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

Tesoro Anacortes Refinery Fatal Explosion and Fire (2 Recommendations)
Governor and Legislature of the State of Washington (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 01, 2014

2010-08-I-WA-7

Work with the regulator, the petroleum refining industry, labor, and other relevant stakeholders in the state of Washington to develop and implement a system that collects, tracks, and analyzes process safety leading and lagging indicators from operators and contractors to promote continuous process 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. Include indicators that measure safety culture, such as incident reporting and action item implementation culture. Require that the reported data be used for continuous process safety improvement and accident prevention;

b. Analyze data to identify trends and poor performer s 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 process safety improvements in Washington.


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

Washington State Department of Labor & Industries - Division of Occupational Safety and Health (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 01, 2014

2010-08-I-WA-9

Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective 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

CSB Safety Study: Remote Isolation of Process Equipment (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 25, 2024

2024-01-H-1

Develop a new publication or revise an existing publication or publications that should be applicable to various facility types such as refineries, chemical and petrochemical facilities, terminals, etc. with major process equipment and atmospheric storage tanks, that details conditions that necessitate the installation of remote isolation devices [use “shall” instead of “should” language] that may be automatically activated or remotely activated from a safe location, particularly during an emergency. When establishing these conditions refer to the guidance published by CCPS entitled Guidelines for Fire Protection in Chemical, Petrochemical, and Hydrocarbon Processing Facilities, Sections 8.1.10 and 8.1.11. At a minimum, the conditions should address major process equipment and atmospheric storage tanks, material volumes/weight as well as flammability, corrosivity, and toxicity


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

Final Report Released On: June 12, 2019

2018-01-I-OK-3

For onshore drilling operations, develop and publish a recommended practice providing guidance on safely tripping drill pipe during (1) overbalanced drilling operations, (2) managed pressure drilling operations, and (3) underbalanced drilling operations. At a minimum, include information on:

(a) Required equipment for tripping operations,

(b) Techniques and procedures for controlling or preventing formation fluid influx, and

(c) Methods to monitor the well and replace the drill pipe displacement volume with drilling fluid (e.g., mud).


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

Husky Energy Superior Refinery Explosion and Fire (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: December 29, 2022

2018-02-I-WI-14

Modify the appropriate existing recommended practice (for example, API RP 553, Refinery Valves and Accessories for Control and Safety Instrumented Systems) to include information about the purpose, design, maintenance, and testing of additional FCC catalyst slide valve components, including the slide valve body. If an API product other than API RP 553 is modified, API RP 553 should guide the reader to that reference.


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

BP - Husky Oregon Chemical Release and Fire (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 24, 2024

2022-01-I-OH-6

Develop a publication that addresses preventing the overflow of pressure vessels such as towers and drums. The publication should be applicable to both new and existing pressure vessels. Include the following at a minimum:

a) Description of typical overflow events that could result during normal, upset, or transient operations (startup, shutdown, standby) including the formation of a vapor cloud,

b) Recommended practices for instrumentation to monitor and detect a pressure vessel overflow,

c) Process hazard analysis guidance for pressure vessel overflow scenarios,

d) Recommended practices for safeguards to prevent a pressure vessel overflow,

e) Recommended field and board operator process safety training topics and methods to prevent a pressure vessel overflow,

f) Guidelines for process safety assessments to prevent a pressure vessel overflow, and

g) Incorporate lessons learned from this CSB investigation and the CSB’s BP Texas City Refinery investigation throughout the document.


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

Dow Louisiana Operations Explosions (1 Recommendations)
Dow Chemical Company (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: February 26, 2026

2023-03-I-LA-1

At all Dow ethylene oxide facilities, identify all process lines in ethylene oxide service that should be or are inerted and currently are not continuously monitored during normal operation. For all lines identified, determine whether the line can be eliminated, and if not, establish proper controls such as inerting and monitoring to ensure the process line is adequately inerted.


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

Didion Milling Company Explosion and Fire (2 Recommendations)
Didion Milling, Inc. (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: December 06, 2023

2017-07-I-WI-2

Contract a competent third party to develop and implement modifications to the pneumatic conveying and dust collector ductwork systems in accordance with guidance such as NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, NFPA 652, Standard on the Fundamentals of Combustible Dust, and NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids, to include, at a minimum:

a. Ensure minimum required transport velocity is maintained throughout the system.

b. Implement a periodic inspection and testing program for pneumatic conveying and dust collector ductwork systems, following industry guidance such as NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Particulate Solids, and FM Global guidance. The program should include cleaning on a set frequency and measuring transport velocities on a routine basis to ensure proper system function.


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

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: 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