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

BP America Refinery Explosion (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 20, 2007

2005-4-I-TX-8

1. Strengthen the planned comprehensive enforcement of the OSHA Process Safety Management (PSM) standard. At a minimum: a. Identify those facilities at greatest risk of a catastrophic accident by using available indicators of process safety performance and information gathered by the EPA under its Risk Management Program (RMP). b. Conduct, or have conducted, comprehensive inspections, such as those under your Program Quality Verification (PQV) program at facilities identified as presenting the greatest risk. c. Establish the capacity to conduct more comprehensive PSM inspections by hiring or developing a sufficient cadre of highly trained and experienced inspectors. d. Expand the PSM training offered to inspectors at the OSHA National Training Institute.


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

PDF Document Recommendation Status Change Summary

Bethune Point Wastewater Plant Explosion (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 13, 2007

2006-3-I-FL-6

Revise 29 CFR 1910.106 to specifically exclude the use of thermoplastics in above ground flammable liquid service.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs.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concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.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

Enterprise Pascagoula Gas Plant Explosion and Fire (4 Recommendations)
GPA Midstream Association (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: February 13, 2019

2016-02-I-MS-2

Revise GPA Technical Bulletin: Brazed Aluminum Heat Exchangers, or develop a new bulletin, to incorporate the significant lessons learned from this incident, including but not limited to:

a. information on the potential of both minor leaks and catastrophic failure as a result of thermal fatigue;

b. clarification on the optimal placement of BAHX temperature and pressure sensors to better monitor operating conditions, including temperature rates of change; and

c. clarification on the need to safely vent layers that have been blocked off after interpass leak repairs, in all BAHX configurations.


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

2016-02-I-MS-3

Develop a database for operators to submit BAHX operational data for collaborative industry learning and analysis. Encourage your members to submit pressure and temperature data associated with the entire service life of brazed aluminum heat exchangers as well as the date(s) of leak(s) or failure(s) for each exchanger on which data is being submitted. At a minimum this system should:

a. provide a way to anonymously input data into the database;

b. specify the time interval between measurements such that data can be normalized across different exchangers; and

c. capture the type of service in which the exchanger was operating.


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.
 

PDF Document Recommendation Status Change Summary

2016-02-I-MS-4

Using available operational process data of BAHXs in midstream gas plant operation collected in fulfillment of 2016-02-I-MS-R3, continue data analysis efforts to determine what, if any, correlation exists between operational process data and the frequency or timing of thermal fatigue-generated cracking to more accurately predict the service life of a BAHX.

Should predictors be identified, develop and offer to your members industry tools, techniques, or criteria for estimating when thermal fatigue warrants preemptive replacement of a BAHX (e.g., risk assessment tools or damage rate calculations).


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.
 

PDF Document Recommendation Status Change Summary

Jackson County Board of Supervisors, Jackson County Emergency Management Agency, Jackson County Local Emergency Planning Committee (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: February 13, 2019

2016-02-I-MS-5

Work with members (industry, emergency response, community) to explicitly define the communication methods for community notification and incident updates (e.g., social media, local news outlets, passive phone system), and the expectations for their use, so that members of the public can efficiently and effectively obtain current safety information. Publish these defined community notification methods and expectations for use on the most appropriate mediums available, such as the Jackson County Emergency Management website, the Jackson County LEPC website, and the social media outlets Jackson County utilizes to disseminate safety information to the community.


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

AirGas Facility Fatal Explosion (1 Recommendations)
Air Liquide (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 20, 2017

2016-04-I-FL-1

The goal of 2016-04-I-FL-R1 is to prevent all nitrous oxide explosions at its facilities, while preventing harm to workers and the public.

Following the August 28, 2016, incident, the company began a comprehensive initiative to review its nitrous oxide production facilities, trucking fleet, and cylinder-filling operations.  The scope of the ongoing Air Liquide initiative is shown in Table 1. 

Complete the development and implementation of the company’s nitrous oxide business process safety initiative as shown in Table 1, consistent with the findings, conclusions, and recommendations contained in this report. 


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

PDF Document Recommendation Status Change

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

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: 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.
 

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

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: 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.
 

DuPont Corporation Toxic Chemical Releases (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 20, 2011

2010-06-I-WV-1

Revise OSHA 29 CFR 1910.101, General Industry Standard for Compressed Gases, to require facilities that handle toxic and highly toxic materials in compressed gas cylinders to incorporate provisions that are at least as effective as the 2010 edition of Section 7.9, Toxic and Highly Toxic Gases, in National Fire Protection Association (NFPA) 55, Compressed Gases and Cryogenic Fluids Code, including enclosures, ventilation and treatment systems, interlocked fail-safe shutdown valves, gas detection and alarm systems, piping system components, and similarly relevant layers of protection.


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

Veolia Environmental Services Flammable Vapor Explosion and Fire (1 Recommendations)
Veolia ES Technical Solutions (1 Recommendations)
Open: 100% | Closed: 0%

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: 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.
 

PDF Document Recommendation Status Change Summary

Pryor Trust Fatal Gas Well Blowout and Fire (8 Recommendations)
International Association of Drilling Contractors (IADC) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 12, 2019

2018-01-I-OK-14

Participate in development of the recommended practice describe in recommendation 2018-01-OK-R4 to [American Petroleum Institute] API.


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 Oilwell Varco (NOV) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 12, 2019

2018-01-I-OK-17

Design the M/D Totco user interface to allow drilling contractors to pre-set different alarms for different operations (e.g., different alarm configurations for drilling, tripping, circulating, and surface operations in a “state-based” alarm system).


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

2018-01-I-OK-18

Design the M/D Totco 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: 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

Pason Systems Corp. (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 12, 2019

2018-01-I-OK-15

Design the Pason user interface to allow drilling contractors to pre-set different alarms for different operations (e.g., different alarm configurations for drilling, tripping, circulating, and surface operations in a “state-based” alarm system).


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

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: 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

Red Mountain Operating (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 12, 2019

2018-01-I-OK-12

Develop a new policy that a well-specific Well Construction Interface Document be in place before drilling operations begin, as specified in API Bulletin 97 Well Construction Interface Document Guidelines. Ensure the policy requires that the Well Construction Interface Document specifies the technical requirements of the rig equipment and technical qualifications of personnel (e.g., conventional drilling, managed pressure drilling, underbalanced drilling) as well as specifies which barriers must be maintained and the expected response if a barrier is lost.


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

2018-01-I-OK-13

Develop a management of change policy governing real-time changes to operations and the drilling plan. As part of this policy, require hazard analysis and consideration of rig equipment, procedures, and personnel training and qualifications.


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

State of Oklahoma/Oklahoma Corporation Commission (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 12, 2019

2018-01-I-OK-19

Establish and implement safety regulations requiring entities who design oil and gas well drilling plans for wells in Oklahoma (e.g., operators) and entities who perform the drilling operation (e.g., drilling contractors) to develop and implement the following prior to conducting drilling operations:

(a) Detailed written operating procedures with specified steps and equipment alignment for all operations;

(b) Written procedures for the management of changes (except replacements in kind) in procedures, the well plan, and equipment;

(c) A risk assessment of hazards associated with the drilling plan;

(d) A requirement to follow Recognized and Generally Accepted Good Engineering Practices (RAGAGEP);

(e) Development of a Well Construction Interface Document between the operator and the drilling contractor prior to the commencement of drilling activities which at a minimum includes a bridging document and well plan specifying barriers and how to manage them;

(f) The performance and documentation of flow checks using acceptable methods at defined points during the operation for a specified duration; and

(g) A requirement for employee participation, similar to the Employee Participation requirement in the OSHA PSM 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