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

Cuisine Solutions Ammonia Release (6 Recommendations)
Cuisine Solutions Inc. Sterling Site (4 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: September 25, 2025

2024-03-I-VA-3

Reduce the likelihood or mitigate the consequences of liquid or two-phase atmospheric discharges from the ammonia refrigeration emergency pressure relief system at the Sterling plant. At a minimum:

a. Identify liquid or two-phase release scenarios, particularly for horizontal surge drums and other vessels containing saturated liquid with little vapor space;

b. Implement engineering controls to reduce the likelihood of high liquid level, overfill, or boiling overpressure scenarios;

c. Implement engineering controls to mitigate the consequences of these scenarios where their likelihood cannot be acceptably reduced, such as through emergency pressure control systems, atmospheric knockout drums, or automatic shutdown systems; and

d. Contract a competent third party to audit the pressure relief systems. The audit should ensure that (i) all relevant relief scenarios have been identified, (ii) preventive and mitigative engineering controls adequately address the hazards, and (iii) engineering controls are maintained in such a way that they function properly when required.


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

2024-03-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: 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

2024-03-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 - 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

2024-03-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 - 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 Institute of All-Natural Refrigeration (IIAR) (2 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: September 25, 2025

2024-03-I-VA-1

Update ANSI/IIAR 2 to include guidance for preventing or mitigating liquid or two-phase atmospheric discharges from emergency pressure relief systems, such as the guidance in API Standard 521, Pressure-relieving and Depressuring Systems. At a minimum, the guidance should:

a. Identify at-risk scenarios such as horizontal surge vessels and other vessels containing saturated liquid with little vapor space;

b. Address design considerations and controls to reduce the likelihood of identified scenarios leading to overpressure or equipment failure and ensure vapor-liquid disengagement (the separation of vapor from liquid) during pressure relief for identified scenarios; and

c. Require mitigative safeguards in cases where vapor-liquid disengagement during pressure relief cannot be reliably ensured. This should also include alternative disposal systems where applicable.


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

2024-03-I-VA-2

Update ANSI/IIAR 2 to include a requirement to assess whether emergency pressure relief devices discharge to a safe location, such as with a dispersion analysis.


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

Yenkin-Majestic Resin Plant Vapor Cloud Explosion and Fire (5 Recommendations)
Yenkin-Majestic/OPC Polymers (5 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: November 30, 2023

2021-04-I-OH-1

Update mechanical integrity procedures for all process vessels in highly hazardous chemicals service, including pressure vessels not exceeding 15 psig, to adopt alteration guidance in API 510 Pressure Vessel Inspection Code or Part 3 of the National Board Inspection Code.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Recommendation Status Change Summary

2021-04-I-OH-2

Assess and document applicable design, construction, and alteration standards for all pressure vessels in highly hazardous chemicals service in new resin plant designs, including pressure vessels not exceeding 15 psig. At a minimum, adopt PIP VESLP001 Low-Pressure, Welded Vessel Specification as design and construction guidance for pressure vessels not exceeding 15 psig. Implement a program to assess the pressure vessels against updated applicable recognized and generally accepted good engineering practices, such as those published by API, ASME, PIP, and other organizations, at least once every five years, and address the gaps identified. Develop and implement written procedures to document and maintain records of (i) all inspections of, (ii) all alterations to, and (iii) all maintenance and repairs on all pressure vessels in highly hazardous chemicals service.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Recommendation Status Change Summary

2021-04-I-OH-3

Demonstrate the use of prevention through design using the hierarchy of controls in future resin plant designs. Specifically, prioritize inherently safer design and engineering controls to prevent process safety events. Refer to sources such as Safety Instrumented Systems: A Life-Cycle Approach by P. Gruhn and S. Lucchini, Human Error in Process Plant Design and Operations – A Practitioner’s Guide by J. Robert Taylor, Guidelines for Preventing Human Error in Process Safety by the Center for Chemical Process Safety (CCPS), Guidelines for Inherently Safer Chemical Processes – A Life Cycle Approach by the CCPS, and Guidelines for Risk Based Process Safety by the CCPS for guidance. Demonstration could include documentation of conceptual design safety reviews, hazard analysis and risk assessments of detailed project designs, and a plan to address the recommendations to control the hazards.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Recommendation Status Change Summary

2021-04-I-OH-4

Identify and document all equipment that could release flammable materials and install LEL detectors in accordance with sources and guidance such as Guidelines for Engineering Design for Process Safety by the Center for Chemical Process Safety and Explosion Hazards in the Process Industries by Rolf K. Eckhoff. Ensure that detection of hazardous conditions automatically triggers both visual and audible alarms to alert plant personnel of the hazard. Develop and implement employee training on actions to take, such as prompt evacuation, when such alarms are activated.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Recommendation Status Change Summary

2021-04-I-OH-5

Develop and implement requirements for personnel to wear flame-resistant uniforms in all operating areas that process flammable chemicals. Update employee training material to include the requirement for and purpose of PPE use.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Recommendation Status Change Summary

Evergreen Packaging Paper Mill - Fire During Hot Work (1 Recommendations)
Universal Blastco (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 24, 2021

2020-07-I-NC-6

Update the Universal Blastco hot work policy and employee training program to specifically identify the use of heat guns as hot work. The policy and programs should make clear that hot work encompasses any method of work that can ignite a fire and not just spark- or flame-producing work methods.


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

Didion Milling Company Explosion and Fire (7 Recommendations)
Didion Milling, Inc. (7 Recommendations)
Open: 43% | Closed: 57%
View Investigation
Final Report Released On: December 06, 2023

2017-07-I-WI-1

Contract a competent third party to develop a comprehensive combustible dust process safety management system, such as OSHA’s Process Safety Management standard or the requirements in the 2019 edition of NFPA 652, Standard on the Fundamentals of Combustible Dust, Chapter 8, which includes, at a minimum, the following elements:

a. Management of Change for combustible dust;

b. Process Safety Information Management;

c. Management of Audits and Inspections;

d. Fugitive Dust Management;

e. Incident Investigation;

f. Dust Hazard Analyses;

g. Management of Engineering Controls for combustible dust

h. Personal Protective Equipment; and

i. Emergency Preparedness.


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

2017-07-I-WI-4

Contract a competent third party to assess and implement engineering controls for the structural design and venting requirements of the reconstructed facility to ensure they meet the requirements and guidance in NFPA 68, Standard on Explosion Protection by Deflagration Venting, for adequacy of venting capacity.


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

2017-07-I-WI-5

Incorporate recording any paper-based process safety information into Didion’s existing electronic records management system so that the information can be reliably retained, retrieved, and analyzed in the event of a catastrophic incident.


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

2017-07-I-WI-6

Contract a competent third party to perform personal protective equipment hazard analyses, such as those prescribed by NFPA 2113, Standard on Selection, Care, Use, and Maintenance of Flame-Resistant Garments for Protection of Industrial Personnel Against Short-Duration Thermal Exposures from Fire, and require appropriate flame-resistant garments for all operations that handle combustible dusts during normal and upset conditions.


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

2017-07-I-WI-7

Contract a competent third party to update the facility emergency response plan and train all employees on updated emergency response plan. The update should include the guidance in NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, and NFPA 652, Standard on the Fundamentals of Combustible Dust, Chapter 8 and Section A.8.10.1, which includes, at a minimum, the following elements:

a. A signal or alarm system;

b. Emergency shutdown procedures; 

c. Provide instructions for when and how to trigger emergency evacuations;

d. Provide instructions for when to notify emergency responders for need of assistance;

e. Response to potential fire scenarios, such as smoldering fires inside equipment; and

f. Prevent firefighting of process fires inside equipment.


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

2017-07-I-WI-8

Contract a competent third party to assess and update the pre-deflagration detection and suppression engineering controls, such as those discussed in Chapter 9 of the 2019 edition of NFPA 69, Standard on Explosion Prevention Systems, for adequacy to detect and alarm employees of an emergency situation, such as a smoldering fire, and trigger an 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

2017-07-I-WI-9

Contract a competent third party to develop and implement a process safety leadership and culture program, based on the guidance of the CCPS’s Guidelines for Auditing Process Safety Management Systems and Process Safety: Leadership from the Boardroom to the Frontline. The program should include, at a minimum, the following elements:

a. A process safety policy;

b. A process safety leadership and culture committee;

c. Appropriate goals for process safety;

d. A commitment to process safety culture;

e. Leading and lagging process safety metrics;

f. Process Safety Culture Assessments; and,

g. Engagement with external process safety leadership and culture experts.


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

PDF Document Recommendation Status Change Summary

Aghorn Operating Inc. Waterflood Station Hydrogen Sulfide Release (1 Recommendations)
Aghorn Operating Inc. (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: May 21, 2021

2020-01-I-TX-7

For all waterflood stations where the potential exists to expose non-employees to H2S concentrations at or above 10 ppm, develop and implement a formal, written, site-specific security program to prevent unknown and unplanned entrance of those not employed by Aghorn, starting with a requirement for employees to lock access gates upon entering and departing the facility.


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