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.

 

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Recommendations

Xcel Energy Company Hydroelectric Tunnel Fire (1 Recommendations)
Southern California Painting and Drywall Industries Joint Apprenticeship and Training Committee (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-18

Require that all journeyman painters who are employees and/or members 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 - 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

Oil Site Safety (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 27, 2011

2011-H-1-5

Create a new standard or amend existing standards covering exploration and production facilities to:

a) Warn that storage tanks at unmanned facilities may be subject to tampering or introduction of ignition sources by members of the public, which could result in a tank explosion or other accidental release to the environment.

b) Recommend the use inherently safer storage tank design features to reduce the likelihood of explosions, including restrictions on the use of open vents for flammable hydrocarbons, flame arrestors, pressure vacuum vent valves, floating roofs, vapor recovery systems or an equivalent alternative.

c) Require security measures at least as protective as API 2610 to prevent non-employee access to flammable storage tanks at upstream E&P sites, including such measures as a full fence surrounding the tank(s) with a locked gate, hatch locks on tank manways, and barriers securely attached to tank external ladders or stairways.

d) Require that hazard signs or placards be displayed on or near tanks to identify the fire and explosion hazards using words and symbols recognizable by the general public.

e) Recommend that new or revised mineral leasing agreements include security and signage requirements as described above.


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

Arkema Inc. Chemical Plant Fire (5 Recommendations)
Arkema Crosby Facility (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 24, 2018

2017-08-I-TX-1

Reduce flood risk to as low as reasonably practicable (ALARP). Ensure that any safeguards for flooding meet independent layer of protection requirements.


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.
 

Arkema Inc. (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 24, 2018

2017-08-I-TX-2

Within 18 months, develop a policy requiring that Arkema and its subsidiaries that manufacture organic peroxides or that have processes which involve more than the threshold quantities of highly hazardous chemicals (HHC) periodically (corresponding with PHA cycle), analyze such facilities to determine whether they are at risk for extreme weather events such as hurricanes or floods.


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.
 

2017-08-I-TX-3

Establish corporate requirements for its facilities that manufacture organic peroxides or that have processes which involve more than the threshold quantities of highly hazardous chemicals (HHC) to ensure that critical safeguards, such as backup power, function as intended during extreme weather events, including hurricanes or floods.


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.
 

Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 24, 2018

2017-08-I-TX-4

Develop broad and comprehensive guidance to help companies assess their U.S. facility risk from all types of potential extreme weather events. Guidance should address the issues identified in this report and cover actions required to prepare for extreme weather, resiliency and protection of physical infrastructure and personnel during extreme weather, as well as recovery operations following an extreme weather event, where appropriate. Include guidance for each of the following:

• Addressing common mode failures of critical safeguards or equipment that could be caused by extreme weather events, including but not limited to flooding. For flooding scenarios, sufficient independent layers of protection should be available if floodwater heights reach the facility.

• Evaluating facility susceptibility to potential extreme weather events. Relevant safety information such as flood maps should be incorporated as process safety information.

• Involving relevant professional disciplines, including engineering disciplines, to help ensure risk assessments and process hazard analyses are as robust as practicable for any given facility.


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.
 

Harris County, TX (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 24, 2018

2017-08-I-TX-5

Update your emergency operations training using lessons learned from the Arkema incident to help ensure that personnel enforcing evacuation perimeters are not harmed by exposure to hazardous chemical releases. Update existing protocols and revise training curricula to include the use of analytical tools, air monitoring, and personal protective equipment, to provide appropriate protection when emergency equipment or personnel need to be moved through an evacuation zone during a hazardous materials release. Include a process for periodic refresher training.


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.
 

Carbide Industries Fire and Explosion (2 Recommendations)
Carbide Industries (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 07, 2013

2011-5-I-KY-2

Modify the design and procedures for the electric arc furnace and related structures including the control room to comply with the NFPA standard developed per R1 of this case study.  


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

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 07, 2013

2011-5-I-KY-1

Establish a committee to evaluate and develop a standard that defines the safety requirements for electric arc furnaces operated with flammable materials and low oxygen atmospheres. At a minimum, establish requirements that electric arc furnaces containing flammables have: • Adequate safety instrumentation and controls to prevent explosions and overpressure events; • Mechanical integrity and inspection programs; • A documented siting analysis to ensure that control rooms and other occupied areas are adequately protected.  


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendations Status Change Summary

Chevron Refinery Fire (7 Recommendations)
Board of Supervisors, Contra Costa County, CA (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2015

2012-03-I-CA-7

Revise the Industrial Safety Ordinance (ISO) to require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.


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

PDF Document Recommendations Status Change Summary

Governor and Legislature of the State of California (6 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2015

2012-03-I-CA-9

Revise the California Code of Regulations, Title 8, Section 5189, Process Safety Management of Acutely Hazardous Materials, to require improvements to mechanical integrity and process hazard analysis programs for all California oil refineries. These improvements shall include engaging 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. Require the analysis and incorporation of applicable industry best practices and inherently safety systems to the greatest extent feasible into this review.


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

2012-03-I-CA-10

For all California oil refineries, identify and require the reporting of leading and lagging process safety indicators, such as the action item completion status of recommendations from damage mechanism hazard reviews, to state and local regulatory agencies that have chemical release prevention authority. These indicators shall be used to ensure that requirements described in 2012-03-I-CA-R9 are effective at improving mechanical integrity and process hazard analysis performance at all California oil refineries and preventing major chemical incidents.


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-11

Establish a multi-agency process safety regulatory program for all California oil refineries to improve the public accountability, transparency, and performance of chemical accident prevention and mechanical integrity programs. This program shall:

  1. Establish a system to report to the regulator the recognized methodologies, findings, conclusions and corrective actions related to refinery mechanical integrity inspection and repair work arising from Process Hazard Analyses, California oil refinery turnarounds and maintenance-related shutdowns;
  2. Require reporting of information such as damage mechanism hazard reviews, notice of upcoming maintenance-related shutdowns, records related to proposed and completed mechanical integrity work lists, and the technical rationale for any delay in work proposed but not yet completed;
  3. Establish procedures for greater workforce and public participation including the public reporting of information; and
  4. Provide mechanisms for federal, state and local agency operational coordination, sharing of data (including safety indicator data), and joint accident prevention activities. The California Department of Industrial Relations will be designated as the lead state agency for establishing a repository of joint investigative and inspection data, coordinating the sharing of data and joint accident prevention activities.

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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-12

Require that Process Hazard Analyses required under California Code of Regulations, Title 8, Section 5189 Section (e) include documentation of the recognized methodologies, rationale and conclusions used to claim that safeguards intended to control hazards will be effective. This process shall use established qualitative, quantitative, and/or semi-quantitative methods such as Layers of Protection Analysis (LOPA).


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

2012-03-I-CA-13

Require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new process, process unit rebuilds, significant process repairs and in the development of corrective actions from incident investigation recommendations.


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-14

Monitor and confirm the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R9 and 2012-03-I-CA-R10), so that all necessary mechanical integrity work at all California Chevron Refineries is identified and recommendations are completed in a timely way.


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

PDF Document Recommendations Status Change Summary

ExxonMobil Refinery Explosion (4 Recommendations)
Torrance Refining Company (4 Recommendations)
Open: 25% | Closed: 75%

Final Report Released On: May 03, 2017

2015-02-I-CA-6

Implement protective systems that prevent ignition of flammable gases (including hydrocarbons not in the presence of CO) inside of the electrostatic precipitator, for each mode of operation.


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

2015-02-I-CA-7

The spent catalyst slide valve, specified as a safety-critical device for normal operation, could not perform its safety-critical function of preventing air and hydrocarbons from mixing while the FCC unit was in its “Safe Park” mode of operation. Require identification of all safety critical equipment and consequence of failure for each mode of operation and ensure safety-critical devices can successfully function when needed. Develop and implement a policy that requires the Torrance refinery to: (1) specify each safety-critical device’s safety function; (2) identify the consequences of failure of each safety-critical device; (3) specify the testing strategy used to verify whether the safety-critical device can function as intended to perform its required safety function; and (4) maintain target availability (e.g. safe operating life) for each safety-critical device through inspection and maintenance. Require that items (1) through (4) above consider each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation.


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

2015-02-I-CA-8

The Torrance refinery extended the maintenance interval of the spent catalyst slide valve and the inspection interval of the pumparound heat exchanger without analyzing whether the extended operation lowered their availability (by operating them beyond their predicted safe operating life) and could result in negative safety consequences. In the event safety critical equipment is operated beyond its inspection and/or maintenance interval (e.g. extended turnaround interval), require the Torrance refinery to perform a risk evaluation (e.g. MOC or risk assessment) to identify the safety consequences of the extended operation. Require that each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation is evaluated during the risk evaluation.


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

2015-02-I-CA-9

Electrostatic precipitators create potential ignition sources during normal operation, and have historically caused explosions within the refining industry. At the Torrance refinery, require a siting risk analysis be performed of the FCC unit electrostatic precipitator and implement appropriate safeguards to minimize the consequences of an electrostatic precipitator explosion.


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