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.

 

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Recommendations

Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire (1 Recommendations)
VSE Corporation (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 17, 2013

2011-06-I-HI-6

Use experts to: • Assist VSE procurement in selecting vendors to properly handle, store, and dispose of explosive hazardous materials, including fireworks, pursuant to prime contract requirements; and, • Assist VSE personnel in overseeing the work to ensure it is being conducted safely. Status:


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 Recommendations Status Change Summary

West Fertilizer Explosion and Fire (2 Recommendations)
Texas A&M Engineering Extension Services (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2016

2013-02-I-TX-15

Develop and administer a hazardous materials training module for career and volunteer fire departments that addresses fertilizer grade ammonium nitrate (FGAN) and other hazardous materials or chemicals that could pose new specialized hazards.  Ensure that the training includes multiple delivery methods to enable a broad reach.  The training 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.

Objectives of the training course should address the following:

a. How to respond to industrial fires involving FGAN and other hazardous materials or chemicals that could pose new specialized hazards to responding firefighters

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

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

d. Pre-incident planning for fires involving FGAN and other hazardous materials or chemicals that could pose new specialized hazards to responding firefighters

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

f. National Incident Management System and Incident Command System.


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 Recommendations Status Change Summary

2013-02-I-TX-16

Develop an outreach program that notifies state, regional, and local fire departments about available FGAN training opportunities.  The program should include the following elements:

a. Guidance for fire departments on how to identify FGAN and other recognized hazards associated with other hazardous materials or chemicals within their communities by engaging with State Emergency Response Commissions and Local Emergency Planning Committees

b. Promotion of use of the hazardous materials training module with TEEX training partners.


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 Recommendations Status Change Summary

Chevron Refinery Fire (4 Recommendations)
Board of Supervisors, Contra Costa County, CA (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2015

2012-03-I-CA-25

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 Contra Cost County, 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 Recommendations Status Change Summary

Governor and Legislature of the State of California (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2015

2012-03-I-CA-13

Require the 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). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new process, process unit rebuilds, significant process repairs and in the development of corrective actions from incident investigation recommendations.


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-14

Monitor and confirm the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R9 and 2012-03-I-CA-R10), so that all necessary mechanical integrity work at all California Chevron Refineries is identified and recommendations are completed in a timely way.


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

PDF Document Recommendations 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-24

Implement or cause to be implemented 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 Richmond, 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

AirGas Facility Fatal Explosion (3 Recommendations)
Compressed Gas Association (CGA) (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2017

2016-04-I-FL-2

Safety Management System for Nitrous Oxide Manufacturing

Develop and implement a safety management system standard for nitrous oxide manufacturing, to manage known process safety hazards, including nitrous oxide decomposition, which includes appropriate elements based on chemical industry good practice guidance, such as CCPS Guidelines for Risk Based Process Safety, Essential Practices for Managing Chemical Reactivity Hazards, and Guidelines for Implementing Process Safety Management.


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 Recommendations Status Change Summary

2016-04-I-FL-3

Ensure Effective Flame Arrestor Design

Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to require testing of safety devices, such as strainers used as flame arrestors, for applications where a safety device is used to quench a nitrous oxide decomposition reaction.  To ensure that these safety devices meet the intended purpose, the user should test the safety device by simulating conditions of use.  In addition, require users to document the required performance standard or test protocol followed. 


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 Recommendations Status Change Summary

2016-04-I-FL-4

Require Pump Run-Dry Safety Interlocks Apply ISA-84

Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to reference and require applying International Society of Automation (ISA) standard ISA-84, Functional Safety: Safety Instrumented Systems for the Process Industry Sector to safety interlocks such as the nitrous oxide pump “run-dry” shutdown.


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 Recommendations Status Change Summary

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

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: 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 Recommendations Status Change Summary

Xcel Energy Company Hydroelectric Tunnel Fire (1 Recommendations)
Southern California Painting and Drywall Industries Joint Apprenticeship and Training Committee (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-18

Require that all journeyman painters who are employees and/or members have received safety training equivalent in content to that covered in the Joint Apprenticeship program. At a minimum, address confined space safety, safe handling of flammables, emergency response and rescue, and fire prevention.


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 Recommendations Status Change Summary

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

Final Report Released On: October 27, 2011

2011-H-1-5

Create a new standard or amend existing standards covering exploration and production facilities to:

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 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) Require security measures at least as protective as API 2610 to prevent non-employee access to flammable storage tanks at upstream E&P sites, including such measures as a full fence surrounding the tank(s) with a locked gate, hatch locks on tank manways, and barriers securely attached to tank external ladders or stairways.

d) Require 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.

e) Recommend that new or revised mineral leasing agreements include security and signage requirements as described above.


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 Recommendations Status Change Summary