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Combustible Dust Hazard Investigation (6 Recommendations)
American National Standards Institute (ANSI) Z400.1 Committee (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 09, 2006

2006-1-H-6

Modify ANSI Z400.1 American National Standard for Hazardous Industrial Chemicals--Material Safety Data Sheets to recommend that MSDSs include information on: - combustible dust hazards, safe handling practices, and references to relevant fire codes in MSDS; - hazard information about the by-products of materials that may generate combustible dusts due to processing or handling; - identification of combustible dust hazards and selection of physical properties to include in MSDS.


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) (5 Recommendations)
Open: 40% | Closed: 60%

Final Report Released On: November 09, 2006

2006-1-H-1

Issue a standard designed to prevent combustible dust fires and explosions in general industry. Base the standard on current National Fire Protection Association (NFPA) dust explosion standards (including NFPA 654 and NFPA 484), and include at least - hazard assessment, - engineering controls, - housekeeping, - building design, - explosion protection, - operating procedures, and - worker training.


Status: Open - Unacceptable Response
Open - Unacceptable Response (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

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2006-1-H-2

Revise the Hazard Communication Standard (HCS) (1910.1200) to: - Clarify that the HCS covers combustible dusts, including those materials that may reasonably be anticipated to generate combustible dusts through downstream processing or handling. - Require Material Safety Data Sheets (MSDSs) to include the hazards and physical properties of combustible dusts, as well as clear information on safe handling practices and references to relevant consensus standards.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2006-1-H-3

Communicate to the United Nations Economic Commission for Europe (UNECE) the need to amend the Globally Harmonized System (GHS) to address combustible dust hazards by: - defining combustible dusts, - specifying the hazards that must be addressed in chemical information sheets, and - addressing the physical properties that must be included on a chemical information sheet pertinent to combustible dusts.


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

2006-1-H-4

Provide training through the OSHA Training Institute (OTI) on recognizing and preventing combustible dust explosions.


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

2006-1-H-5

While a standard is being developed, identify manufacturing industries at risk and develop and implement a national Special Emphasis Program (SEP) on combustible dust hazards in general industry. Include in the SEP an outreach program focused on the information in the Safety and Health Information Bulletin (SHIB), Combustible Dust in Industry: Preventing and Mitigating the Effects of Fire and Explosions.


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.
 

ConAgra Natural Gas Explosion and Ammonia Release (4 Recommendations)
American Gas Association (AGA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 04, 2010

2010-12-I-NC-1 URGENT!

Enact a Tentative Interim Amendment as well as permanent changes to the National Fuel Gas Code (NFPA 54/ANSI Z223.1) to require that during the purging of fuel gas piping at industrial, commercial, and public facilities: (a) Purged fuel gases shall be directly vented to a safe location outdoors, away from personnel and ignition sources 

(b) If it is not possible to vent purged gases outdoors, purging gas to the inside of a building shall be allowed only upon approval by the authority having jurisdiction of a documented risk evaluation and hazard control plan. The evaluation and plan shall establish that indoor purging is necessary and that adequate safeguards are in place such as:

     • Evacuating nonessential personnel from the vicinity of the purging;      • Providing adequate ventilation to maintain the gas concentration at an established safe level, substantially below   
     the lower explosive limit; and

     • Controlling or eliminating potential ignition sources
(c) Combustible gas detectors are used to continuously monitor the gas concentration at appropriate locations in the vicinity where purged gases are released

(d) Personnel are trained about the problems of odor fade and odor fatigue and warned against relying on odor alone for detecting releases of fuel gases


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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ICC International Fuel Gas Code Committee Chair (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 04, 2010

2010-12-I-NC-2 URGENT!

Incorporate the revised gas purging provisions of the National Fuel Gas Code, consistent with CSB recommendation 2009-12-I-NC-R1, into the International Fuel Gas Code


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

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

Final Report Released On: February 04, 2010

2010-12-I-NC-2 URGENT!

Incorporate the revised gas purging provisions of the National Fuel Gas Code, consistent with CSB recommendation 2009-12-I-NC-R1, into the International Fuel Gas Code


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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National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 04, 2010

2010-12-I-NC-1 URGENT!

Enact a Tentative Interim Amendment as well as permanent changes to the National Fuel Gas Code (NFPA 54/ANSI Z223.1) to require that during the purging of fuel gas piping at industrial, commercial, and public facilities: (a) Purged fuel gases shall be directly vented to a safe location outdoors, away from personnel and ignition sources 

(b) If it is not possible to vent purged gases outdoors, purging gas to the inside of a building shall be allowed only upon approval by the authority having jurisdiction of a documented risk evaluation and hazard control plan. The evaluation and plan shall establish that indoor purging is necessary and that adequate safeguards are in place such as:

     • Evacuating nonessential personnel from the vicinity of the purging;      • Providing adequate ventilation to maintain the gas concentration at an established safe level, substantially below   
     the lower explosive limit; and

     • Controlling or eliminating potential ignition sources
(c) Combustible gas detectors are used to continuously monitor the gas concentration at appropriate locations in the vicinity where purged gases are released

(d) Personnel are trained about the problems of odor fade and odor fatigue and warned against relying on odor alone for detecting releases of fuel gases


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

Hoeganaes Corporation Fatal Flash Fires (13 Recommendations)
City of Gallatin, TN (1 Recommendations)
Open: 100% | Closed: 0%

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: 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.
 

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City of Gallatin, TN Fire Department (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 05, 2012

2011-4-I-TN-12

Ensure that all industrial facilities in the City of Gallatin are inspected periodically against the International Fire Code. All facility inspections shall be documented.


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

2011-4-I-TN-13

Implement a program to ensure that fire inspectors and response personnel are trained to recognize and address 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.
 

PDF Document Download

Hoeganaes Corporation (4 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 05, 2012

2011-4-I-TN-6

Conduct periodic independent audits of the Hoeganaes Gallatin facility for compliance with the following NFPA standards, using knowledgeable experts, and implement all recommended corrective actions:

  • NFPA 484, Standard for Combustible Metals, Metal Powders, and Metal Dusts
  • NFPA 499, Recommended Practice for the Classification of Combustible Dusts and of Hazardous Locations for Electrical Installations in Chemical Process Areas
  • NFPA 497, Recommended Practice for the Classification of Flammable Liquids, Gases, or Vapors and of Hazardous (Classified) Locations for Electrical Installations in Chemical Process Areas
  • NFPA 2, Hydrogen Technologies Code
  • NFPA 2113, Standard on Selection, Care, Use, and Maintenance of Flame-Resistant Garments for Protection of Industrial Personnel Against Flash Fire


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.
 

2011-4-I-TN-7

Develop training materials that address combustible dust and plant-specific metal dust hazards and train all employees and contractors. Require periodic (e.g., annual) refresher training for all employees and contractors.


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.
 

2011-4-I-TN-8

Implement a preventive maintenance program and leak detection and leak mitigation procedures for all flammable gas piping and gas processing equipment.


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.
 

2011-4-I-TN-9

Develop and implement a near-miss reporting and investigation policy that includes the following at a minimum:

  • Ensure facility-wide worker participation in reporting all near-miss events and operational disruptions (such as significant iron powder accumulations, smoldering fires, or unsafe conditions or practices) that could result in worker injury.
  • Ensure that the near-miss reporting program requires prompt investigations, as appropriate, and that results are promptly circulated throughout the Hoeganaes Corporation.
  • Establish roles and responsibilities for the management, execution, and resolution of all recommendations from near-miss investigations
  • Ensure the near-miss program is operational at all times (e.g. nights, weekends, holiday shifts).


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

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

Final Report Released On: January 05, 2012

2011-4-I-TN-4

Revise IFC Chapter 22 Combustible Dust Producing Operations; Section 2204.1 Standards, to require mandatory compliance and enforcement with the detailed requirements of the NFPA standards cited in the chapter, including NFPA 484.


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.
 

Metal Powders Producers Association (MPPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 05, 2012

2011-4-I-TN-10

Communicate the findings of this report to all your members, e.g. through a safety article in an upcoming monthly newsletter.


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

Final Report Released On: January 05, 2012

2011-4-I-TN-1

Ensure that the forthcoming OSHA Combustible Dust Standard includes coverage for combustible metal dusts including iron and steel powders.


Status: Open - Unacceptable Response
Open - Unacceptable Response (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Download

2011-4-I-TN-2

Develop and publish a proposed combustible dust standard for general industry within one year of the approval of this case study.


Status: Open - Unacceptable Response
Open - Unacceptable Response (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Download

2011-4-I-TN-3

Revise the Combustible Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities nationwide under these codes to inform them of the
hazards of combustible metal dusts and NEP coverage.


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.
 

Tennessee Division of Occupational Safety & Health (TOSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 05, 2012

2011-4-I-TN-5

Revise the state-adopted Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities statewide under these codes to inform them of the
hazards of combustible metal dusts and NEP coverage.


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.
 

Tesoro Refinery Fatal Explosion and Fire (16 Recommendations)
American Petroleum Institute (API) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 01, 2014

2010-08-I-WA-10

Revise American Petroleum Institute API RP 941: Steels for Hydrogen Service at Elevated Temperatures
and Pressures in Petroleum Refineries and Petrochemical Plants
to: 

a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems;

b. Require the use of inherently safer materials to the greatest extent feasible;

c. Require verification of actual operating conditions to confirm that material of construction selection prevents HTHA equipment failure; and

d. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure.


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.
 

2010-08-I-WA-11

Revise American Petroleum Institute API RP 581: Risk-Based Inspection Technology to:

a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems;

b. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure; and

c. Require verification of actual operating conditions to determine potential equipment damage mechanisms.

 


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Environmental Protection Agency (EPA) (4 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 01, 2014

2010-08-I-WA-1

Revise the Chemical Accident Prevention Provisions under 40 CFR Part 68 to require the documented use
of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible when
facilities are establishing safeguards for identified process hazards. The goal shall be to reduce the risk of major accidents to the greatest extent practicable, to be interpreted as equivalent to as low as reasonably practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all management of change, incident investigation, and process hazard analysis reviews and recommendations, prior to the construction of a new process, process unit rebuilds, significant process repairs, and in the development of corrective actions.


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.
 

2010-08-I-WA-2

Until Recommendation 2010-08-I-WA-R1 is in effect, enforce through the Clean Air Act’s General Duty
Clause, section 112(r)(1), 42 U.S.C.§7412(r)(1) the use of inherently safer systems analysis and the
hierarchy of controls to the greatest extent feasible when facilities are establishing safeguards for
identified process hazards.


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.
 

2010-08-I-WA-3

Develop guidance for the required use of inherently safer systems analysis and the hierarchy of controls for enforcement under 40 CFR Part 68 and the Clean Air Act’s General Duty Clause, section 112(r)(1),42 U.S.C. §7412(r)(1).


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.
 

2010-08-I-WA-4

Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective actions.


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.
 

Governor and Legislature of the State of Washington (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 01, 2014

2010-08-I-WA-5

Based on the findings in this report, augment your existing process safety management regulations for
petroleum refineries in the state of Washington with the following more rigorous goal-setting attributes:

a. A comprehensive process hazard analysis written by the company that includes:

i. Systematic analysis and documentation of all major hazards and safeguards, using the hierarchy of controls to reduce those risks to as low as reasonably practicable (ALARP);

ii. Documentation of the recognized methodologies,rationale and conclusions used to claim that safeguards intended to control hazards will be effective;

iii. Documented damage mechanism hazard review conducted by a diverse team of qualified personnel. 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 effective safeguards are in place to control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safer design to the greatest extent feasible into this review; and

iv. 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.

b. A thorough review of the comprehensive process hazard analysis by technically competent regulatory
personnel;

c. Required preventative audits and preventative inspections by the regulator; 

d. Require that all safety codes, standards, employer internal procedures and recognized and generally
accepted good engineering practices (RAGAGEP) used in the implementation of the regulations contain adequate minimum requirements;

e. Require an increased role for workers in management of process safety by establishing the rights and responsibilities of workers and their representatives on health and safety-related matters, and the election of safety representatives and establishment of safety committees (with equal representation between management and labor) to serve health and safety-related functions. The elected representatives should have a legally recognized role that goes beyond consultation in activities such as the development of the comprehensive process hazard analysis, management of change, incident investigation, audits, and identification and effective control of hazards. The representatives should also have the authority to stop work that is perceived to be unsafe or that presents a serious hazard until the regulator intervenes to resolve the safety concern. Work force participation practices should be documented by the company to the regulator; and

f. Requires reporting of information to the public to the greatest extent feasible such as a summary of the comprehensive process hazard analysis which includes a list of safeguards implemented and standards utilized to reduce risk, and process safety indicators that demonstrate the effectiveness of the safeguards and management systems.

 


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.
 

2010-08-I-WA-6

Establish a well-funded, well-staffed, technically qualified regulator with a compensation system to
ensure the Washington Department of Labor and Industries regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical qualifications. Periodically conduct a market analysis and benchmarking review to ensure the
compensation system remains competitive with Washington petroleum refineries. 


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.
 

2010-08-I-WA-7

Work with the regulator, the petroleum refining industry, labor, and other relevant stakeholders in the
state of Washington to develop and implement a system that collects, tracks, and analyzes process safety leading and lagging indicators from operators and contractors to promote continuous process safety improvements. At a minimum, this program shall: 

a. Require the use of leading and lagging process safety indicators to actively monitor the effectiveness of process safety management systems and safeguards for major accident prevention. Include leading
and lagging indicators that are measureable, actionable, and standardized. Include indicators that measure safety culture, such as incident reporting and action item implementation culture. Require that the reported data be used for continuous process safety improvement and accident prevention;

b. Analyze data to identify trends and poor performer s and publish annual reports with the data at
facility and corporate levels;

c. Require companies to publicly report required indicators annually at facility and corporate levels;

d. Use process safety indicators (1) to drive continuous improvement for major accident prevention
by using the data to identify industry and facility safety trends and deficiencies and (2) to
determine appropriate allocation of regulator resources and inspections; and

e. Be periodically updated to incorporate new learning from world-wide industry improvements in order to drive continuous major accident process safety improvements in Washington.


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.
 

Tesoro Anacortes Refinery (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 01, 2014

2010-08-I-WA-15

Implement a process safety culture continuous improvement program at the Tesoro Anacortes Refinery
including a written procedure for periodic process safety culture surveys across the work force. The
process safety culture program shall be overseen by a tripartite committee of Tesoro management, USW
representatives, Washington State Department of Labor and Industries – Division of Occupational Safety
and Health, and the U.S. Environmental Protection Agency. This oversight committee shall:

a. Select an expert third party that will administer a periodic process safety culture survey;

b. Review and comment on the third party expert report developed from the survey;

c. Oversee the development and effective implementation of action items to address identified process safety culture issues; and

d. Develop process safety culture indicators to measure major accident prevention performance.

The process safety program shall include a focus on items that measure, at a minimum, willingness to
report incidents, normalization of hazardous conditions, burden of proof of safety in plant process safety programs and practices, and management involvement and commitment to process safety. The periodic process safety culture report shall be made available to the plant workforce. The minimum frequency of process safety culture surveys shall be at least once every three years.

 


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.
 

Tesoro Refining & Marketing Company LLC (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 01, 2014

2010-08-I-WA-12

Actively participate with API in the completion ofrecommendation 2010-08-I-WA-R10. Document this participation.


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.
 

2010-08-I-WA-13

Once recommendation 2010-08-I-WA-R12 is in effect, develop and implement a plan to meet therequirements established through the acceptable completion of recommendation 2010-08-I-WA-R10. Document the implementation of the plan and the corrective actions taken.


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.
 

2010-08-I-WA-14

Revise and improve the Process Hazard Analysis (PHA), the Integrity Operating Window (IOW), and the
damage mechanism hazard review (DMHR) programs and cross-linking among these three programs such that all identified hazards are effectively managed in each program. For all Tesoro refineries require:

a. the IOW to review damage mechanism hazards from the most recent PHA and safeguards identified to control these hazards;

b. the IOW review or revalidation to be conducted at least every five years;

c. the IOW to analyze and incorporate applicable industry best practice, the hierarchy of controls, and inherently safer design to the greatest extent reasonably practicable;

d. the DMHR report to be developed by the DMHR team and not just the “corrosion expert;”

e.the DMHR team to review the operating data to verify an accurate understanding of how the data was obtained, what it represents, and that it appropriately addresses both routine and nonroutine operations;

f. the DMHR and/or IOW review to identify and review gaps between current industry best practices and existing Tesoro practices with regard to material selection and process controls and make recommendations that reduce risks from damage mechanism hazards;

g. the DMHR and IOW review to review applicable Tesoro and industry-wide damage mechanism incidents as part of the respective DMHR or IOW review;

h. the DMHR to review relevant MOCs to fully evaluate the impact of the MOC on damage mechanism hazards;

i. the identification of minimum qualifications for the “corrosion expert” and ensure that the DMHR team has the necessary skills to meet these requirements;

j. for sites that have a corrosion/materials engineer, the corrosion/materials engineer shall be a required participant in the DMHR; 

k. the PHA to review the most recent DMHR and IOW reviews in order to contain a complete record of all identified damage mechanism hazards, evaluate existing safeguards, and propose new safeguards to control the identified hazards;

l. the PHA to review the consequence of damage mechanism hazards identified in the risk-based inspection (RBI) program and IOW reviews to ensure effective safeguards are present to control the damage mechanism hazard; and

m. the PHA to use the hierarchy of controls and implement opportunities for inherently safer design
to the greatest extent reasonably practicable.  


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.
 

USW Local 12-591 (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 01, 2014

2010-08-I-WA-16

Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight
committee as recommended under recommendation 2010-08-I-WA-R15.  


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.
 

Washington State Department of Labor & Industries - Division of Occupational Safety and Health (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 01, 2014

2010-08-I-WA-8

Perform a verification audit at all Washington petroleum refineries to ensure: 

a. Prevention of HTHA equipment failure and safe operation of the equipment. Audit HTHA prevention and process condition monitoring techniques used at all Washington petroleum refineries. Verify that all affected equipment in use meets the requirements contained in Recommendation 2010-08-I-WA-R10;

b. For nonroutine work, a written hazard evaluation is performed by a multidisciplinary team and, where feasible, conducted during the job planning process prior to the day of the job execution. Verify that each facility has an effective written decision-making protocol used to determine when it is necessary to shut a process down to safely perform work or conduct repairs. Ensure the program reflects the guidance in the CCPS Risk Based Process Safety book related to hazardous nonroutine work; and

c. Effective programs are in place to control of the number of essential personnel present during all
hazardous nonroutine work.


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.
 

2010-08-I-WA-9

Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight
committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure
the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective actions.


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.
 

Acetylene Service Company Gas Explosion (5 Recommendations)
Acetylene Service Company (ASCO) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 26, 2006

2005-3-I-NJ-1

Improve isolation on acetylene generator water lines by incorporating a double-block-and-bleed with a vent to a safe location, or other isolation means of comparable effectiveness.


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).
 

2005-3-I-NJ-2

Implement an effective Process Safety Management program, in accordance with OSHA 1910.119. Include written operating procedures and checklists that are understood by the workers responsible for using them. Train workers on the procedures and periodically confirm that they are being properly followed.


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).
 

Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 26, 2006

2005-3-I-NJ-5

Update the OSHA 1910.102 Acetylene Standard (a. Cylinders, b. Piped Systems, and c. Generators and filling cylinders) to remove the existing references to unavailable and obsolete Compressed Gas Association Pamphlets (CGA G-1-1966, G 1.3-1959, G 1.4-1966). As an alternative, consider incorporating by reference NFPA 51A Standard for Acetylene Cylinder Charging Plants.


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

Rexarc, Inc. (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 26, 2006

2005-3-I-NJ-3

Immediately inform existing acetylene generator users that the check valve did not prevent acetylene gas backflow in this incident. Recommend interim actions be taken to ensure that Rexarc check valves in service on acetylene production equipment will operate reliably.


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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2005-3-I-NJ-4

Replace check valves of this or similar design supplied by Rexarc with valves that will perform more reliably in recycle water service.


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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AL Solutions Fatal Dust Explosion (5 Recommendations)
AL Solutions, Inc. (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 16, 2014

2011-3-I-WV-1

For all new and existing equipment and operations at AL Solutions facilities that process combustible dusts or powders, apply the following chapters of NFPA 484-2012, Standard for Combustible Metals:

  • Chapter 12, Titanium
  • Chapter 13, Zirconium
  • Chapter 15, Fire Prevention, Fire Protection, and Emergency Response
  • Chapter 16, Combustible Metal Recycling Facilities

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2011-3-I-WV-2

Develop training materials that address combustible dust hazards and plant-specific metal dust hazards and then train all employees and contractors.  Require periodic (e.g., annual) refresher training for all employees and contractors.


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.
 

AL Solutions, Inc. facility in Burgettstown, PA (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 16, 2014

2011-3-I-WV-3

Prohibit the use of sprinkler systems and water deluge systems in all buildings that process or store combustible metals.


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.
 

2011-3-I-WV-4

Conduct a process hazard analysis as defined in NFPA 484-2012, Section 12.2.5, and submit a copy to the local fire department or the enforcing authority for the fire code.


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

Final Report Released On: July 16, 2014

2006-1-H-1

Issue a standard designed to prevent combustible dust fires and explosions in general industry.  Base the standard on current National Fire Protection Association (NFPA) dust explosion standards (including NFPA 654 and NFPA 484), and include at least

  • hazard assessment
  • engineering controls
  • housekeeping
  • building design
  • explosion protection
  • operating procedures, and
  • worker training

This recommendation was reiterated upon issuance of the AL Solutions, Inc. Case Study. It was originally issued as part of the CSB's 2006 Combustible Dust Hazard Investigation Study.


Status: Open - Unacceptable Response
Open - Unacceptable Response (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

Allied Terminals Fertilizer Tank Collapse (11 Recommendations)
Accreditation Board for Engineering and Technology, Inc. (ABET) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 26, 2009

2014-2009-3-I-VA-I-VA-11

test


Status: Open - Unacceptable Response
Open - Unacceptable Response (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

Allied Terminals Inc. (5 Recommendations)
Open: 20% | Closed: 80%

Final Report Released On: May 26, 2009

2009-3-I-VA-1 URGENT!

Take immediate action to reduce the risk of a catastrophic failure of Tanks 202, 205, and 209 at the Allied Terminals Hill Street facility including but not limited to significantly reducing the maximum liquid levels ("safe fill height") based on sound engineering principles. Report the actions taken to the City of Chesapeake.


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).
 

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2009-3-I-VA-2 URGENT!

Select and retain a qualified, independent tank engineering firm to evaluate Tanks 202, 205, and 209 and determine their fitness for continued service. The evaluation should be based on recognized and generally accepted good engineering practices, such as API 653 - Tank Inspection, Repair Alteration, and Reconstruction and API 579 - Fitness for Service.


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).
 

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2009-3-I-VA-3 URGENT!

Within 30 days, provide the report prepared by the independent tank engineering firm to the City of Chesapeake, together with a comprehensive action plan and schedule to address any identified deficiencies.


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).
 

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2009-3-I-VA-6

Hire a qualified independent reviewer to verify that maximum liquid levels for all tanks at Allied’s Norfolk and Chesapeake terminals meet the requirements of American Petroleum Institute Standard 653, Tank Inspection, Repair, Alteration, and Reconstruction. At a minimum, the review should verify that all requirements for welding, inspection of welds, and In-Service and Out-of-Service tank inspections are met. Make the complete review report for both terminals available to the Cities of Norfolk, Chesapeake, and Portsmouth, Virginia, as well as the Virginia Department of Environmental Quality.


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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2009-3-I-VA-7

Develop and implement worker safety procedures for initial filling of tanks following major modification or change-in-service. At a minimum, require the exclusion of all personnel from secondary containment during the initial filling.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%

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: 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.
 

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

Final Report Released On: May 26, 2009

2009-3-I-VA-10

Formally recommend to all member companies the incorporation of The Fertilizer Institute tank inspection guidelines into contracts for the storage of liquid fertilizer at terminals.


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.
 

Govenor and Legislature of the Commonwealth of Virginia (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 26, 2009

2009-3-I-VA-5

Require state regulation of 100,000-gallon and larger fertilizer storage tanks (which presently are located solely along and in the area of the Elizabeth River) or authorize local jurisdictions to regulate these tanks. The regulations should: 1) Address design, construction, maintenance, and inspection of 100,000-gallon and larger liquid fertilizer storage tanks, and 2) Incorporate generally recognized and accepted good engineering practice.


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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HMT Inspection, Inc. (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 26, 2009

2009-3-I-VA-8

Implement The Fertilizer Institute’s inspection guidelines as part of tank inspector training and inspection procedures for fertilizer tank inspection.


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.
 

2009-3-I-VA-9

Revise company procedures to require tank inspectors to verify that radiography required as part of the calculation for a maximum liquid level has been performed.


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.
 

Barton Solvents Explosions and Fire (9 Recommendations)
American Chemistry Council (ACC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-4

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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.
 

American National Standards Institute (ANSI) Z400.1 Committee (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-3

Revise ANSI Z400.1 to advise chemical manufacturers and importers that prepare MSDSs to: -Identify and include a warning for materials that are static-accumulators and that may form ignitable vapor-air mixtures in storage tanks; -Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)); and -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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.
 

American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-5

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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

National Association of Chemical Distributors (NACD) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-6

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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

National Paint and Coatings Association (NPCA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-7

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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

National Petrochemical and Refiners Association (NPRA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-8

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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

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

Final Report Released On: June 26, 2008

2007-6-I-KS-1

Revise the "Guidance for Hazard Determination for compliance with the OSHA Hazard Communication Standard" to advise chemical manufacturers and importers that prepare MSDSs to: -Evaluate flammable liquids to determine their potential to accumulate static electricity and form ignitable vapor-air mixtures in storage tanks. -Test the conductivity of the flammable liquid and include the testing results in the MSDS.


Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2007-6-I-KS-2

Prior to the next revision, communicate to the Sub-Committee on the Globally Harmonized System of Classification and Labeling of Chemicals (SCEGHS) the need to amend the GHS to advise chemical manufacturers and importers that prepare MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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.
 

Society for Chemical Hazard Communication (SCHC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-9

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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.
 

Bayer CropScience Pesticide Waste Tank Explosion (13 Recommendations)
Bayer CropScience- Institute, West Virginia (4 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 20, 2011

2008-08-I-WV-2

Review and revise, as necessary, all Bayer production unit standard operating procedures to ensure they address all operating modes (startup, normal operation, temporary operations, emergency shutdown, emergency operations, normal shutdown, and startup following a turnaround or emergency shutdown), are accurate, and approved.


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.
 

2008-08-I-WV-3

Ensure that all facility fire brigade members are trained in the National Incident Management System, consistent with municipal and state emergency response agencies.


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.
 

2008-08-I-WV-4

Evaluate the fenceline air monitor program against federal, state, and local regulations, and Bayer corporate policies, and upgrade and install air monitoring devices as necessary to ensure effective monitoring of potential releases of high-hazard chemicals at the perimeter of the facility.


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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2008-08-I-WV-5

Commission an independent human factors and ergonomics study of all Institute site PSM/RMP covered process control rooms to evaluate the human-control system interface, operator fatigue, and control system familiarity and training. Develop and implement a plan to resolve all recommendations identified in the study that includes assigned responsibilities, required corrective actions, and completion dates.


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

Bayer CropScience- Research Triangle Park, NC (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 20, 2011

2008-08-I-WV-1

Revise the corporate PHA policies and procedures to require:
a. Validation of all PHA assumptions to ensure that risk analysis of each PHA scenario specifically examines the risk(s) of intentional bypassing or other nullifications of safeguards,
b. Addressing all phases of operation and special topics including those cited in chapter 9 of "Guidelines for Hazard Evaluation Procedures" (CCPS, 2008), and
c. Training all PHA facilitators on the revised policies and procedures prior to assigning the facilitator to a PHA team.
Ensure all PHAs are updated to conform to the revised procedures.


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.
 

Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%

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: 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 Download

Kanawha-Charleston Health Department, Director of the (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 20, 2011

2008-08-I-WV-6

Establish a Hazardous Chemical Release Prevention Program to enhance the prevention of accidental releases of highly hazardous chemicals, and optimize responses in the event of their occurrence. In establishing the program, study and evaluate the possible applicability of the experience of similar programs in the country, such as those summarized in Section 5.3 of this report. As a minimum:

a. Ensure that the new program:
1. Implements an effective system of independent oversight and other services to enhance the prevention of accidental releases of highly hazardous chemicals
2. Facilitates the collaboration of multiple stakeholders in achieving common goals of chemical safety; and,
3. Increases the confidence of the community, the workforce, and the local authorities in the ability of the facility owners to prevent and respond to accidental releases of highly hazardous chemicals.

b. Define the characteristics of chemical facilities that would be covered by the new Program, such as the hazards and potential risks of their chemicals and processes, their quantities, and similar relevant factors;

c. Ensure that covered facilities develop, implement, and submit for review and approval:
1. Applicable hazard and process information and evaluations.
2. Written safety plans with appropriate descriptions of hazard controls, safety culture and human factors programs with employee participation, and consideration of the adoption of inherently safer systems to reduce risks
3. Emergency response plans; and,
4. Performance indicators addressing the prevention of incidents and chemical incidents.

d. Ensure that the program has the right to evaluate the documents submitted by the covered facilities, and to require modifications, as necessary

e. Ensure that the program has right-of-entry to covered facilities, and access to requisite information to conduct periodic audits of safety systems and investigations of chemical releases;

f. Establish a system of fees assessed on covered facilities sufficient to cover the oversight and related services to be provided to the facilities including necessary technical and administrative personnel; and,

g. Consistent with applicable law, ensure that the program provides reasonable public participation with the program staff in review of facility programs and access to:
1. The materials submitted by covered facilities (e.g., hazard evaluations, safety plans, emergency response plans);
2. The reviews conducted by program staff and the modifications triggered by those reviews;
3. Records of audits and incident investigations conducted by the program;
4. Performance indicator reports and data submitted by the facilities, and;
5. Other relevant information concerning the hazards and the control methods overseen by the program.

h. Ensure that the program will require a periodic review of the designated agency activities and issue a periodic public report of its activities and recommended action items


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.
 

Kanawha-Putnam Emergency Planning Committee (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 20, 2011

2008-08-I-WV-8

Work with the Kanawha and Putnam counties Emergency Response Directors to prepare and issue a revision to the Kanawha Putnam County Emergency Response Plan and Annexes to address facility emergency response and Incident Command when such functions are provided by the facility owner.


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%

Final Report Released On: January 20, 2011

2008-08-I-WV-10

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 Process Safety Management (PSM) inspection of the complex. Coordinate with the Environmental Protection Agency, as appropriate.


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 Download

2008-08-I-WV-11

Revise the Chemical National Emphasis Program and the targeting criteria to:
a. Expand the coverage to all OSHA regions,
b. Include in the targeting criteria from which potential inspections are selected all establishments that have submitted certifications of completions of actions in response to previous PSM citations;
c. Require NEP inspections to examine the status of compliance of all previously cited PSM program items for which the company has submitted certifications of completion to OSHA.


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 Virginia Department of Environmental Protection, Secretary of the (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 20, 2011

2008-08-I-WV-7

Work with the Director of the Kanawha-Charleston Health Department to ensure the successful planning, fee collection, and implementation of the Hazardous Chemical Release Prevention Program as described in Recommendation 2008-08-WV-R6, above, including the provision of services to all eligible facilities in the State.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

West Virginia Department of Health and Human Services, Secretary of the (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 20, 2011

2008-08-I-WV-7

Work with the Director of the Kanawha-Charleston Health Department to ensure the successful planning, fee collection, and implementation of the Hazardous Chemical Release Prevention Program as described in Recommendation 2008-08-WV-R6, above, including the provision of services to all eligible facilities in the State.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

West Virginia Fire Commission (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 20, 2011

2008-08-I-WV-9

Revise the Fire Department Evaluation Administrative Section Matrix addressing the periodic inspection of local fire departments to include a requirement for inspectors to examine and identify the status of National Incident Management System fire department personnel 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.
 

Bethlehem Steel Corporation Gas Condensate Fire (13 Recommendations)
AFL-CIO Building Trades Council (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: December 06, 2001

2001-02-I-IN-10

Communicate findings of this report to your membership.


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

American Iron and Steel Institute (AISI) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: December 06, 2001

2001-02-I-IN-10

Communicate findings of this report to your membership.


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

Association of Iron and Steel Engineers (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: December 06, 2001

2001-02-I-IN-10 URGENT!

Communicate findings of this report to your membership.


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

Bethlehem Steel Corporation (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: December 06, 2001

2001-02-I-IN-7

Conduct periodic audits of work authorization, line and equipment opening, deadleg management programs, and decommissioning and demolition activities at your steelmaking facilities. Share findings with the workforce.


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.
 

2001-02-I-IN-8

Revise the Material Safety Data Sheet (MSDS) for COG condensate to highlight the potential flammability hazard. Ensure that management at your steelmaking facilities trains employees and informs contractors with regard to the potential presence of flammable liquids when working with or opening COG condensate piping and equipment.


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.
 

2001-02-I-IN-9

Communicate findings of this report to the workforce and contractors at Bethlehem Steel's steelmaking facilities.


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.
 

Bethlehem Steel Corporation, Burns Harbor Mill (6 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: December 06, 2001

2001-02-I-IN-1

Implement a work authorization program that requires higher levels of management review, approval, and oversight for jobs that present higher levels of risk, such as opening lines potentially containing flammable liquids where there is no low point drain.


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.
 

2001-02-I-IN-2

Monitor the accumulation and flammability of COG condensate throughout the mill. Address potentially hazardous changes in condensate accumulation rates and flammability.


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.
 

2001-02-I-IN-3

Survey the mill for deadlegs and implement a program for resolving the hazards. Develop guidance for plant personnel on the risks of deadlegs and their prevention. Include deadlegs in plant winterization planning.


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.
 

2001-02-I-IN-4

Provide drains at low points in piping to allow for the safe draining of potentially flammable material.


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.
 

2001-02-I-IN-5

Ensure that Burns Harbor and contractor employees are trained with regard to the potential presence of flammable liquids when working with or opening COG or condensate piping and equipment.


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.
 

2001-02-I-IN-6

Establish procedures to ensure that insulation is replaced when removed for maintenance.


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.
 

United Steelworkers of America (USWA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: December 06, 2001

2001-02-I-IN-10

Communicate findings of this report to your membership.


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

Bethune Point Wastewater Plant Explosion (13 Recommendations)
Camp Dresser & McKee Inc. (3 Recommendations)
Open: 0% | Closed: 100%

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

2006-3-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: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2006-3-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: 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.
 

City of Daytona Beach (2 Recommendations)
Open: 0% | Closed: 100%

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

2006-3-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: 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.
 

Governor and Legislature of the State of Florida (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 13, 2007

2006-3-I-FL-1

Enact legislation requiring state agencies and each political subdivision (i.e. counties and municipalities) of Florida to implement policies, practices, procedures, including chemical hazards covering the workplace health and safety of Florida public employees that are at least as effective as OSHA. Establish and fund a mechanism to ensure compliance with these standards. Consider legislation providing coverage of Florida public employees under an occupational safety and health program in accordance with Section 18(b) of the Occupational Safety and Health Act of 1970, and Code of Federal Regulations 29 CFR 1956.1.


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.
 

2006-3-I-FL-2

Develop and fund a workplace safety and health consultation program for Florida public employees similar to the private sector program currently administered by the Florida Safety Consultation Program at the University of South Florida.


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.
 

Methanol Institute (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 13, 2007

2006-3-I-FL-9

Work with the Water Environment Federation to prepare and distribute a technical bulletin containing information on the safe receipt, storage, use, and dispensing of methanol in wastewater treatment plants. In addition, include information on basic fire and explosion prevention measures when using bulk methanol (e.g., flame arrester maintenance, hot work programs, electrical classification).


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

2006-3-I-FL-10

Work with the Water Environment Federation to prepare safety training materials for wastewater treatment facilities that use methanol.


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

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: March 13, 2007

2006-3-I-FL-5

Revise NFPA 30 to specifically exclude the use of thermoplastics in aboveground flammable liquid service.


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

Final Report Released On: March 13, 2007

2006-3-I-FL-6

Revise 29 CFR 1910.106 to specifically exclude the use of thermoplastics in above ground flammable liquid service.


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.
 

Water Environment Federation (2 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: March 13, 2007

2006-3-I-FL-7

Work with the Methanol Institute to prepare and distribute a technical bulletin containing information on the safe receipt, storage, use, and dispensing of methanol in wastewater treatment plants. In addition, include information on basic fire and explosion prevention measures when using bulk methanol (e.g., flame arrester maintenance, hot work programs, electrical classification).


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.
 

2006-3-I-FL-8

Work with the Methanol Institute to prepare safety training materials for wastewater treatment facilities that use methanol.


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.
 

BLSR Operating Ltd. Vapor Cloud Fire (18 Recommendations)
American Petroleum Institute (API) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 17, 2003

2003-06-I-TX-16

Revise API RP-2219, Safe Operation of Vacuum Trucks in Petroleum Service, and API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities, to discuss the hazards of unloading potentially flammable or flammable liquids onto an open unloading area, such as a concrete pad. Recommend other alternatives for minimizing vapor generation, such as unloading of flammable liquids into a closed piping 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.
 

2003-06-I-TX-17

Communicate the findings and recommendations of this report to your membership. Emphasize that basic sediment and water (BS&W) removed from crude oil and condensate storage tanks requires special handling, in addition to compliance with Occupational Safety and Health Administration (OSHA) or U.S. Department of Transportation (DOT) regulations, if it contains sufficient hydrocarbons (either residual or mixed in during the removal process) to be classified a flammable liquid as defined by each regulation.


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.
 

BLSR Operating, Ltd. (4 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 17, 2003

2003-06-I-TX-8

Develop a written Waste Acceptance Plan as recommended by API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities. Require the shipper or carrier to properly classify the flammability hazard of exploration and production (E&P) waste liquids. Require the hauler to provide information that identifies the flammability hazard of the material before accepting the load, such as a material safety data sheet (MSDS).


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.
 

2003-06-I-TX-9

Develop and implement written procedures and provide training to employees on the safe handling of all waste liquids delivered to the facility in accordance with API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities; and API RP-2219, Safe Operation of Vacuum Trucks in Petroleum Service. Include requirements for proper grounding of trucks and eliminating other sources of ignition (e.g., facility electrical equipment and smoking in unloading areas). Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel.


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.
 

2003-06-I-TX-10

Develop written procedures and provide training to employees on unloading all flammable or potentially flammable E&P waste liquids. Avoid unloading flammable liquids onto an open work area, such as the mud disposal and washout pad. Include alternative unloading method(s), such as using a closed piping system to minimize vapor generation. Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel.


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.
 

2003-06-I-TX-11

Develop written emergency procedures and provide training to employees on response to abnormal or emergency situations, including uncontrolled flammable vapor releases that can result in a fire or explosion hazard. Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel.


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

National Tank Truck Carriers, Inc. (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 17, 2003

2003-06-I-TX-18

Communicate the findings and recommendations of this report to your membership. Emphasize emergency response to diesel engine overspeed caused by exposure to flammable vapor atmospheres.


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.
 

Noble Energy (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 17, 2003

2003-06-I-TX-1

Provide documentation of the potential flammability hazard of exploration and production (E&P) waste liquids-such as a material safety data sheet (MSDS)- to all employees, contract personnel, and haulers handling waste liquids generated at well sites. Emphasize that mixing condensate with basic sediment and water (BS&W) during the removal process can significantly increase the flammability hazard. The mixture in the transport container should be treated as a flammable liquid absent positive identification to the contrary.


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.
 

2003-06-I-TX-2

Review and revise company gauging and waste liquid removal protocols as necessary to minimize the inadvertent removal and subsequent disposal of hydrocarbon product when removing BS&W from product storage tanks.


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

Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 17, 2003

2003-06-I-TX-13

Issue a Safety and Health Information Bulletin on the potential flammability hazard associated with bulk transportation of oilfield exploration and production (E&P) waste liquids. Summarize OSHA requirements for proper hazard classification by the shipper and for the use of material safety data sheets (MSDS). Summarize U.S. Department of Transportation (DOT) requirements for proper hazard classification and manifesting of flammable liquids, approved container design, and periodic testing. Discuss safe handling to minimize the generation of flammable vapor and to control ignition sources from vehicle-mounted equipment and facility equipment. Discuss the need for the employer to provide all worker safety information in languages or formats that are clearly understood by all affected personnel. Summarize the requirements for proper labeling of storage tanks to clearly identify the hazard of the contents to all employees and contractors working at the well site.


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.
 

T and L Environmental Services, Inc. (5 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 17, 2003

2003-06-I-TX-3

Ensure that the written procedures for hazard identification require that all customers requesting loading and transportation of exploration and production (E&P) waste liquids provide written notification, such as a material safety data sheet (MSDS), listing the potential flammability hazard.


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

2003-06-I-TX-4

Ensure that the written procedures for safe operation of vacuum trucks incorporate applicable good practices, including techniques to minimize the possibility of exposing the diesel engine to flammable vapor, as provided in API RP-2219, Guidelines for Commercial Exploration and Production Waste Management Facilities.


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

2003-06-I-TX-5

Develop written operating procedures that incorporate best practices for unloading storage tank waste liquids, such that drivers accurately measure the quantity of liquid removed from the storage tank and minimize removal of product, such as flammable condensate.


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.
 

2003-06-I-TX-6

Ensure that written emergency procedures address the safe response to abnormal diesel engine operation due to a flammable vapor atmosphere. Explain that the normal engine shutoff method will not function as long as flammable vapor continues to enter the intake 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.
 

2003-06-I-TX-7

Conduct and document training for all personnel who handle waste liquids, using languages or formats that are clearly understood by all affected personnel. Address the potential flammability hazard associated with E&P waste liquids, emphasizing how the withdrawal procedure is likely to increase the flammability of the vacuum truck contents through unavoidable mixing of product and basic sediment and water (BS&W). Describe operating and emergency response to diesel engine overspeed caused by a flammable vapor 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.
 

Texas Railroad Commission (RRC) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 17, 2003

2003-06-I-TX-14

Require that all permitted drillers and producers identify and document (e.g., material safety data sheet [MSDS]) the potential flammability hazard of exploration and production (E&P) waste liquids. Provide the information to workers and contractors in languages clearly understood by the 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.
 

2003-06-I-TX-15

Provide information (e.g., safety bulletin) to industry on the potential flammability hazard associated with basic sediment and water (BS&W) and other E&P waste liquids. Waste liquids can contain sufficient hydrocarbons to be classified as flammable liquids. The waste liquid removal method can result in removing significant quantities of flammable hydrocarbon product such that the mixture in the transport container may require classification as a flammable liquid under Occupational Safety and Health Administration (OSHA) or U.S. Department of Transportation (DOT) regulations.


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.
 

U.S. Department of Transportation (DOT) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 17, 2003

2003-06-I-TX-12

Publish an information document for exploration and production (E&P) industry employers (including producers/shippers/offerors, motor carriers, and disposal facility operators) involved in the transportation of basic sediment and water (BS&W) and other E&P waste liquids on public highways. (2003-06-I-TX-R12): -Emphasize the importance of, and responsibility for, properly classifying and identifying flammable waste liquids. -Reference the Occupational Safety and Health Administration (OSHA) requirements for obtaining material safety data sheets (MSDS) from the shipper and the required content of DOT shipping papers. -Include specific reference to this CSB Investigation Report and the American Petroleum Institute (API) recommended practices cited in this report.


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.
 

BP America Refinery Explosion (26 Recommendations)
American Petroleum Institute (API) (5 Recommendations)
Open: 60% | Closed: 40%

Final Report Released On: March 20, 2007

2005-4-I-TX-2 URGENT!

In light of the findings concerning the March 23rd incident at BP's Texas City refinery, revise your Recommended Practice 752, Management of Hazards Associated with Location of Process Plant Buildings or issue a new Recommended Practice to ensure the safe placement of occupied trailers and similar temporary structures away from hazardous areas of process plants. Ensure that the new recommended practice: - Protects occupants from accident hazards such as heat, blast overpressure, and projectiles; - Establishes minimum safe distances for trailers and similar temporary structures away from hazardous areas of process plants; - Evaluates the siting of trailers under a separate methodology from permanent structures, since trailers are more susceptible to damage, are more readily relocated, and likely do not need to be placed near hazardous areas.


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.
 

2005-4-I-TX-3 URGENT!

Issue a safety alert to your membership to take prompt action to ensure the safe placement of occupied trailers away from hazardous areas of process plants.


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

2005-4-I-TX-4

Revise API Recommended Practice 521, Guide for Pressure Relieving and Depressurizing Systems to ensure that the guidelines: - Identifies overfilling vessels as a potential hazard for evaluation in selecting and designing pressure relief and disposal systems; - Addresses the need to adequately size disposal drums for credible worse-case liquid relief scenarios, based on accurate relief valve and disposal collection piping studies; - Warns against the use of atmospheric blowdown drums and stacks attached to collection piping systems that receive flammable discharges from multiple relief valves and urges the use of appropriate inherently safer alternatives such as a flare system


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2005-4-I-TX-6

Work together to develop two new consensus American National Standards Institute (ANSI) standards. a. In the first standard, create performance indicators for process safety in the refinery and petrochemical industries. Ensure that the standard identifies leading and lagging indicators for nationwide public reporting as well as indicators for use at individual facilities. Include methods for the development and use of the performance indicators. (CSB2005-04-I-TX-R6A) In the development of each standard, ensure that a. the committees are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


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.
 

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2005-4-I-TX-7

Work together to develop two new consensus American National Standards Institute (ANSI) standards. b. In the second standard, develop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. (CSB2005-04-I-TX-R7a) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


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.
 

BP Global Executive Board of Directors (4 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: March 20, 2007

2005-4-I-TX-1 URGENT!

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: 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.
 

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: 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.
 

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: 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.
 

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: 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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BP Texas City Refinery (8 Recommendations)
Open: 0% | Closed: 100%

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: 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.
 

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: 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.
 

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: 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.
 

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: 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.
 

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: 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.
 

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: 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.
 

2005-4-I-TX-20

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


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.
 

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: 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.
 

Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 0% | Closed: 100%

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: 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.
 

JV Industrial Companies (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 20, 2007

2005-4-B-TX-2

Develop / update the written piping component installation quality control procedure to require positive material identification testing or other suitable verification or tracking process for all alloy steel piping components removed during maintenance.


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

National Petrochemical and Refiners Association (NPRA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 20, 2007

2005-4-I-TX-3 URGENT!

Issue a safety alert to your membership to take prompt action to ensure the safe placement of occupied trailers away from hazardous areas of process plants.


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

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

Final Report Released On: March 20, 2007

2005-4-I-TX-5

1. Implement a national emphasis program for all oil refineries that focuses on: - The hazards of blowdown drums and stacks that release flammables to the atmosphere instead of to an inherently safer disposal system such as a flare. Particular attention should be paid to blowdown drums attached to collection piping systems servicing multiple relief valves; - The need for adequately sized disposal knockout drums to safely contain discharged flammable liquid based on accurate relief valve and disposal collection piping studies 2. Urge states that administer their own OSHA plan to implement comparable emphasis programs within their respective jurisdictions.


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.
 

2005-4-I-TX-8

1. Strengthen the planned comprehensive enforcement of the OSHA Process Safety Management (PSM) standard. At a minimum: a. Identify those facilities at greatest risk of a catastrophic accident by using available indicators of process safety performance and information gathered by the EPA under its Risk Management Program (RMP). b. Conduct, or have conducted, comprehensive inspections, such as those under your Program Quality Verification (PQV) program at facilities identified as presenting the greatest risk. c. Establish the capacity to conduct more comprehensive PSM inspections by hiring or developing a sufficient cadre of highly trained and experienced inspectors. d. Expand the PSM training offered to inspectors at the OSHA National Training Institute.


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.
 

2005-4-I-TX-9

2. Amend the OSHA PSM standard to require that a management of change (MOC) review be conducted for organizational changes that may impact process safety including: a. major organizational changes such as mergers, acquisitions, or reorganizations; b. personnel changes, including changes in staffing levels or staff experience; and c. policy changes such as budget cutting.


Status: Open - Unacceptable Response
Open - Unacceptable Response (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

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United Steelworkers of America (USWA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: March 20, 2007

2005-4-I-TX-6

Work together to develop two new consensus American National Standards Institute (ANSI) standards. a. In the first standard, create performance indicators for process safety in the refinery and petrochemical industries. Ensure that the standard identifies leading and lagging indicators for nationwide public reporting as well as indicators for use at individual facilities. Include methods for the development and use of the performance indicators.(CSB2005-04-I-TX-R6b) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


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.
 

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2005-4-I-TX-7

Work together to develop two new consensus American National Standards Institute (ANSI) standards. b. In the second standard, develop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. (CSB2005-04-I-TX-R7b) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


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.
 

USW Local 13-1 (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 20, 2007

2005-4-I-TX-21

Work with BP to establish a joint program that promotes reporting, investigating, and analyzing 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: 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.
 

BP Amoco Thermal Decomposition Incident (11 Recommendations)
American Chemistry Council (ACC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 20, 2002

2001-03-I-GA-10

Communicate the findings of this report to your membership.


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

BP Chemicals Group (1 Recommendations)
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: 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.
 

Society of Plastics Engineers (SPE) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 20, 2002

2009-03-I-GA-11

Communicate the findings of this report to your membership.


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

Solvay Advanced Polymers, LLC (8 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 20, 2002

2001-03-I-GA-1

Examine the manufacturing businesses acquired from BP Amoco Performance Polymers and ensure that a systematic safety review procedure is developed and implemented for identifying and controlling hazards from unintended chemical reactions. Additionally, ensure that reactive hazards are identified and evaluated: - During product R&D, during conceptual design of a new process, and during detailed design of a new process. - Before changes are made to existing equipment or process chemistry. - Communicate the results of this review to the 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.
 

2001-03-I-GA-2

Ensure that a program is in place at facilities acquired from BP Amoco Performance Polymers to systematically review the hazards associated with new and modified processes and equipment as operating experience accrues. Ensure that facilities correct all identified design, operation, and maintenance deficiencies. Verify that operating experience does not invalidate the design basis for equipment.


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.
 

2001-03-I-GA-3

Revise the Material Safety Data Sheet (MSDS) for Amodel to warn of the hazards of accumulating large masses of molten polymer. Communicate the MSDS changes to current and past customers (who may retain inventories of this 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.
 

2001-03-I-GA-4

Implement a program to conduct periodic management reviews of incidents and near-miss incidents. Look for trends and patterns among incidents. Address root causes and implement and track corrective measures.


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.
 

2001-03-I-GA-5

Revise process safety information to include: - Information regarding the decomposition reactions of Amodel. - Design intent, basis, capacity, and limitations of equipment. - Hazards and consequences of deviations from design intent and operating limits.


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.
 

2001-03-I-GA-6

Revalidate hazard analyses for the Amodel process to address: - Credible deviations from process intent and their consequences. - Hazards associated with startup and shutdown operations. - Prevention of accumulations of potentially hazardous masses of polymer.


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.
 

2001-03-I-GA-7

Revise your lockout/tagout program to ensure that equipment is rendered safe prior to opening for maintenance. At a minimum, ensure that equipment opening procedures contain a stop work provision that requires higher levels of management review and approval when safe opening conditions, such as equipment depressurization, cannot be verified.


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.
 

2001-03-I-GA-8

Ensure that your management of change policy applies to operational and procedural modifications.


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.
 

CAI / Arnel Chemical Plant Explosion (11 Recommendations)
CAI, Inc. (1 Recommendations)
Open: 0% | Closed: 100%

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: 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.
 

Commonwealth of Massachusetts Office of Public Safety, Department of Fire Services (4 Recommendations)
Open: 25% | Closed: 75%

Final Report Released On: May 13, 2008

2007-03-I-MA-3

Incorporate the Flammable and Combustible Liquids Code (NFPA 30) and Standard for the Manufacture of Organic Coatings (NFPA 35) into the Massachusetts Board of Fire Prevention Regulations.


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.
 

2007-03-I-MA-4

Revise 527 CMR 14 to specify the maximum interval (such as annually) for local fire departments to conduct inspections of manufacturing facilities holding one or more licenses and permits to store and handle flammable materials.


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

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2007-03-I-MA-5

Develop mandatory written inspection criteria to be used by the local fire departments when performing manufacturing facility inspections. Develop inspection training material and provide training to the local fire departments.


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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2007-03-I-MA-6

Revise the license and registration forms (FP-2 and FP-5) to require listing each hazardous material type and quantity. Identify the requirement that a separate license and permit are required for each of the eight classes of flammable material when the facility possesses more than the listed threshold quantity specified in 527 CMR 14.03 (2).


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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General Court of the Commonwealth of Massachusetts (2 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: May 13, 2008

2007-03-I-MA-1

Revise the General Laws of Massachusetts addressing flammable materials licensing and registration: - As part of the annual registration renewal, require new and existing product manufacturing registrants to submit written certification to local governments stating that the facility complies with, at a minimum, all state and local fire codes and hazardous chemical regulations. -Require all companies holding a license and current registration to apply for an amended license and re-register the facility before increasing any flammable material quantity above the licensed amount or adding a different regulated chemical. Include a requirement in the approval process to solicit input from affected landowners, similar to the requirement for obtaining the original license and registration.


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

2007-03-I-MA-2

Amend the General Laws of Massachusetts to require the Office of the State Fire Marshal to audit local governments for compliance with the flammable materials licensing regulation and audit fire departments for compliance with permit issuance and inspection of manufacturing facilities licensed to store and handle flammable liquids and solids. The audits should be conducted at least once every five years.


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.
 

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

Final Report Released On: May 13, 2008

2007-03-I-MA-11

Revise the International Fire Code: Chapter 20: - Specifically include "printing inks" in the definition of "organic coating." - Define equipment specifically discussed in the standard, such as open and closed kettles. - Require heated tanks and vessels containing flammable and combustible liquids to have equipment to prevent overheating, such as: devices to stop the heating process if the temperature exceeds the safe operating limits; devices to stop the heating process if the flammable vapor control equipment malfunctions (e.g., building ventilation system or heated tank vent); and a heating medium that is unable to heat the tank above safe operating temperatures. Chapters 20, 27, and 34: -Define "open", "closed", and "sealed and vented" process tanks. -Define "non-listed" process tanks. -Prohibit heating flammable and combustible liquids above their flashpoints in tanks inside buildings unless the tanks are sealed and vented to the building exterior.


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.
 

National Fire Protection Association (NFPA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 13, 2008

2007-03-I-MA-9

Revise Flammable and Combustible Liquids Code (NFPA 30): - Prohibit heating flammable and combustible liquids above their flashpoints in tanks inside buildings, unless the tanks are sealed and vented to the building exterior. - Require heated tanks and vessels containing flammable and combustible liquids to have equipment to prevent overheating, such as: devices to stop the heating process if the temperature exceeds the safe operating limits; devices to stop the heating process if the flammable vapor control equipment malfunctions (e.g., building ventilation system or heated tank vent); and a heating medium that is unable to heat the tank above safe operating temperatures.


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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2007-03-I-MA-10

Revise The Standard for the Manufacture of Organic Coatings (NFPA 35): -Define equipment specifically discussed in the standard, such as kettles and thin-down tanks. -Define the terms "open, "closed", and "sealed" and "vented." -Prohibit heating flammable and combustible liquids above their flashpoints in tanks inside buildings unless the tanks are sealed and vented to the building exterior. -Require heated tanks and vessels containing flammable and combustible liquids to have equipment to prevent overheating, such as: Devices to stop the heating process if the temperature exceeds the safe operating limits; Devices to stop the heating process if the flammable vapor control equipment malfunctions (e.g., building ventilation system or heated tank vent); and a heating medium that is unable to heat the tank above safe operating temperatures.


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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Town of Danvers (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 13, 2008

2007-03-I-MA-7

Pending revision of the Massachusetts Fire Safety Code (527 CMR), revise the town bylaws addressing 527 CMR 14 requirements applicable to facility licensing and annual registration to: -Require new and current product manufacturing registrants to certify in writing that the facility complies with, at a minimum, all state and local fire codes and hazardous chemical regulations as part of the annual registration renewal. -Require companies holding a license and current registration for any of the eight classes of flammable materials specified in 527 CMR 14.03 (2) to re-register the facility before increasing any chemical quantity above the registered amount or adding a different regulated chemical at the facility. Include a requirement in the approval process to solicit input from affected landowners, similar to the requirement for obtaining the original license and registration. -Revise the license and registration forms to require listing each hazardous material type and quantity, and require a separate license and permit for each of the eight classes of flammable materials specified in 527 CMR 14.03 (2) . -Require the fire department to annually inspect licensed manufacturing facilities for compliance with the fire code.


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.
 

Carbide Industries Fire and Explosion (3 Recommendations)
Carbide Industries (1 Recommendations)
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: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

National Fire Protection Association (NFPA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: February 07, 2013

2013-2011-5-I-KY-I-KY-1

Establish a committee to evaluate and develop a standard that defines the safety requirements for electric arc furnaces operated with flammable materials and low oxygen atmospheres. At a minimum, establish requirements that electric arc furnaces containing flammables have: • Adequate safety instrumentation and controls to prevent explosions and overpressure events; • Mechanical integrity and inspection programs; • A documented siting analysis to ensure that control rooms and other occupied areas are adequately protected.  


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.
 

2013-2011-5-I-KY-I-KY-2

Modify the design and procedures for the electric arc furnace and related structures including the control room to comply with the NFPA standard developed per R1 of this case study.  


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.
 

Chevron Refinery Fire (21 Recommendations)
Board of Supervisors, Contra Costa County, CA (4 Recommendations)
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: 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.
 

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: 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.
 

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: 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.
 

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: 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.
 

California Air Quality Management Divisions (1 Recommendations)
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: 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.
 

California Environment Protection Agency (Cal/EPA) (1 Recommendations)
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: 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.
 

Chevron USA (2 Recommendations)
Open: 100% | Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-1 URGENT!

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: 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.
 

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: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Environmental Protection Agency (EPA) (2 Recommendations)
Open: 100% | Closed: 0%

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: 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.
 

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: 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.
 

Governor and Legislature of the State of California (7 Recommendations)
Open: 100% | Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-9

Revise the California Code of Regulations, Title 8, Section 5189, Process Safety Management of Acutely Hazardous Materials, to require improvements to mechanical integrity and process hazard analysis programs for all California oil refineries. These improvements shall include engaging 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. Require the analysis and incorporation of applicable industry best practices and inherently safety systems to the greatest extent feasible into this review.


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.
 

2012-03-I-CA-10

For all California oil refineries, identify and require the reporting of leading and lagging process safety indicators, such as the action item completion status of recommendations from damage mechanism hazard reviews, to state and local regulatory agencies that have chemical release prevention authority. These indicators shall be used to ensure that requirements described in 2012-03-I-CA-R9 are effective at improving mechanical integrity and process hazard analysis performance at all California oil refineries and preventing major chemical incidents.


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.
 

2012-03-I-CA-11

Establish a multi-agency process safety regulatory program for all California oil refineries to improve the public accountability, transparency, and performance of chemical accident prevention and mechanical integrity programs. This program shall:

  1. Establish a system to report to the regulator the recognized methodologies, findings, conclusions and corrective actions related to refinery mechanical integrity inspection and repair work arising from Process Hazard Analyses, California oil refinery turnarounds and maintenance-related shutdowns;
  2. Require reporting of information such as damage mechanism hazard reviews, notice of upcoming maintenance-related shutdowns, records related to proposed and completed mechanical integrity work lists, and the technical rationale for any delay in work proposed but not yet completed;
  3. Establish procedures for greater workforce and public participation including the public reporting of information; and
  4. Provide mechanisms for federal, state and local agency operational coordination, sharing of data (including safety indicator data), and joint accident prevention activities. The California Department of Industrial Relations will be designated as the lead state agency for establishing a repository of joint investigative and inspection data, coordinating the sharing of data and joint accident prevention activities.

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.
 

2012-03-I-CA-12

Require that Process Hazard Analyses required under California Code of Regulations, Title 8, Section 5189 Section (e) 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: 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.
 

2012-03-I-CA-13

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 process, process unit rebuilds, significant process repairs and in the development of corrective actions from incident investigation recommendations.


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.
 

2012-03-I-CA-14

Monitor and confirm the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R9 and 2012-03-I-CA-R10), so that all necessary mechanical integrity work at all California Chevron Refineries is identified and recommendations are completed in a timely way.


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.
 

2012-03-I-CA-21

Test


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.
 

Mayor and City Council, City of Richmond, CA (4 Recommendations)
Open: 100% | Closed: 0%

Date of Accident: August 06, 2012

2012-03-I-CA-3

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: 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.
 

2012-03-I-CA-4

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: 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.
 

2012-03-I-CA-5

Ensure 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: 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.
 

2012-03-I-CA-17

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: 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.
 

CITGO Refinery Hydrofluoric Acid Release and Fire (2 Recommendations)
CITGO, Inc. (2 Recommendations)
Open: 0% | Closed: 100%

Date of Accident: July 19, 2009

2009-14-I-TX-1 URGENT!

  • 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: 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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2009-14-I-TX-2 URGENT!

  • 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: 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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CTA Acoustics Dust Explosion and Fire (22 Recommendations)
American Chemistry Council (ACC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-19

Communicate the findings and recommendations of this report to your membership. Emphasize that dusts from phenolic resins can explode


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.
 

Borden Chemical, Inc. (3 Recommendations)
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: 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.
 

2003-09-I-KY-12

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


Status: 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.
 

2003-09-I-KY-13

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


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.
 

CertainTeed Corporation (2 Recommendations)
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: 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.
 

2003-09-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: 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.
 

CTA Acoustics, Inc. (8 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-1

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Minimize surfaces where combustible dust could accumulate in the design or modification of the plant.


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.
 

2003-09-I-KY-2

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Ensure phenolic resin-handling facilities are designed to prevent the spread of fires or explosions involving combustible dust. Options include measures such as the use of firewalls and blast-resistant construction.


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.
 

2003-09-I-KY-3

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Prevent the unsafe accumulation and dispersion of combustible dust by frequently cleaning process areas, including locations above production lines.


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.
 

2003-09-I-KY-4

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Minimize the dispersion of combustible dust by using appropriate dust-cleaning methods and tools.


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.
 

2003-09-I-KY-5

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Address the dangers of combustible dust and the prevention of dust explosions in the hazard communication training 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.
 

2003-09-I-KY-6

Conduct hazard assessments of ovens to ensure that fire detection and suppression systems are adequate, using good practice guidelines such as NFPA 86, Standard for Ovens and Furnaces.


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.
 

2003-09-I-KY-7

Develop procedures to maintain safety during nonroutine operating conditions, such as the loss of oven temperature control.


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.
 

2003-09-I-KY-8

Revise the incident investigation program to ensure that the underlying causes of incidents such as fires are identified and corrective actions implemented.


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.
 

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

Final Report Released On: February 15, 2005

2003-09-I-KY-16

Incorporate the findings and recommendations of this report in your training of employees who conduct inspections at facilities that may handle combustible dusts.


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.
 

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

Final Report Released On: February 15, 2005

2003-09-I-KY-20

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


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

Kentucky Office of Housing, Buildings, and Construction (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-17

Incorporate the findings and recommendations of this report in your continuing training of inspectors, plan reviewers, technical advisors, and fire marshal general inspectors who interface with facilities that may handle combustible dusts.


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.
 

2003-09-I-KY-18

Identify sites that handle combustible dusts when facilities apply for new or modified construction permits, and use this information to help prioritize establishments that will be inspected by the fire marshal.


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

Kentucky Office of Occupational Safety and Health (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-14

Develop and distribute an educational bulletin on the prevention of combustible dust explosions.


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.
 

2003-09-I-KY-15

Enhance the training program for compliance officers regarding the recognition and prevention of combustible dust explosion 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.
 

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-21

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


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

Society of the Plastics Industry- Phenolic Division (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 15, 2005

2003-09-I-KY-22

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


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

D.D. Williamson & Co. Catastrophic Vessel Failure (10 Recommendations)
Commonwealth of Kentucky (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 12, 2004

2003-11-I-KY-7

Communicate to the owners of pressure vessels, mechanical contractors, engineering consulting companies, and insurance companies doing business in Kentucky that used pressure vessels are not exempt from registration and initial inspection before being placed in service in Kentucky.


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.
 

D.D. Williamson and Co., Inc. (6 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 12, 2004

2003-11-I-KY-1

Institute procedures to ensure that pressure vessels are designed, fabricated, and operated according to applicable codes and standards.


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.
 

2003-11-I-KY-2

Audit all vessels at all D. D. Williamson facilities and ensure that they are: Equipped with adequate overpressure protection, as warranted. Equipped with alarms or interlocks, as warranted.


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.
 

2003-11-I-KY-3

Implement a program to review existing equipment when it is used for new purposes and when safety devices are removed or altered.


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.
 

2003-11-I-KY-4

Implement a hazard evaluation procedure to determine the potential for catastrophic incidents and necessary safeguards.


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.
 

2003-11-I-KY-5

Audit manual control of process conditions, such as temperature and pressure, and determine if safeguards are needed.


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.
 

2003-11-I-KY-6

Upgrade written operating procedures and train operators on the revised procedures.


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

Mechanical Contractors Association of Kentucky (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 12, 2004

2003-11-I-KY-8

Communicate to your members that used pressure vessels are not exempt from registration and initial inspection before being placed in service in Kentucky.


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

National Board of Boiler and Pressure Vessel Inspectors (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 12, 2004

2003-11-I-KY-10

Communicate the findings of this report to your membership.


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

Risk and Insurance Management Society (RIMS) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 12, 2004

2003-11-I-KY-9

Communicate the findings of this report to your membership.


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

Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire (12 Recommendations)
Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) (1 Recommendations)
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: 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.
 

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Department of Treasury - Office of Procurement Executive (OPE) (3 Recommendations)
Open: 33% | Closed: 67%

Final Report Released On: January 17, 2013

2013-2011-06-I-HI-I-HI-2

Establish formal policy requiring that: • Solicitations for contracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, incorporate rigorous safety-related contractor selection provisions such as those provided in the DoD’s Contractor’s Safety Manual for Ammunition and Explosives, Section C1.5, “Pre-Award Safety Survey”; and • Contracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, include a provision requiring that any subcontract (regardless of tier) for the storage, handling, and disposal of explosives (including fireworks) be selected based on rigorous safety-related contractor selection provisions such as those provided in the DOD's Contractor Safety Manual for Ammunition and Explosives, Section C1.5, "Pre-Award Safety Survey."


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

2013-2011-06-I-HI-I-HI-3

Establish a formal policy requiring that contracts and subcontracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, incorporate rigorous safety-related contractor oversight provisions such as those provided in the DoD’s Contractor’s Safety Manual for Ammunition and Explosives, Section C1.6, “Pre-Operational Safety Survey” and C1.7, “Post-Award Contractor Responsibilities” to provide effective oversight of subcontractors handling and disposing of explosives and hazardous materials.


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

PDF Document Download

2013-2011-06-I-HI-I-HI-4

When the NFPA guidance developed by the National Fire Protection Association for the safe disposal of fireworks as recommended under recommendation 2011-06-I-HI-R7 is completed, incorporate this document by reference into the formal policies established by 2011-06-I-HI-R2 and 2011-06-I-HI-R3.


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 Download

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

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: 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.
 

2013-2011-06-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: 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.
 

2013-2011-06-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: 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.
 

Federal Aquisition Regulatory (FAR) Council (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 17, 2013

2013-2011-06-I-HI-I-HI-1

Establish an additional contractor responsibility determination requirement under Subpart 9.104-1 of the Federal Acquisition Regulation (FAR) addressing contractor safety performance. The analysis under this requirement should focus on incident prevention, and environmental and system safety. At a minimum, the language should specifically require the review of a prospective contractor’s: • Environmental and safety programs; • Safety record and incident history; • Ability to use safe methods for any work involving hazardous materials (including explosives); and • Suitable training and qualifications for the personnel involved in the work including prior relevant safety experience.


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.
 

National Fire Protection Association (NFPA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 17, 2013

2013-2011-06-I-HI-I-HI-7

Develop a new standard, or incorporate within an existing standard, best practices for the safe disposal of waste fireworks that are consistent with environmental requirements. At a minimum this guidance or standard should: • Discourage the disassembly of waste fireworks as a step in the disposal process; • Minimize the accumulation of waste explosive materials, and encourage practices that reduce, recycle, reuse,or repurpose fireworks; and • Incorporate input from ATF, EPA, and other agencies, experts, and available resources on fireworks disposal methodologies.


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.
 

2013-2011-06-I-HI-I-HI-8

Once fireworks disposal best practices under recommendation 2011-06-I-HI-R7 is completed, develop and implement an outreach plan to promptly communicate the new NFPA practices to relevant government agencies and private entities that dispose of waste fireworks


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.
 

Treasury Executive Office for Asset Forfeiture (TEOF) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 17, 2013

2013-2011-06-I-HI-I-HI-5

Require additional provisions within the TEOAF seized property management contract, such as a contract line item number (CLIN), that provide for the prime contractor to use expert(s) to assist the prime contractor’s personnel in the selection and oversight of subcontractors who handle, store, or dispose of explosive hazardous materials, including fireworks, pursuant to the main contract.


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

Final Report Released On: January 17, 2013

2013-2011-06-I-HI-I-HI-6

Use experts to: • Assist VSE procurement in selecting vendors to properly handle, store, and dispose of explosive hazardous materials, including fireworks, pursuant to prime contract requirements; and, • Assist VSE personnel in overseeing the work to ensure it is being conducted safely. Status:


Status: Open - Unacceptable Response
Open - Unacceptable Response (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

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DPC Enterprises Festus Chlorine Release (24 Recommendations)
Agency for Toxic Substances and Disease Registry (ATSDR) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2003

2002-04-I-MO-17

Work with State and local agencies to address concerns about the long-term health effects of the chlorine release in Festus, Missouri, and communicate your findings to the community.


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).
 

Branham Corporation (1 Recommendations)
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: 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.
 

Chlorine Institute (4 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2003

2002-04-I-MO-18

Work with the Association of Hose and Accessories Distributors (NAHAD) and chlorine hose manufacturers, such as Crane-Resistoflex, to develop and implement a recommended practice requiring continuous positive identification (e.g., coding, stenciling, stamping) throughout the supply chain, from manufacturing to the end user 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.
 

2002-04-I-MO-19

Develop recommended practices to address moisture in dry chlorine piping systems. Include information on suggested material specifications, prevention and corrective measures, and adverse consequences (particularly for emergency shutdown [ESD] systems).


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.
 

2002-04-I-MO-20

Develop recommended practices for testing, inspection, and preventative maintenance of ESD systems for bulk transfer of chlorine.


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.
 

2002-04-I-MO-21

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


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

DPC Enterprises, Festus Site (7 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2003

2002-04-I-MO-1

Revise the mechanical integrity program: Develop and implement a quality assurance management system, such as positive materials identification, to confirm that chlorine transfer hoses (CTH) are of the appropriate materials of construction.


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.
 

2002-04-I-MO-2

Revise the mechanical integrity program: Implement procedures and practices to ensure the emergency shutdown (ESD) system operates properly. Include procedures to verify that the ESD valves will close to shut down the flow of chlorine.


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.
 

2002-04-I-MO-3

Revise the mechanical integrity program: Revise the preventive maintenance and inspection program for the chlorine transfer system to address moisture-related corrosion. Evaluate and correct any problems associated with corrosion that could potentially lead to chlorine transfer and safety system failure.


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.
 

2004-04-I-MO-4

Revise the mechanical integrity program: Require periodic inspection of the above critical safety systems by the operations or facility manager.


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.
 

2002-04-I-MO-5

Revise the Emergency Response Plan: Develop procedures to clearly designate the roles and responsibilities of facility emergency response personnel, including post-incident remediation.


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.
 

2002-04-I-MO-6

Revise the Emergency Response Plan: Develop and implement a timetable for drills to test emergency response personnel on various levels of response, including a large uncontrolled release that could affect the public. Coordinate these drills with local emergency response authorities. Provide a copy of the revised Emergency Response Plan to the local emergency planning committee, and review the plan with the committee and the local fire department. Work with these authorities to implement an improved community emergency notification 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.
 

2002-04-I-MO-7

Revise the Emergency Response Plan: Improve accessibility of equipment required for emergency response, considering likely response scenarios.


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.
 

DX Group (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2003

2002-04-I-MO-8

In light of the findings of this report, conduct periodic audits of the safety management systems involved in this incident, such as mechanical integrity, emergency response, and material quality assurance. Ensure that the audit recommendations are tracked and implemented. Share findings and recommendations with the work force at your repackaging facilities.


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.
 

2002-04-I-MO-9

To improve supervision of day-to-day operations, revise your corporate safety management training program on chlorine repackaging operations. Emphasize safety critical systems, including verification of safety system performance.


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.
 

2002-04-I-MO-10

Communicate the findings and recommendations of this report to all DPC facilities.


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.
 

Jefferson County Emergency Management Agency (EMA) (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2003

2002-04-I-MO-12

Work with DPC to implement a community notification system that will immediately alert neighboring residents and businesses of a chemical release.


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.
 

2002-04-I-MO-13

Work with DPC, local emergency planning and response authorities in Jefferson and adjacent counties, the City of Festus, and Crystal City to improve overall response and mitigation time.


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.
 

2002-04-I-MO-14

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


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

Missouri Department of Natural Resources (DNR) and other Appropriate Agencies (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2003

2002-04-I-MO-16

In collaboration with appropriate agencies, hold a community meeting in Festus, Missouri, to hear concerns raised by local citizens affected by the DPC incident and to respond to issues raised by the community.


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).
 

Missouri State Emergency Response Commission (MERC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2003

2009-04-I-MO-15

Communicate the findings and recommendations of this report to local emergency planning committees (LEPC), emergency management agencies (EMA), and local fire departments.


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

National Association of Chemical Distributors (NACD) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2003

2009-04-I-MO-24

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


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

National Association of Hose and Accessories Distributors (NAHAD) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2003

2002-04-I-MO-22

Work with The Chlorine Institute and chlorine hose manufacturers, such as Crane-Resistoflex, to develop and implement a recommended practice requiring continuous positive identification (e.g.,coding, stenciling, stamping) throughout the supply chain, from manufacturing to the end user 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.
 

2009-04-I-MO-23

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


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

DPC Enterprises Glendale Chlorine Release (14 Recommendations)
Chlorine Institute (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 28, 2007

2004-2-I-AZ-14

Clarify the chemistry involved in over-chlorination incidents so that "Chlorine Scrubbing Systems, Pamphlet 89," and other pertinent publications: -Ensure that the recommended practices and safeguards prevent, mitigate, and control hazardous releases due to bleach decomposition. -Provide sufficient detail on the safety and environmental consequences of over-chlorination to enable companies to provide emergency responders with information on the potential characteristics of over-chlorination events, and on the best means of mitigating the bleach decomposition reaction following a release.


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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DPC Enterprises, L.P. (6 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 28, 2007

2004-2-I-AZ-1

Establish and implement DPC corporate engineering standards that include adequate layers of protection on chlorine scrubbers at DPC facilities, including: -additional interlocks and shutdowns, such as automatically stopping chlorine flow to the scrubber upon oxidation-reduction potential alarm; -mitigation measures, such as systems to automatically add caustic to over-chlorinated scrubbers, or back-up scrubbing capability to treat emissions from over-chlorinated scrubbers; -increases in the final caustic concentration in the scrubbers to eight percent or higher to provide a substantial safety margin against over-chlorination; and -use of the site's continuous bleach manufacturing system to convert scrubber solution to saleable bleach.


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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2004-2-I-AZ-2

Revise scrubber SOPs to include: -clearly described operating limits and warnings about the consequences of exceeding those limits, and -the safety and environmental hazards associated with scrubber over-chlorination.


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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2004-2-I-AZ-3

Train employees on the revised SOPs and include a test to verify understanding. Periodically review operator understanding of and conformance to the scrubber SOPs.


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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2004-2-I-AZ-4

Include scrubber operation in facility PHAs. Ensure that they: -include lessons learned from this incident and other DPC scrubber incidents, as well as industry experience with over-chlorination, and -consider off-site consequences when evaluating the adequacy of existing safeguards.


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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2004-2-I-AZ-5

Use a qualified, independent auditor to evaluate DPC's PSM and RMP programs against best practices. Implement audit recommendations in a timely manner at all DPC chlorine repackaging sites.


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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2004-2-I-AZ-6

Implement a recognized safety management system, including third party verification and certification, to achieve documented continuous improvement in safety performance at Glendale and the other DPC chlorine repackaging sites.


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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Glendale, AZ Fire Department (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 28, 2007

2004-2-I-AZ-7

Work with the Glendale Police Department to integrate them into the incident command structure during hazardous material incidents, and address communications issues, such as radio interoperability, to ensure the timely transmission of critical safety information to responding officers.


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.
 

2004-2-I-AZ-8

Conduct hazardous materials exercises with the Glendale Police Department to identify and resolve police/fire integration issues. Coordinate exercise planning with the Arizona Division of Emergency Management Exercise Officer and with the Maricopa County LEPC. Schedule periodic hazardous materials incident drills to ensure safe and effective responses to future hazardous materials incidents.


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.
 

Glendale, AZ Police Department (4 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 28, 2007

2004-2-I-AZ-9

Work with the Glendale Fire Department to integrate the Glendale Police Department into the command structure during hazardous material incidents, and address communications issues, such as radio interoperability, to ensure the timely transmission of critical safety information to responding officers.


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.
 

2004-2-I-AZ-10

Ensure that police officers responding to hazardous material incidents are briefed on specific incident conditions, and are equipped with and trained on the proper use, capabilities, and limitations of appropriate protective equipment.


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.
 

2004-2-I-AZ-11

Ensure that police officers receive hazardous materials - operations level training, and annual hazardous materials and air purifying respirator (APR) refresher 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.
 

2004-2-I-AZ-12

Conduct exercises with the Glendale Fire Department to identify and resolve police/fire integration issues. Coordinate exercise planning with the Arizona Division of Emergency Management Exercise Officer and with the Maricopa County LEPC. Schedule periodic hazardous materials incident drills to ensure safe and effective responses to future hazardous materials incidents.


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.
 

Maricopa County Department of Air Quality (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 28, 2007

2004-2-I-AZ-13

Revise DPC's permitted operating conditions to specify a minimum scrubber caustic concentration of 8 percent or more, as determined by laboratory measurement, with measurements taken daily and upon completion of each scrubber batch.


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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DuPont Corporation Toxic Chemical Releases (14 Recommendations)
American Chemistry Council Phosgene Panel (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 20, 2011

2010-06-I-WV-11

Revise the Phosgene Safe Practice Guidelines Manual  to

  • Advise against the use of hoses for phosgene transfer that are constructed of permeable cores and materials subject to chlorides corrosion.
  • Include guidance for the immediate reporting and prompt investigation of all potential (near-miss) phosgene releases.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Compressed Gas Association (CGA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 20, 2011

2010-06-I-WV-9

Revise CGA P-1, Safe Handling of Compressed Gases in Containers, to include specific requirements for storing and handling highly toxic compressed gas, including enclosure ventilation and alarm requirements at least as protective as Section 7.9, Toxic and Highly Toxic Gases and NFPA 55, Compressed Gases and Cryogenics Fluids Code.


Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2010-06-I-WV-10

Revise CGA P-1, Safe Handling of Compressed Gases in Containers, to incorporate by reference CGA E-9, Standard for Flexible, PTFE-lined Pigtails for Compressed Gas Service.


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.
 

DuPont Belle Plant (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 20, 2011

2010-06-I-WV-3

Improve the existing maintenance management by

  • Supplementing the computerized system with sufficient redundancy to ensure tracking and timely scheduling of preventive maintenance for all PSM-critical equipment.
  • Conducting Management-of-Change (MOC) reviews for all changes to preventive maintenance orders for all PSM-critical equipment in the computerized maintenance management 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.
 

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2010-06-I-WV-4

Revise the facility emergency response protocol to require that a responsible and accountable DuPont employee always be available (all shifts, all days) to provide timely and accurate information to the Kanawha County Emergency Ambulance Authority (KCEAA) and Metro 9-1-1 dispatchers.


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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2010-06-I-WV-5

Revise the near-miss reporting and investigation policy and implement a program that includes the following at a minimum:

  • Ensures employee participation in reporting, investigating, analyzing, and recommending corrective actions as appropriate for all near-misses and disruptions of normal operations.
  • Develops and encourages use of an anonymous electronic and/or hard copy near-miss reporting process for all DuPont Belle site employees.
  • Establishes roles and responsibilities for ownership, management, execution, and resolution of recommendations from incident or near-miss investigations at the DuPont Belle facility.
  • Ensures that the near-miss investigation program requires prompt investigations, as appropriate, and that results are promptly circulated to well-suited recipients throughout the DuPont Corp.
  • Ensures that this program is operational at all times (e.g. nights, weekends, and holiday shifts).

 


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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E. I. duPont de Nemours and Company (6 Recommendations)
Open: 33% | Closed: 67%

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: 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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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: 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.
 

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: 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.
 

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: 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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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: 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

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

Final Report Released On: September 20, 2011

2010-06-I-WV-1

Revise OSHA 29 CFR 1910.101, General Industry Standard for Compressed Gases, to require facilities that handle toxic and highly toxic materials in compressed gas cylinders to incorporate provisions that are at least as effective as the 2010 edition of Section 7.9, Toxic and Highly Toxic Gases, in National Fire Protection Association (NFPA) 55, Compressed Gases and Cryogenic Fluids Code, including enclosures, ventilation and treatment systems, interlocked fail-safe shutdown valves, gas detection and alarm systems, piping system components, and similarly relevant layers of protection.


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.
 

2010-06-I-WV-2

Take sustained measures to minimize the exposure of hazards to workers handling highly toxic gases from cylinders and associated regulators, gages, hoses, and appliances. Ensure that OSHA managers, compliance officers, equivalent state OSHA plan personnel, and regulated parties conform, under the Process Safety Management Standard (29 CFR 1910.119) Recognized and Generally Accepted Good Engineering Practices (RAGAGEP) provisions, to industry practices at least as effective as the following:

  1. NFPA 55 - Compressed Gases and Cryogenic Fluids Code (2010)
  2. CGA P-1 Safe Handling of Compressed Gases in Containers (2008)
  3. CGA E-9 Standard for Flexible, PTFE-lined Pigtails for Compressed Gas Service (2010)
  4. ASME B31.3 Process Piping (2008)


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.
 

E. I. DuPont De Nemours Co. Fatal Hotwork Explosion (4 Recommendations)
E. I. duPont de Nemours and Company (4 Recommendations)
Open: 0% | Closed: 100%

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: 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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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: 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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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: 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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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: 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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Emergency Shutdown Systems for Chlorine Transfer (1 Recommendations)
U.S. Department of Transportation (DOT) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 14, 2007

2005-06-I-LA-1

Expand the scope of DOT regulatory coverage to include chlorine railcar unloading operations. Ensure the regulations specifically require remotely operated emergency isolation devices that will quickly isolate a leak in any of the flexible hoses (or piping components) used to unload a chlorine railcar. The shutdown system must be capable of stopping a chlorine release from both the railcar and the facility chlorine receiving equipment. Require the emergency isolation system be periodically maintained and operationally tested to ensure it will function in the event of an unloading system chlorine leak.


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.
 

EQ Hazardous Waste Plant Explosions and Fire (6 Recommendations)
Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%

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: 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.
 

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

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: 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.
 

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: 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.
 

Mobile Aerospace Engineering, Inc. (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 16, 2008

2007-1-I-NC-1 URGENT!

Revise and or develop company procedures and policies to require and ensure that unspent chemical oxygen generators that have exceeded their service life be actuated so that the chemical core is expended before shipping by any transport mode.


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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2007-1-I-NC-2 URGENT!

Review and revise as necessary company procedures and policies for transporting hazardous waste to ensure that hazardous waste is correctly characterized on the shipping manifest.


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.
 

2007-1-I-NC-3 URGENT!

Communicate to all of your waste brokers and treatment, storage, and disposal facilities to which unspent oxygen generators were shipped: - the hazards associated with unspent chemical oxygen generators and - that the incorrect shipping name and UN code was, or might have been used, for unspent chemical oxygen generators shipped from your facility.


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.
 

First Chemical Corp. Reactive Chemical Explosion (15 Recommendations)
American Chemistry Council (ACC) (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 15, 2003

2003-01-I-MS-10

Amend the Technical Specifications guidelines in the Responsible Care Management System to explicitly require facilities to identify findings and lessons learned from process hazard analyses and incident investigations in one unit and apply them to other equipment that processes similar material.


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

2003-01-I-MS-11

Ensure that ACC members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility process safety programs.


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.
 

2003-01-I-MS-12

Communicate the findings of this report to your membership.


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

DuPont-First Chemical Pascagoula Facility (6 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 15, 2003

2003-01-I-MS-2

Establish a program for conducting process hazard analyses of processes involving reactive materials.


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

2003-01-I-MS-3

Evaluate the need for layers of protection and install appropriate safeguards, such as alarms and interlocks, to reduce the likelihood of a runaway reaction and catastrophic release of material.


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

2003-01-I-MS-4

Review and revise as necessary procedures for units that process highly energetic material, effectively communicate the updated procedures, and train workers appropriately. Revised procedures should include: Specific steps for isolation of energy sources. Warnings and cautions concerning process chemicals and consequences of deviations from operating limits. Critical operating limits and guidance when the limits are exceeded. Instruction on how to perform a shutdown for all foreseeable causes, to ensure proper isolation, and to continue monitoring critical parameters (such as temperature) while the column is shut down; in addition, review conditions under which material must be deinventoried (such as during extended shutdowns).


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.
 

2003-01-I-MS-5

Conduct a facility-wide survey of pressure vessels to ensure that all equipment that processes reactive materials has appropriate overpressure protection.


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.
 

2003-01-I-MS-6

Identify equipment critical to safe operation of processes containing reactive materials. Upgrade the maintenance program and establish inspection schedules to ensure the integrity of such equipment.


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.
 

2003-01-I-MS-7

Survey and take appropriate action to ensure that buildings occupied by plant personnel are of adequate construction and are located so as to protect people inside in the event of an explosion in equipment processing reactive materials.


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

E. I. duPont de Nemours and Company (1 Recommendations)
Open: 0% | Closed: 100%

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: 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.
 

Jackson County Board of Supervisors, Jackson County Emergency Management Agency, Jackson County Local Emergency Planning Committee (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 15, 2003

2003-01-I-MS-8

Update the community notification system to: Immediately alert residents in the Moss Point community when an incident occurs that could affect their health and safety. Determine when a community response should be initiated. Communicate the nature of the incident and the appropriate response by residents. Alert residents when the incident is over (i.e., the all-clear has sounded).


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.
 

2003-01-I-MS-9

Conduct an awareness campaign to educate residents on the proper steps for a shelter-in-place and orderly evacuation.


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.
 

Synthetic Organic Chemical Manufacturers Association (SOCMA) (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 15, 2003

2003-01-I-MS-13

Amend the Technical Specifications in the Responsible Care Management System to explicitly require facilities to identify findings and lessons learned from process hazard analyses and incident investigations in one unit and apply them to other equipment that processes similar material.


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).
 

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2003-01-I-MS-14

Ensure that SOCMA members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility process safety programs.


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).
 

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2003-01-I-MS-15

Communicate the findings of this report to your membership.


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

Formosa Plastics Propylene Explosion (6 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
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: 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.
 

Formosa Plastics USA (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 20, 2006

2006-1-I-TX-1

Revise policies and procedures for process hazard analysis and pre-startup safety review to more fully evaluate vehicle impact hazards, passive fire protection, and catastrophic releases.


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

2006-1-I-TX-2

Require flame resistant clothing for workers in units at the Point Comfort complex where there is a risk of flash fires.


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.
 

Kellogg, Brown, and Root (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 20, 2006

2006-1-I-TX-3

Communicate the findings and recommendations of this report to all companies that contracted with either M. W. Kellogg or Kellogg, Brown, and Root (KBR) for plant designs similar to the Formosa Olefins II unit.


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

2006-1-I-TX-4

Communicate the findings and recommendations of this report to your petrochemical process plant design engineers. Emphasize the importance of using current consensus safety standards when designing and constructing petrochemical process plants, including the earlier designs reused for new facilities.


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

2006-1-I-TX-5

Revise KBR petrochemical process plant design procedures to ensure they address the use of current safety standards for new designs and earlier designs reused for new facilities.


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.
 

Formosa Plastics Vinyl Chloride Explosion (8 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
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: 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.
 

Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%

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: 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.
 

Formosa Plastics USA (4 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2007

2004-10-I-IL-1

Review the design and operation of FPC USA manufacturing facilities and implement policies and procedures to ensure that: -Site-wide policies are implemented to address necessary steps and approval levels required to bypass safety interlocks and other critical safety systems. -Chemical processes are designed to minimize the likelihood and consequences of human error that could result in a catastrophic release. -Safety impacts of staffing changes are evaluated. -Risks identified during hazard analyses and near-miss and incident investigations are characterized, prioritized, and that corrective actions are taken promptly. -High-risk hazards are evaluated using layers of protection analysis (LOPA) techniques and that appropriate safeguards are installed to reduce the likelihood of a catastrophic release of material. -All credible consequences are considered in near-miss investigations. -Emergency procedures clearly characterize emergency scenarios, address responsibilities and duties of responders, describe evacuation procedures, and ensure adequate training. Ensure that periodic drills are conducted. -The siting of offices for administrative and support personnel is evaluated to ensure the safety of personnel should an explosi