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.

To contact CSB Recommendations Staff please email [email protected] 

 

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Recommendations

Givaudan Sense Colour Explosion (12 Recommendations)
Corn Refiners Association (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: May 27, 2026

2024-06-I-KY-12

Alert association members who manufacture corn syrup of the November 12, 2024, Givaudan incident and its causes, including but not limited to the sugar ingredient decomposition reaction that led to Reactor 6’s rupture. Request that they update their corn syrup safety data sheets to include: the decomposition temperature, the consequences of exceeding that temperature, and the decomposition products produced (for example, carbon dioxide).


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.
 

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Givaudan - Corporate (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: May 27, 2026

2024-06-I-KY-8

Create and fill a corporate senior leadership position responsible for overseeing process safety at all Givaudan caramel coloring facilities or identify a current senior leader who is competent in process safety management concepts to fill this role. Establish this senior leader’s job duties to oversee the process safety management system implementation at all Givaudan caramel coloring facilities. Assign this individual to develop corporate-level process safety management system policies to ensure consistent development and implementation of process safety management systems at all Givaudan caramel coloring facilities. One of the policies will address training operations personnel on defined safe operating limits and actions to take if those limits are exceeded.


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 Recommendation Status Change Summary

Givaudan Caramel Coloring Facilities (7 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: May 27, 2026

2024-06-I-KY-1

Contract a third party to analyze the reactivity of the sugar ingredients in the caramel coloring product manufacturing process by, at a minimum:

a. Conducting calorimetry testing on at least one representative recipe for all caramel coloring product types to determine their temperature and pressure behavior upon heating.

b. Testing the composition of any produced non-condensable gases.

Maintain this information for use during future equipment design efforts and hazard analyses.


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.
 

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2024-06-I-KY-2

Contract a third party to conduct a hazard analysis of each caramel coloring facility. Require this analysis to address reactivity hazards and include a review of the reactivity data obtained from implementing CSB Recommendation 2024-06-I-KY-R1. Implement the recommendations issued by the third party as a result of the hazard analyses.


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 Recommendation Status Change Summary

2024-06-I-KY-3

Contract a third party to develop a process safety management system to be used at each caramel coloring facility. This third party shall:

a. Ensure the process safety management system is in alignment with current industry guidance such as the CCPS’s Guidelines for Risk Based Process Safety.

b. Ensure that the process safety management system requires hazard reviews/analyses to be conducted at prescribed intervals and include:

(1) the review/incorporation of reactivity data from CSB Recommendation 2024-06-I-KY-R1 and any additional reactivity data obtained during the course of operating any caramel coloring facility,

(2) the review/analysis of any process changes that could affect relief system designs, and

(3) the review/updating of the facility siting study from CSB Recommendation 2024-06-I-KY-R7, as appropriate.


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 Recommendation Status Change Summary

2024-06-I-KY-4

At each caramel coloring facility, hire a new or identify a current employee who is competent in process safety management concepts. Establish this employee’s job duties to specifically include overseeing the caramel coloring facility’s process safety management system established in 2024-06-I-KY-R3, its implementation, and personnel training on the system’s elements.


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 Recommendation Status Change Summary

2024-06-I-KY-5

For each caramel coloring facility, contract a third party to design adequate emergency pressure relief systems for the vessels involved in caramel coloring manufacturing. Ensure the third party reviews/incorporates all reactivity data obtained from the testing required by CSB Recommendation 2024-06-I-KY-R1 when designing the emergency pressure relief systems. Document and maintain each vessel’s relief system design basis for the service life of the vessel.


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 Recommendation Status Change Summary

2024-06-I-KY-6

For each caramel coloring facility, establish automatic alerts, such as alarms or control screen indications, to notify operators when a safe operating limit has been reached. Follow industry guidance, such as the guidance presented in the Center for Chemical Process Safety Book Guidelines for Engineering Design for Process Safety (2nd Edition), Chapter 5 General Design. Provide initial and refresher training for operations personnel on the established safe operating limits including the actions to take if these limits are exceeded.


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.
 

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2024-06-I-KY-7

Contract a third party to conduct a facility siting study before constructing caramel coloring facility(ies) to help protect facility occupants and critical equipment from hazards created by explosion, fire, or toxic material release, using published industry guidance, such as that in the Center for Chemical Process Safety book, Guidelines for Siting and Layout of Facilities.


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.
 

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International Molasses Corporation LTD (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: May 27, 2026

2024-06-I-KY-11

Update all invert sugar safety data sheets to include: the decomposition temperature, the consequences of exceeding that temperature, and the decomposition products produced (for example, carbon dioxide).


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 Recommendation Status Change Summary

International Technical Caramel Association (ITCA) (2 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: May 27, 2026

2024-06-I-KY-9

Publish a technical safety bulletin for caramel coloring manufacturing that encourages caramel color manufacturers to ensure known hazards, including sugar ingredient decomposition, are addressed. Emphasize the importance of obtaining information on calorimetric properties of sugar ingredients and ensuring appropriately sized emergency pressure relief systems to safely vent pressure and gases that could be produced by sugar ingredient decomposition reactions, as well as other overpressure scenarios identified in hazard analyses. Refer caramel color manufacturers to the CSB’s investigation report for additional details. Recommend in the technical safety bulletin that caramel coloring manufacturers implement, as appropriate, process safety management systems that are in alignment with local requirements and chemical industry good practice guidance, such as the Center for Chemical Process Safety 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.
 

PDF Document Recommendation Status Change Summary

2024-06-I-KY-10

Alert association members that manufacture caramel coloring of the November 12, 2024, Givaudan incident and its causes, including but not limited to the sugar ingredient decomposition reaction that led to Reactor 6’s rupture.


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 Recommendation Status Change Summary

PEMEX Deer Park Chemical Release (2 Recommendations)
American Society of Mechanical Engineers (ASME) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: February 23, 2026

2024-05-I-TX-4

Develop written guidelines for marking equipment for opening. The guidelines should define a standard practice for equipment marking that includes clear identifiers of the area to be opened and means to remove the markings at the conclusion of the work.


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 Recommendation Status Change Summary

PEMEX Deer Park (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: February 23, 2026

2024-05-I-TX-3

Establish a conduct of operations system that establishes and enforces behavioral and performance metrics in accordance with CCPS’s Conduct of Operations and Operational Discipline. The system should include:

a) the management commitment to process safety,
b) employee input on policies and procedures,
c) methods to ensure that policies and procedures can be effectively followed, to include, at a minimum:

1) permitting,

2) equipment marking, and

3) energy isolation procedures, and

d) regular audits to verify adherence to conduct of operations metrics, to include, at a minimum:

1) performance expectations,

2) training,

3) management visibility,

4) leadership by example, and

5) worker knowledge and awareness.


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 Recommendation Status Change Summary

Cuisine Solutions Ammonia Release (3 Recommendations)
Cuisine Solutions Inc. Sterling Site (3 Recommendations)
Open: 67% | Closed: 33%
View Investigation
Final Report Released On: September 25, 2025

2024-03-I-VA-4

Implement an electronic process data historian and management system to ensure that critical process parameters are collected, tracked, and stored. The system should be available to refrigeration technicians so that they can monitor the refrigeration system and respond to and investigate process upsets.


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

2024-03-I-VA-5

Update the Cuisine Solutions Sterling site’s Emergency Action Plan using guidance such as the IIAR’s Critical Task Guidance for Ammonia Refrigeration System Emergency Planning. At a minimum, the updated plan should:

a. Address indoor and outdoor ammonia releases separately, including the distinct alarms and responses to them;

b. Clearly specify appropriate evacuation routes and muster points, including alternates;

c. Provide guidance for using windsocks to remain upwind of a release during evacuation;

d. Implement shelter-in-place strategies, emergency protective equipment, and emergency shutdowns, as appropriate; and

e. Include requirements to conduct annual ammonia release drills that include all onsite personnel (including corporate employees). The annual drills should include separate indoor and outdoor ammonia release scenarios and address the use of windsocks to assist with determining evacuation routes, alternate evacuation routes, muster points, and consideration for the decision to shelter-in-place. Additionally, the drills should exercise each evacuation alarm, emergency protective equipment, and emergency shutdowns, where appropriate.


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

2024-03-I-VA-6

Add an alarm or alarms specific to ammonia releases, so that workers can properly respond to a release. The alarm response should be documented in the updated Emergency Action Plan, and may include multiple distinct alarms and responses, such as one for shelter-in-place and one for evacuation.


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

Intercontinental Terminals Company (ITC) Tank Fire (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 06, 2023

2019-01-I-TX-6

Update API STD 2610, Design, Construction, Operation, Maintenance, and Inspection of Terminal and Tank Facilities, or other appropriate products to include flammable gas detection systems within the leak detection section or where appropriate. The discussion of flammable gas and/or leak detection should address both engineering and administrative controls, including actions associated with responding to a catastrophic or emergency leak.


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

PDF Document Recommendation Status Change Summary

Husky Energy Superior Refinery Explosion and Fire (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: December 29, 2022

2018-02-I-WI-15

Incorporate lessons learned from the FCC Unit Explosion and Asphalt Fire at Husky Superior Refinery incident into the appropriate API products (for example, API RP 2023, Guide for Safe Storage and Handling of Heated Petroleum-Derived Asphalt Products and Crude Oil Residua, or API RP 2021, Management of Atmospheric Storage Tank Fires). At a minimum, topics shall include the flammability of heated material such as asphalt and the ignition risk of pyrophoric material inside asphalt storage tanks. Include a reference to this CSB investigation in the document’s bibliography.


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

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Foundation Food Group Fatal Chemical Release (1 Recommendations)
Messer LLC (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 11, 2023

2021-03-I-GA-3

Create an informational product that provides Messer customers with information on the safety issues described in this report. In this informational product, recommend that Messer customers develop and implement effective safety management systems to control asphyxiation hazards from inert gases based on the guidance published in CGA P-86 Guideline for Process Safety Management, CGA P-12 Guideline for Safe Handling of Cryogenic and Refrigerated Liquids, CGA P-18 Standard for Bulk Inert Gas Systems, and CGA P-76 Hazards of Oxygen-Deficient Atmospheres.


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