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

Loy Lange Box Company Pressure Vessel Explosion (8 Recommendations)
Arise, Inc (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 29, 2022

2017-04-I-MO-7

Update company policies and/or procedures by including prescriptive elements in the boiler and pressure vessel repair and alteration inspection and acceptance process that would prevent the acceptance of a non-conforming repair or alteration.


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.
 

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Board of Aldermen, City of St. Louis, MO (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 29, 2022

2017-04-I-MO-4

Revise the City of St. Louis Mechanical Code to adopt a national consensus standard such as NBIC Part 2 to govern the requirements for inservice inspection of boilers and pressure vessels.


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.
 

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2017-04-I-MO-5

Revise the City of St. Louis Mechanical Code to require pressure vessel inspections be performed by a National Board of Boiler and Pressure Vessel Inspectors (NBBI) inservice (IS) commissioned inspector.


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.
 

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Loy Lange Box Company (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 29, 2022

2017-04-I-MO-1

Develop and implement a comprehensive safety management system. Include in that system process safety elements recommended in industry guidance publications, such as the Center for Chemical Process Safety (CCPS) publication Guidelines for Risk Based Process Safety.


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.
 

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2017-04-I-MO-2

Engage a qualified third-party to conduct a comprehensive review or audit of Loy Lange’s regulatory compliance practices and current compliance status.


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.
 

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2017-04-I-MO-3

Implement an electronic records and data management system that preserves all critical company records, safety policies and procedures, and operational data. Ensure that such records are stored and can be accessed remotely in the event of a catastrophic incident


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.
 

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Mayor, City of St. Louis, MO (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 29, 2022

2017-04-I-MO-6

Distribute and communicate the findings of this report to all licensed stationary engineers and all registered boiler and pressure vessel owning/operating entities in the City of St. Louis. 


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.
 

PDF Document Recommendation Status Change Summary

National Board of Boiler and Pressure Vessel Inspectors (NBBI) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 29, 2022

2017-04-I-MO-8

Update NB-263 Rules for Commissioned Inspectors to include prescriptive elements in the boiler and pressure vessel repair and alteration inspection and acceptance process that would prevent the acceptance of a non-conforming repair.


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.
 

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Packaging Corporation of America Hot Work Explosion (1 Recommendations)
Packaging Corporation of America (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 24, 2018

2017-03-I-LA-1

Apply the CSB safety guidance to PCA pulp and paper mills that produce NCG and operate NCG systems, which includes all foul condensate tanks. For these NCG systems:

  • Apply effective process safety management elements using good practice guidance, such as CCPS Guidelines for Risk Based Process Safety, and Guidelines for Implementing Process Safety Management;
  • Consider further expanding process safety management program boundaries beyond the minimum legal requirements to provide heightened coverage of process safety hazards;
  • Apply NFPA 69, Standard on Explosion Prevention Systems, to provide effective explosion prevention;
  • Where explosions cannot be prevented in accordance with NFPA 69, apply NFPA 68, Standard on Explosion Protection by Deflagration Venting, to provide explosion protection;
  • Ensure safety instrumented systems (safety interlocks) achieve desired risk reduction by applying the life-cycle approach provided in ISA-84, Functional Safety: Safety Instrumented Systems for the Process Industry Sector;
  • Apply TIP 0416-09, Collection and burning of concentrated noncondensible gases: regulations, design and operation, for effective NCG system design and operation;
  • Provide workers with periodic training to ensure they have an understanding of all process safety hazards applicable to areas of their responsibility and job tasks, including the safety conditions needed to permit hot work.

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.
 

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Chevron Refinery Fire (1 Recommendations)
Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2015

2012-03-I-CA-15

Jointly plan and conduct inspections with Cal/OSHA, California EPA and other state and local regulatory agencies with chemical accident prevention responsibilities to monitor the effective implementation of the damage mechanism hazard review and disclosure requirements under 2012-03-I-CA-R9 and R10 above.


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

PDF Document Recommendation Status Change Summary

DuPont La Porte Facility Toxic Chemical Release (2 Recommendations)
DuPont LaPorte, Texas Chemical Facility (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 25, 2019

2015-01-I-TX-8

Work together with emergency response team (ERT) member companies (DuPont, Chemours, Kuraray, and Invista), the International Chemical Workers Union Council of the United Food and Commercial Workers (ICWUC/UFCW) Local 900C, and the ICWUC/UFCW staff (if requested by the Local 900C) to update the DuPont La Porte emergency response plan. The emergency response program should ensure that periodic exercises or drills are performed on new procedures developed to address key lessons to strengthen ERT capabilities. The emergency response program should address the following:

  • Preidentifying unit experts as technical support personnel and ensuring that backup capability is available in the event the primary technical support personnel become unavailable. (Section 4.2: Process Coordinator Was Missing)
  • Clearly detailing in plant emergency procedures the alerting and notification protocols for different types of plant emergencies. Provide initial training to new plant personnel and periodic training to all plant personnel on these emergency communication procedures. These procedures should also include guidance for emergency responders when there is insufficient initial information to effectively assess the nature of the problem and the level of ERT resources required. (Section 4.3.1: Call for ERT Response)
  • Developing and applying regular maintenance schedules for emergency response vehicles consistent with the National Fire Protection Association’s Standard for the Inspection, Maintenance, Testing, and Retirement of In-Service Emergency Vehicles (NFPA 1911), which requires weekly visual and operational checks of emergency vehicles and has example checklists to use when performing preventive maintenance on emergency vehicles. (Section 4.3.2: ERT Mini-Pumper Truck Not Operational)
  • Ensuring that ERTs have reliable means to characterize hazardous atmospheres, for example equipment that monitors toxicity, explosivity, and oxygen levels. Additionally, ensure that ERT members know where the equipment is stored, can access it, and are trained on its proper use. (Section 4.4.1: Entry into Potentially Explosive Atmosphere)
  • Evaluating high-hazard areas, including PSM covered processes, to determine whether detectors and alarms are necessary to identify chemical releases (or other types of emergencies). Additionally, consider equipping high-hazard areas with surveillance technology to identify personnel in the field. (Section 4.4.2: No Technology to Locate Missing Workers)
  • Developing and implementing written policy and procedures to update emergency response plan documents when hazards are identified. For example, personnel can identify these types of hazards in process hazard analyses, facility siting studies, management of change reviews, and incident investigations. Changes to emergency planning documents should be effectively communicated to the site ERT as soon as possible after identifying the hazard. (Section 4.4.3: Unrecognized Manufacturing Building Collapse Hazard)
  • Ensuring that emergency response planning accounts for difficulties in conducting response efforts, including (1) maps included in emergency response plans to show the layout of buildings containing hazardous chemicals, for use by emergency responders and to aid evacuation and rescue efforts; (2) coordination of periodic (at least annual) site tours for plant and external emergency responders; (3) training emergency responders to help ensure familiarity with facility access points, hazards, emergency response issues, and site or facility layout; and (4) building teamwork by having members (from the different companies) of the ERT field train (by conducting drills) together when practicable. (Section 4.5: Difficulties Navigating Manufacturing Building)
  • Assigning knowledgeable personnel the responsibility to analyze process data to assess the source, scope, and magnitude of any incident. (Section 4.6: No Analysis of Process Data to Identify Source of Leak)
  • Training emergency response team members to (1) physically designate the hot zone; (2) communicate the location of the hot zone and entry control points to all personnel assisting with the emergency response, including operations personnel; and (3) control entry and exit points of the hot zone. (Section 4.7: Inadequate Control of Hot Zone)
  • Addressing in the emergency response plan how to characterize (including size, concentration, location, and direction of release) hazardous chemical releases and providing guidance on how and where people should take protective action (e.g., sheltering-in-place) in the event of a chemical release. (Section 4.8.1: Release Modeling)
  • Developing a procedure in the emergency response plan to effectively monitor for hazardous gases along the fence line at chemical facilities during the release to help workers understand and clearly communicate the extent of a release. (Section 4.8.4: Air Monitoring)

In addition, provide a copy of the emergency response plan to the Emergency Response Team and their local union representatives.


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

International Chemical Workers Union Council (ICWUC) of the United Food and Commercial Workers (UFCW) and Local 900C (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 25, 2019

2015-01-I-TX-9

Work together with DuPont to develop and implement the emergency response plan described in Recommendation R8 (2015-01-I-TX-R8).


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

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-2

Establish and convene a group of experts with drilling, engineering, and instrumentation expertise to discuss methods to achieve widespread implementation of automatic safety instrumented systems that could bring a well to a safe state in the event other operational barriers fail. Publish a technical bulletin discussing the strategies to implementing Blowout Preventer (BOP) safety instrumented systems.


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

Macondo Blowout and Explosion (2 Recommendations)
American Petroleum Institute (API) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2016

2010-10-I-OS-3

Publish an offshore exploration and production safety standard for the identification and effective management of safety critical elements (SCEs)— technical, operational, and organizational— with the goal of reducing major accident risk to As Low As Reasonably Practicable (ALARP), including but not limited to:
a. development and implementation of a SCE management system that includes the minimum necessary “shall” requirements in the standard to establish and maintain effective safety barriers to prevent major accidents;
b. methodologies for (1) the identification of SCEs and (2) the development of performance standards of each SCE, including its functionality, availability, reliability, survivability, and interactions with other systems;
c. establishment of assurance schemes for continuous active monitoring of all identified SCEs throughout each SCE’s lifecycle;
d. fulfillment of independent verification requirements and use of those verification activities to demonstrate robustness of the SCE management process;
e. development of process safety key performance indicators pertaining to the effective management of SCEs to drive continuous improvement.


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

2010-10-I-OS-5

Based on the analysis presented in the CSB Macondo investigation report, Volumes 3 and 4, and the requirements listed in R11, revise Recommended Practice 75, Development of a Safety and Environmental Management Program for Offshore Operations and Facilities, 3rd ed., May 2004 (reaffirmed May 2008), to require a specific focus on major accident prevention and address the following issues:
a.    Incorporate the following listed safety management system issues as explicit program elements and include language throughout API 75 regarding each element’s explicit and defined applicability to all of the other existing program elements:
1.    Human factors program requirements for the design, planning, execution, management, assessment, and decommissioning of well operations for the prevention of major accidents, as well as in the investigation of accidents and near-misses;
2.    Corporate governance and Board of Director responsibilities for major accident risk management;
3.    Workforce involvement and engagement in all aspects of the SEMS program;
4.    Contractor oversight and effective coordination for major accident prevention; and
5.    Leading and lagging key performance indicators that drive major accident prevention.
b.    Define and expand the roles and responsibilities for major accident prevention among the primary parties engaged in offshore drilling and production (i.e., the leaseholder/operator and owner/drilling contractor) by expanding applicability of this standard to the parties with primary control over major hazard operations and day-to-day activities and thus best positioned to implement and oversee a safety and environmental management system (SEMS) program to control major accident hazards.
c.    Incorporate into the Principles section of the document, as well as within the Setting Objectives and Goals section, as overarching provisions for the overall successful implementation and execution of a SEMS program:
1.    Management of major accident risk to As Low As Reasonably Practicable or similar risk-reduction target;
2.    Use the hierarchy of controls for identifying, establishing, and implementing barriers meant to prevent or mitigate major accident hazards.


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

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

Final Report Released On: October 21, 2015

2010-02-I-PR-7

Revise ANSI/API 2350, Overfill Protection for Storage Tanks in Petroleum Facilities (2015), to require the installation of an automatic overfill prevention systems for existing and new facilities at bulk aboveground storage tanks storing gasoline, jet fuel, other fuel mixtures or blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher. At a minimum, this system shall meet the following requirements:
a. Separated physically and independent from the level control and monitoring system.
b. Engineered, operated, and maintained to achieve an appropriate safety integrity level in accordance with the requirements of Part 1 of International Electrotechnical Commission (IEC) 61511-SER ed1-2004, Functional Safety – Safety Instrumented Systems for the Process Industry Sector.
c. Specified to achieve the necessary risk reduction as determined by a documented risk assessment methodology set in accordance with Center for Chemical Process Safety Guidelines for Hazard Evaluation Procedures, 3rd Edition, accounting for the following factors:
1. The existence of nearby populations and contamination of nearby environmental resources;
2. The nature and intensity of facility operations;
3. Realistic reliability for the tank gauging system; and
4. The extent/rigor of operator monitoring.
d. Proof tested with sufficient frequency in accordance with the validated arrangements and procedures to maintain the required safety integrity level.
e. Ensure that the above changes are not subject to grandfathering provisions in the standard.

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