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] 

 

Expand All

Recommendations

Optima Belle Explosion and Fire (5 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 06, 2023

2021-02-I-WV-15

Update Guidelines for Process Safety in Outsourced Manufacturing Operations or develop a new tolling guidance document to supplement existing guidelines. The publication should include current best practices, introduce guidance specific to tolling brokers and/or project managing companies such as Richman Chemical Inc., and cross-reference and align with the comprehensive management systems framework and terminology contained in Guidelines for Risk Based Process Safety and other contemporary industry good practice guidance.


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

Optima Belle LLC (4 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 06, 2023

2021-02-I-WV-1

Develop and implement a written thermal and reactive hazards evaluation and management program. The program should adhere to industry guidance provided in publications such as the Center for Chemical Process Safety’s Essential Practices for Managing Chemical Reactivity Hazards. At a minimum, the program should identify the process that Optima Belle will use to manage chemical reactivity hazards, resources for collecting and assessing reactivity hazards, steps for determining how and when to test for chemical reactivity, documentation requirements, and training.


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

2021-02-I-WV-2

Develop and implement a written program for tolling process design and equipment selection using guidance from the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety and Guidelines for Process Safety in Outsourced Manufacturing Operations to ensure that:

a) equipment design basis is adequate for any new tolling process or product;

b) safeguards and ancillary equipment are considered and adequately designed, installed, and function as designed and required; and

c) new processes are evaluated for potential process hazards at the laboratory and/or pilot scale before production scale.

This written program should incorporate the information developed in Optima Belle’s thermal and reactive hazards evaluation program (see CSB recommendation 2021-02-I-WV-R1) to ensure that chemical hazards are fully understood and controlled.

 


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

2021-02-I-WV-3

Develop and implement a formalized program for the development of toll manufacturing agreements using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety. Ensure that the program provides for the following:

a) Identification of roles and responsibilities of all parties, including the client, toller, and any third-party technical service providers, for all phases of a proposed arrangement; 

b) Evaluation of equipment requirements/specifications to ensure that they are adequate for intended operation; and

c) Participation by all parties in the tolling process development, including process hazards analysis and emergency planning, and appropriate stages of the pre-planning, pre-startup, and production phases.


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

2021-02-I-WV-4

Develop and implement a process safety management system consistent with industry guidance publications such as is contained in the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety. At a minimum, the process safety management system should address hazard identification, risk analysis, and management of risk.


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

Pryor Trust Fatal Gas Well Blowout and Fire (1 Recommendations)
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 - 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

Motiva Enterprises Sulfuric Acid Tank Explosion (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 28, 2002

2001-05-I-DE-10

Work with NACE International (National Association of Corrosion Engineers) to develop API guidelines to inspect storage tanks containing fresh or spent H2SO4 at frequencies at least as often as those recommended in the latest edition of NACE Standard RP 0294-94, Design, Fabrication, and Inspection of Tanks for the Storage of Concentrated Sulfuric Acid and Oleum at Ambient Temperatures.


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

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

Final Report Released On: May 01, 2014

2010-08-I-WA-5

Based on the findings in this report, augment your existing process safety management regulations for
petroleum refineries in the state of Washington with the following more rigorous goal-setting attributes:

a. A comprehensive process hazard analysis written by the company that includes:

i. Systematic analysis and documentation of all major hazards and safeguards, using the hierarchy of controls to reduce those risks to as low as reasonably practicable (ALARP);

ii. Documentation of the recognized methodologies,rationale and conclusions used to claim that safeguards intended to control hazards will be effective;

iii. Documented damage mechanism hazard review conducted by a diverse team of qualified personnel. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure effective safeguards are in place to control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safer design to the greatest extent feasible into this review; and

iv. 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 processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.

b. A thorough review of the comprehensive process hazard analysis by technically competent regulatory
personnel;

c. Required preventative audits and preventative inspections by the regulator; 

d. Require that all safety codes, standards, employer internal procedures and recognized and generally
accepted good engineering practices (RAGAGEP) used in the implementation of the regulations contain adequate minimum requirements;

e. Require an increased role for workers in management of process safety by establishing the rights and responsibilities of workers and their representatives on health and safety-related matters, and the election of safety representatives and establishment of safety committees (with equal representation between management and labor) to serve health and safety-related functions. The elected representatives should have a legally recognized role that goes beyond consultation in activities such as the development of the comprehensive process hazard analysis, management of change, incident investigation, audits, and identification and effective control of hazards. The representatives should also have the authority to stop work that is perceived to be unsafe or that presents a serious hazard until the regulator intervenes to resolve the safety concern. Work force participation practices should be documented by the company to the regulator; and

f. Requires reporting of information to the public to the greatest extent feasible such as a summary of the comprehensive process hazard analysis which includes a list of safeguards implemented and standards utilized to reduce risk, and process safety indicators that demonstrate the effectiveness of the safeguards and management systems.

 


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

PDF Document Recommendation Status Change Summary

Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire (1 Recommendations)
National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 17, 2013

2011-06-I-HI-7

Develop a new standard, or incorporate within an existing standard, best practices for the safe disposal of waste fireworks that are consistent with environmental requirements. At a minimum this guidance or standard should: • Discourage the disassembly of waste fireworks as a step in the disposal process; • Minimize the accumulation of waste explosive materials, and encourage practices that reduce, recycle, reuse,or repurpose fireworks; and • Incorporate input from ATF, EPA, and other agencies, experts, and available resources on fireworks disposal methodologies.


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)
Gold Creek Foods (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 11, 2023

2021-03-I-GA-1

Include in the emergency action program provisions for proactively interacting with and informing local emergency response resources of all emergencies at the former FFG Plant 4 facility to which Gold Creek expects them to respond. At a minimum, Gold Creek should:

a) inform local emergency responders of the existence, nature, and location of hazardous substances at its facilities, including liquid nitrogen;

b) inform local emergency responders of the location of emergency-critical equipment such as bulk storage tanks, points of use, isolation valves, E-stop switches, and any other emergency equipment or systems with which emergency responders may need to interact; and,

c) provide local emergency responders with information, such as facility plot plans, engineering drawings, or other information needed to mount an effective emergency response.


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

Macondo Blowout and Explosion (1 Recommendations)
Department of the Interior (DOI) [delegated to DOI-BSEE] (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 20, 2016

2010-10-I-OS-8

Expand upon the principles of the BSEE Safety Culture policy and establish a process safety culture improvement program for responsible parties as defined in R11(a) that periodically administers process safety culture assessments and implements identified major accident prevention improvements. The process safety culture improvement program shall include a focus on items that measure, at a minimum, willingness to report incidents and near-misses, effectiveness of workforce participation efforts, organizational drift from safety policies and procedures, and management involvement and commitment to process safety.


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

Wacker Polysilicon Chemical Release (1 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 15, 2023

2021-01-I-TN-8

Develop and publish a safety product on Safe Work Practices, including detailed and practical guidelines for evaluating simultaneous operations (SIMOPs). The guidelines, at a minimum, should:

a. Address the content found in CCPS’s website resource for implementing Safe Work Practices; and

b. Discuss guidelines for a SIMOPs life cycle, including:

1. methods to identify SIMOPs;
2. methods to conduct a SIMOPs hazard assessment;
3. safeguards and controls pertaining to SIMOPs;
4. preparation for SIMOPs; and
5. SIMOPs execution.

In developing this safety product, consider the findings presented in the CSB report titled Fire During Hot Work at Evergreen Packaging Paper Mill and this CSB report, titled Equipment Fracture and Fatal Hydrogen Chloride Release at Wacker Polysilicon North America.


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

Husky Energy Superior Refinery Explosion and Fire (7 Recommendations)
Cenovus Superior Refinery (7 Recommendations)
Open: 14% | Closed: 86%

Final Report Released On: December 29, 2022

2018-02-I-WI-1

Establish safeguards to prevent explosions in the FCC unit during transient operation (including startup, shutdown, standby, and emergency procedures). Incorporate these safeguards into written operating procedures. At a minimum establish the following specific safeguards:

a) Implementation of the reactor steam barrier, or a similar inert gas flow, to maintain an inert barrier at an elevated pressure between the main column (containing hydrocarbon) and the regenerator (containing air);

b) Purging the main column with a non-condensable gas as needed to prevent a dangerous accumulation of oxygen in the main column overhead receiver;

c) Monitoring to ensure that there is a sufficient non-condensable gas purge of the main column to prevent a dangerous accumulation of oxygen in the main column overhead receiver (either through direct measurement of the oxygen concentration and/or through engineering calculation);

d) Monitoring of critical operating parameters for flows, pressures, pressure differences, and catalyst levels;

e) Documentation of consequences of deviating from the transient operation safe operating limits and of predetermined corrective actions; and

f) Inclusion of the above items in the appropriate FCC operator training curricula.


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

2018-02-I-WI-2

Based on licensor input and good industry practices, determine the appropriate point(s) in the FCC unit’s shutdown procedures to shut down all wet gas compressor(s). Incorporate this information into all FCC unit shutdown procedures and operator training material.


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

2018-02-I-WI-3

Develop and implement a slide valve mechanical integrity program that addresses erosion and ensures proper functioning of the slide valves during a shutdown. The program must include, at a minimum:

a) A slide valve mechanical integrity standard that defines monitoring and inspection requirements, with acceptance criteria, required for the safe operation of the FCC unit during transient operation (such as a startup, shutdown, standby, and emergency).

b) Monitoring that includes process data analysis and mechanical preventive activities to evaluate the mechanical condition of the slide valves during the operation of the FCC unit between turnarounds;

c) Quarterly presentations of process data and mechanical preventive maintenance data to refinery operations management and maintenance management to drive key decisions such as shortening the turnaround cycle and/or planning a maintenance outage;

d) During turnarounds and other potential slide valve maintenance outages, evaluate the adequacy of the slide valve mechanical integrity program for the safe operation of the FCC unit during transient operation. If the inspection demonstrates unsuccessful performance, make appropriate corrections.

During the next major FCC unit turnaround at Cenovus Superior Refinery, demonstrate that the slide valve mechanical program is adequate for the safe operation of the FCC unit during transient operation. If the inspection demonstrates unsuccessful performance, make appropriate corrections to the slide valve mechanical integrity program.


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

2018-02-I-WI-4

Develop emergency procedures for responding to a loss of catalyst slide valve function (for example, when it leaks excessively or fails to close on demand).


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

2018-02-I-WI-5

Develop guidance for analyzing operating procedures to improve transient operation hazard evaluations during PHAs. Refer to section Chapter 9.1 in the CCPS publication Guidelines for Hazard Evaluation Procedures, 3rd Ed. or an appropriate equivalent resource to develop the guidance. Incorporate the guidance into the appropriate Cenovus Superior Refinery PHA procedural documents and policies.


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

2018-02-I-WI-6

Develop and implement an FCC unit operator, supervisor, and manager training program based on the licensor’s guidance and on available industry guidance. Elements of the training program shall include:

a) A set of written training materials (such as a manual) consistent with the licensor’s technology information, encompassing:

i) FCC equipment;
ii) Normal operations;
iii) Transient operations (including startup, shutdown, standby, and emergency); and
iv) Case studies of industry FCC industry incidents, including ExxonMobil Torrance (2015) and this incident; and

b) Training delivery methods including:

i) Group and individual training; and
ii) Simulator training for board operators.


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

2018-02-I-WI-7

Incorporate lessons learned from this incident into the appropriate training materials for the Cenovus Superior Refinery Emergency Response Team. At a minimum, topics shall include the proper response to liquids potentially stored above their flash point, such as asphalt, and the ignition risk of pyrophoric material inside asphalt storage tanks.


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 (1 Recommendations)
TPC Group (1 Recommendations)
Open: 0% | Closed: 100%

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: 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