closed valves, blind flanges or pancake blanks) and the equipment appropriately vented before authorizing any hot work.


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.
 

2011-01-I-NY-3

Revise corporate policies and procedures to require that the atmosphere inside the container be monitored for flammable vapor prior to performing any welding, cutting, or grinding on the container surface.


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.
 

2011-01-I-NY-4

Revise corporate policies and procedures to require air monitoring for flammable vapor inside the container for the duration of the hot work consistent with industry standards (NFPA 326, NFPA 51B). Create a policy for determining criteria for requiring continuous or periodic testing for the duration of hot work.


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.
 

First Chemical Corp. Reactive Chemical Explosion
Open: 13%  |  Closed: 87%
View Investigation
Final Report Released On: October 15, 2003

2003-01-I-MS-1

Conduct audits to ensure that the First Chemical Pascagoula facility addresses the issues detailed below. Communicate results of these audits to 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.
 

East Baton Rouge Parish Office of Homeland Security and Emergency
Honeywell Chemical Incidents
Open: 13%  |  Closed: 87%
View Investigation
Final Report Released On: August 08, 2005

2003-13-I-LA-24

Conduct an awareness campaign to educate residents on the proper response during a chemical release. Include instructions on the way residents (including those outside the affected area) can obtain information during an emergency.


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.
 

El Paso Production Company
Sonat Exploration Co. Catastrophic Vessel Overpressurization
Open: 0%  |  Closed: 100%
View Investigation
Final Report Released On: September 21, 2000

1998-002-I-LA-1

Institute a formal engineering design review process for all oil and gas production facilities,following good engineering practices and including analyses of process hazards.


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.
 

1998-002-I-LA-2

Implement a program to ensure that all oil and gas production equipment that is potentially subject to overpressurization is equipped with adequate pressure-relief systems, and audit compliance with the program.


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.
 

1998-002-I-LA-3

Develop written operating procedures for oil and gas production facilities and implement programs to ensure that all workers, including contract employees, are trained in the use of the procedures. Ensure the procedures address, at a minimum, purging and start-up operations and provide information on process-related hazards.


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.
 

Electric Power Research Institute (EPRI)
Kleen Energy Natural Gas Explosion
Open: 33%  |  Closed: 67%
View Investigation
Final Report Released On: June 28, 2010

2010-01-I-CT-18

Work with the six turbine manufacturers identified in this document – General Electric, Siemens, Solar, Mitsubishi Power Systems, Pratt & Whitney, and Rolls-Royce – to publish technical guidance addressing the safe cleaning of fuel gas piping supplying gas turbines. At minimum:

a. For cleaning methodology, require the use of inherently safer alternatives such as air blows and pigging with air in lieu of flammable gas.

b. Provide comprehensive technical guidance on inherently safer methods for cleaning fuel gas piping, such as the use of air or pigging with air.


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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Environmental Protection Agency (EPA)
Allied Terminals Fertilizer Tank Collapse
Open: 60%  |  Closed: 40%
View Investigation
Final Report Released On: May 26, 2009

2009-3-I-VA-4

Revise and reissue the Chemical Emergency Preparedness and Prevention Office Rupture Hazard from Liquid Storage Tanks Chemical Safety Alert. At a minimum, revise the alert to: 1) Include the Allied Terminals tank failure, 2) Discuss the increased rupture hazard during first fill or hydrostatic testing, and 3) List The Fertilizer Institute fertilizer tank inspection guidelines in the reference section.


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.
 

Bayer CropScience Pesticide Waste Tank Explosion
Open: 31%  |  Closed: 69%
View Investigation
Final Report Released On: January 20, 2011

2008-08-I-WV-12

In light of the findings of this report and the serious potential hazards to workers and the public from chemicals used and stored at the Bayer Institute site (such as phosgene, MIC, and methomyl), conduct a comprehensive Risk Management Program (RMP) inspection of the complex. Coordinate with the Occupational Safety and Health Administration, as appropriate.


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).
 

Chevron Refinery Fire
Open: 100%  |  Closed: 0%
View Investigation
Date of Accident: August 06, 2012

2012-03-I-CA-15

Jointly plan and conduct inspections with Cal/OSHA, California EPA and other state and local regulatory agencies with chemical accident prevention responsibilities to monitor the effective implementation of the damage mechanism hazard review and disclosure requirements under 2012-03-I-CA-R9 and R10 above.


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-19

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.
 

Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire
Open: 100%  |  Closed: 0%
View Investigation
Final Report Released On: January 17, 2013

2013-2011-06-I-HI-I-HI-9

Revise the Resource Conservation and Recovery Act (RCRA) Subtitle C regulations to require a permitting process with rigorous safety reviews to replace the use of emergency permits under 40 CFR §270.61 for the disposal of explosive hazardous materials, including fireworks. At a minimum, the new process should require the use of best available technology, safe disposal methodologies, as well as safety management practices, such as those required by OSHA’s Process Safety Management Standard (PSM), 29 CFR §1910.119 (e.g., hazard analysis and control, management of change).


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.
 

2013-2011-06-I-HI-I-HI-10

Until recommendation 2011-06-I-HI-R9 can be implemented, develop and issue a policy guidance document to provide a regulatory process with rigorous safety reviews to replace the use of emergency permits under 40 CFR §270.61 for the disposal of explosive hazardous materials, including fireworks. At a minimum, the new process should require the use of best available technology, safe disposal methodologies, as well as safety management practices, such as those required by OSHA’s Process Safety Management Standard (PSM), 29 CFR §1910.119 (e.g., hazard analysis and control, management of change). Ensure its effective communication to all EPA regional administrators, state environmental agencies, and organizations within the fireworks 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.
 

2013-2011-06-I-HI-I-HI-11

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


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.
 

EQ Hazardous Waste Plant Explosions and Fire
Open: 0%  |  Closed: 100%
View Investigation
Final Report Released On: April 16, 2008

2007-1-I-NC-1

Ensure that the emergency response planning required for permitted hazardous waste treatment, storage, and disposal facilities (40 CFR 264.37) includes providing written information to state and local emergency response officials on the type, approximate quantities, and locations of materials within the facility (similar to reporting requirements of the Emergency Planning and Community Right-to-Know Act). Additionally, ensure that permit holders periodically update this information throughout the ten-year permit period.


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%
View Investigation
Final Report Released On: March 06, 2007

2004-10-I-IL-7

Ensure that the EPA's Enforcement Alert concerning PVC facilities includes the causes and lessons learned from this investigation. Emphasize the importance of analyzing human factors and the need to implement adequate safeguards to minimize the likelihood and consequences of human error that could result in catastrophic incidents.


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%
View Investigation
Final Report Released On: September 17, 2002

2001-01-H-3

Revise the Accidental Release Prevention Requirements, 40 CFR 68, to explicitly cover catastrophic reactive hazards that have the potential to seriously impact the public, including those resulting from self-reactive chemicals and combinations of chemicals and process-specific conditions. Take into account the recommendations of this report to OSHA on reactive hazard coverage. Seek congressional authority if necessary to amend the regulation.


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.
 

2009-01-H-4

Modify the accident reporting requirements in RMP* Info to define and record reactive incidents. Consider adding the term "reactive incident" to the four existing "release events" in EPA's current 5-year accident reporting requirements (Gas Release, Liquid Spill/Evaporation, Fire, and Explosion). Structure this information collection to allow EPA and its stakeholders to identify and focus resources on industry sectors that experienced the incidents; chemicals and processes involved; and impact on the public, the workforce, and the environment.


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.
 

Morton International Inc. Runaway Chemical Reaction
Open: 0%  |  Closed: 100%
View Investigation
Final Report Released On: August 16, 2000

1998-06-I-NJ-9

Participate in a hazard investigation of reactive chemical process safety conducted by the CSB. The objectives of the special investigation will include: Determine the frequency and severity of reactive chemical incidents. Examine how industry, OSHA, and EPA are currently addressing reactive chemical hazards. Determine the differences, if any, between large/medium/small companies with regard to reactive chemical policies, practices, in-house reactivity research, testing, and process engineering. Analyze the effectiveness of industry and OSHA use of the National Fire Protection Association Reactivity Rating system for process safety management purposes. Develop recommendations for reducing the number and severity of reactive chemical incidents.


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.
 

1998-06-I-NJ-8

Issue joint guidelines on good practices for handling reactive chemical process hazards. Ensure that these guidelines, at a minimum, address the following issues: The evaluation of reactive hazards and the consequences of reasonably foreseeable and worst-case deviations from normal operations. The importance of reporting and investigating deviations from normal operations. The determination of proper design for pressure relief capability, emergency cooling process controls, alarms, and safety interlocks, as well as other good-practice design features for handling reactive substances. The appropriate use of chemical screening techniques such as differential scanning calorimetry.


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.
 

Oil Site Safety
Open: 100%  |  Closed: 0%
View Investigation
Final Report Released On: October 27, 2011

2011-H-1-1

Publish a safety alert directed to owners and operators of exploration and production facilities with flammable storage tanks, advising them of their general duty clause responsibilities for accident prevention under the Clean Air Act. At a minimum, the safety alert should:

a. Warn that storage tanks at unmanned facilities may be subject to tampering or introduction of ignition sources by members of the public, which could result in a tank explosion or other accidental release to the environment

b. Recommend the use of inherently safer storage tank design features to reduce the likelihood of explosions, including restrictions on the use of open vents for flammable hydrocarbons, flame arrestors, pressure vacuum vent valves, floating roofs, vapor recovery systems or an equivalent alternative.

c. Describe sufficient security measures to prevent non-employee access to flammable storage tanks, including such measures as a full fence surrounding the tank with locked gate, hatch locks on tank manways, and barriers securely attached to tank external ladders or stairways

d. Recommend that hazard signs or placards be displayed on or near tanks to identify the fire and
explosion hazards using words and symbols recognizable by the general public


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.
 

Sterigenics Ethylene Oxide Explosion
Open: 0%  |  Closed: 100%
View Investigation
Final Report Released On: March 30, 2006

2004-11-I-CA-16

Communicate the findings and recommendations of this report to the states that require EO backvent emissions treatment. Emphasize the need for facilities 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.
 

Environmental Technology Council
EQ Hazardous Waste Plant Explosions and Fire
Open: 0%  |  Closed: 100%
View Investigation
Final Report Released On: April 16, 2008

2007-1-I-NC-2

Superseded by 2009-10-I-OH-R6
Petition the National Fire Protection Association, following the guidelines of their "Codes and Standards Development Process" (http://www.nfpa.org/index.asp), to develop a fire protection standard (occupancy standard) specific to hazardous waste treatment, storage, and disposal facilities. This standard should address fire prevention, detection, control, and suppression requirements.


Status: C-R/S
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.
 

2007-1-I-NC-3

Superseded by 2009-10-I-OH-R7
Develop standardized guidance for the handling and storage of hazardous waste to reduce the likelihood of releases and fires at hazardous waste treatment, storage, and disposal facilities.


Status: C-R/S
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.
 

Veolia Environmental Services Flammable Vapor Explosion and Fire
Open: 57%  |  Closed: 43%
View Investigation
Final Report Released On: July 21, 2010

2010-10-I-OH-6

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


Status: 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.
 

2010-10-I-OH-7

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


Status: 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.
 

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