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

Enterprise Pascagoula Gas Plant Explosion and Fire (5 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: February 13, 2019

2016-02-I-MS-1

Develop a new informational product or incorporate into the next revision of Brazed Aluminum Plate-Fin Heat Exchangers for General Refinery Services 1st ed.; ANSI/API Standard 668 (formerly Standard 662, Part 2), guidance focused on the safe operation, maintenance, and repair of brazed aluminum heat exchangers (BAHX) to advance understanding of thermal fatigue hazards and how to mitigate them. At a minimum the informational product/incorporated material must include:

a. Information on the potential for both minor leaks and catastrophic failure as a result of accumulated thermal fatigue (beyond a single cyclic thermal shock event);

b. Clarification on the optimal placement of BAHX temperature and pressure sensors to effectively monitor the operating conditions for the potential impact of accumulated thermal fatigue on BAHX, including temperature rates of change; and

c. Clarification on the need to safely vent layers that have been blocked off as part of the repair process for interpass leaks in all BAHX configurations, as well as information describing the consequences when safe venting does not occur.

d. Should applicable data from CSB Recommendation No. 2016-02-I-MS-R4 (R4) be available prior to finalizing the requirements of this recommendation, then the data from R4 will be considered for inclusion and/or incorporation by reference in the product required by this recommendation. If the decision is made not to include/incorporate by reference the data from R4, then a detailed explanation for the exclusion will be provided.


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.
 

GPA Midstream Association (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: February 13, 2019

2016-02-I-MS-2

Revise GPA Technical Bulletin: Brazed Aluminum Heat Exchangers, or develop a new bulletin, to incorporate the significant lessons learned from this incident, including but not limited to:

a. information on the potential of both minor leaks and catastrophic failure as a result of thermal fatigue;

b. clarification on the optimal placement of BAHX temperature and pressure sensors to better monitor operating conditions, including temperature rates of change; and

c. clarification on the need to safely vent layers that have been blocked off after interpass leak repairs, in all BAHX configurations.


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.
 

2016-02-I-MS-3

Develop a database for operators to submit BAHX operational data for collaborative industry learning and analysis. Encourage your members to submit pressure and temperature data associated with the entire service life of brazed aluminum heat exchangers as well as the date(s) of leak(s) or failure(s) for each exchanger on which data is being submitted. At a minimum this system should:

a. provide a way to anonymously input data into the database;

b. specify the time interval between measurements such that data can be normalized across different exchangers; and

c. capture the type of service in which the exchanger was operating.


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.
 

2016-02-I-MS-4

Using available operational process data of BAHXs in midstream gas plant operation collected in fulfillment of 2016-02-I-MS-R3, continue data analysis efforts to determine what, if any, correlation exists between operational process data and the frequency or timing of thermal fatigue-generated cracking to more accurately predict the service life of a BAHX.

Should predictors be identified, develop and offer to your members industry tools, techniques, or criteria for estimating when thermal fatigue warrants preemptive replacement of a BAHX (e.g., risk assessment tools or damage rate calculations).


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.
 

Jackson County Board of Supervisors, Jackson County Emergency Management Agency, Jackson County Local Emergency Planning Committee (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: February 13, 2019

2016-02-I-MS-5

Work with members (industry, emergency response, community) to explicitly define the communication methods for community notification and incident updates (e.g., social media, local news outlets, passive phone system), and the expectations for their use, so that members of the public can efficiently and effectively obtain current safety information. Publish these defined community notification methods and expectations for use on the most appropriate mediums available, such as the Jackson County Emergency Management website, the Jackson County LEPC website, and the social media outlets Jackson County utilizes to disseminate safety information to the community.


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.
 

BP America Refinery Explosion (2 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: March 20, 2007

2005-4-I-TX-7

Work together to develop two new consensus American National Standards Institute (ANSI) standards. b. In the second standard, develop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. (CSB2005-04-I-TX-R7a) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


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

United Steelworkers of America (USWA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: March 20, 2007

2005-4-I-TX-7

Work together to develop two new consensus American National Standards Institute (ANSI) standards. b. In the second standard, develop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. (CSB2005-04-I-TX-R7b) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


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

CAI / Arnel Chemical Plant Explosion (1 Recommendations)
Town of Danvers (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 13, 2008

2007-03-I-MA-7

Pending revision of the Massachusetts Fire Safety Code (527 CMR), revise the town bylaws addressing 527 CMR 14 requirements applicable to facility licensing and annual registration to: -Require new and current product manufacturing registrants to certify in writing that the facility complies with, at a minimum, all state and local fire codes and hazardous chemical regulations as part of the annual registration renewal. -Require companies holding a license and current registration for any of the eight classes of flammable materials specified in 527 CMR 14.03 (2) to re-register the facility before increasing any chemical quantity above the registered amount or adding a different regulated chemical at the facility. Include a requirement in the approval process to solicit input from affected landowners, similar to the requirement for obtaining the original license and registration. -Revise the license and registration forms to require listing each hazardous material type and quantity, and require a separate license and permit for each of the eight classes of flammable materials specified in 527 CMR 14.03 (2) . -Require the fire department to annually inspect licensed manufacturing facilities for compliance with the fire code.


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

Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire (1 Recommendations)
VSE Corporation (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 17, 2013

2011-06-I-HI-6

Use experts to: • Assist VSE procurement in selecting vendors to properly handle, store, and dispose of explosive hazardous materials, including fireworks, pursuant to prime contract requirements; and, • Assist VSE personnel in overseeing the work to ensure it is being conducted safely. Status:


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

West Fertilizer Explosion and Fire (2 Recommendations)
Texas A&M Engineering Extension Services (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2016

2013-02-I-TX-15

Develop and administer a hazardous materials training module for career and volunteer fire departments that addresses fertilizer grade ammonium nitrate (FGAN) and other hazardous materials or chemicals that could pose new specialized hazards.  Ensure that the training includes multiple delivery methods to enable a broad reach.  The training should allow for instructor-led, web-based, and train-the-trainer courses; initial orientation; and refresher training.  The training also should accommodate both resident and mobile capabilities to facilitate flexibility in delivery.

Objectives of the training course should address the following:

a. How to respond to industrial fires involving FGAN and other hazardous materials or chemicals that could pose new specialized hazards to responding firefighters

b. Previous FGAN fire and explosion incidents, incorporating lessons learned

c. Hazards posed by other materials and chemicals stored near the FGAN, including FGAN incompatibility with those materials and chemicals

d. Pre-incident planning for fires involving FGAN and other hazardous materials or chemicals that could pose new specialized hazards to responding firefighters

e. On-scene emergency response and decision-making requirements for FGAN fires, including risk assessment, scene size-up, and situational awareness

f. National Incident Management System and Incident Command System.


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

2013-02-I-TX-16

Develop an outreach program that notifies state, regional, and local fire departments about available FGAN training opportunities.  The program should include the following elements:

a. Guidance for fire departments on how to identify FGAN and other recognized hazards associated with other hazardous materials or chemicals within their communities by engaging with State Emergency Response Commissions and Local Emergency Planning Committees

b. Promotion of use of the hazardous materials training module with TEEX training partners.


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

Chevron Refinery Fire (2 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-25

Implement a compensation system to ensure the regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical competency at all levels of process safety regulatory oversight and policy development in Contra Cost County, California. A market analysis and benchmarking review should be periodically conducted to ensure the compensation system remains competitive with California petroleum refineries.


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

Mayor and City Council, City of Richmond, CA (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2015

2012-03-I-CA-24

Implement or cause to be implemented a compensation system to ensure the regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical competency at all levels of process safety regulatory oversight and policy development in Richmond, California. A market analysis and benchmarking review should be periodically conducted to ensure the compensation system remains competitive with California petroleum refineries.

 


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

AirGas Facility Fatal Explosion (3 Recommendations)
Compressed Gas Association (CGA) (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2017

2016-04-I-FL-2

Safety Management System for Nitrous Oxide Manufacturing

Develop and implement a safety management system standard for nitrous oxide manufacturing, to manage known process safety hazards, including nitrous oxide decomposition, which includes appropriate elements based on chemical industry good practice guidance, such as CCPS Guidelines for Risk Based Process Safety, Essential Practices for Managing Chemical Reactivity Hazards, and Guidelines for Implementing Process Safety Management.


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

2016-04-I-FL-3

Ensure Effective Flame Arrestor Design

Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to require testing of safety devices, such as strainers used as flame arrestors, for applications where a safety device is used to quench a nitrous oxide decomposition reaction.  To ensure that these safety devices meet the intended purpose, the user should test the safety device by simulating conditions of use.  In addition, require users to document the required performance standard or test protocol followed. 


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

2016-04-I-FL-4

Require Pump Run-Dry Safety Interlocks Apply ISA-84

Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to reference and require applying International Society of Automation (ISA) standard ISA-84, Functional Safety: Safety Instrumented Systems for the Process Industry Sector to safety interlocks such as the nitrous oxide pump “run-dry” shutdown.


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