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statistics

Total # of Recommendations
804
Total # of Open Recommendations
175
Total # of Closed Recommendations
629
Total % of Open 22 vs. Closed 78

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
Williams Olefins Plant Explosion and Fire (2 Recommendations)
Williams Geismer Olefins Facility (2 Recommendations)
Open: 0% | Closed: 100%

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: 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

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: 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

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

Final Report Released On: January 28, 2015

2012-03-I-CA-28

Revise API 570: Piping Inspection Code:  In-service Inspection, Rating, Repair, and Alteration of Piping Systems to:   

 

a.       Use terminology consistent with API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries and other API standards and recommended practices discussed in this report.  Replace the terminology “high-temperature sulfur corrosion” with “sulfidation corrosion”;

b.      Specify that sulfidation corrosion rates in carbon steel piping can be significantly faster in some individual piping components than in others;

c.       Establish a new section that details inspection requirements to identify low-silicon piping components in carbon steel circuits susceptible to sulfidation corrosion.  This section shall require users to identify carbon steel piping circuits at risk to contain low-silicon components by following the requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to 2012-03-I-CA-R26(a)) and API RP 578: Material Verification Program for New and Existing Alloy Piping Systems (pursuant to 2012-03-I-CA-R29).  At a minimum, require users to either:

                                                              i.      Inspect every component within all carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components once.  The purpose of this practice is to identify any low-silicon components that are corroding at accelerated rates.  Inspection may be performed through ultrasonic thickness measurements to establish corrosion rates for each component, destructive laboratory analysis, or other methods.  Following the inspection, require users to follow the low-silicon corrosion rate monitoring requirements established in 2012-03-I-CA-R26(c); or    

                                                            ii.      Replace the identified at-risk carbon steel piping with a steel alloy that is more resistant to sulfidation corrosion.

 

d.      Incorporate as a “normative reference” API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries; and

e.       Require users to follow the minimum leak response guidance establishedinAPI RP 2001: Fire Protection in Refineries, developed in response to recommendation 2012-03-I-CA-R31.


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

Xcel Energy Company Hydroelectric Tunnel Fire (1 Recommendations)
American Public Power Association (APPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-17

Publish safety guidance addressing the hazards and controls for using hazardous materials including flammables in confined spaces and the unique hazards of penstocks. At a minimum

a. In controlling hazards in confined spaces, implement a hierarchy of controls by first attempting to eliminate hazards or substitute with a less hazardous material(s) or method(s). Examples include performing work outside of a confined space where reasonably practicable or substituting a flammable material with a non-flammable one.

b. Establish a maximum permissible percentage substantially below the LEL for safe entry and occupancy of permit-required confined spaces.

c. Recommend that confined spaces that are large, or part of a continuous system such as a penstock, always be managed as permit-required as defined in the OSHA Confined Space Standard, and that such spaces always be monitored for hazardous atmospheres both prior to entry and continuously in areas where work is being performed.

d. Ensure that evacuation plans for penstocks that have only one egress point provide for alternative escape routes or refuge chambers.

e. Provide guidance for implementing a written confined space rescue plan. Address staging and methods of rescue for each designated permit space including whether a rescue team is required to stand by outside the space. Require that confined space rescue teams be standing by at the permit spaces where the hazards pose an immediate threat to life or health, including the hazard of a potential flammable atmosphere.


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

PDF Document Download

Tesoro Refinery Fatal Explosion and Fire (1 Recommendations)
Tesoro Refining & Marketing Company LLC (1 Recommendations)
Open: 0% | Closed: 100%

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: 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

Partridge Raleigh Oilfield Explosion and Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 12, 2007

2006-7-I-MS-4

Implement a Local Emphasis Program (LEP) to inspect companies in the oil and gas production and extraction sector.


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

PDF Document Download

Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire (1 Recommendations)
National Fire Protection Association (NFPA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 17, 2013

2011-06-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 - 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

Veolia Environmental Services Flammable Vapor Explosion and Fire (1 Recommendations)
Environmental Technology Council (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 21, 2010

2009-10-I-OH-6

Supersedes 2007-01-I-NC-R2, issued pursuant to EQ Hazardous Waste Plant Explosions and Fire

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


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

PDF Document Download

ExxonMobil Refinery Explosion (10 Recommendations)
American Fuel and Petrochemical Manufacturers (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 03, 2017

2015-02-I-CA-10

Facilitate forum(s)—attended by fluid catalytic cracking unit engineers and other relevant personnel from American Fuel and Petrochemical Manufacturers member companies—to discuss the causal factors of the February 18, 2015 ExxonMobil Torrance refinery incident. Encourage participants to share topics such as design, maintenance, and procedural practices that can prevent a similar incident. Topics of discussion should include: (1) Detection of hydrocarbons flowing to an ESP; (2) Isolation strategies to prevent mixing of air and hydrocarbons during standby operations; (3) Safe operation during unit standby; (4) Use of SCSVs as a safeguard during standby operations; (5) Use of reactor steam as a safeguard during standby operations; (6) Measuring reactor / main column differential pressure during standby operations; (7) ESP explosion safeguards; and (8) Preventing ESP explosions. Create documentation that creates institutional knowledge of the information discussed in the forum(s), and share with the member companies and forum attendees.


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.
 

ExxonMobil Corporation (5 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 03, 2017

2015-02-I-CA-1

A Variance to a safety policy or procedure requires robust analysis of the proposed safeguards prior to its approval and implementation. To ensure the proposed methodology described in the Variance is safe and the proposed safeguards are sufficiently robust, revise corporate and U.S. refinery standard(s) to require that a multidisciplinary team reviews the Variance before it is routed to management for their approval. Include knowledgeable personnel on the Variance multidisciplinary team such as: (1) the developer of the Variance; (2) a technical process representative (e.g. process engineer for the applicable unit); (3) an hourly operations representative (e.g. experienced operator in the applicable unit); and (4) a health and safety representative. The role of the multidisciplinary team is to formally meet to review, discuss, and analyze the proposed Variance, and adjust the safety measures as needed to ensure a safe operation. In the event the expert team members do not come to a consensus that the Variance measures can result in a safe operation, require the proposed work to be routed to a higher management level for final approval.


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.
 

2015-02-I-CA-2

ExxonMobil did not have an operating procedure for operating the FCC unit in its Safe Park mode of operation. At all ExxonMobil U.S. refineries, develop a program to ensure operating procedures are written and available for each mode of operation—such as unit standby—for all ExxonMobil U.S. refinery FCC units. Specify in the program that ExxonMobil U.S. refineries develop and train operators on any new procedure.


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.
 

2015-02-I-CA-3

The spent catalyst slide valve, specified as a safety-critical device for normal operation, could not perform its safety-critical function of preventing air and hydrocarbons from mixing while the FCC unit was in its “Safe Park” mode of operation. Also, ExxonMobil Torrance did not operate the FCC unit as if the reactor steam was a safety critical safeguard. Require identification of all safety critical equipment and consequence of failure for each mode of operation and ensure safety critical devices can successfully function when needed. Develop and implement a policy that requires all U.S. ExxonMobil refineries to: (1) specify each safety-critical device’s safety function; (2) identify the consequences of failure of each safety-critical device; (3) specify the testing strategy used to verify whether the safety-critical device can function as intended to perform its required safety function; and (4) maintain target availability (e.g. safe operating life) for each safety-critical device through inspection and maintenance. Require that items (1) through (4) above consider each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation.


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.
 

2015-02-I-CA-4

ExxonMobil extended the maintenance interval of the spent catalyst slide valve and the inspection interval of the pumparound heat exchanger without analyzing whether the extended operation lowered their availability (by operating them beyond their predicted safe operating life) and could result in negative safety consequences. In the event safety-critical equipment is operated beyond its inspection and/or maintenance interval (e.g. extended turnaround interval), require all ExxonMobil U.S. refineries to perform a risk evaluation (e.g. MOC or risk assessment) to identify the safety consequences of the extended operation. Require that each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation is evaluated during the risk evaluation.


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.
 

2015-02-I-CA-5

Electrostatic precipitators create potential ignition sources during normal operation, and have historically caused explosions within the refining industry. At all U.S. ExxonMobil refineries, require a siting risk analysis be performed of all electrostatic precipitators and implement appropriate safeguards to minimize the consequences of an electrostatic precipitator explosion.


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.
 

Torrance Refining Company (4 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 03, 2017

2015-02-I-CA-6

Implement protective systems that prevent ignition of flammable gases (including hydrocarbons not in the presence of CO) inside of the electrostatic precipitator, for each mode of operation.


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.
 

2015-02-I-CA-7

The spent catalyst slide valve, specified as a safety-critical device for normal operation, could not perform its safety-critical function of preventing air and hydrocarbons from mixing while the FCC unit was in its “Safe Park” mode of operation. Require identification of all safety critical equipment and consequence of failure for each mode of operation and ensure safety-critical devices can successfully function when needed. Develop and implement a policy that requires the Torrance refinery to: (1) specify each safety-critical device’s safety function; (2) identify the consequences of failure of each safety-critical device; (3) specify the testing strategy used to verify whether the safety-critical device can function as intended to perform its required safety function; and (4) maintain target availability (e.g. safe operating life) for each safety-critical device through inspection and maintenance. Require that items (1) through (4) above consider each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation.


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.
 

2015-02-I-CA-8

The Torrance refinery extended the maintenance interval of the spent catalyst slide valve and the inspection interval of the pumparound heat exchanger without analyzing whether the extended operation lowered their availability (by operating them beyond their predicted safe operating life) and could result in negative safety consequences. In the event safety critical equipment is operated beyond its inspection and/or maintenance interval (e.g. extended turnaround interval), require the Torrance refinery to perform a risk evaluation (e.g. MOC or risk assessment) to identify the safety consequences of the extended operation. Require that each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation is evaluated during the risk evaluation.


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.
 

2015-02-I-CA-9

Electrostatic precipitators create potential ignition sources during normal operation, and have historically caused explosions within the refining industry. At the Torrance refinery, require a siting risk analysis be performed of the FCC unit electrostatic precipitator and implement appropriate safeguards to minimize the consequences of an electrostatic precipitator explosion.


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.
 

Valero Refinery Propane Fire (1 Recommendations)
Valero Energy Corporation (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 09, 2008

2007-5-I-TX-6

Establish corporate requirements for written freeze protection programs at Valero refineries subject to freezing temperatures, including identification, mitigation, MOC, and audit 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

US Ink Fire (1 Recommendations)
US Ink/Sun Chemical Corporation (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 15, 2015

2013-01-I-NJ-7

Revise the Capital Appropriations/Asset Request (CAR) form procedure for new installations and modifications to existing equipment to require at a minimum the following:

  • Process hazard analysis (PHA)
  • Management of change (MOC)
  • Review of engineering drawings for permits
  • Safety management of contractors
  • Training of plant operators based on applicable dust collection system guidelines and standards, including NFPA 91 and 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.
 

PDF Document Recommendations Status Change Summary

 
 
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