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statistics

Total # of Recommendations
794
Total # of Open Recommendations
172
Total # of Closed Recommendations
622
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
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

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

Final Report Released On: January 28, 2015

2012-03-I-CA-1 URGENT!

At all Chevron U.S. refineries, engage a diverse team of qualified personnel to perform a documented damage mechanism hazard review. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure safeguards are in place to control hazards presented by those damage mechanisms. Analyze and incorporate into this review applicable industry best practices, Chevron Energy Technology Company findings and recommendations, and inherently safer systems to the greatest extent feasible.


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

MFG Chemical Inc. Toxic Gas Release (1 Recommendations)
City of Dalton, GA (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 11, 2006

2004-9-I-GA-9

Revise fire department and police department procedures and training to clearly define facility and evacuation zone access control responsibilities when hazardous chemicals are involved or suspected in an emergency.


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 Company, Inc. (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 28, 2016

2014-01-I-WV-2

Establish requirements for all American Water state utilities’ surface water treatment plants to undertake the following activities:

1. Conduct an inventory of all hazardous chemicals or classes of hazardous chemicals that are considered a potential source of significant contamination stored in the utility’s most vulnerable source water protection area (e.g., Zone of Critical Concern). Chemicals may be identified by accessing publicly available information, which may include Tier II reporting forms submitted to local emergency planning committees and electronically available information from federal, state or local databases.

2. For each inventoried chemical or class of chemicals, conduct a prioritized assessment to determine if existing analytical methods are available to detect the presence and/or concentration of the chemical or class of chemicals in the event of a release to the water supply and if the chemical or class of chemicals is capable of being treated or removed by the utility’s water treatment process.

3. For all chemicals or classes of chemicals that are not capable of being treated or removed by the treatment process, develop a contingency plan to respond to contamination events (e.g., as modeled by WVAW’s Kanawha Valley Water System June 2016 Source Water Protection Plan).


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

AirGas Facility Fatal Explosion (6 Recommendations)
ACD, LLC (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2017

2016-04-I-FL-5

Provide effective warning about nitrous oxide decomposition hazards

Modify nitrous oxide pump product literature to include warnings about nitrous oxide decomposition hazards, illustrated by examples from historical incidents, and refer users to this CSB investigation report for additional information.


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.
 

Air Liquide (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2017

2016-04-I-FL-1

The goal of 2016-04-I-FL-R1 is to prevent all nitrous oxide explosions at its facilities, while preventing harm to workers and the public.

Following the August 28, 2016, incident, the company began a comprehensive initiative to review its nitrous oxide production facilities, trucking fleet, and cylinder-filling operations.  The scope of the ongoing Air Liquide initiative is shown in Table 1. 

Complete the development and implementation of the company’s nitrous oxide business process safety initiative as shown in Table 1, consistent with the findings, conclusions, and recommendations contained in this 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.
 

PDF Document Table 1

Compressed Gas Association (CGA) (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2017

2016-04-I-FL-2

Safety Management System for Nitrous Oxide Manufacturing

Develop and implement a safety management system standard for nitrous oxide manufacturing, to manage known process safety hazards, including nitrous oxide decomposition, which includes appropriate elements based on chemical industry good practice guidance, such as CCPS Guidelines for Risk Based Process Safety, Essential Practices for Managing Chemical Reactivity Hazards, and Guidelines for Implementing Process Safety 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.
 

2016-04-I-FL-3

Ensure Effective Flame Arrestor Design

Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to require testing of safety devices, such as strainers used as flame arrestors, for applications where a safety device is used to quench a nitrous oxide decomposition reaction.  To ensure that these safety devices meet the intended purpose, the user should test the safety device by simulating conditions of use.  In addition, require users to document the required performance standard or test protocol followed. 


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.
 

2016-04-I-FL-4

Require Pump Run-Dry Safety Interlocks Apply ISA-84

Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to reference and require applying International Society of Automation (ISA) standard ISA-84, Functional Safety: Safety Instrumented Systems for the Process Industry Sector to safety interlocks such as the nitrous oxide pump “run-dry” shutdown.


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.
 

Cryostar USA, LLC (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2017

2016-04-I-FL-6

Provide effective warning about nitrous oxide decomposition hazards

Modify nitrous oxide pump product literature to include warnings about nitrous oxide decomposition hazards, illustrated by examples from historical incidents, and refer users to this CSB investigation report for additional information.


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.
 

Xcel Energy Company Hydroelectric Tunnel Fire (6 Recommendations)
RPI Coating, Inc. (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-15

Ensure that all journeyman painters have received safety training equivalent in content to that covered in the Joint Apprenticeship program. At a minimum, address confined space safety, safe handling of flammables, emergency response and rescue, and fire prevention.


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

Xcel Energy, Inc. (5 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-8

Revise your policies for solicitation and procurement of construction services to

a. Ensure that requests for proposals (RFPs) and selection processes include criteria and procedures for prequalifying or disqualifying contractors based on specific safety performance measures and qualifications.

b. Implement written verification procedures for the safety information and documentation submitted by contractors during the bidding and selection process.


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

2008-01-I-CO-9

Revise your contractor safety policies to require a comprehensive review and evaluation of contractor safety policies and procedures such as the permit-required confined space program and safety performance of contractors working in confined spaces to ensure that any bidding contractor meets or exceeds Xcel Energy safety 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

2008-01-I-CO-10

Conduct periodic safety audits of contractor selection and oversight at your power-generating facilities to ensure adherence to corporate contractor procurement and safety policies.


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

2008-01-I-CO-11

Report key findings, causes and recommendations of the CSB report to Xcel shareholders so that the owners of Xcel are fully informed of the report contents and how Xcel intends to prevent a similar accident in the future.


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

2008-01-I-CO-12

Revise your confined space entry program and practices. At a minimum

a. Require continuous monitoring for flammable atmospheres at appropriate locations and elevations within a confined space where work activities involve the use of flammables or where flammable atmospheres may be created.

b. Prohibit entry or require evacuation of a confined space if the atmospheric concentration of flammable vapors is 10 percent of the LEL or higher.

c. Ensure that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Ensure that such spaces are monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working.

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

e. Ensure the implementation of a written confined space rescue preplan for each designated permit space. Address staging and methods of rescue for each designated permit space including whether a rescue team is required to standby 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 - 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

Williams Olefins Plant Explosion and Fire (3 Recommendations)
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 - 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

2013-3-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 - 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

2013-3-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 - 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

 
 
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