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

AirGas Facility Fatal Explosion (1 Recommendations)
ACD, LLC (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 20, 2017

2016-04-I-FL-5

Provide effective warning about nitrous oxide decomposition hazards

Modify nitrous oxide pump product literature to include warnings about nitrous oxide decomposition hazards, illustrated by examples from historical incidents, and refer users to this CSB investigation report for additional information.


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

Freedom Industries Chemical Release (2 Recommendations)
American Water Works Company, Inc. (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 11, 2017

2014-01-I-WV-2

Establish requirements for all American Water state utilities’ surface water treatment plants to undertake the following activities:

1. Conduct an inventory of all hazardous chemicals or classes of hazardous chemicals that are considered a potential source of significant contamination stored in the utility’s most vulnerable source water protection area (e.g., Zone of Critical Concern). Chemicals may be identified by accessing publicly available information, which may include Tier II reporting forms submitted to local emergency planning committees and electronically available information from federal, state or local databases.

2. For each inventoried chemical or class of chemicals, conduct a prioritized assessment to determine if existing analytical methods are available to detect the presence and/or concentration of the chemical or class of chemicals in the event of a release to the water supply and if the chemical or class of chemicals is capable of being treated or removed by the utility’s water treatment process.

3. For all chemicals or classes of chemicals that are not capable of being treated or removed by the treatment process, develop a contingency plan to respond to contamination events (e.g., as modeled by WVAW’s Kanawha Valley Water System June 2016 Source Water Protection Plan).


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

Eastman Chemical Company (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 11, 2017

2014-01-I-WV-3

Update appropriate sections of the Crude MCHM Safety Data Sheet to include toxicological and ecological information based on the June 1, 2016, National Toxicology Program’s toxicity evaluation of Crude MCHM. Include information about the effects of Crude MCHM on fetal and early life growth and development. Distribute the revised Crude MCHM SDS to all customers that previously received and are currently using or storing MCHM from Eastman, and ensure all new MCHM customers receive the revised SDS with shipment.


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

DuPont LaPorte Facility Toxic Chemical Release (3 Recommendations)
DuPont LaPorte, Texas Chemical Facility (3 Recommendations)
Open: 0% | Closed: 100%

Date of Accident: November 15, 2014

2015-01-I-TX-1

Prior to resuming Insecticide Business Unit (IBU) manufacturing operations, conduct a comprehensive
engineering analysis of the manufacturing building and the discharge of pressure relief systems with toxic
chemical scenarios to assess potential inherently safer design options. At a minimum, evaluate the use of
an open building structure, and the direction of toxic chemical leaks and the discharge of pressure relief
systems with toxic chemical scenarios to a destruction system. Implement inherently safer design
principles to the greatest extent feasible and effectively apply the hierarchy of controls such that neither
workers nor the public are harmed from potential highly toxic chemical releases. Detail the analysis,
findings, and corrective actions in a written report and make this report available to DuPont La Porte
employees, their representatives, and the CSB.

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

2015-01-I-TX-2

Prior to resuming Insecticide Business Unit (IBU) manufacturing operations, conduct a robust
engineering evaluation of the manufacturing building and the dilution air ventilation system that includes
the implementation of corrective action(s) to the greatest extent feasible in order to ensure a safe
environment for all workers. Develop a documented design basis for the manufacturing building and the
air dilution ventilation system that identifies effective controls for highly toxic, asphyxiation, and
flammability hazards and implement these controls to the greatest extent feasible. Address nonroutine
operations and emergency response activities in the design basis. The design basis for the manufacturing
building and the dilution air ventilation system must use the hierarchy of controls and inherently safer
design principles to the greatest extent feasible.

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

2015-01-I-TX-3

Prior to resuming manufacturing operations, ensure all Insecticides Business Unit (IBU) pressure relief
systems are routed to a safe location and effectively apply the hierarchy of controls to protect workers and
the public. Commission a pressure relief device analysis, consistent with API Standard 521 and the
ASME Code, including a field review. Include an evaluation of relief system discharge location to ensure
that relief systems are discharged to a safe location that will prevent toxic exposure, flammability, or
asphyxiation hazards in order to ensure public and worker health and safety to the greatest extent feasible.
Include an evaluation of relief scenarios consistent with API Standard 521.

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

Hoeganaes Corporation Fatal Flash Fires (1 Recommendations)
International Code Council (ICC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 05, 2012

2011-4-I-TN-4

Revise IFC Chapter 22 Combustible Dust Producing Operations; Section 2204.1 Standards, to require mandatory compliance and enforcement with the detailed requirements of the NFPA standards cited in the chapter, including NFPA 484.


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.
 

Tesoro Refinery Fatal Explosion and Fire (2 Recommendations)
Tesoro Anacortes Refinery (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2014

2010-08-I-WA-15

Implement a process safety culture continuous improvement program at the Tesoro Anacortes Refinery
including a written procedure for periodic process safety culture surveys across the work force. The
process safety culture program shall be overseen by a tripartite committee of Tesoro management, USW
representatives, Washington State Department of Labor and Industries – Division of Occupational Safety
and Health, and the U.S. Environmental Protection Agency. This oversight committee shall:

a. Select an expert third party that will administer a periodic process safety culture survey;

b. Review and comment on the third party expert report developed from the survey;

c. Oversee the development and effective implementation of action items to address identified process safety culture issues; and

d. Develop process safety culture indicators to measure major accident prevention performance.

The process safety program shall include a focus on items that measure, at a minimum, willingness to
report incidents, normalization of hazardous conditions, burden of proof of safety in plant process safety programs and practices, and management involvement and commitment to process safety. The periodic process safety culture report shall be made available to the plant workforce. The minimum frequency of process safety culture surveys shall be at least once every three years.

 


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

PDF Document Recommendations Status Change Summary

USW Local 12-591 (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2014

2010-08-I-WA-16

Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight
committee as recommended under recommendation 2010-08-I-WA-R15.  


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

Chevron Refinery Fire (2 Recommendations)
Chevron USA (2 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: January 28, 2015

2012-03-I-CA-2 URGENT!

At all California Chevron U.S. refineries, report leading and lagging process safety indicators, such as the action item completion status of recommendations from damage mechanism hazard reviews, to the federal, state, and local regulatory agencies that have chemical release prevention authority.


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

2012-03-I-CA-33

Develop a method to assign accountability at Chevron to determine whether any whether any new Energy Technology Company (ETC) recommended program or industry best practice, such as API guidance must be followed to ensure process safety or employee personal safety.  This method shall include monitoring of these practices and guidance at a refining system level and at the refinery level.  Develop a tracking system to monitor the progress of implementing these selected practices and guidance to completion.


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

MGPI Processing, Inc. Toxic Chemical Release (5 Recommendations)
Atchison County Department of Emergency Management (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 02, 2018

2017-01-I-KS-5

Coordinate planning and training activities to ensure emergency responders within Atchison County are prepared for future incidents involving hazardous materials. The Atchison County Local Emergency Planning Committee should do the following:

a) Review facility Risk Management Plans as they are submitted or revised and conduct pre-planning at Risk Management Program covered facilities and all other facilities within the county that, based on annual Tier II reporting forms, store large amounts of hazardous chemicals.

b) Conduct a full-scale hazardous materials exercise that involves an offsite chemical release scenario within the next three years. The exercise should include participants from local emergency response organizations, hospitals, schools, and fixed facilities. Identify and resolve coordination or communication issues identified during the exercise.

c) Increase participation in state and regional emergency response training and programs. Work with the Kansas Department of Emergency Management to submit a Hazardous Materials Emergency Preparedness (HMEP) grant proposal to assist in funding additional training and pre-planning activities within the county.


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.
 

Harcros Chemicals (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 02, 2018

2017-01-I-KS-3

Establish a refresher training program to ensure drivers know the location of various CTMV emergency shut-off devices, when to use them, and the effectiveness of those devices to stop the flow of chemicals during emergencies. The refresher training program should include drills for drivers to simulate the activation of all shut-off devices in defined incident scenarios (e.g., inadvertent mixing, chemical releases, etc.) during unloading operations. Establish a process to evaluate the effectiveness of the refresher training program.


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.
 

2017-01-I-KS-4

Establish a process whereby the respiratory hazards associated with chemical unloading at customer sites are evaluated. The evaluations should, at a minimum, determine whether drivers need emergency escape respirators in the event of an accidental reaction and/or release of chemicals. If the results of the evaluations indicate that respiratory protection is needed, provide the equipment and training for such protection as appropriate. The equipment and training should be provided in accordance with OSHA’s Respiratory Protection Standard (29 C.F.R § 1910.134). The equipment should also be stored in an area that allows for immediate access.


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.
 

MGPI Processing, Inc. (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 02, 2018

2017-01-I-KS-1

Commission an independent engineering evaluation of the Mod B building and ventilation system and, based on the results of that evaluation, implement design changes and controls to protect occupants from a chemical release. At a minimum, the evaluation should assess the effectiveness of the building ventilation system, indoor and outdoor sources of chemicals, air intake locations, contaminant control methods such as filtration and removal, contaminant monitoring devices, and automation. The engineering evaluation of the ventilation system should consider airborne contaminants during normal operations as well as spills, releases, and chemicals produced from unintended reactions and inadvertent mixing.


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.
 

2017-01-I-KS-2

Conduct an evaluation of the Mod B chemical transfer equipment (e.g., fill lines, transfer valves, transfer piping, tanks and other associated equipment) and install appropriate engineering safeguards to prevent and mitigate an unintended reaction, chemical release, or spill during bulk unloading. Where feasible, install safeguards, such as alarms and interlocks, to prevent personnel from opening the incorrect chemical transfer valves during deliveries. In addition, install mitigation measures to automatically shut down the transfer of chemicals into the facility based on process deviations or abnormal conditions (e.g., pressure, temperature, flow or level indications; gas detection).


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.