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

BP - Husky Oregon Chemical Release and Fire (3 Recommendations)
International Society of Automation (ISA) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: June 24, 2024

2022-01-I-OH-7

Revise American National Standard ANSI/ISA 18.2-2016, Management of Alarm Systems for the Process Industries, to include performance targets for short-term alarm flood analysis so that users can evaluate alarm flood performance for a single alarm flood event. The performance targets should include:

a) number of alarm floods,
b) duration of each flood,
c) alarm count in each flood, and
d) peak alarm rate for each flood.

At a minimum, a target peak alarm flood rate should be defined, such as in the guidance provided by the ASM Consortium or Engineering Equipment and Materials Users Association (EEMUA), to establish trigger points that require alarm performance improvement actions.


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

Ohio Refining Company (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 24, 2024

2022-01-I-OH-2

Revise the Abnormal Situation Management policy to incorporate guidance provided by the ASM Consortium and the Center for Chemical Process Safety (CCPS). The revised policy should include, at a minimum:

a) A broader definition of abnormal situations, such as that defined by the CCPS,

b) Additional predictable abnormal situations and their associated corrective procedures. At a minimum include the following abnormal situations:

1) unplanned crude slate changes,
2) continued operation of the Crude 1 unit with the naphtha hydrotreater unit shut down, and
3) an emergency pressure-relief valve opening.

c) Guidance to determine when an abnormal situation is becoming too difficult to manage and the appropriate actions to take, such as shutting down a process, putting it into a circulation mode, or implementing proper procedures for bringing it to a safe state.


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

PDF Document Recommendation Status Change Summary

2022-01-I-OH-3

Develop and implement a policy or revise existing policy that clearly provides employees with the authority to stop work that is perceived to be unsafe until the employer can resolve the matter. This should include detailed procedures and regular training on how employees would exercise their stop work authority. Emphasis should be placed on exercising this authority during abnormal situations, including alarm floods.


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

Pryor Trust Fatal Gas Well Blowout and Fire (3 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-4

 

The International Association of Drilling Contractors (IADC) implemented this recommendation instead of API.

 

Develop a recommended practice on alarm management specifically for the drilling industry based on guidance in ANSI/ISA 18.2 Management of Alarm Systems for the Process Industries. The recommended practice will address the unique dynamic environment of the drilling industry and provide guidance on implementing a state-based alarm system for different operating modes (e.g., drilling, circulating, tripping, etc.). Include International Association of Drilling Contractors (IADC) in the development of this recommended practice.


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

PDF Document Recommendation Status Change Summary

International Association of Drilling Contractors (IADC) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-14

Participate in development of the recommended practice describe in recommendation 2018-01-OK-R4 to [American Petroleum Institute] API.


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

State of Oklahoma/Oklahoma Corporation Commission (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-19

Establish and implement safety regulations requiring entities who design oil and gas well drilling plans for wells in Oklahoma (e.g., operators) and entities who perform the drilling operation (e.g., drilling contractors) to develop and implement the following prior to conducting drilling operations:

(a) Detailed written operating procedures with specified steps and equipment alignment for all operations;

(b) Written procedures for the management of changes (except replacements in kind) in procedures, the well plan, and equipment;

(c) A risk assessment of hazards associated with the drilling plan;

(d) A requirement to follow Recognized and Generally Accepted Good Engineering Practices (RAGAGEP);

(e) Development of a Well Construction Interface Document between the operator and the drilling contractor prior to the commencement of drilling activities which at a minimum includes a bridging document and well plan specifying barriers and how to manage them;

(f) The performance and documentation of flow checks using acceptable methods at defined points during the operation for a specified duration; and

(g) A requirement for employee participation, similar to the Employee Participation requirement in the OSHA PSM standard.


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 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-13

 

The American Fuel & Petrochemical Manufacturers (AFPM) implemented this recommendation instead of API.

 

Using API’s processes to determine the appropriate safety product, develop a publicly available technical publication for the safe operation of fluid catalytic cracking (FCC) units. The document should be applicable to both new and existing units. Include the following topics at a minimum:

a) Description of typical FCC unit hazards, including air leaks into hydrocarbon systems or hydrocarbon leaks into air systems that could form a flammable mixture during transient operation (startup, shutdown, standby, and the actions required to transition between these modes). If needed, include differences between possible reactor/regenerator configurations;

b) Recommended practices for safeguards to control FCC unit hazards;

c) Recommended monitoring for process safety during FCC unit transient operations;

d) Recommended emergency operating procedures for FCC-specific scenarios;

e) PHA guidance for key FCC-specific scenarios, including transient operation;

f) Recommended FCC-specific field and board operator process safety training topics and methods;

g) Guidelines for process safety assessments of FCC units; and

h) Incorporate lessons learned from this CSB investigation and the CSB’s ExxonMobil Torrance Refinery Electrostatic Precipitator Explosion investigation throughout the document and include references in the document’s bibliography.


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

PDF Document Recommendation Status Change Summary

Marathon Martinez Renewable Fuels Fire (8 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: March 13, 2025

2024-01-I-CA-8

Revise API RP 556 Instrumentation, Control, and Protective Systems for Gas Fired Heaters, or successor API products, with the following:

  1. Requirements for proper response to high tube metal temperatures, including 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;
  1. Design requirements (“shall” rather than “should” language) 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 
  1. Engineering safeguard requirements (“shall” rather than “should” language) to detect and prevent afterburning in fired heaters. These requirements 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 requirements shall address monitoring capability from the control room.

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

Marathon Martinez Renewables (4 Recommendations)
Open: 100% | Closed: 0%
View Investigation
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: 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

2024-01-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 - 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

2024-01-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;
  1. Improve policies and practices for communications among and between shifts to ensure that operators understand abnormal line-ups in their units; and
  1. 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 - 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

2024-01-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 - 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

Marathon Petroleum Corporation (3 Recommendations)
Open: 100% | Closed: 0%
View Investigation
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 - 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

2024-01-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
  1. 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 - 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

2024-01-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 - 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

Didion Milling Company Explosion and Fire (5 Recommendations)
Didion Milling, Inc. (5 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 06, 2023

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: 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

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: 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

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 - 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

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 - 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

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: 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