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 recommendations@csb.gov 

 

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Recommendations

US Ink Fire (2 Recommendations)
New Jersey Department of Community Affairs (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 15, 2015

2013-01-I-NJ-3

Revise the exemption for “manufacturing, production, and process equipment” under the New Jersey Uniform Construction Code (N.J.A.C 5:23-2.2) to require that equipment involved in processing, handling, or conveying combustible dust comply with the design and operating requirements of the current edition of the International Building Code.


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

2013-01-I-NJ-5

Promulgate a regulation that requires all occupancies handling hazardous materials to inform the local enforcement agency of any type of construction or installation of equipment at an industrial or manufacturing facility. Also require local enforcement agencies to evaluate the information to determine whether a construction permit is required.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).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 Recommendation Status Change Summary

Enterprise Pascagoula Gas Plant Explosion and Fire (3 Recommendations)
GPA Midstream Association (3 Recommendations)
Open: 0% | Closed: 100%

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: 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

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: 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 Recommendation Status Change Summary

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: 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 Recommendation Status Change Summary

Chevron Refinery Fire (6 Recommendations)
American Petroleum Institute (API) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2015

2012-03-I-CA-27

Revise API RP 571: Damage Mechanisms Affecting Fixed Equipment in the Refining Industry to:

a.       Describe the potential for increased rates of sulfidation corrosion occurring in low-silicon carbon steel in Section 4.4.2.3 Critical Factors

b.      Specify that sulfidation corrosion rates in carbon steel piping can be significantly faster in a few, individual piping components in section 4.4.2.5 Appearance or Morphology of Damage; and

c.       Refer the reader to the 100 percent component inspection or pipe replacement requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to recommendation 2012-03-I-CA-R26)  and API 570: Piping Inspection Code:  In-service Inspection, Rating, Repair, and Alteration of Piping Systems (pursuant to 2012-03-I-CA-R28(c)) for carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components.  


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

2012-03-I-CA-30

Revise API RP 574: Inspection Practices for Piping System Components (3rd edition) to: 

a.       Incorporate as a normative reference API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries;

b.      Reference API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries when discussing that nonsilicon-killed carbon steel is susceptible to sulfidation corrosion; and

c.       In Section 9.3 Investigation of Leaks, require users to follow the leak response protocol requirements established in API RP 2001: Fire Protection in Refineries (pursuant to 2012-03-I-CA-R31).


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

PDF Document Recommendations Status Change Summary

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

Final Report Released On: January 28, 2015

2012-03-I-CA-36

Revise the Industrial Safety Ordinance (ISO) regulations for petroleum refineries to require a process safety culture continuous improvement program including a written procedure for periodic process safety culture surveys across the work force. Require an oversight committee comprised of the regulator, the company, the company’s workforce and their representatives, and community representatives. 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 effectively address identified process safety culture issues; and

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

The periodic process safety culture report shall be made available to the plant workforce.


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

PDF Document Recommendation Status Change Summary

Governor and Legislature of the State of California (2 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: January 28, 2015

2012-03-I-CA-22

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 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

2012-03-I-CA-23

Work with the regulator, the petroleum refining industry, labor, and other relevant stakeholders in the state of California to develop and implement a systemthat collects, tracks, and analyzes process safety leading and lagging indicators from refineries and contractors to promote continuous safety improvements. At a minimum, this program shall:

a. Require the use of leading and lagging process safety indicators to actively monitor the effectiveness of process safety management systems and safeguards for major accident prevention. Include leading and lagging indicators that are measureable, actionable, and standardized. Require that the reported data be used for continuous process safety improvement and accident prevention;

b. Analyze data to identify trends and poor performers and publish annual reports with the data at facility and corporate levels;

c. Require companies to publicly report required indicators annually at facility and corporate levels;

d. Use process safety indicators (1) to drive continuous improvement for major accident prevention by using the data to identify industry and facility safety trends and deficiencies and (2) to determine appropriate allocation of regulator resources and inspections; and

e. Be periodically updated to incorporate new learning from world-wide industry improvements in order to drive continuous major accident safety improvements in California.


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

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-37

Revise the Richmond Industrial Safety Ordinance (RISO) regulations for petroleum refineries to require a process safety culture continuous improvement program including a written procedure for periodic process safety culture surveys across the work force. Require an oversight committee comprised of the regulator, the company, the company’s workforce and their representatives, and community representatives. 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 effectively address identified process safety culture issues; and

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

The periodic process safety culture report shall be made available to the plant workforce.


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

PDF Document Recommendation Status Change Summary

Aghorn Operating Waterflood Station Hydrogen Sulfide Release (2 Recommendations)
Aghorn Operating Inc. (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 21, 2021

2020-01-I-TX-1

For all waterflood stations where the potential exists to expose workers or non-employees to H2S concentrations at or above 10 ppm, mandate the use of personal H2S detection devices as an integral part of every employee or visitor personal protective equipment (PPE) kit prior to entering the vicinity of the facility. Ensure detector use is in accordance with manufacturer specifications.


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

2020-01-I-TX-2

For all Aghorn facilities, develop a site-specific, formalized and comprehensive Lockout / Tagout program, to include policies, procedures, and training, to protect workers from energized equipment hazards, such as exposure to H2S. Ensure the program meets the requirements outlined in 29 CFR 1910.147 and includes energy control procedures, training, and periodic inspections.


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%

Final Report Released On: June 12, 2019

2018-01-I-OK-5

Develop a new recommended practice or modify an existing recommended practice (e.g. API RP 54 Recommended Practice for Occupational Safety for Oil and Gas Well Drilling and Servicing Operations) addressing the protection of rig workers on onshore drilling rigs from fire and explosion hazards in the event of a blowout. The recommended practice will specifically address:

(a) Protecting drilling cabin occupants from blowout hazards including heat, blast overpressure, and projectiles, such as requiring an increased fire rating for the driller’s cabin that would allow enough time for occupants to evacuate during a blowout and fire;

(b) Minimum required evacuation methods from the drilling cabin, rig floor, and mast or derrick in the event of a blowout so that personnel can quickly escape in variable hazard location conditions. For example, floor exit hatches and exits on the driller’s cabin wall opposite the rig floor could provide safe evacuation routes during a blowout and fire; and

(c) Proximity of the Blow Out Preventer (BOP) activation controls with the driller.

The above options could be retrofitted on existing drilling rigs. Additionally, formally evaluate alternative locations for the drilling cabin that establishes a safe distance from fire and explosion hazards (e.g., ground level).


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

National Oilwell Varco (NOV) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 12, 2019

2018-01-I-OK-18

Design the M/D Totco electronic drilling data system so that alarm information, including alarm set points, alarm activation log, alarm horn status (on or off), and alarm system status (on or off) is provided to customers.


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

Patterson-UTI (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 12, 2019

2018-01-I-OK-8

Develop an alarm philosophy and alarm rationalization for rig operations. Based on the alarm philosophy and alarm rationalization, specify necessary alarms, at a minimum, for (1) drilling, (2) tripping, (3) circulating, and (4) rig floor activities (no drill pipe in well). Additionally, develop a policy implementing the alarm philosophy and rationalization.


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

PDF Document Recommendation Status Change Summary

Tesoro Refinery Fatal Explosion and Fire (1 Recommendations)
Tesoro Refining & Marketing Company LLC (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2014

2010-08-I-WA-14

Revise and improve the Process Hazard Analysis (PHA), the Integrity Operating Window (IOW), and the
damage mechanism hazard review (DMHR) programs and cross-linking among these three programs such that all identified hazards are effectively managed in each program. For all Tesoro refineries require:

a. the IOW to review damage mechanism hazards from the most recent PHA and safeguards identified to control these hazards;

b. the IOW review or revalidation to be conducted at least every five years;

c. the IOW to analyze and incorporate applicable industry best practice, the hierarchy of controls, and inherently safer design to the greatest extent reasonably practicable;

d. the DMHR report to be developed by the DMHR team and not just the “corrosion expert;”

e.the DMHR team to review the operating data to verify an accurate understanding of how the data was obtained, what it represents, and that it appropriately addresses both routine and nonroutine operations;

f. the DMHR and/or IOW review to identify and review gaps between current industry best practices and existing Tesoro practices with regard to material selection and process controls and make recommendations that reduce risks from damage mechanism hazards;

g. the DMHR and IOW review to review applicable Tesoro and industry-wide damage mechanism incidents as part of the respective DMHR or IOW review;

h. the DMHR to review relevant MOCs to fully evaluate the impact of the MOC on damage mechanism hazards;

i. the identification of minimum qualifications for the “corrosion expert” and ensure that the DMHR team has the necessary skills to meet these requirements;

j. for sites that have a corrosion/materials engineer, the corrosion/materials engineer shall be a required participant in the DMHR; 

k. the PHA to review the most recent DMHR and IOW reviews in order to contain a complete record of all identified damage mechanism hazards, evaluate existing safeguards, and propose new safeguards to control the identified hazards;

l. the PHA to review the consequence of damage mechanism hazards identified in the risk-based inspection (RBI) program and IOW reviews to ensure effective safeguards are present to control the damage mechanism hazard; and

m. the PHA to use the hierarchy of controls and implement opportunities for inherently safer design
to the greatest extent reasonably practicable.  


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