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

Loy Lange Box Company Pressure Vessel Explosion (2 Recommendations)
Board of Aldermen, City of St. Louis, MO (2 Recommendations)
Open: 0% | Closed: 100%
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: 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

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: 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

Kuraray Pasadena Release and Fire (1 Recommendations)
Kuraray America, Inc. (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: December 21, 2022

2018-03-I-TX-11

Modify the EVAL Plant’s safe operating limits program to prevent operating under conditions that rely upon equipment design safety factors, such as the American Society of Mechanical Engineers (ASME) code material safety factors.


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

Intercontinental Terminals Company (ITC) Tank Fire (1 Recommendations)
Intercontinental Terminals Company, LLC (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 06, 2023

2019-01-I-TX-3

Install flammable gas detection systems with associated alarm functions in product storage and transfer areas at the ITC Deer Park terminal where flammable substance releases could occur. Develop and implement a response plan and operator training for actions to take when an alarm sounds.


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

Bio-Lab Lake Charles Chemical Fire and Release (2 Recommendations)
Bio-Lab Lake Charles (2 Recommendations)
Open: 50% | Closed: 50%
View Investigation
Final Report Released On: April 24, 2023

2020-05-I-LA-3

Perform process hazard analyses (PHAs) on all buildings and units processing or storing trichloroisocyanuric acid. Ensure that the PHAs are revalidated at least every five years. Also include the building design basis as process safety information for the PHA team to reference during their analysis.


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

2020-05-I-LA-4

Revise the Bio-Lab Lake Charles emergency response plan to require the following:

a. The site’s fire protection system is properly maintained and routinely function-tested in accordance with published industry guidance and NFPA requirements. Require in the emergency response plan that any equipment identified as nonfunctional must be repaired in a timely manner in accordance with NFPA requirements;

b. Emergency and fire protection equipment (in particular fire water pumps) must be checked regularly to ensure it is in good working order one month before the start of the U.S. hurricane season, as recommended by the Center for Chemical Process Safety Monograph Assessment of and Planning for Natural Hazards; and

c. Site personnel must be trained on the use of all emergency generators and other emergency equipment at least one month before the start of the U.S. hurricane season.


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

Valero McKee Refinery Propane Fire (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 09, 2008

2007-5-I-TX-4

Revise API Standard 2510, Design and Construction of LPG Installations, and API Publication 2510A, Fire-Protection Considerations for the Design and Operation of Liquefied Petroleum Gas (LPG) Storage Facilities, to address effective deluge system activation during emergencies originating in nearby process units.


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

LyondellBasell La Porte Fatal Chemical Release (3 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 25, 2023

2021-05-I-TX-5

Revise API Standard 599 Metal Plug Valves—Flanged, Threaded, and Welding Ends as follows:

a. State that there have been multiple incidents in which workers have inadvertently removed pressure-retaining components from plug valves while workers were attempting to remove the valve’s actuator or gearbox.

b. Recommend 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 at the facility.

c. For existing plug valves, require facilities to clearly mark all pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with ASME and VMA to ensure a consistent methodology is specified across both API and ASME standards.

d. Require that 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. Work with ASME and VMA to ensure a consistent methodology is specified across both API and ASME standards.


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

PDF Document Recommendation Status Change Summary

LyondellBasell Industries (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 25, 2023

2021-05-I-TX-1

Update LyondellBasell policy documents to require that procedures are developed for properly removing actuating equipment from plug valves. Require that the procedures clearly identify which non-pressure-retaining components are safe to remove and pressure-retaining components that shall not be removed, as well as ensure LyondellBasell personnel are trained on these procedures. Ensure that hazardous energy is controlled when performing these procedures, as required by 29 C.F.R. 1910.147. Require in the policy document that risk assessments for process safety are conducted before the actuating equipment removal work is authorized. Ensure that sufficient procedures and safeguards are in place to prevent worker exposure to process fluid.


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

2021-05-I-TX-2

Update LyondellBasell policy documents to require that LyondellBasell competent employee(s), as defined by 29 C.F.R. 1926.32(f), verify that contractors are competent, adequately trained, and qualified to perform the required work. To make this determination and to ensure work on process equipment is conducted in a safe manner, LyondellBasell competent employees may be required to oversee the work conducted by contractors on the process equipment. In the updated policy documents, include requirements to ensure that contract employees are informed of relevant process hazards and relevant details about the process equipment and are provided with equipment-specific procedures necessary to safely conduct their work.


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

PDF Document Recommendation Status Change Summary

United States Steel Corporation Clairton Plant Coke Oven Explosion (2 Recommendations)
U.S. Steel Clairton Coke Works (2 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Date of Accident: August 11, 2025

2025-03-I-PA-1

Conduct a siting evaluation for all occupied and potentially occupied buildings at the Clairton Coke Works facility. Utilize the guidance contained in the Center for Chemical Process Safety’s Guidelines for Evaluating Process Plant Buildings for External Explosions, Fires, and Toxic Releases, the American Petroleum Institute’s Recommended Practices 752, 753, and 756, and other industry good practice guidance documents.


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

2025-2025-03-I-PA-2-PA-2

Using the results from the evaluation performed in 2025-03-I-PA-R1, ensure that all documented facility siting hazards are mitigated in accordance with the guiding principles contained in the American Petroleum Institute’s Recommended Practices 752, 753, and 756.


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

TS USA Molten Salt Eruption (7 Recommendations)
HEF Groupe (4 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: June 03, 2025

2024-01-I-TN-4

Include physical, protective barriers as part of the standard design for liquid nitriding processes. These protective barriers shall be intended to isolate employees from molten salt releases.


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

2024-01-I-TN-5

Develop a safety management system that incorporates industry guidance and includes, but is not limited to:

a. A hazard analysis program for assessing the nitriding process. The program shall incorporate industry guidance, such as the Center for Chemical Process Safety’s (CCPS) Guidelines for Risk-Based Process Safety, the National Fire Protection Association’s (NFPA) Standard for Ovens and Furnaces, and ASM International’s Handbook. The program shall apply to new and existing parts, assess parts for accumulation hazards and sealed cavities, and include non-routine tasks such as reprocessing unsatisfactory parts.

b. Written operating procedures for the nitriding process. The procedures shall be based on the information gathered from the hazard analysis program. The procedures shall incorporate industry guidance, such as the Center for Chemical Process Safety’s (CCPS) Guidelines for Risk-Based Process Safety and the CCPS’s Guidelines for Writing Effective Operating and Maintenance Procedures.

c. A training program, including written materials, for the employees involved in the nitriding process. This program shall be based on the nitriding facility’s operating procedures and other relevant information from the hazard analysis program. The program shall incorporate industry guidance, such as the Center for Chemical Process Safety’s (CCPS) Guidelines for Risk-Based Process Safety.

d. An incident investigation program. This program shall include requirements for performing causal analysis, producing written reports, and communicating findings and corrective actions throughout the entire HEF Groupe organization. The program shall incorporate industry guidance, such as the Center for Chemical Process Safety’s (CCPS) Guidelines for Risk-Based Process Safety and the CCPS’s Guidelines for Investigating Process Safety Incidents.


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

2024-01-I-TN-6

Develop and implement an effective and comprehensive Knowledge Management program for sharing knowledge throughout the HEF Groupe organization. Knowledge shall include all information from audits, hazard analyses, and incident investigations, including causal analyses and corrective actions recommended and taken. This program shall incorporate industry guidance, such as the Center for Chemical Process Safety’s (CCPS) Guidelines for Process Safety Knowledge 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 Recommendation Status Change Summary

2024-01-I-TN-7

Develop and implement a comprehensive and effective Corporate Governance program. This program shall include regular audits of subordinate facilities throughout the organization, with tracking and accountability for implementation of all recommendations and corrective actions identified in the audits. Facility adherence to the safety management system recommended above shall be evaluated during the audits. The program shall require documentation of audit findings, prompt responses to deficiencies, development of corrective actions, and implementation of the corrective actions throughout the organization. This program shall incorporate industry guidance, such as the Center for Chemical Process Safety’s (CCPS) 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 Recommendation Status Change Summary

Techniques Surfaces USA (TS USA) (3 Recommendations)
Open: 67% | Closed: 33%
View Investigation
Final Report Released On: June 03, 2025

2024-01-I-TN-1

Implement physical, protective barriers around the molten salt baths that isolate employees from hazardous releases at all locations that perform liquid nitriding.


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

2024-01-I-TN-2

Develop a safety management system that incorporates industry guidance and includes, but is not limited to:

a. A hazard analysis program for assessing the nitriding process. The program shall incorporate industry guidance, such as the Center for Chemical Process Safety’s (CCPS) Guidelines for Risk-Based Process Safety, the National Fire Protection Association’s (NFPA) Standard for Ovens and Furnaces, and ASM International’s Handbook. The program shall apply to new and existing parts, assess parts for accumulation hazards and sealed cavities, and include non-routine tasks such as reprocessing unsatisfactory parts.

b. Written operating procedures for the nitriding process. The procedures shall be based on the information gathered from the hazard analysis program. The procedures shall incorporate industry guidance, such as the Center for Chemical Process Safety’s (CCPS) Guidelines for Risk-Based Process Safety and the CCPS’s Guidelines for Writing Effective Operating and Maintenance Procedures.

c. A training program, including written materials, for the employees involved in the nitriding process. This program shall be based on the nitriding facility’s operating procedures and other relevant information from the hazard analysis program. The program shall incorporate industry guidance, such as the Center for Chemical Process Safety’s (CCPS) Guidelines for Risk-Based Process Safety.

d. An incident investigation program. This program shall include requirements for performing causal analysis, producing written reports, and communicating findings and corrective actions throughout the entire TS USA organization. The program shall incorporate industry guidance, such as the Center for Chemical Process Safety’s (CCPS) Guidelines for Risk-Based Process Safety and the CCPS’s Guidelines for Investigating Process Safety Incidents.


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

2024-01-I-TN-3

For each TS USA facility, establish a position with specific professional expertise and experience in safety management systems, such as risk-based process safety. This position shall be responsible for TS USA’s safety management system, ensuring that HEF Groupe’s safety information is incorporated at the site level, and implementing regulatory and industry safety 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

Foundation Food Group Fatal Chemical Release (1 Recommendations)
National Fire Protection Association (NFPA) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 11, 2023

2021-03-I-GA-11

Update NFPA 55 Compressed Gases and Cryogenic Fluids Code to:

a) require the use of atmospheric monitoring with cryogenic asphyxiants in accordance with industry guidance such as is contained in CGA P-76 Hazards of Oxygen-Deficient Atmospheres and CGA P-12 Safe Handling of Cryogenic Liquids in addition to CGA P-18 Standard for Bulk Inert Gas Systems; and,

b) include guidance on the adequate safe location of manual shutoff valves and devices such as emergency push buttons used to activate remotely operated emergency isolation valves (ROEIVs). At a minimum this guidance should be harmonized with the requirements of ISO 13850 Safety of machinery – Emergency stop function – Principles for design.


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