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

LyondellBasell La Porte Fatal Chemical Release (1 Recommendations)
Valve Manufacturers Association of America (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: May 25, 2023

2021-05-I-TX-6

Work with ASME and API and develop a white paper to the Valve Manufacturers Association of America addressing the issue of plug valve design with a focus on the following:

a. Recommend as an industry good practice that facilities using plug valves establish written procedures detailing the correct way to remove the plug valve actuator or gearbox for each specific plug valve design.

b. For existing plug valves, recommend as an industry good practice for facilities to clearly mark all pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with ASME and API to ensure a consistent methodology is specified to the industry.

c. Recommend new plug valves be designed, consistent with Prevention through Design principles, to prevent the inadvertent removal of pressure-retaining components when removing the actuator or gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those incidents, when formulating a new plug valve design recommendation. Work with ASME and API to ensure a consistent design is recommended to the industry.


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

Foundation Food Group Fatal Chemical Release (2 Recommendations)
Messer LLC (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: December 11, 2023

2021-03-I-GA-2

Update the company product stewardship policy to:

a) include participation by Messer in customers’ process hazard analyses (PHAs). The policy should require that these PHAs be conducted in a manner which conforms with CCPS Guidelines for Hazard Evaluation Procedures prior to the startup of a cryogenic freezing process;

b) require verification that proper signage, in accordance with CGA P-76 Hazards of Oxygen-Deficient Atmospheres, is displayed on and/or near equipment; and,

c) require a facility and/or equipment siting review to ensure that emergency shutoff devices, including E-stops, are located such that they can be safely actuated during a release of liquid nitrogen.


Status: Closed - Exceeds Recommended Action
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

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2021-03-I-GA-3

Create an informational product that provides Messer customers with information on the safety issues described in this report. In this informational product, recommend that Messer customers develop and implement effective safety management systems to control asphyxiation hazards from inert gases based on the guidance published in CGA P-86 Guideline for Process Safety Management, CGA P-12 Guideline for Safe Handling of Cryogenic and Refrigerated Liquids, CGA P-18 Standard for Bulk Inert Gas Systems, and CGA P-76 Hazards of Oxygen-Deficient Atmospheres.


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

PDF Document Recommendation Status Change Summary

Didion Milling Company Explosion and Fire (2 Recommendations)
Didion Milling, Inc. (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: December 06, 2023

2017-07-I-WI-3

Contract a competent third party to perform dust hazard analyses (DHAs) on all buildings and units that process combustible dust. Ensure that the DHAs are revalidated at least every five years. Implement pre-deflagration detection, deflagration venting, deflagration suppression, deflagration isolation, and deflagration pressure containment engineering controls identified in the initial and revalidation DHA in accordance with NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, NFPA 68, Standard on Explosion Protection by Deflagration Venting, NFPA 69, Standard on Explosion Prevention Systems, and NFPA 652, Standard on the Fundamentals of Combustible Dust.


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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2017-07-I-WI-8

Contract a competent third party to assess and update the pre-deflagration detection and suppression engineering controls, such as those discussed in Chapter 9 of the 2019 edition of NFPA 69, Standard on Explosion Prevention Systems, for adequacy to detect and alarm employees of an emergency situation, such as a smoldering fire, and trigger an evacuation.


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

Givaudan Sense Colour Explosion (1 Recommendations)
Corn Refiners Association (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 27, 2026

2024-06-I-KY-12

Alert association members who manufacture corn syrup of the November 12, 2024, Givaudan incident and its causes, including but not limited to the sugar ingredient decomposition reaction that led to Reactor 6’s rupture. Request that they update their corn syrup safety data sheets to include: the decomposition temperature, the consequences of exceeding that temperature, and the decomposition products produced (for example, carbon dioxide).


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

United States Steel Corporation Clairton Plant Coke Oven Explosion (5 Recommendations)
MPW Industrial Services, Inc. (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: August 10, 2026

2025-03-I-PA-7

Develop written policies and procedures in accordance with industry guidance such as NFPA 56 Standard for Fire and Explosion Prevention During Cleaning and Purging of Flammable Gas Piping Systems, governing cleaning piping systems containing flammable or toxic gas. Ensure that all workers who will or might participate in such operations are trained on the policies and procedures.


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

Nippon Steel North America, Inc. (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: August 10, 2026

2025-03-I-PA-6

Develop and implement a corporate process safety governance program to ensure the implementation of process safety management at applicable facilities. At a minimum, this program shall:

a. include regular audits of subordinate facilities throughout the organization;

b. require the documentation of process safety deficiencies, when identified, and prompt corrective action; and,

c. incorporate industry guidance, such as the Center for Chemical Process Safety’s (CCPS) Guidelines for Implementing Process Safety Management, the CCPS’s Process Safety – Leadership from the Boardroom to the Frontline, and other industry good practice guidance publications.


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

U.S. Steel Clairton Coke Works (3 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: August 10, 2026

2025-03-I-PA-3

Develop a written procedure in accordance with industry guidance such as NFPA 56 Standard for Fire and Explosion Prevention During Cleaning and Purging of Flammable Gas Piping Systems, for washing valve seats with pressurized water. Ensure that the procedure includes steps and other controls, including overpressure protection, to minimize the hazards of the operation. Ensure that workers who will or might perform the operation are involved in the development of the procedure and are trained on the procedure.


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

2025-03-I-PA-4

Conduct a hazard analysis or safety validation of the written valve washing procedure in accordance with NFPA 56 Standard for Fire and Explosion Prevention During Cleaning and Purging of Flammable Gas Piping Systems. Ensure that workers who will or might perform the operation are involved in the analysis or validation.


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

2025-03-I-PA-5

Develop a comprehensive process safety management system, incorporating guidance from the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety and other industry good practice guidance publications, and apply it to all coke oven gas processes at the Clairton facility.


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

Bio-Lab Inc. Conyers Fire and Chemical Release (7 Recommendations)
KIK Consumer Products (4 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 21, 2026

2024-04-I-GA-1

Develop and implement a corporate standard for the storage (including storage configuration) and handling of bulk pool-treatment chemicals, including but not limited to chlorinated isocyanurates and BCDMH, at facilities in the company’s Pool Division. At a minimum, the standard shall ensure compliance with NFPA 400 Hazardous Materials Code (for storage, construction, and other requirements) and NFPA 13 Standard for the Installation of Sprinkler Systems (for corrosion resistance and other requirements), and that any non-compliance is addressed within a specified timeframe. The incident history of KIK Consumer Product facilities, including the Bio-Lab Lake Charles and Bio-Lab Conyers sites, shall be used to guide the development of the standard.


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

2024-04-I-GA-2

Develop and implement a corporate standard that requires an assessment of all KIK Consumer Products / Bio-Lab, Inc. third-party facilities that manufacture and/or store bulk pool-treatment chemicals, including but not limited to chlorinated isocyanurates and BCDMH, to ensure compliance with NFPA 400 Hazardous Materials Code (for storage, construction, and other requirements) and NFPA 13 Standard for the Installation of Sprinkler Systems (for corrosion resistance and other requirements). The standard shall ensure that any non-compliance with NFPA 400 and NFPA 13 is appropriately addressed prior to operations. The standard shall ensure that existing third-party facilities that manufacture and/or store bulk chlorinated isocyanurates and BCDMH are assessed for compliance with NFPA 400 and NFPA 13, and that any non-compliance is addressed within a specified timeframe. The incident history of KIK Consumer Product facilities, including the Bio-Lab Lake Charles and Bio-Lab Conyers sites, shall be used to guide the development of the standards.


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

2024-04-I-GA-3

Contract a third party to audit the implementation of the PSM Lite program within KIK’s Pool Division, including all facilities that handle and/or store bulk pool-treatment chemicals, including but not limited to chlorinated isocyanurates and BCDMH. Address all identified deficiencies resulting from the audit within a specified timeframe.


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

2024-04-I-GA-4

Contract a third party to audit the implementation of the corporate standards developed in recommendations 2024-04-I-GA-R1 and 2024-04-I-GA-R2 at KIK Consumer Products / Bio-Lab, Inc. Pool Division facilities and third-party facilities that manufacture and/or store bulk pool-treatment chemicals. Address all identified deficiencies resulting from the audit within a specified timeframe.


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 Fire Protection Association (NFPA) (3 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 21, 2026

2024-04-I-GA-5

Revise NFPA 400 Hazardous Materials Code, Section 4.1 Hazardous Material Classification, or a more appropriate section, to clarify that materials are required to be assessed and a determination reached for each of the categories of hazardous materials (1) through (14).


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

2024-04-I-GA-6

Revise NFPA 400 Hazardous Materials Code, Section G.4 Safety Information on Oxidizers Used in Swimming Pools, to address the potential for pool-treatment chemicals to demonstrate characteristics of hazard classifications other than those of oxidizers, and that each additional hazard classification must conform to the code requirements for each applicable hazardous material classification in accordance with Section 4.4 Multiple Hazards.


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

2024-04-I-GA-7

Revise NFPA 400 Hazardous Materials Code, Section G.4 Safety Information on Oxidizers Used in Swimming Pools, to include information regarding the potential for oxidizers to corrode metals such as sprinkler components and reference NFPA 13 Standard for the Installation of Sprinklers.


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

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