Recommendations

Open: 33% | Closed: 67%

Final Report Released On: December 29, 2022

2018-02-I-WI-13

 

The American Fuel & Petrochemical Manufacturers (AFPM) implemented this recommendation on behalf of API.

 

Using API’s processes to determine the appropriate safety product, develop a publicly available technical publication for the safe operation of fluid catalytic cracking (FCC) units. The document should be applicable to both new and existing units. Include the following topics at a minimum:

a) Description of typical FCC unit hazards, including air leaks into hydrocarbon systems or hydrocarbon leaks into air systems that could form a flammable mixture during transient operation (startup, shutdown, standby, and the actions required to transition between these modes). If needed, include differences between possible reactor/regenerator configurations;

b) Recommended practices for safeguards to control FCC unit hazards;

c) Recommended monitoring for process safety during FCC unit transient operations;

d) Recommended emergency operating procedures for FCC-specific scenarios;

e) PHA guidance for key FCC-specific scenarios, including transient operation;

f) Recommended FCC-specific field and board operator process safety training topics and methods;

g) Guidelines for process safety assessments of FCC units; and

h) Incorporate lessons learned from this CSB investigation and the CSB’s ExxonMobil Torrance Refinery Electrostatic Precipitator Explosion investigation throughout the document and include references in the document’s bibliography.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

2018-02-I-WI-14

Modify the appropriate existing recommended practice (for example, API RP 553, Refinery Valves and Accessories for Control and Safety Instrumented Systems) to include information about the purpose, design, maintenance, and testing of additional FCC catalyst slide valve components, including the slide valve body. If an API product other than API RP 553 is modified, API RP 553 should guide the reader to that reference.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2018-02-I-WI-15

Incorporate lessons learned from the FCC Unit Explosion and Asphalt Fire at Husky Superior Refinery incident into the appropriate API products (for example, API RP 2023, Guide for Safe Storage and Handling of Heated Petroleum-Derived Asphalt Products and Crude Oil Residua, or API RP 2021, Management of Atmospheric Storage Tank Fires). At a minimum, topics shall include the flammability of heated material such as asphalt and the ignition risk of pyrophoric material inside asphalt storage tanks. Include a reference to this CSB investigation in the document’s bibliography.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

Open: 0% | Closed: 100%

Final Report Released On: December 29, 2022

2018-02-I-WI-8

For all Cenovus operated refineries with FCC units, develop and implement an FCC unit-specific PHA guidance document as part of each FCC unit’s ongoing PHA update/revalidation cycle, including the Cenovus Superior Refinery. The PHA guidance document should be updated with new industry knowledge as it becomes available (for example, from AFPM, CCPS, and API). The PHA guidance document should include a requirement to review available licensor and industry guidance for FCC unit PHA scenarios and recommended safeguards and at a minimum, include information related to transient operation safeguards listed in CSB Recommendation 2018-02-I-WI-R1.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-02-I-WI-9

Develop and implement a technology-specific knowledge-sharing network program across all Cenovus operated refineries, which at a minimum includes an FCC technology peer network. The peer network(s) must include engineers, operations management, and operations staff from each site that uses the technology, including the Cenovus Superior Refinery. The network(s) must meet at least annually to discuss process safety topics in the technology including:

a) Relevant incidents and near-misses at the refineries and/or in industry;
b) Refinery learnings in implementing process safety improvements;
c) Relevant industry tools, bulletins, and knowledge-sharing documents, such as those published by AFPM, CCPS, and API; and
d) Relevant updates to industry publications and standards.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-02-I-WI-10

Include and maintain the FCC technology licensors’ operating manuals in the process safety information packages for all FCC units, including the FCC unit at Cenovus Superior Refinery.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

Open: 14% | Closed: 86%

Final Report Released On: December 29, 2022

2018-02-I-WI-1

Establish safeguards to prevent explosions in the FCC unit during transient operation (including startup, shutdown, standby, and emergency procedures). Incorporate these safeguards into written operating procedures. At a minimum establish the following specific safeguards:

a) Implementation of the reactor steam barrier, or a similar inert gas flow, to maintain an inert barrier at an elevated pressure between the main column (containing hydrocarbon) and the regenerator (containing air);

b) Purging the main column with a non-condensable gas as needed to prevent a dangerous accumulation of oxygen in the main column overhead receiver;

c) Monitoring to ensure that there is a sufficient non-condensable gas purge of the main column to prevent a dangerous accumulation of oxygen in the main column overhead receiver (either through direct measurement of the oxygen concentration and/or through engineering calculation);

d) Monitoring of critical operating parameters for flows, pressures, pressure differences, and catalyst levels;

e) Documentation of consequences of deviating from the transient operation safe operating limits and of predetermined corrective actions; and

f) Inclusion of the above items in the appropriate FCC operator training curricula.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-02-I-WI-2

Based on licensor input and good industry practices, determine the appropriate point(s) in the FCC unit’s shutdown procedures to shut down all wet gas compressor(s). Incorporate this information into all FCC unit shutdown procedures and operator training material.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-02-I-WI-3

Develop and implement a slide valve mechanical integrity program that addresses erosion and ensures proper functioning of the slide valves during a shutdown. The program must include, at a minimum:

a) A slide valve mechanical integrity standard that defines monitoring and inspection requirements, with acceptance criteria, required for the safe operation of the FCC unit during transient operation (such as a startup, shutdown, standby, and emergency).

b) Monitoring that includes process data analysis and mechanical preventive activities to evaluate the mechanical condition of the slide valves during the operation of the FCC unit between turnarounds;

c) Quarterly presentations of process data and mechanical preventive maintenance data to refinery operations management and maintenance management to drive key decisions such as shortening the turnaround cycle and/or planning a maintenance outage;

d) During turnarounds and other potential slide valve maintenance outages, evaluate the adequacy of the slide valve mechanical integrity program for the safe operation of the FCC unit during transient operation. If the inspection demonstrates unsuccessful performance, make appropriate corrections.

During the next major FCC unit turnaround at Cenovus Superior Refinery, demonstrate that the slide valve mechanical program is adequate for the safe operation of the FCC unit during transient operation. If the inspection demonstrates unsuccessful performance, make appropriate corrections to the slide valve mechanical integrity program.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2018-02-I-WI-4

Develop emergency procedures for responding to a loss of catalyst slide valve function (for example, when it leaks excessively or fails to close on demand).

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-02-I-WI-5

Develop guidance for analyzing operating procedures to improve transient operation hazard evaluations during PHAs. Refer to section Chapter 9.1 in the CCPS publication Guidelines for Hazard Evaluation Procedures, 3rd Ed. or an appropriate equivalent resource to develop the guidance. Incorporate the guidance into the appropriate Cenovus Superior Refinery PHA procedural documents and policies.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-02-I-WI-6

Develop and implement an FCC unit operator, supervisor, and manager training program based on the licensor’s guidance and on available industry guidance. Elements of the training program shall include:

a) A set of written training materials (such as a manual) consistent with the licensor’s technology information, encompassing:

i) FCC equipment;
ii) Normal operations;
iii) Transient operations (including startup, shutdown, standby, and emergency); and
iv) Case studies of industry FCC industry incidents, including ExxonMobil Torrance (2015) and this incident; and

b) Training delivery methods including:

i) Group and individual training; and
ii) Simulator training for board operators.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-02-I-WI-7

Incorporate lessons learned from this incident into the appropriate training materials for the Cenovus Superior Refinery Emergency Response Team. At a minimum, topics shall include the proper response to liquids potentially stored above their flash point, such as asphalt, and the ignition risk of pyrophoric material inside asphalt storage tanks.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

Open: 100% | Closed: 0%

Final Report Released On: December 29, 2022

2018-02-I-WI-12

Develop a program that prioritizes and emphasizes inspections of FCC units in refineries that operate HF alkylation units (for example, under EPA’s National Compliance Initiative called Reducing Risks of Accidental Releases at Industrial and Chemical Facilities). As part of this program, verify FCC unit safeguards that prevent explosions during transient operation (including startup, shutdown, standby, and emergency procedures). At a minimum the program will verify the following specific safeguards:

a) Implementation of the reactor steam barrier, or a similar inert gas flow, to maintain an inert barrier at an elevated pressure between the main column (containing hydrocarbon) and the regenerator (containing air);

b) Purging the main column with a non-condensable gas as needed to prevent a dangerous accumulation of oxygen in the main column overhead receiver;

c) Monitoring to ensure that there is a sufficient non-condensable gas purge of the main column to prevent a dangerous accumulation of oxygen in the main column overhead receiver (either through direct measurement of the oxygen concentration and/or through engineering calculation);

d) Monitoring of critical operating parameters for flows, pressures, pressure differences, and catalyst levels;

e) Documentation of consequences of deviating from the transient operation safe operating parameters and of predetermined corrective actions; and

f) Inclusion of the above items in the appropriate FCC operator training curricula.

This recommendation is in addition to the recommendations to EPA relating to hydrofluoric acid outlined in the CSB’s report on the 2019 fire and explosions at the Philadelphia Energy Solutions refinery. In that report, the CSB recommended (1) that the EPA prioritize inspections of refinery HF alkylation units to ensure units are complying with API good practice guidance, (2) to require petroleum refineries with HF alkylation units to evaluate inherently safer technology, and (3) to initiate prioritization and, as applicable, risk evaluation of HF under the Toxic Substances Control Act.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

Open: 0% | Closed: 100%

Final Report Released On: December 29, 2022

2018-02-I-WI-16

Participate in the API committee that develops a technical publication for the safe operation of FCC units.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

Open: 100% | Closed: 0%

Final Report Released On: December 29, 2022

2018-02-I-WI-11

Develop guidance documents for performing process hazard analysis on operating procedures to address transient operation hazards in facilities with Process Safety Management (PSM) covered processes.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Recommendation Status Change Summary

Open: 8% | Closed: 92%

Final Report Released On: December 21, 2022

2018-03-I-TX-1

Develop and implement an emergency pressure-relief system design standard to ensure that each of these safety systems will discharge to a safe location. Include a requirement to periodically evaluate the site’s emergency pressure-relief systems and make appropriate modifications to ensure that each of these systems discharge to a safe location such that material that could discharge from these safety systems will not harm people.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2018-03-I-TX-2

Implement a site-wide system to evacuate nonessential personnel during upset conditions and exclude nonessential workers from being near equipment during transient operating modes, such as startup.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-03-I-TX-3

Develop and implement a system requiring a periodic evaluation of the adequacy and effectiveness of any safeguard used to mitigate or otherwise lower the risk of process safety hazards. This safeguard protection analysis should be based on the requirements of Cal/OSHA’s Process Safety Management for Petroleum Refineries regulations or an appropriate equivalent methodology.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-03-I-TX-4

Develop and implement a policy detailing how to effectively address recommendations generated from company process safety management systems, including audits, incident investigations, management of change, and process hazard analysis that is consistent with existing OSHA guidance. Include a periodic training requirement for managers and other employees involved with evaluating and managing proposed recommendations to help ensure proposed safety improvements are effectively evaluated and appropriately implemented.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-03-I-TX-5

Review the Center for Chemical Process Safety guidance on recognizing catastrophic incident warning signs and then develop and implement a program for the EVAL Plant that incorporates warning signs into its safety management system.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-03-I-TX-6

Clarify the lower equipment design pressure of the EVAL Reactor 2 within the operator training systems, written procedures, and in the control system interface.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-03-I-TX-7

Develop and implement a program to ensure that the company’s EVAL Plant nightly operating instructions do not conflict with its written operating procedures. Ensure that employees use the management of change system when changes to the written operating procedures are desired. Additionally, develop and implement a written procedure and conduct training on how to perform the EVAL Reactor methanol flush operation.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-03-I-TX-8

Strengthen the EVAL Plant’s operator training program by 1) including the known activities, such as bringing ethylene back into the unit, upset conditions like the reactor’s High-High-Pressure alarm, and providing guidance or otherwise clarifying when nonessential personnel should be excluded from being in the unit; 2) including alarm setpoints and actions that operators should take in response to specific process alarms, such as high pressure inside an EVAL Reactor; 3) including directions on when operators should use the emergency open valve; and 4) including safe operating limits, the consequence of deviating beyond the safe operating limits, and the predetermined steps operators need to take to return the process to a safe condition.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-03-I-TX-9

Complete the alarm management efforts at the EVAL Plant and implement a continual program to meet or be lower than the alarm rate performance targets established in ISA 18.2.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-03-I-TX-10

Improve the EVAL Plant’s safety management system by 1) controlling when chilled liquid is circulated through the heat exchanger during startup; 2) enhancing recognition of liquid ethylene accumulation and response to low-temperature conditions inside an EVAL Reactor through alarms, written procedures, and operator training; 3) implementing a system to manage abnormal operating conditions effectively by, at a minimum, including appropriate technical representation, performing a hazard analysis of temporary or troubleshooting operations, and providing management oversight of any abnormal condition; 4) updating the written startup procedures to include guidance on the appropriate operator actions to take in response to process alarms; 5) using control system guidance to aid operator response to abnormal or upset conditions to keep the process within the safe operating limits; and 6) removing the physical and procedural controls used at the EVAL Plant to restrict board operators from accessing or using the emergency open valve, and updating the written procedures and operator training to provide guidance on when to open the emergency open valve.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-03-I-TX-11

Modify the EVAL Plant’s safe operating limits program to prevent operating under conditions that rely upon equipment design safety factors, such as the American Society of Mechanical Engineers (ASME) code material safety factors.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-03-I-TX-12

Acquire the services of an independent third party to perform a comprehensive assessment of its EVAL Plant’s process safety management systems. In addition to meeting the requirements outlined in Appendix B of this report, this comprehensive assessment should evaluate whether existing policies meet minimum federal process safety regulatory requirements and apply the Center for Chemical Process Safety model to verify both the suitability of these systems and their effective, consistent implementation.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

Open: 100% | Closed: 0%

Final Report Released On: March 13, 2025

2024-01-I-CA-8

Revise API RP 556 Instrumentation, Control, and Protective Systems for Gas Fired Heaters, or successor API products, with the following:

1. Requirements for proper response to high tube metal temperatures, including guidance to alert operators when safe operating limits are exceeded and to specify predetermined response actions, such as shutting down the fired heater remotely. The predetermined response actions must include actions that specify when to stop troubleshooting and remove personnel from the vicinity of the fired heater;

2. Design requirements (“shall” rather than “should” language) for protecting fired heaters from low process flow where process piping diverges downstream of a flow meter. Requirements may include achieving proof of flow to the heater through valve position indicators and interlocks on branch 

3. Engineering safeguard requirements (“shall” rather than “should” language) to detect and prevent afterburning in fired heaters. These requirements may include the use of instrumentation such as combustibles measurements, flame detectors, and/or thermocouples that measure tube metal, flue gas, and process fluid temperatures. The requirements shall address monitoring capability from the control room.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Recommendation Status Change Summary

Open: 75% | Closed: 25%

Final Report Released On: March 13, 2025

2024-01-I-CA-1

Implement engineering safeguards to detect and prevent afterburning in the fired heater involved in the November 19, 2023, incident. The safeguards may include the use of instrumentation such as combustibles measurements, flame detectors, and/or thermocouples that measure tube metal, flue gas, and process fluid temperatures. The safeguards shall be capable of being monitored from the control room.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2024-01-I-CA-2

For the fired heater involved in the incident, after Marathon Petroleum Corporation’s “Process Heater Not-to-Exceed (NTE) Limits and Alarms” standard is updated according to 2024-01-I-CA-R5, implement tube metal temperature alarming consistent with corporate guidance to alert operators when safe operating limits are exceeded and to specify predetermined response actions, such as shutting down the fired heater remotely. The predetermined response actions must include actions that specify when to stop troubleshooting and remove personnel from the vicinity of the fired heater.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2024-01-I-CA-3

Implement changes to improve Walk the Line performance at the Martinez facility by ensuring that the facility’s practices are consistent with tools in the AFPM Safety Portal and guidance in Marathon Petroleum Corporation’s refining reference document titled Operations Excellence. At a minimum:

1. Require that operator field walkdowns ensure that valves are correctly aligned before all unit startup activities from planned or unplanned shutdowns, such as those due to non-normal operations, emergencies, turnarounds, and major maintenance;

2. Improve policies and practices for communications among and between shifts to ensure that operators understand abnormal line-ups in their units; and

3. Reinforce Walk the Line concepts, including the expectation for only trained operators to control valve line-ups at their units, through training for all levels of management in the Operations department.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2024-01-I-CA-4

Complete a comprehensive gap assessment of the Martinez facility against Marathon Petroleum Corporation policies. At a minimum, address the following policies:

a. Operating Limits;

b. Process Hazard Analysis; and

c. PSM/RMP Refining Operating Procedures.

Develop and implement action items to effectively address findings from the assessment.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

Open: 100% | Closed: 0%

Final Report Released On: March 13, 2025

2024-01-I-CA-5

Update the corporate “Process Heater Not-to-Exceed (NTE) Limits and Alarms” standard with tube metal temperature alarming guidance to alert operators when safe operating limits are exceeded and to specify predetermined response actions, such as shutting down the fired heater remotely. The predetermined response actions must include actions that specify when to stop troubleshooting and remove personnel from the vicinity of the fired heater.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2024-01-I-CA-6

Update the corporate “Heater Application Standard” with the following requirements:

1. Requirements for protecting fired heaters from low process flow where process piping diverges downstream of a flow meter. Requirements may include achieving proof of flow to the heater through valve position indicators and interlocks on branch connections downstream of flow meters to prevent backflow, reverse flow, or other diverted flow scenarios that could defeat the safety instrumented system; and

2. Engineering safeguard requirements to detect and prevent afterburning in fired heaters. The safeguards may include the use of instrumentation such as combustibles measurements, flame detectors, and/or thermocouples that measure tube metal, flue gas, and process fluid temperatures. The safeguards shall be capable of being monitored from the control room.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2024-01-I-CA-7

Confirm the results of the Martinez facility’s comprehensive gap assessment required in 2024-01-I-CA-R4. Upon completion, conduct an Operations Excellence full assessment on the Martinez facility. Develop and implement action items to effectively address findings from the assessment.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

Open: 100% | Closed: 0%

Final Report Released On: February 23, 2026

2024-05-I-TX-4

Develop written guidelines for marking equipment for opening. The guidelines should define a standard practice for equipment marking that includes clear identifiers of the area to be opened and means to remove the markings at the conclusion of the work.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Recommendation Status Change Summary

Open: 100% | Closed: 0%

Final Report Released On: February 23, 2026

2024-05-I-TX-1

Label all piping in ARU6 and ARU7 in accordance with ANSI/ASME A 13.1 Scheme for the identification of Piping Systems. 

Status: Open - Awaiting Response or Evaluation/Approval of Response
Recommendation Status Change Summary

2024-05-I-TX-2

Develop procedures to ensure that any craftworkers introduced to or removed from a unit in Positive Isolation Status receive instructions that define the hazards, safeguards, and requirements of the unit associated with the work. The procedures should require each craftworker to receive clear communication on the identified hazards, control measures, and all other requirements before commencing work in a new area.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Recommendation Status Change Summary

2024-05-I-TX-3

Establish a conduct of operations system that establishes and enforces behavioral and performance metrics in accordance with CCPS’s Conduct of Operations and Operational Discipline. The system should include:

a) the management commitment to process safety,
b) employee input on policies and procedures,
c) methods to ensure that policies and procedures can be effectively followed, to include, at a minimum:

1) permitting,

2) equipment marking, and

3) energy isolation procedures, and

d) regular audits to verify adherence to conduct of operations metrics, to include, at a minimum:

1) performance expectations,

2) training,

3) management visibility,

4) leadership by example, and

5) worker knowledge and awareness.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Recommendation Status Change Summary

Open: 100% | Closed: 0%

Final Report Released On: October 11, 2022

2019-04-I-PA-4

Update API RP 751 Safe Operation of Hydrofluoric Acid Alkylation Units to require the following:

1. Protection of critical safeguards and associated control system components, including but not limited to wiring and cabling for control systems and primary and backup power supplies, from fire and explosion hazards, including radiant heat and flying projectiles; and
2. Installation of remotely-operated emergency isolation valves on the inlet(s) and outlet(s) of all hydrofluoric acid containing vessels, and hydrocarbon containing vessels meeting defined threshold quantities.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Recommendation Status Change Summary

Open: 0% | Closed: 100%

Final Report Released On: October 11, 2022

2019-04-I-PA-5

Revise ASTM A234 to incorporate supplementary requirements for piping used in HF service, as defined in HF supplementary requirements S9.1 through S9.7 in ASTM A106 version 19a.

Status: Closed - Reconsidered/Superseded
Recommendation Status Change Summary

Open: 33% | Closed: 67%

Final Report Released On: October 11, 2022

2019-04-I-PA-1

Develop a program that prioritizes and emphasizes inspections of refinery HF alkylation units, for example under EPA’s National Compliance Initiative called Reducing Risks of Accidental Releases at Industrial and Chemical Facilities. As part of this program, verify that HF alkylation units are complying with API RP 751 Safe Operation of Hydrofluoric Acid Alkylation Units, including but not limited to the implementation of a special emphasis inspection program to inspect all individual carbon steel piping components and welds to identify areas of accelerated corrosion; the protection of safety-critical safeguards and associated control system components, including but not limited to wiring and cabling for control systems and primary and backup power supplies, from fire and explosion hazards including radiant heat and flying projectiles (per recommendation 2019-04-I-PA-R4); and the installation of remotely-operated emergency isolation valves on the inlet(s) and outlet(s) of all hydrofluoric acid containing vessels, and hydrocarbon containing vessels meeting defined threshold quantities (per recommendation 2019-04-I-PA-R4).

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2019-04-I-PA-2

Revise 40 C.F.R. Part 68 (EPA Risk Management Plan) to require new and existing petroleum refineries with HF alkylation units to conduct a safer technology and alternatives analysis (STAA) and to evaluate the practicability of any inherently safer technology (IST) identified. Require that these evaluations are performed every 5 years as a part of an initial PHA as well as PHA revalidations.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2019-04-I-PA-3

(Superseded by 2023-02-I-LA-R4 from the Honeywell Geismar report)

Per the requirements in EPA Rule Procedures for Prioritization of Chemicals for Risk Evaluation Under the Toxic Substances Control Act, initiate prioritization to evaluate whether hydrofluoric acid is a High-Priority Substance for risk evaluation. If it is determined to be a High-Priority Substance, conduct a risk evaluation of hydrofluoric acid to determine whether it presents an unreasonable risk of injury to health or the environment. If it is determined to present an unreasonable risk of injury to health or the environment, apply requirements to hydrofluoric acid to the extent necessary to eliminate or significantly mitigate the risk, for example by using a methodology such as the hierarchy of controls.

Status: Closed - Reconsidered/Superseded
Recommendation Status Change Summary

Open: 0% | Closed: 100%

Final Report Released On: December 19, 2022

2020-02-I-TX-4

Revise the Butadiene Product Stewardship Guidance Manual to include guidance on identifying and controlling or eliminating dead legs in high-purity butadiene service. Specifically, provide guidance on the potential for dead legs to be formed when equipment, such as primary or spare pumps, is out of service. In the Manual, also provide guidance on method(s) to identify dead legs that could be formed when equipment, such as primary or spare pumps, is temporarily or permanently out of service. Recommend actions to mitigate, control, and prevent hazardous popcorn polymer buildup in these in-process or temporary dead legs, such as through monitoring, use of inhibitor(s), or conducting maintenance activities to minimize the presence of dead legs.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

2020-02-I-TX-5

Revise the Butadiene Product Stewardship Guidance Manual to provide guidance on a methodology to help identify what should be considered excessive or dangerous amounts of popcorn polymer in a unit. Provide mitigation strategies that describe the actions that owner/operators should take during those polymer excursions to control or eliminate the popcorn polymer to reduce the likelihood of popcorn polymer-induced process loss of containment.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

Open: 0% | Closed: 100%

Final Report Released On: December 19, 2022

2020-02-I-TX-1

For all TPC PNO terminal operations in high-purity butadiene service (e.g., greater than 80 percent butadiene concentration), develop and implement a program to identify and control, or eliminate, dead legs. At a minimum, the program must require:

a)   a comprehensive review of equipment configurations in high-purity butadiene service using both Piping and Instrumentation Diagrams (P&IDs) and field evaluations to identify all permanent dead legs. Implement a process to identify changes in operating conditions in high-purity butadiene service that could result in the formation of temporary or new permanent dead legs, such as when primary or spare pumps are temporarily or permanently out of service. Ensure this review is conducted at least every five years;

b)   evaluation and implementation of design strategies, where practical, to prevent dead legs in areas susceptible to popcorn polymer formation;

c)   mitigation, control, or prevention of hazardous popcorn polymer buildup in all identified dead legs in high-purity butadiene service, such as through increased monitoring, flushing of equipment, use of inhibitor(s), or planning maintenance activities to minimize the amount of time that a temporary dead leg is present; and

d)   periodic continual auditing (at a minimum annually) by TPC PNO management to ensure that the process is being implemented.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2020-02-I-TX-2

For all TPC PNO terminal operations, passivate all storage vessels, fixed equipment, and associated piping systems in high-purity butadiene service consistent with industry good practice guidance.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2020-02-I-TX-3

At the TPC PNO facility, incorporate the recording of any paper-based process performance information into TPC PNO’s existing electronic records management system so that the information can be reliably retained, retrieved, and analyzed in the event of a catastrophic incident. At a minimum, those records shall include Dead Leg Inspection check sheets, Spare Pump Rotation check sheets, and handwritten logs documenting the performance of all critical process instrumentation (e.g., the oxygen analyzer).

Status: Closed - Acceptable Action
Recommendation Status Change Summary

Open: 100% | Closed: 0%

Final Report Released On: November 30, 2023

2021-04-I-OH-6

Develop specific design, construction, and alteration guidance for low-pressure process vessels in flammable and other highly hazardous chemicals service not exceeding an internal pressure of 15 psig in API 510 Pressure Vessel Inspection Code, API RP 572 Inspection Practices for Pressure Vessels, and/or other appropriate products. At a minimum, include guidance for:

(i) determining and documenting the low-pressure vessel’s design pressure (such as through a data sheet and a nameplate affixed to the vessel);

(ii) determining when or if all or parts of the ASME Boiler and Pressure Vessel Code should be applied;

(iii) acceptable alternative engineering methods, if applicable; and,

(iv) alteration requirements, such as design assessments, inspections, and pressure testing.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Recommendation Status Change Summary

Open: 100% | Closed: 0%

Final Report Released On: November 30, 2023

2021-04-I-OH-7

Assist API in developing design, construction, and alteration guidance for low-pressure vessels in flammable and other highly hazardous chemicals service not exceeding an internal pressure of 15 psig. If any new design and construction guidance is specifically developed for pressure vessels in flammable and other highly hazardous chemicals service not exceeding an internal pressure of 15 psig, reference the design and construction guidance in the Section VIII, Division 1 of the ASME Boiler and Pressure Vessel Code (BPVC).

Status: Open - Awaiting Response or Evaluation/Approval of Response
Recommendation Status Change Summary

Open: 100% | Closed: 0%

Final Report Released On: November 30, 2023

2021-04-I-OH-1

Update mechanical integrity procedures for all process vessels in highly hazardous chemicals service, including pressure vessels not exceeding 15 psig, to adopt alteration guidance in API 510 Pressure Vessel Inspection Code or Part 3 of the National Board Inspection Code.

Status: Open - Unacceptable Response/No Response Received
Recommendation Status Change Summary

2021-04-I-OH-2

Assess and document applicable design, construction, and alteration standards for all pressure vessels in highly hazardous chemicals service in new resin plant designs, including pressure vessels not exceeding 15 psig. At a minimum, adopt PIP VESLP001 Low-Pressure, Welded Vessel Specification as design and construction guidance for pressure vessels not exceeding 15 psig. Implement a program to assess the pressure vessels against updated applicable recognized and generally accepted good engineering practices, such as those published by API, ASME, PIP, and other organizations, at least once every five years, and address the gaps identified. Develop and implement written procedures to document and maintain records of (i) all inspections of, (ii) all alterations to, and (iii) all maintenance and repairs on all pressure vessels in highly hazardous chemicals service.

Status: Open - Unacceptable Response/No Response Received
Recommendation Status Change Summary

2021-04-I-OH-3

Demonstrate the use of prevention through design using the hierarchy of controls in future resin plant designs. Specifically, prioritize inherently safer design and engineering controls to prevent process safety events. Refer to sources such as Safety Instrumented Systems: A Life-Cycle Approach by P. Gruhn and S. Lucchini, Human Error in Process Plant Design and Operations – A Practitioner’s Guide by J. Robert Taylor, Guidelines for Preventing Human Error in Process Safety by the Center for Chemical Process Safety (CCPS), Guidelines for Inherently Safer Chemical Processes – A Life Cycle Approach by the CCPS, and Guidelines for Risk Based Process Safety by the CCPS for guidance. Demonstration could include documentation of conceptual design safety reviews, hazard analysis and risk assessments of detailed project designs, and a plan to address the recommendations to control the hazards.

Status: Open - Unacceptable Response/No Response Received
Recommendation Status Change Summary

2021-04-I-OH-4

Identify and document all equipment that could release flammable materials and install LEL detectors in accordance with sources and guidance such as Guidelines for Engineering Design for Process Safety by the Center for Chemical Process Safety and Explosion Hazards in the Process Industries by Rolf K. Eckhoff. Ensure that detection of hazardous conditions automatically triggers both visual and audible alarms to alert plant personnel of the hazard. Develop and implement employee training on actions to take, such as prompt evacuation, when such alarms are activated.

Status: Open - Unacceptable Response/No Response Received
Recommendation Status Change Summary

2021-04-I-OH-5

Develop and implement requirements for personnel to wear flame-resistant uniforms in all operating areas that process flammable chemicals. Update employee training material to include the requirement for and purpose of PPE use.

Status: Open - Unacceptable Response/No Response Received
Recommendation Status Change Summary