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.

 

Expand All

Recommendations

West Fertilizer Explosion and Fire (4 Recommendations)
State Firefighters' and Fire Marshals' Association of Texas (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2016

2013-02-I-TX-13

Develop a fertilizer grade ammonium nitrate (FGAN) training certification program for fire departments that either have FGAN facilities in their jurisdictions or respond as mutual aid to other jurisdictions with FGAN facilities.  The certification program should include multiple delivery methods to enable a broad reach.  The certification program 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.

The criteria for the certification program should address the following:

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

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

c. Pre-incident planning for fires involving FGAN

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

e. National Incident Management System and Incident Command System.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs.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concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.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

2013-02-I-TX-14

Develop an outreach component for the training certification program that notifies regional, state, and local fire departments with FGAN facilities in their jurisdictions about the training certification opportunities available for FGAN.  Ensure that the following items are included in the development of this program:

a. Guidance for fire departments on how to identify FGAN hazards within their communities by engaging State Emergency Response Commissions and Local Emergency Planning Committees

b. Encouragement for members in jurisdictions with FGAN facilities to become certified in FGAN training

c. Information on training partners and programs that provide FGAN training.


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

PDF Document Recommendation Status Change Summary

Texas Department of Insurance (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2016

2013-02-I-TX-17

For companies that provide insurance to agricultural facilities storing bulk fertilizer grade ammonium nitrate (FGAN) in Texas, including surplus lines insurers and Texas-registered risk retention groups, develop and issue guidance to assist in underwriting risk and conducting annual loss control surveys.  Guidance should include the following:

a. Combustible materials of construction for facilities and bins storing FGAN

b. Storage of combustible materials near FGAN piles

c. Adequate ventilation for indoor FGAN storage areas

d. Automatic sprinklers and smoke detection systems for indoor FGAN storage areas

e. Separation distances between FGAN and other hazardous materials onsite

f. Potential for offsite consequences from a fire or explosion, including the proximity of FGAN facilities to nearby residences, schools, hospitals, and other community structures.

Provide references in the guidance document to existing materials from the following sources or to other equivalent guidance:

a. National Fire Protection Association (NFPA), NFPA 400, Hazardous Materials Code, 2016 Edition, Chapter 11, “Ammonium Nitrate”

b. FM Global, “Property Loss Prevention Data Sheet 7-89”

c. U.S. Environmental Protection Agency, Occupational Safety and Health Administration, and Bureau of Alcohol, Tobacco, Firearms and Explosives; “Chemical Advisory: Safe Storage, Handling, and Management of Solid Ammonium Nitrate Prills”

d. TDI, “Best Practices for the Storage of Ammonium Nitrate”

e. National Fire Protection Research Foundation, “Separation Distances and NFPA Codes and Standards.”


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendation Status Change Summary

West Volunteer Fire Department (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2016

2013-02-I-TX-18

Develop standard operating procedures for pre-incident planning for facilities that store or handle hazardous materials such as fertilizer grade ammonium nitrate (FGAN).


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendation Status Change Summary

Chevron Refinery Fire (1 Recommendations)
Governor and Legislature of the State of California (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2015

2012-03-I-CA-21

Based on the findings in this report, enhance and restructure California’s process safety management (PSM) regulations for petroleum refineries by including the following goal-setting attributes:

a. Require a comprehensive process hazard analysis (PHA) written by the company that includes:

i. Systematic analysis and documentation of all major hazards and safeguards, using the hierarchy of controls to identify hazards and significantly reduce risks to a goal of as low as reasonably practicable (ALARP) or similar;

ii. Documentation of the recognized methodologies, rationale and conclusions used to claim that inherently safer systems have been implemented to as low as reasonably practicable (ALARP) or similar, and that additional safeguards intended to control remaining hazards will be effective;

iii. Documented damage mechanism hazard review conducted by a diverse team of qualified personnel. This review shall be an integral part of the process hazard analysis (PHA) cycle and shall be conducted on all covered processes, piping circuits and equipment. The damage mechanism hazard review shall identify potentia process damage mechanisms and consequences of failure, and shall ensure effective safeguards are in place to prevent or control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safer design to the greatest extent feasible into this review; and

iv. 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) or similar. Include requirements for inherently safer systems analysis to be automatically triggered for all management of change (MOC) and process hazard analysis (PHA) reviews, as well as prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.

b. Require a thorough review of the comprehensive process hazard an alysis by technically competent regulatory personnel;

c. Require preventative audits and preventative inspections by the regulator to ensure the effective implementation of the comprehensive process hazard analysis (PHA);

d. Require that all safety codes, standards, employer internal procedures and recognized and generally accepted good engineering practices (RAGAGEP) used in the implementation of the regulations contain adequate minimum requirements;

e. Require mechanisms for the regulator, the refinery, and workers and their representatives to play an equal and essential role in the direction of preventing major incidents. Require an expanded role for workers in management of process safety by establishing the rights and responsibilities of workers and their representatives on health and safety-related matters, and the election of safety representatives and establishment of safety committees (with equal representation between management and labor) to serve health and safety-related functions. The elected representatives should have a legally recognized role that goes beyond consultation in activities such as the development of the comprehensive process hazard analysis, implementation of corrective actions generated from hierarchy of control analyses, management of change, incident investigation, audits, and the identification, prevention, and control of all processhazards. The regulation should provide workers and their representatives with the authority to stop work that is perceived to be unsafe until the employer resolves the matter or the regulator intervenes.  Workforce participation practices should be documented by the refinery to the regulator;

f. Require reporting of information to the public to the greatest extent feasible, such as a summary of the comprehensive process hazard analysis (PHA) which should include a list of inherently safer systems implemented; safeguards implemented for remaining hazards; standards utilized to reduce risks to As Low As Reasonably Practicable (ALARP) or similar; and process safety indicators that demonstrate the effectiveness of the safeguards and management systems;

g. Implement an approach or system that determines when new or improved industry standards and practices are needed and initiate programs and other activities, such as an advisory committee or forum, toprompt the timely development and implementation of such standards and practices; and

h. Ensure that a means of sustained funding is established to support an independent, well-funded, well-staffed, technically competent regulator.


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

PDF Document Recommendation Status Change Summary

Pryor Trust Fatal Gas Well Blowout and Fire (2 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 12, 2019

2018-01-I-OK-6

Update API Bulletin 97 Well Construction Interface Document Guidelines to specify that it applies to both onshore and offshore drilling operations.


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

PDF Document Recommendation Status Change Summary

Pason Systems Corp. (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 12, 2019

2018-01-I-OK-16

Design the Pason 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

Kleen Energy Natural Gas Explosion (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 28, 2010

2010-07-I-CT-1 URGENT!

Promulgate regulations that address fuel gas safety for both construction and general industry. At a minimum:

a. Prohibit the release of flammable gas to the atmosphere for the purpose of cleaning fuel gas piping.

b. Prohibit flammable gas venting or purging indoors. Prohibit venting or purging outdoors where fuel gas may form a flammable atmosphere in the vicinity of workers and/or ignition sources.

c. Prohibit any work activity in areas where the concentration of flammable gas exceeds a fixed low percentage of the lower explosive limit (LEL) determined by appropriate combustible gas monitoring.

d. Require that companies develop flammable gas safety procedures and training that involves contractors, workers, and their representatives in decision-making.


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendation Status Change Summary

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

Final Report Released On: May 24, 2018

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: 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

Caribbean Petroleum Refining Tank Explosion and Fire (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 21, 2015

2010-02-I-PR-8

Develop detailed guidance on conducting a risk assessment for onsite and offsite impacts of a potential tank overfill during transfer operations involving one and multiple tanks and for determining the Safety Integrity Level of the required overfill prevention safeguard to replace Annex E of ANSI/API 2350, Overfill Protection for Storage Tanks in Petroleum Facilities (2015).

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

Oil Site Safety (1 Recommendations)
Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 27, 2011

2011-H-1-1

Publish a safety alert directed to owners and operators of exploration and production facilities with flammable storage tanks, advising them of their general duty clause responsibilities for accident prevention under the Clean Air Act. At a minimum, the safety alert should:

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 of 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. Describe sufficient security measures to prevent non-employee access to flammable storage tanks, including such measures as a full fence surrounding the tank with locked gate, hatch locks on tank manways, and barriers securely attached to tank external ladders or stairways

d. Recommend 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


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