Recent Recommendation Status Updates

Open: 75% | Closed: 25%

Final Report Released On: March 13, 2025

2024-01-I-CA-1

Implement engineering safeguards to detect and prevent afterburning in the fired heater involved in the November 19, 2023, incident. The safeguards may include the use of instrumentation such as combustibles measurements, flame detectors, and/or thermocouples that measure tube metal, flue gas, and process fluid temperatures. The safeguards shall be capable of being monitored from the control room.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2024-01-I-CA-2

For the fired heater involved in the incident, after Marathon Petroleum Corporation’s “Process Heater Not-to-Exceed (NTE) Limits and Alarms” standard is updated according to 2024-01-I-CA-R5, implement tube metal temperature alarming consistent with corporate guidance to alert operators when safe operating limits are exceeded and to specify predetermined response actions, such as shutting down the fired heater remotely. The predetermined response actions must include actions that specify when to stop troubleshooting and remove personnel from the vicinity of the fired heater.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2024-01-I-CA-3

Implement changes to improve Walk the Line performance at the Martinez facility by ensuring that the facility’s practices are consistent with tools in the AFPM Safety Portal and guidance in Marathon Petroleum Corporation’s refining reference document titled Operations Excellence. At a minimum:

1. Require that operator field walkdowns ensure that valves are correctly aligned before all unit startup activities from planned or unplanned shutdowns, such as those due to non-normal operations, emergencies, turnarounds, and major maintenance;

2. Improve policies and practices for communications among and between shifts to ensure that operators understand abnormal line-ups in their units; and

3. Reinforce Walk the Line concepts, including the expectation for only trained operators to control valve line-ups at their units, through training for all levels of management in the Operations department.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2024-01-I-CA-4

Complete a comprehensive gap assessment of the Martinez facility against Marathon Petroleum Corporation policies. At a minimum, address the following policies:

a. Operating Limits;

b. Process Hazard Analysis; and

c. PSM/RMP Refining Operating Procedures.

Develop and implement action items to effectively address findings from the assessment.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

Open: 100% | Closed: 0%

Final Report Released On: March 13, 2025

2024-01-I-CA-5

Update the corporate “Process Heater Not-to-Exceed (NTE) Limits and Alarms” standard with tube metal temperature alarming guidance to alert operators when safe operating limits are exceeded and to specify predetermined response actions, such as shutting down the fired heater remotely. The predetermined response actions must include actions that specify when to stop troubleshooting and remove personnel from the vicinity of the fired heater.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2024-01-I-CA-6

Update the corporate “Heater Application Standard” with the following requirements:

1. Requirements for protecting fired heaters from low process flow where process piping diverges downstream of a flow meter. Requirements may include achieving proof of flow to the heater through valve position indicators and interlocks on branch connections downstream of flow meters to prevent backflow, reverse flow, or other diverted flow scenarios that could defeat the safety instrumented system; and

2. Engineering safeguard requirements to detect and prevent afterburning in fired heaters. The safeguards may include the use of instrumentation such as combustibles measurements, flame detectors, and/or thermocouples that measure tube metal, flue gas, and process fluid temperatures. The safeguards shall be capable of being monitored from the control room.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2024-01-I-CA-7

Confirm the results of the Martinez facility’s comprehensive gap assessment required in 2024-01-I-CA-R4. Upon completion, conduct an Operations Excellence full assessment on the Martinez facility. Develop and implement action items to effectively address findings from the assessment.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

Open: 0% | Closed: 100%

Final Report Released On: December 21, 2022

2018-03-I-TX-5

Review the Center for Chemical Process Safety guidance on recognizing catastrophic incident warning signs and then develop and implement a program for the EVAL Plant that incorporates warning signs into its safety management system.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

2018-03-I-TX-12

Acquire the services of an independent third party to perform a comprehensive assessment of its EVAL Plant’s process safety management systems. In addition to meeting the requirements outlined in Appendix B of this report, this comprehensive assessment should evaluate whether existing policies meet minimum federal process safety regulatory requirements and apply the Center for Chemical Process Safety model to verify both the suitability of these systems and their effective, consistent implementation.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

Open: 0% | Closed: 100%

Final Report Released On: July 06, 2023

2019-01-I-TX-1

Develop and implement a process safety management system for the ITC Deer Park terminal applicable to all atmospheric storage tanks and associated equipment in highly hazardous chemical service. The program should follow industry guidance provided in publications such as the American Petroleum Industry's API STD 2610, Design, Construction, Operation, Maintenance, and Inspection of Terminal and Tank Facilities and the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety.

Status: Closed - Acceptable Action
Recommendation Status Change Summary

Open: 0% | Closed: 100%

Final Report Released On: December 29, 2022

2018-02-I-WI-16

Participate in the API committee that develops a technical publication for the safe operation of FCC units.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

Open: 100% | Closed: 0%

Final Report Released On: May 27, 2025

2023-02-I-LA-1

Perform a comprehensive third-party audit of the Geismar facility’s process safety and allied management systems as soon as practicable. The audit shall:

A. Be performed or led by an individual, firm, or team meeting the requirements outlined in paragraphs (b), (c), and (d) of Appendix E of this report.

B. Evaluate compliance with applicable federal standards (40 C.F.R. § 68 and 29 C.F.R. § 1910.119). In particular, the audit shall include the required elements that contributed to these incidents, including but not limited to:

1. management of change;
2. mechanical integrity;
3. quality assurance;
4. pre-startup safety reviews;
5. operating procedures; and
6. contractor management.

C. Evaluate other internal management systems that contributed to these incidents. In particular, the audit shall include but not be limited to:

1. management of organizational and personnel change;
2. management of safety-related capital projects;
3. organizational resilience; and
4. safe work practices including, but not limited to:

a. work permitting;
b. preparation of equipment for maintenance;
c. control of hazardous energy;
d. line break safety; and
e. personal protective equipment.

D. Use the Center for Chemical Process Safety’s Guidelines for Auditing Process Safety Management Systems as guidance to verify both the suitability of these systems and their effective, consistent implementation and performance.

E. Result in the development of a comprehensive report meeting the requirements outlined in paragraphs (e) and (f) of Appendix E of this report. If any findings are rejected, the rationale for and documentation supporting the merit of the rejection shall be included. The report in its entirety shall be made available to the Honeywell workforce at the Geismar, Louisiana; Baton Rouge, Louisiana; and Metropolis, Illinois, sites.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2023-02-I-LA-2

Require periodic reporting updates from the Geismar site regarding the closure of the audit findings. The periodic updates shall continue until all audit findings are fully closed.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

2023-02-I-LA-3

Perform a Safer Technologies and Alternatives Analysis (STAA) for the Honeywell Geismar HFC-245fa unit. The STAA shall meet the requirements outlined in paragraphs (a) and (b) of Appendix F of this report.

Status: Open - Acceptable Response or Alternate Response
Recommendation Status Change Summary

Open: 0% | Closed: 100%

Final Report Released On: May 21, 2021

2020-01-I-TX-3

For all waterflood stations where the potential exists to expose workers to H2S concentrations at or above 10 ppm, commission an independent and comprehensive analysis of each facility design vis-à-vis ventilation and mitigation systems to ensure that, in the event of an accidental release, workers are protected from exposure to toxic gas levels.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

Open: 0% | Closed: 100%

Final Report Released On: April 20, 2016

2010-10-I-OS-3

Publish an offshore exploration and production safety standard for the identification and effective management of safety critical elements (SCEs)— technical, operational, and organizational— with the goal of reducing major accident risk to As Low As Reasonably Practicable (ALARP), including but not limited to:
a. development and implementation of a SCE management system that includes the minimum necessary “shall” requirements in the standard to establish and maintain effective safety barriers to prevent major accidents;
b. methodologies for (1) the identification of SCEs and (2) the development of performance standards of each SCE, including its functionality, availability, reliability, survivability, and interactions with other systems;
c. establishment of assurance schemes for continuous active monitoring of all identified SCEs throughout each SCE’s lifecycle;
d. fulfillment of independent verification requirements and use of those verification activities to demonstrate robustness of the SCE management process;
e. development of process safety key performance indicators pertaining to the effective management of SCEs to drive continuous improvement.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

Open: 0% | Closed: 100%

Final Report Released On: April 20, 2016

2010-10-I-OS-1

Augment 30 C.F.R §250 Subpart S to require the responsible parties, including the lessee, operator, and drilling contractor, to effectively manage all safety critical elements (SCEs)— technical, operational, and organizational—thereby ensuring their effective operation and reducing major accident risk to As Low As Reasonably Practicable (ALARP).  At a minimum, require the following improvements:

a. Written identification of all safety critical elements for offshore operations through hazard analysis. This list will be made available for audits and inspections performed by the responsible parties, external entities (e.g., independent competent parties, third-party auditors), and the regulator, and it will be shared among the lessee, operator, and drilling contractor. Identifying all safety critical elements shall ensure the establishment and maintenance of effective safety barriers to prevent major accidents;

b. Documented performance standards (as defined in Section 5.2 of the CSB Macondo Investigation Report Volume 2) describing the required performance of each SCE, including its functionality, availability, reliability, survivability, and interactions with other systems;

c. Augmentation of 30 C.F.R §250.1916 to include requirements for all responsible parties, including contractors, to conduct monitoring for continuous active assurance of all identified SCEs through each SCE’s lifecycle (as described in Section 5.0 of the CSB Macondo Investigation Report Volume 2);

d. Documented independent verification scheme for the identified SCEs reported to and subject to review by the regulator (as described in Section 5.5 of the CSB Macondo Investigation Report Volume 2), where:

1. the independent party meets BSEE criteria that guarantees its competence and independence from the company or facility for which it is providing verification;
2. the independent verification occurs prior to commencement of the offshore drilling or production activity and periodically, as defined by BSEE;
3. all resulting assessments of the independent verification activities will be tracked in a formal records management system; and
4. corrective action shall be taken to address negative verification findings and non-compliance. Verified noncompliance shall be tracked by the responsible party as a process safety key performance indicator and be used to drive continuous improvement.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

2010-10-I-OS-2

Publish safety guidance to assist the responsible parties in fulfillment of regulatory obligations stipulated in R1 for the identification and effective management of safety critical elements (SCEs)—technical, operational, and organizational— with the goal of reducing major accident risk to As Low As Reasonably Practicable (ALARP), including but not limited to each of the identified minimum requirements (See R1, items a-d).

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

Open: 0% | Closed: 100%

Final Report Released On: April 20, 2016

2010-10-I-OS-11

Revise and augment the offshore safety regulations, including the SEMS Rule (C.F.R. 250 subpart S), and issue guidance as it relates to those revisions/augmentations, to:
a.    Establish clear and consistent safety and environmental management responsibilities to prevent major accidents for the companies having primary control over the hazardous activities being undertaken (e.g., the owner/drilling contractor for a non-production installation and the leaseholder/operator for the production installation);
b.    Require all responsible parties as defined in R11(a) to develop documentation for each hazardous operation/facility it maintains primary control over, where the documentation demonstrates the party’s systematic analysis that risks posed by all identifiable major accident hazards are reduced to As Low As Reasonably Practicable (ALARP) or similar risk-reduction target. The documentation shall include:
1.    Identification of major hazards and the barriers and safety management systems controls (including augmented SEMS elements) that will be used to reduce risk to ALARP or similar risk reduction target;
2.    Use of the hierarchy of controls to the greatest extent feasible in establishing safety barriers and controls;
3.    Identification of safety critical elements and tasks to establish and maintain safety barriers and controls, in fulfillment of R1 (See Volume 2);
4.    Demonstrate use of established qualitative, quantitative and semi-quantitative methods in determining (1) the barriers and safety management systems necessary to achieve ALARP risk reduction levels and (2) the performance requirements of those barriers and controls (e.g., reliability, functionality, and availability) to ensure their effectiveness;
5.    Identification of all US and international standards that have been applied, or will be applied, in relation to the facility, hazardous operation, or equipment used on/in connection with the operation for which required documentation is submitted. Should the responsible party wish to use standards other than well-recognized US or international consensus safety standards developed by a representative committee of diverse stakeholders, a detailed technical justification that those standards achieve risk-reduction to ALARP must accompany submitted documentation. The regulator may challenge or reject the technical justification. Remove from the US offshore safety regulatory scheme the provisions that allow companies to substitute requirements to use the best available and safest technology with a showing of compliance with BSEE regulations.
c.    Require responsible parties as defined by R11(a) to fully implement all aspects of the documentation stipulated in R11(b) and establish a documented process to verify that all methods to manage, reduce, and control those hazards are effectively maintained throughout the lifecycle of the operation/facility.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary

2010-10-I-OS-12

Augment the capabilities and functioning of BSEE to incorporate the following proactive oversight mechanisms:
a.    Review of the documentation required to be submitted under CSB 2010-I-OS-R11(b) by technically qualified regulatory personnel who have the capability and authority to require modifications and improvements to the major hazards report as necessary, either before an acceptance process and commencement of the major hazards operation(s) or during periodic proactive review by the regulator;
b.    Establish a program for preventive, comprehensive inspections and audits with technically qualified staff as described in R13(a) to ensure that the responsible party as defined in R11(a) can demonstrate the risk reduction commitments stipulated in its major hazards report.

Status: Closed - Acceptable Alternative Action
Recommendation Status Change Summary