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

Veolia Environmental Services Flammable Vapor Explosion and Fire (1 Recommendations)
Veolia ES Technical Solutions (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 21, 2010

2009-10-I-OH-2

During the rebuild, design and install a closed relief system and develop a policy for safe venting (e.g., use of a flare) for relief systems to the atmosphere.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs.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concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

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Loy Lange Box Company Pressure Vessel Explosion (3 Recommendations)
Board of Aldermen, City of St. Louis, MO (2 Recommendations)
Open: 100% | Closed: 0%
View Investigation
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 - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

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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 - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

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Mayor, City of St. Louis, MO (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
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 - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

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Kuraray Pasadena Release and Fire (3 Recommendations)
Kuraray America, Inc. (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: December 21, 2022

2018-03-I-TX-2

Implement a site-wide system to evacuate nonessential personnel during upset conditions and exclude nonessential workers from being near equipment during transient operating modes, such as startup.


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

2018-03-I-TX-6

Clarify the lower equipment design pressure of the EVAL Reactor 2 within the operator training systems, written procedures, and in the control system interface.


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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2018-03-I-TX-9

Complete the alarm management efforts at the EVAL Plant and implement a continual program to meet or be lower than the alarm rate performance targets established in ISA 18.2.


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

TPC Port Neches Explosions and Fire (3 Recommendations)
TPC Group (3 Recommendations)
Open: 33% | Closed: 67%
View Investigation
Final Report Released On: December 19, 2022

2020-02-I-TX-1

For all TPC PNO terminal operations in high-purity butadiene service (e.g., greater than 80 percent butadiene concentration), develop and implement a program to identify and control, or eliminate, dead legs. At a minimum, the program must require:

a)   a comprehensive review of equipment configurations in high-purity butadiene service using both Piping and Instrumentation Diagrams (P&IDs) and field evaluations to identify all permanent dead legs. Implement a process to identify changes in operating conditions in high-purity butadiene service that could result in the formation of temporary or new permanent dead legs, such as when primary or spare pumps are temporarily or permanently out of service. Ensure this review is conducted at least every five years;

b)   evaluation and implementation of design strategies, where practical, to prevent dead legs in areas susceptible to popcorn polymer formation;

c)   mitigation, control, or prevention of hazardous popcorn polymer buildup in all identified dead legs in high-purity butadiene service, such as through increased monitoring, flushing of equipment, use of inhibitor(s), or planning maintenance activities to minimize the amount of time that a temporary dead leg is present; and

d)   periodic continual auditing (at a minimum annually) by TPC PNO management to ensure that the process is being implemented.


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.
 

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2020-02-I-TX-2

For all TPC PNO terminal operations, passivate all storage vessels, fixed equipment, and associated piping systems in high-purity butadiene service consistent with industry good practice guidance.


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

2020-02-I-TX-3

At the TPC PNO facility, incorporate the recording of any paper-based process performance information into TPC PNO’s existing electronic records management system so that the information can be reliably retained, retrieved, and analyzed in the event of a catastrophic incident. At a minimum, those records shall include Dead Leg Inspection check sheets, Spare Pump Rotation check sheets, and handwritten logs documenting the performance of all critical process instrumentation (e.g., the oxygen analyzer).


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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Caribbean Petroleum Refining Tank Explosion and Fire (4 Recommendations)
Environmental Protection Agency (EPA) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 21, 2015

2010-02-I-PR-1

(Superseded by 2019-01-I-TX-R8)
 
Revise where necessary the Spill Prevention, Control and Countermeasure (SPCC); Facility Response Plan (FRP); and/or Accidental Release Prevention Program (40 CFR Part 68) rules to prevent impacts to the environment and/or public from spills, releases, fires, and explosions that can occur at bulk aboveground storage facilities storing gasoline, jet fuels, blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher.
 
At a minimum, these revisions shall incorporate the following provisions:
 
a) Ensure bulk above ground storage facilities conduct and document a risk assessment that takes into account the following factors:
1. The existence of nearby populations and sensitive environmenls;
2. The nature and intensity of facility operations;
3. Realistic reliability of the tank gauging system; and
4. The extent/rigor of operator monitoring
b) Equip bulk aboveground storage containers/tanks with automatic overfill prevention systems that are physically separate and independent from the lank level control systems.
c) Ensure these automatic overfill prevention systems follow good engineering practices.
d) Engineer, operate, and maintain automatic overfill prevention systems to achieve appropriate safety integrity levels in accordance with good engineering practices, such as Part 1 of lnternational Electro-technical Commission (IEC) 61511-SER ed1.0B-2004, Functional Safety - Safety Instrumented Systems for the Process Industry Sector.
e) Regularly inspect and test automatic overfill prevention systems to ensure their proper operation in accordance with good engineering practice.

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.
 

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2010-02-I-PR-2

Conduct a survey of randomly selected bulk aboveground storage containers storing gasoline or other flammable liquids with a NFPA 704 flammability rating of 3 or higher, at terminals in high risk locations (such as near population centers or sensitive environments) that are already subject to the Spill Prevention, Control and Countermeasure (SPCC) and/or Facility Response Plan (FRP) rules to determine:
a) The nature of the safety management systems in place to prevent overfilling a storage tank during loading operations. Analysis of the safety management systems should include equipment, training, staffing, operating procedures and preventative maintenance programs.
b) The extent to which terminals use independent high level alarms, automated shutoff/diversion systems, redundant level alarms or other technical means to prevent overfilling a tank
c) The history of overfilling incidents at the facilities, with or without consequence
d) Whether additional reporting requirements are needed to understand the types of incidents leading to overfilling spills that breach secondary containment and have the potential to impact the environment and/or the public, as well as the number of safeguards needed to prevent them.

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

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National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 21, 2015

2010-02-I-PR-6

Revise NFPA 30, Storage of Flammable and Combustible Liquids, Section 21.7.1.1 (2015) for bulk aboveground storage tank terminals storing gasoline, jet fuel, other fuel mixtures or blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or greater. This modification shall meet the following requirements:
a. More than one safeguard to prevent a tank overfill, all within an automatic overfill prevention system as described in ANSI/API Standard 2350 (2015) Overfill Protection for Storage Tanks in Petroleum Facilities with an independent level alarm as one of the safeguards. The safeguards should meet the following standards:
1. Separated physically and electronically and independent from the tank gauging system;
2. Engineered, operated, and maintained for an appropriate level of safety based on the predetermined risk level after considering part b of this recommendation; and
3. Proof tested with sufficient frequency in accordance with the validated arrangements and procedures.
b. Specified to achieve the necessary risk reduction as determined by a documented risk assessment methodology conducted 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.
c. Ensure that the above changes not subject to grandfathering provisions in the code.

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

Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 21, 2015

2010-02-I-PR-4

(Superseded by 2019-01-I-TX-R7)
 
a) Revise the Flammable and Combustible Liquids standard (29 CFR§ 1910.106) to require installing, using, and maintaining a high-integrity automatic overfill prevention system with a means of level detection, logic/control equipment, and independent means of flow control for bulk aboveground storage tanks containing gasoline, jet fuel, other fuel mixtures or blends tocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher, to protect against loss of containment. At a minimum, this system
shall meet the following requirements:
1. Separated physically and electronically and independent from the tank gauging system.
2. Engineered, operated, and maintained to achieve an appropriate level of safety integrity in accordance with the rrequirements of Part 1 of International Electro-technical Commission (IEC) 61511-SER ed1.0B-2004, Functional Safety - Safety Instrumented Systems for the Process Industry Sector. Such a system would employ a safety integrity level (SIL) documented in accordance with the principles in Part 3 of IEC 61511-SER ed1.0B-2004, accounting for the following factors:
i. The existence of nearby populations and sensitive environments;
ii. The nature and intensity of facility operations;
iv. The extent/ rigor of operator monitoring.
3. Proof tested in accordance with the validated arrangements and procedures with sufficient frequency to ensure the specified safety integrity level is maintained.
b) Establish hazard analysis, management of change and mechanical integrity management system elements for bulk above ground storage tanks in the revised 1910.106 standard that are similar to those in the Process Safety Management of Highly Hazardous Chemicals standard (29 CFR § 1910.119) and ensure these facilities are subject to Recognized and Generally Accepted Good Engineering Practices (RAGAGEP).

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.
 

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Improving Reactive Hazard Management (1 Recommendations)
Environmental Protection Agency (EPA) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: October 08, 2002

2001-01-H-3

Revise the Accidental Release Prevention Requirements, 40 CFR 68, to explicitly cover catastrophic reactive hazards that have the potential to seriously impact the public, including those resulting from self-reactive chemicals and combinations of chemicals and process-specific conditions. Take into account the recommendations of this report to OSHA on reactive hazard coverage. Seek congressional authority if necessary to amend the regulation.


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

Motiva Enterprises Sulfuric Acid Tank Explosion (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 28, 2002

2001-05-I-DE-1

(Superseded by 2019-01-I-TX-R7)

Ensure coverage under the Process Safety Management Standard (29 CFR 1910.119) of atmospheric storage tanks that could be involved in a potential catastrophic release as a result of being interconnected to a covered process with 10,000 pounds of a flammable substance.


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