Skip to Main Content

An independent federal agency investigating chemical accidents to protect workers, the public, and the environment.

Text Size AA
PRINT PAGE

Recommendations

Follow Us

YouTube Facebook Twitter
 

Email Sign-up



statistics

Total # of Recommendations
784
Total # of Open Recommendations
195
Total # of Closed Recommendations
589
Total % of Open 25 vs. Closed 75

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
NDK Crystal Inc. Explosion with Offsite Fatality (1 Recommendations)
Illinois Office of the State Fire Marshal, Boiler & Pressure Vessel Safety Division (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 14, 2013

2010-4-I-IL-4

Develop and implement state requirements and procedures to ensure the pressure vessel approval process accurately identifies vessels that may be subject to corrosion or similar deterioration mechanisms, and ensure regular inspections in accordance with these state requirements.


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

Valero Refinery Propane Fire (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 09, 2008

2007-5-I-TX-3

Revise API Recommended Practice 2001, Fire Protection in Refineries, and API 2030, Application of Fixed Water Spray Systems for Fire Protection in the Petroleum Industry, so that conformance with these recommended practices includes the design, installation, and use of ROSOVs and interlocked equipment controls to enable the safe and rapid emergency isolation of process equipment containing highly pressurized flammables.


Status: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendations Status Change Summary

Tesoro Refinery Fatal Explosion and Fire (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

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: 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

BP America Refinery Explosion (1 Recommendations)
BP Global Executive Board of Directors (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 20, 2007

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: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

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-10

Work with NIST in developing and implementing a publicly available database for reactive hazard test information. Promote submissions of data by your membership.


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

West Fertilizer Explosion and Fire (2 Recommendations)
Texas Commission on Fire Protection (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2016

2013-02-I-TX-11

Develop minimum standards for course curricula to include hazard awareness of fertilizer grade ammonium nitrate (FGAN) for those fire departments that either have FGAN facilities in their jurisdictions or respond as mutual aid to other jurisdictions with FGAN facilities.  In addition, develop a training program specific to FGAN.

Objectives of the program’s 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: 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-12

Implement outreach to regional, state, and local fire departments that either have FGAN facilities in their jurisdictions or respond as mutual aid to jurisdictions with FGAN facilities, informing them about the new FGAN training certification requirements and opportunities to receive training.  Include the following in the outreach:

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. Encouragement for fire departments in jurisdictions with FGAN facilities to become certified in 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

Carbide Industries Fire and Explosion (1 Recommendations)
Carbide Industries (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 07, 2013

2011-5-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: 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 Recommendation Status Change Summary

Macondo Blowout and Explosion (12 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2016

2010-10-I-OS-5

Based on the analysis presented in the CSB Macondo investigation report, Volumes 3 and 4, and the requirements listed in R10, revise Recommended Practice 75, Development of a Safety and Environmental Management Program for Offshore Operations and Facilities, 3rd ed., May 2004 (reaffirmed May 2008), to require a specific focus on major accident prevention and address the following issues:
a.    Incorporate the following listed safety management system issues as explicit program elements and include language throughout API 75 regarding each element’s explicit and defined applicability to all of the other existing program elements:
1.    Human factors program requirements for the design, planning, execution, management, assessment, and decommissioning of well operations for the prevention of major accidents, as well as in the investigation of accidents and near-misses;
2.    Corporate governance and Board of Director responsibilities for major accident risk management;
3.    Workforce involvement and engagement in all aspects of the SEMS program;
4.    Contractor oversight and effective coordination for major accident prevention; and
5.    Leading and lagging key performance indicators that drive major accident prevention.
b.    Define and expand the roles and responsibilities for major accident prevention among the primary parties engaged in offshore drilling and production (i.e., the leaseholder/operator and owner/drilling contractor) by expanding applicability of this standard to the parties with primary control over major hazard operations and day-to-day activities and thus best positioned to implement and oversee a safety and environmental management system (SEMS) program to control major accident hazards.
c.    Incorporate into the Principles section of the document, as well as within the Setting Objectives and Goals section, as overarching provisions for the overall successful implementation and execution of a SEMS program:
1.    Management of major accident risk to As Low As Reasonably Practicable or similar risk-reduction target;
2.    Use the hierarchy of controls for identifying, establishing, and implementing barriers meant to prevent or mitigate major accident 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.
 

Ocean Energy Safety Institute (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2016

2010-10-I-OS-10

Conduct further study on riser gas unloading scenarios, testing, and modeling and publish a white paper containing technical guidance that communicates findings and makes recommendations for industry safety improvements.


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.
 

Sustainability Acconting Standards Board (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2016

2010-10-I-OS-9

Update, strengthen, and finalize the SASB’s provisional Oil & Gas Exploration & Production Sustainability Accounting Standard by enhancing standard NR0101-18. Expand recommended coverage of “Process Safety Event rates for Loss of Primary Containment of greater consequences” in accordance with the findings of this report. Specifically, this expanded coverage shall:
a.    Recommend the disclosure of additional leading and lagging indicators and emphasize the greater preventive value of disclosure of a company’s use of leading indicators to actively monitor the health and performance of major accident safety barriers and the management systems for ensuring their effectiveness. Specifically add:
1.    Indicators addressing the health of safety barriers to be communicated to the workforce, and to shareholders in required SEC disclosures, and also to be made readily available to the regulator.  
2.    Guidance emphasizing and promoting the concept that personal safety metrics such as those captured in NR0101-17 (total recordable injury rate, fatality rate, near-miss frequency rate) are important but separate from leading and lagging process safety performance indicators, which better correlate to major accident prevention.
•    Accomplish this communication within NR0101-18.
•    Supplement this effort within the SASB’s Oil & Gas Exploration & Production Research Briefs, based on the findings of this report as well other current safety scholarship that demonstrates the lack of correlation between personal safety efforts and process safety and major accident prevention initiatives.


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.
 

U.S. Department of the Interior (9 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2016

2010-10-I-OS-6

Drawing upon best available global standards and practices, develop guidance to assist industry in the incorporation of human factors principles into the systematic analysis of their major accident hazards, development of their SEMS programs, and in the preparation of their major hazards report documentation. This standard shall provide guidance on topics including, but not limited to, safety critical task assessment and the development and verification of non-technical skills. Include the participation of diverse expertise in the development of the standard including industry, workforce, and subject matter expert representatives.


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.
 

2010-10-I-OS-7

Drawing upon best available global standards and practices, develop guidance addressing the roles and responsibilities of corporate board of directors and executives for effective major accident prevention. Among other topics, this standard shall provide specific guidance on how boards and executives could best communicate major accident safety risks to their stakeholders, as well as corporate level strategies to effectively manage those risks.


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.
 

2010-10-I-OS-8

Expand upon the principles of the BSEE Safety Culture policy and establish a process safety culture improvement program for responsible parties as defined in R11(a) that periodically administers process safety culture assessments and implements identified major accident prevention improvements. The process safety culture improvement program shall include a focus on items that measure, at a minimum, willingness to report incidents and near-misses, effectiveness of workforce participation efforts, organizational drift from safety policies and procedures, and management involvement and commitment to process safety.


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.
 

2010-10-I-OS-11

Revise and augment the offshore safety regulations, including the SEMS Rule (C.F.R. 250 subpart S), and issue guidance as it relates to those revisions/augmentations, to:
a.    Establish clear and consistent safety and environmental management responsibilities to prevent major accidents for the companies having primary control over the hazardous activities being undertaken (e.g., the owner/drilling contractor for a non-production installation and the leaseholder/operator for the production installation);
b.    Require all responsible parties as defined in R11(a) to develop documentation for each hazardous operation/facility it maintains primary control over, where the documentation demonstrates the party’s systematic analysis that risks posed by all identifiable major accident hazards are reduced to As Low As Reasonably Practicable (ALARP) or similar risk-reduction target. The documentation shall include:
1.    Identification of major hazards and the barriers and safety management systems controls (including augmented SEMS elements) that will be used to reduce risk to ALARP or similar risk reduction target;
2.    Use of the hierarchy of controls to the greatest extent feasible in establishing safety barriers and controls;
3.    Identification of safety critical elements and tasks to establish and maintain safety barriers and controls, in fulfillment of R1 (See Volume 2);
4.    Demonstrate use of established qualitative, quantitative and semi-quantitative methods in determining (1) the barriers and safety management systems necessary to achieve ALARP risk reduction levels and (2) the performance requirements of those barriers and controls (e.g., reliability, functionality, and availability) to ensure their effectiveness;
5.    Identification of all US and international standards that have been applied, or will be applied, in relation to the facility, hazardous operation, or equipment used on/in connection with the operation for which required documentation is submitted. Should the responsible party wish to use standards other than well-recognized US or international consensus safety standards developed by a representative committee of diverse stakeholders, a detailed technical justification that those standards achieve risk-reduction to ALARP must accompany submitted documentation. The regulator may challenge or reject the technical justification. Remove from the US offshore safety regulatory scheme the provisions that allow companies to substitute requirements to use the best available and safest technology with a showing of compliance with BSEE regulations.
c.    Require responsible parties as defined by R12(a) to fully implement all aspects of the documentation stipulated in R12(b) and establish a documented process to verify that all methods to manage, reduce, and control those hazards are effectively maintained throughout the lifecycle of the operation/facility.


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.
 

2010-10-I-OS-12

Augment the capabilities and functioning of BSEE to incorporate the following proactive oversight mechanisms:
a.    Review of the documentation required to be submitted under CSB 2010-I-OS-R11(b) by technically qualified regulatory personnel who have the capability and authority to require modifications and improvements to the major hazards report as necessary, either before an acceptance process and commencement of the major hazards operation(s) or during periodic proactive review by the regulator;
b.    Establish a program for preventive, comprehensive inspections and audits with technically qualified staff as described in R13(a) to ensure that the responsible party as defined in R5(a) can demonstrate the risk reduction commitments stipulated in its major hazards report.


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.
 

2010-10-I-OS-13

Further enhance the qualifications, professional competency, and diversity of BSEE staff to implement major accident prevention programs by:
a.    Continuing efforts to enhance recruiting and retention of sufficient staff with a diversity of expertise, professional backgrounds and skill sets, such that BSEE has staff competencies in a variety of safety-critical and technical areas, including petroleum, chemical, and mechanical engineering; human and organizational factors; well design and control; and process safety, as well as those with industry experience to perform an even more expanded mission as envisioned in this report;  
b.    Retaining the services of a human resources consulting firm to complement BSEE’s efforts to date on human capital management and workforce planning issues, in light of documented difficulties in recruiting and retaining necessary staff, including the development of a plan with respect to large numbers of retirements facing the agency in the coming decade, as well as a compensation analysis (and a plan for subsequent periodic market analyses and benchmarking) to ensure BSEE remains competitive with other employers in the offshore industry. Augment the agency’s compensation system as necessary to enable BSEE to attract and retain the level of staffing needed to perform BSEE’s mission.
c.    Continuing to assess, expand, and improve ongoing BSEE training programs for new hires to provide all employees with robust skill sets, including appropriate technical training as well as interpersonal skills such as communications, negotiation and advocacy.

If funding, legislative authority, or other approvals are required to implement the recommended regulatory provisions in Recommendation R11 – R13, the Secretary of the Interior shall seek such authority from Congress or expedited hiring authority from the Office of Personnel Management.


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.
 

2010-10-I-OS-14

Expand the offshore safety regulatory program that collects, tracks, and analyzes safety performance indicators from industry to further influence industry efforts in reducing major accident risks to ALARP. At a minimum, this program shall:
a.    Require the reporting of safety indicator data by all responsible parties, as defined in R11(a);
b.    Emphasize the greater preventive value of using leading indicators to actively monitor the health and performance of major accident safety barriers and the management systems meant to ensure their effectiveness, and work with industry to develop leading indicators that are measurable, actionable, normalized across industry, and that occur with sufficient frequency to allow for meaningful trending and analysis at the facility and corporate levels;
c.    Augment current reporting requirements to include leading safety performance indicators;
d.    Use the safety performance indicator data to:
1.    identify industrywide, companywide, and facility-specific safety trends and deficiencies;
2.    set annual process safety goals or targets for the industry, company and/or facility, as appropriate, based upon those identified safety trends and deficiencies;
3.    issue, at a minimum, annual reports that publicly communicate those trends, deficiencies, targets, and goals; and
4.    determine future appropriate allocations of BSEE resources and the prioritization of BSEE inspections;
e.    Include use of significant lagging indicators data (including those already mandated by 30 C.F.R. 250.188(a) and (b), such as major events like explosions, fires, gas releases, fatalities, INCs) as qualification criteria in the lease-approval and permit-to-drill decision-making processes by the regulator.


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.
 

2010-10-I-OS-15

Issue participation regulations and training requirements for workers and their representatives that include the following:
a.    Worker-elected safety representatives and safety committees for each staffed offshore facility chosen under procedures overseen by the regulator; these safety representatives will have the authority to interact with employers (such as operators and drillers) and regulators on issues of worker health and safety risks and the development and implementation of the major hazard report documentation;
b.    The elected worker representative has the right to issue an enforceable stop-work order if an operation or task is perceived as unsafe; all efforts should be made to resolve the issue at the workplace level, but if the issue remains unresolved, BSEE shall establish mechanisms such that the worker representative has the right and ability to seek regulator intervention to resolve the issue, and the regulator must respond in a timely fashion;
c.    The regulator will host an annual tripartite forum for workforce representatives, industry management, and the regulator to promote opportunities for interaction by all three entities on safety matters and to advance initiatives for major accident prevention.
d.    Protections for workers participating in safety activities with a specific and effective process that workers can use to seek redress from retaliatory action with the goal to provide a workplace free from fear that encourages discussion and resolution of safety issues and concerns. Protected activities include, but are not limited to reporting unsafe working conditions, near misses, and situations where stop work authority is used.


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.
 

2010-10-I-OS-16

Incorporate by reference into the offshore safety regulations the revised version of Recommended Practice 75, Development of a Safety and Environmental Management Program for Offshore Operations and Facilities, 3rd Ed., May 2004 (reaffirmed May 2008) upon the inclusion of the CSB recommendations in R11 by API.


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.
 

 
 
© csb.gov. All rights reserved