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statistics

Total # of Recommendations
809
Total # of Open Recommendations
163
Total # of Closed Recommendations
646
Total % of Open 20 vs. Closed 80

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
MGPI Processing, Inc. Toxic Chemical Release (5 Recommendations)
Atchison County Department of Emergency Management (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 03, 2018

2017-01-I-KS-5

Coordinate planning and training activities to ensure emergency responders within Atchison County are prepared for future incidents involving hazardous materials. The Atchison County Local Emergency Planning Committee should do the following:

a) Review facility Risk Management Plans as they are submitted or revised and conduct pre-planning at Risk Management Program covered facilities and all other facilities within the county that, based on annual Tier II reporting forms, store large amounts of hazardous chemicals.

b) Conduct a full-scale hazardous materials exercise that involves an offsite chemical release scenario within the next three years. The exercise should include participants from local emergency response organizations, hospitals, schools, and fixed facilities. Identify and resolve coordination or communication issues identified during the exercise.

c) Increase participation in state and regional emergency response training and programs. Work with the Kansas Department of Emergency Management to submit a Hazardous Materials Emergency Preparedness (HMEP) grant proposal to assist in funding additional training and pre-planning activities within the county.


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.
 

Harcros Chemicals (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 03, 2018

2017-01-I-KS-3

Establish a refresher training program to ensure drivers know the location of various CTMV emergency shut-off devices, when to use them, and the effectiveness of those devices to stop the flow of chemicals during emergencies. The refresher training program should include drills for drivers to simulate the activation of all shut-off devices in defined incident scenarios (e.g., inadvertent mixing, chemical releases, etc.) during unloading operations. Establish a process to evaluate the effectiveness of the refresher training 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.
 

2017-01-I-KS-4

Establish a process whereby the respiratory hazards associated with chemical unloading at customer sites are evaluated. The evaluations should, at a minimum, determine whether drivers need emergency escape respirators in the event of an accidental reaction and/or release of chemicals. If the results of the evaluations indicate that respiratory protection is needed, provide the equipment and training for such protection as appropriate. The equipment and training should be provided in accordance with OSHA’s Respiratory Protection Standard (29 C.F.R § 1910.134). The equipment should also be stored in an area that allows for immediate access.


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.
 

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

Final Report Released On: January 03, 2018

2017-01-I-KS-1

Commission an independent engineering evaluation of the Mod B building and ventilation system and, based on the results of that evaluation, implement design changes and controls to protect occupants from a chemical release. At a minimum, the evaluation should assess the effectiveness of the building ventilation system, indoor and outdoor sources of chemicals, air intake locations, contaminant control methods such as filtration and removal, contaminant monitoring devices, and automation. The engineering evaluation of the ventilation system should consider airborne contaminants during normal operations as well as spills, releases, and chemicals produced from unintended reactions and inadvertent mixing.


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.
 

2017-01-I-KS-2

Conduct an evaluation of the Mod B chemical transfer equipment (e.g., fill lines, transfer valves, transfer piping, tanks and other associated equipment) and install appropriate engineering safeguards to prevent and mitigate an unintended reaction, chemical release, or spill during bulk unloading. Where feasible, install safeguards, such as alarms and interlocks, to prevent personnel from opening the incorrect chemical transfer valves during deliveries. In addition, install mitigation measures to automatically shut down the transfer of chemicals into the facility based on process deviations or abnormal conditions (e.g., pressure, temperature, flow or level indications; gas detection).


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 Refinery Explosion (2 Recommendations)
American Fuel and Petrochemical Manufacturers (1 Recommendations)
Open: 0% | Closed: 100%

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: 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

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

Final Report Released On: May 03, 2017

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: 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 Refinery Fatal Explosion and Fire (1 Recommendations)
Tesoro Anacortes Refinery (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2014

2010-08-I-WA-15

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

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

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

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

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

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

 


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

PDF Document Recommendations Status Change Summary

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

Final Report Released On: January 28, 2015

2012-03-I-CA-33

Develop a method to assign accountability at Chevron to determine whether any whether any new Energy Technology Company (ETC) recommended program or industry best practice, such as API guidance must be followed to ensure process safety or employee personal safety.  This method shall include monitoring of these practices and guidance at a refining system level and at the refinery level.  Develop a tracking system to monitor the progress of implementing these selected practices and guidance to completion.


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

2012-03-I-CA-34

Develop an auditable process to be available for all recommended turnaround work items necessary to address mechanical integrity deficiencies or inspection recommendations that are denied or deferred.  This process shall provide the submitter of the denied or deferred recommendation with the option to seek further review by his or her manager, who can further elevate and discuss the recommendation with higher level management, such as the Area Business Unit Manager.  Maintain an auditable log of each of these potential turnaround work items, including the ultimate determination of approval, deferral, or rejection, justification determination, and the person or team responsible for that decision.


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

Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire (2 Recommendations)
Environmental Protection Agency (EPA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 17, 2013

2011-06-I-HI-9

Revise the Resource Conservation and Recovery Act (RCRA) Subtitle C regulations to require a permitting process with rigorous safety reviews to replace the use of emergency permits under 40 CFR §270.61 for the disposal of explosive hazardous materials, including fireworks. At a minimum, the new process should require the use of best available technology, safe disposal methodologies, as well as safety management practices, such as those required by OSHA’s Process Safety Management Standard (PSM), 29 CFR §1910.119 (e.g., hazard analysis and control, management of change).


Status: 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

2011-06-I-HI-10

Until recommendation 2011-06-I-HI-R9 can be implemented, develop and issue a policy guidance document to provide a regulatory process with rigorous safety reviews to replace the use of emergency permits under 40 CFR §270.61 for the disposal of explosive hazardous materials, including fireworks. At a minimum, the new process should require the use of best available technology, safe disposal methodologies, as well as safety management practices, such as those required by OSHA’s Process Safety Management Standard (PSM), 29 CFR §1910.119 (e.g., hazard analysis and control, management of change). Ensure its effective communication to all EPA regional administrators, state environmental agencies, and organizations within the fireworks industry


Status: 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

Macondo Blowout and Explosion (2 Recommendations)
U.S. Department of the Interior (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 20, 2016

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: 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

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: 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

Kleen Energy Natural Gas Explosion (1 Recommendations)
American Society of Mechanical Engineers (ASME) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 28, 2010

2010-07-I-CT-3 URGENT!

Make appropriate changes to the 2012 version of Power Piping, ASME B31.1, to require the use of inherently safer fuel gas piping cleaning methodologies rather than natural gas blows. At a minimum, for the cleaning or flushing methods discussed in B31.1 paragraph 122.10, require the use of inherently safer alternatives such as air blows and pigging with air as the motive force in lieu of flammable gas.


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 Recommendation Status Change Summary

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

Final Report Released On: November 02, 2006

2006-2-I-DE-6

Revise Guidelines for Safe Work in Inert Confined Spaces in the Petroleum and Petrochemical Industries (API, 2005) to clearly address the following: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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

PDF Document Recommendations Status Change Summary

 
 
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