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statistics

Total # of Recommendations
788
Total # of Open Recommendations
180
Total # of Closed Recommendations
608
Total % of Open 23 vs. Closed 77

Recent Recommendation Status Updates

Each recommendation the CSB issues is monitored by CSB staff from the time it is issued to closing. CSB staff evaluate recipient responses, and the Board votes to assign status designations to recommendations based on staff evaluation. This page highlights recommendations for which the Board has recently voted to change the status of the recommendation. For more information on how the CSB defines its recommendation statuses, please visit the Recommendations Frequently Asked Questions page.


Recommendations
West Fertilizer Explosion and Fire (4 Recommendations)
Department of Homeland Security, Federal Emergency Management Agency (FEMA) (4 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: January 28, 2016

2013-02-I-TX-7

Through a new or existing program and in conjunction with training partners, create and implement a competitive funding mechanism to provide training to regional, state, and local career and volunteer fire departments on how to respond to fire and explosion incidents at facilities that store fertilizer grade ammonium nitrate (FGAN).  Continue to use available funding to ensure training effectiveness.


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

PDF Document Recommendations Status Change Summary

2013-02-I-TX-8

During the proposal review process for the program, ensure that the FGAN training includes multiple delivery methods to enable a broad reach.  Training should allow for instructor-led, web-based, and train-the-trainer courses; initial orientation; and refresher training.  Training also should accommodate both resident and mobile capabilities to facilitate flexible delivery.
Objectives of the selected training course should address the following:
a. Previous FGAN fire and explosion incidents, incorporating lessons learned

b. Hazards posed by other materials and chemicals stored near FGAN, including FGAN incompatibility with those materials and chemicals

c. Pre-incident planning for fires involving FGAN d. On-scene emergency response and decision-making requirements for FGAN fires, including risk assessment, scene size-up, and situational awareness

e. National Incident Management System and Incident Command System.


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

PDF Document Recommendations Status Change Summary

2013-02-I-TX-9

Assist training partners to develop and provide continual oversight for an FGAN training program.  In addition, evaluate the training curriculum to confirm that it adequately meets course objectives as well as the details of recommendation 2013-02-I-TX R8.


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 Recommendations Status Change Summary

2013-02-I-TX-10

Develop an outreach program that notifies regional, state, and local fire departments about available FGAN training opportunities.  The program should include the following:

a. Guidance for fire departments on how to identify FGAN hazards within their communities by engaging State Emergency Response Commissions and Local Emergency Planning Committees

b. Details on how to obtain FGAN training by submitting a proposal in response to the funding opportunity

c. Information on training partners and programs that provide FGAN training.


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 Recommendations Status Change Summary

Tesoro Refinery Fatal Explosion and Fire (2 Recommendations)
Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2014

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: 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 Recommendations Status Change Summary

Tesoro Refining & Marketing Company LLC (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2014

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: 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 Recommendation Status Change Summary

Third Coast Industries Petroleum Products Facility Fire (1 Recommendations)
International Code Council (ICC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2002-03-I-TX-3

Revise the International Fire Code to address the following issues: For facilities that are not staffed around the clock, specify circumstances where automatic fire detection is needed. Narrow exemptions for Class IIIB liquids. Expand fire protection analysis requirements to include all areas of a facility where there may be flammable or combustible fire risks.


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.
 

PDF Document Recommendations Status Change Summary

CAI / Arnel Chemical Plant Explosion (1 Recommendations)
International Code Council (ICC) (1 Recommendations)
Open: 0% | Closed: 100%

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: 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.
 

PDF Document Recommendations Status Change Summary

Chevron Refinery Fire (2 Recommendations)
American Society of Mechanical Engineers (ASME) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2015

2012-03-I-CA-32

Revise ASME PCC-2-2011: Repair of Pressure Equipment and Piping to require users to follow the minimum process fluid leak response requirements established in API RP 2001: Fire Protection in Refineries, developed in response to recommendation 2012-03-I-CA-R31, before conducting process fluid leak repair.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (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 Recommendations Status Change Summary

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

Final Report Released On: January 28, 2015

2012-03-I-CA-35

Develop an approval process that includes a technical review that must be implemented prior to resetting the minimum alert thickness to a lower value in the inspection database.


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 Recommendations Status Change Summary

Freedom Industries Chemical Release (1 Recommendations)
American Water Works Association (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 28, 2016

2014-01-I-WV-1

Communicate the findings, lessons learned and recommendations contained within this report to all American Water Works Association members. Emphasize the importance of source water protection planning, emergency planning, and coordination with local, state and federal entities, and the public, to ensure timely notification of potential water contamination events and emergencies.


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 Recommendations Status Change Summary

Improving Reactive Hazard Management (1 Recommendations)
American Chemistry Council (ACC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 17, 2002

2001-01-H-9

Develop and implement a program for reporting reactive incidents that includes the sharing of relevant safety knowledge and lessons learned with your membership, the public, and government to improve safety system performance and prevent future incidents.


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.
 

PDF Document Recommendations Status Change Summary

Williams Olefins Plant Explosion and Fire (5 Recommendations)
American Petroleum Institute (API) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: October 19, 2016

2013-3-I-LA-4

To help prevent future major incidents such as a rupture of a pressure vessel in a special operating status, strengthen API Standard 521, Pressure-relieving and Depressuring Systems, by defining the various types of equipment operating statuses. Include definitions for “standby” and “out-of-service.” Specify pressure relief requirements for each type of equipment operating 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.
 

2013-3-I-LA-5

To help prevent future major incidents such as pressure vessel rupture from ineffective or failed administrative controls, clarify API Standard 521, Pressure-relieving and Depressuring Systems, to require a pressure relief device for overpressure scenarios where internal vessel pressure can exceed what is allowed by the design code. Although some portions of API Standard 521 already require a pressure relief device for these scenarios, other areas, such as Section 4.4.12 Hydraulic Expansion, are not as protective. Section 4.4.12 Hydraulic Expansion (the failure mode that caused the Williams overpressure incident) permits omitting a pressure relief device and allows the exclusive use of administrative controls.


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.
 

Williams Geismer Olefins Facility (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: October 19, 2016

2013-3-I-LA-1

Implement a continual improvement program to improve the process safety culture at the Williams Geismar Olefins Plant. Ensure oversight of this program by a committee of Williams personnel (“committee”) that, at a minimum, includes safety and health representative(s), Williams management representative(s), and operations and maintenance workforce representative(s). Ensure the continual improvement program contains the following elements:
 
a. Process Safety Culture Assessments. Engage a process safety culture subject-matter expert, who is selected by the committee and is independent of the Geismar site, to administer a periodic process safety culture assessment that includes surveys of personnel, interviews with personnel, and document analysis. Consider the process safety culture audit guidance provided in Chapter 4 of the CCPS book Guidelines for Auditing Process Safety Management Systems as a starting point. Communicate the results of the Process Safety Culture Assessment in a report; and
 
b. Workforce Involvement. Engage the committee to (1) review and comment on the expert
report developed from the Process Safety Culture Assessments, and (2) oversee the development and effective implementation of action items to address process safety culture issues identified in the Process Safety Culture Assessment report. 
 
As a component of the process safety culture continual improvement program, include a focus on the facility’s ability to comply with its internal process safety management program requirements. Make the periodic process safety culture report available to the plant workforce. Conduct the process safety culture assessments at least once every five 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.
 

2013-3-I-LA-2

Develop and implement a permanent process safety metrics program that tracks leading and lagging process safety indicators. Consider available industry guidance, such as the guidance presented in the Center for Chemical Process Safety (CCPS) book Guidelines for Process Safety Metrics and the example metrics provided in the book’s accompanying CD. Design this metrics program to measure the effectiveness of the Williams Geismar Olefins Facility’s process safety management programs. Include the following components in this program:
 
a. Measure the effectiveness of the Williams Geismar Management of Change (MOC)
program, including evaluating whether MOCs were performed for all applicable changes,
the quality of MOC review, and the completeness of the MOC review;
 
b. Measure the effectiveness of the Williams Geismar Pre-Startup Safety Review (PSSR)
program, including the quality of the PSSR review and the completeness of the PSSR
review;
 
c. Measure the effectiveness of the Williams Geismar methods to effectively and timely
complete action items developed as a result of Process Hazard Analyses (PHAs),
Management of Change (MOC), incident investigations, audits, and safety culture
assessments; and
 
d. Measure the effectiveness of the Williams Geismar development and implementation of
operating procedures.
 
Develop a system to drive continual process safety performance improvements based upon the data identified and analysis developed as a result of implementing the permanent process safety metrics program.

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.
 

2013-3-I-LA-3

Develop and implement a program that demands robust and comprehensive assessments of the process safety programs at the Williams Geismar facility, at a minimum including Management of Change, Pre-Startup Safety Review, Process Hazard Analyses, and Operating Procedures. Ensure that the assessments thoroughly evaluate the effectiveness of these important safety programs. To drive continual improvement of process safety programs to meet good practice guidance, ensure these assessments result in the development and implementation of robust action items that address identified weaknesses. Engage an expert independent of the Geismar site to lead these assessments 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.
 

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

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: 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 Recommendations Status Change Summary

NDK Crystal Inc. Explosion with Offsite Fatality (2 Recommendations)
NDK Crystal, Inc. (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 14, 2013

2010-4-I-IL-7

Implement an annual inspection and corrective action program to ensure vessels remain resistant to environmentally induced damage mechanisms based on the inspection guidelines set forth in the American Petroleum Institute (API) Standard 510, Pressure Vessel Inspection Code.


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 Recommendations Status Change Summary

2010-4-I-IL-8

Commission a facility siting study of the NDK Crystal facility by an independent consultant. Identify all vessel failure scenarios prior to restarting the crystal growing process. The siting study should include the consequences, necessary preventive measures, and emergency planning and response programs relevant to each failure scenario for all surrounding points of concern. Provide a copy of this study to the City of Belvidere Building and Zoning Department and the Illinois Boiler and Pressure Vessel Safety Division.


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 Recommendations Status Change Summary

 
 
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