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

Improving Reactive Hazard Management (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 17, 2002

2001-01-H-2

Implement a program to define and record information on reactive incidents that OSHA investigates or requires to be investigated under OSHA regulations. Structure the collected information so that it can be used to measure progress in the prevention of reactive incidents that give rise to catastrophic releases.


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

Barton Solvents Explosions and Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-2

Prior to the next revision, communicate to the Sub-Committee on the Globally Harmonized System of Classification and Labeling of Chemicals (SCEGHS) the need to amend the GHS to advise chemical manufacturers and importers that prepare MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in 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

Pryor Trust Fatal Gas Well Blowout and Fire (1 Recommendations)
National Oilwell Varco (NOV) (1 Recommendations)
Open: 0% | Closed: 100%

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: 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

Bayer CropScience Pesticide Waste Tank Explosion (3 Recommendations)
Kanawha-Charleston Health Department, Director of the (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 20, 2011

2008-08-I-WV-6

Establish a Hazardous Chemical Release Prevention Program to enhance the prevention of accidental releases of highly hazardous chemicals, and optimize responses in the event of their occurrence. In establishing the program, study and evaluate the possible applicability of the experience of similar programs in the country, such as those summarized in Section 5.3 of this report. As a minimum:

a. Ensure that the new program:
1. Implements an effective system of independent oversight and other services to enhance the prevention of accidental releases of highly hazardous chemicals
2. Facilitates the collaboration of multiple stakeholders in achieving common goals of chemical safety; and,
3. Increases the confidence of the community, the workforce, and the local authorities in the ability of the facility owners to prevent and respond to accidental releases of highly hazardous chemicals.

b. Define the characteristics of chemical facilities that would be covered by the new Program, such as the hazards and potential risks of their chemicals and processes, their quantities, and similar relevant factors;

c. Ensure that covered facilities develop, implement, and submit for review and approval:
1. Applicable hazard and process information and evaluations.
2. Written safety plans with appropriate descriptions of hazard controls, safety culture and human factors programs with employee participation, and consideration of the adoption of inherently safer systems to reduce risks
3. Emergency response plans; and,
4. Performance indicators addressing the prevention of incidents and chemical incidents.

d. Ensure that the program has the right to evaluate the documents submitted by the covered facilities, and to require modifications, as necessary

e. Ensure that the program has right-of-entry to covered facilities, and access to requisite information to conduct periodic audits of safety systems and investigations of chemical releases;

f. Establish a system of fees assessed on covered facilities sufficient to cover the oversight and related services to be provided to the facilities including necessary technical and administrative personnel; and,

g. Consistent with applicable law, ensure that the program provides reasonable public participation with the program staff in review of facility programs and access to:
1. The materials submitted by covered facilities (e.g., hazard evaluations, safety plans, emergency response plans);
2. The reviews conducted by program staff and the modifications triggered by those reviews;
3. Records of audits and incident investigations conducted by the program;
4. Performance indicator reports and data submitted by the facilities, and;
5. Other relevant information concerning the hazards and the control methods overseen by the program.

h. Ensure that the program will require a periodic review of the designated agency activities and issue a periodic public report of its activities and recommended action items


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendation Status Change Summary

West Virginia Department of Environmental Protection, Secretary of the (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 20, 2011

2008-08-I-WV-7

Work with the Director of the Kanawha-Charleston Health Department to ensure the successful planning, fee collection, and implementation of the Hazardous Chemical Release Prevention Program as described in Recommendation 2008-08-WV-R6, above, including the provision of services to all eligible facilities in the State.
 


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

PDF Document Recommendation Status Change Summary

West Virginia Department of Health and Human Services, Secretary of the (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 20, 2011

2008-08-I-WV-7

Work with the Director of the Kanawha-Charleston Health Department to ensure the successful planning, fee collection, and implementation of the Hazardous Chemical Release Prevention Program as described in Recommendation 2008-08-WV-R6, above, including the provision of services to all eligible facilities in the State.
 


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

PDF Document Recommendation Status Change Summary

Enterprise Pascagoula Gas Plant Explosion and Fire (1 Recommendations)
Jackson County Board of Supervisors, Jackson County Emergency Management Agency, Jackson County Local Emergency Planning Committee (1 Recommendations)
Open: 0% | Closed: 100%

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: 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

Hoeganaes Corporation Fatal Flash Fires (4 Recommendations)
Hoeganaes Corporation (4 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 05, 2012

2011-4-I-TN-6

Conduct periodic independent audits of the Hoeganaes Gallatin facility for compliance with the following NFPA standards, using knowledgeable experts, and implement all recommended corrective actions:

  • NFPA 484, Standard for Combustible Metals, Metal Powders, and Metal Dusts
  • NFPA 499, Recommended Practice for the Classification of Combustible Dusts and of Hazardous Locations for Electrical Installations in Chemical Process Areas
  • NFPA 497, Recommended Practice for the Classification of Flammable Liquids, Gases, or Vapors and of Hazardous (Classified) Locations for Electrical Installations in Chemical Process Areas
  • NFPA 2, Hydrogen Technologies Code
  • NFPA 2113, Standard on Selection, Care, Use, and Maintenance of Flame-Resistant Garments for Protection of Industrial Personnel Against Flash Fire

 


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendation Status Change Summary

2011-4-I-TN-7

Develop training materials that address combustible dust and plant-specific metal dust hazards and train all employees and contractors. Require periodic (e.g., annual) refresher training for all employees and contractors.


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendation Status Change Summary

2011-4-I-TN-8

Implement a preventive maintenance program and leak detection and leak mitigation procedures for all flammable gas piping and gas processing equipment.


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendation Status Change Summary

2011-4-I-TN-9

Develop and implement a near-miss reporting and investigation policy that includes the following at a minimum:

  • Ensure facility-wide worker participation in reporting all near-miss events and operational disruptions (such as significant iron powder accumulations, smoldering fires, or unsafe conditions or practices) that could result in worker injury.
  • Ensure that the near-miss reporting program requires prompt investigations, as appropriate, and that results are promptly circulated throughout the Hoeganaes Corporation.
  • Establish roles and responsibilities for the management, execution, and resolution of all recommendations from near-miss investigations
  • Ensure the near-miss program is operational at all times (e.g. nights, weekends, holiday shifts).

 


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendation Status Change Summary

West Fertilizer Explosion and Fire (1 Recommendations)
El Dorado Chemical Company (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2016

2013-02-I-TX-19

For all distributors and bulk retail sites (i.e., customers) that receive fertilizer grade ammonium nitrate (FGAN) manufactured by El Dorado Chemical Company (EDC) for storage, shipment, and sale:

a. Encourage customers to conduct internal monitoring and auditing (in accordance with recent industry standards and guidelines) in locations where FGAN will be stored or used.  Communicate that such internal monitoring and auditing may be conducted through established product safety programs, including ResponsibleAg.

b. Develop a process to establish mutual product stewardship expectations for the downstream chain of customers.  Communicate expectations to existing customers, and to new customers before their first shipment of FGAN.  Include the following components:

i. For all FGAN sold to distributors, encourage distributors to provide Safety Data Sheets and FGAN safety guidance to their customers and bulk retail sites to which FGAN is sold or shipped

ii. For all EDC bulk retailers and non-EDC bulk retailers that store and sell FGAN, encourage bulk retailers to address, such as through certification checklists, the following:

• Written procedures for the safe handling of FGAN, including employee training

• Emergency response plans to be sent to Local Emergency Planning Committees and local fire departments

• Tier II Chemical Inventory Report submissions.


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

PDF Document Recommendation Status Change Summary

Macondo Blowout and Explosion (3 Recommendations)
Ocean Energy Safety Institute (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 20, 2016

2010-10-I-OS-10

Conduct further study on riser gas unloading scenarios, testing, and modeling and publish a white paper containing technical guidance that communicates findings and makes recommendations for industry safety improvements.


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

U.S. Department of the Interior (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 20, 2016

2010-10-I-OS-13

Further enhance the qualifications, professional competency, and diversity of BSEE staff to implement major accident prevention programs by:
a.    Continuing efforts to enhance recruiting and retention of sufficient staff with a diversity of expertise, professional backgrounds and skill sets, such that BSEE has staff competencies in a variety of safety-critical and technical areas, including petroleum, chemical, and mechanical engineering; human and organizational factors; well design and control; and process safety, as well as those with industry experience to perform an even more expanded mission as envisioned in this report;  
b.    Retaining the services of a human resources consulting firm to complement BSEE’s efforts to date on human capital management and workforce planning issues, in light of documented difficulties in recruiting and retaining necessary staff, including the development of a plan with respect to large numbers of retirements facing the agency in the coming decade, as well as a compensation analysis (and a plan for subsequent periodic market analyses and benchmarking) to ensure BSEE remains competitive with other employers in the offshore industry. Augment the agency’s compensation system as necessary to enable BSEE to attract and retain the level of staffing needed to perform BSEE’s mission.
c.    Continuing to assess, expand, and improve ongoing BSEE training programs for new hires to provide all employees with robust skill sets, including appropriate technical training as well as interpersonal skills such as communications, negotiation and advocacy.

If funding, legislative authority, or other approvals are required to implement the recommended regulatory provisions in Recommendation R11 – R13, the Secretary of the Interior shall seek such authority from Congress or expedited hiring authority from the Office of Personnel Management.


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

PDF Document Recommendation Status Change Summary

2010-10-I-OS-14

Expand the offshore safety regulatory program that collects, tracks, and analyzes safety performance indicators from industry to further influence industry efforts in reducing major accident risks to ALARP. At a minimum, this program shall:
a.    Require the reporting of safety indicator data by all responsible parties, as defined in R11(a);
b.    Emphasize the greater preventive value of using leading indicators to actively monitor the health and performance of major accident safety barriers and the management systems meant to ensure their effectiveness, and work with industry to develop leading indicators that are measurable, actionable, normalized across industry, and that occur with sufficient frequency to allow for meaningful trending and analysis at the facility and corporate levels;
c.    Augment current reporting requirements to include leading safety performance indicators;
d.    Use the safety performance indicator data to:
1.    identify industrywide, companywide, and facility-specific safety trends and deficiencies;
2.    set annual process safety goals or targets for the industry, company and/or facility, as appropriate, based upon those identified safety trends and deficiencies;
3.    issue, at a minimum, annual reports that publicly communicate those trends, deficiencies, targets, and goals; and
4.    determine future appropriate allocations of BSEE resources and the prioritization of BSEE inspections;
e.    Include use of significant lagging indicators data (including those already mandated by 30 C.F.R. 250.188(a) and (b), such as major events like explosions, fires, gas releases, fatalities, INCs) as qualification criteria in the lease-approval and permit-to-drill decision-making processes by the regulator.


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

PDF Document Recommendation Status Change Summary

Honeywell Chemical Incidents (1 Recommendations)
American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 08, 2005

2003-13-I-LA-22

Develop guidance on the effective design and maintenance of HVAC systems and other necessary control room components designed to protect employees and equipment in the event of a release of hazardous materials.


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

AB Specialty Silicones, LLC (3 Recommendations)
AB Specialty Silicones, LLC (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 24, 2021

2019-03-I-IL-1

Develop hazardous gas detection and alarm programs and associated procedures based on manufacturer specifications, current codes, standards, and industry good practice guidance, for all hazardous gases that could be released near workers, including hydrogen. The program must address proper installation, calibration, inspection, maintenance, training, and routine operations. Ensure such hazardous gas detection and alarm systems are functional at all times.


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

2019-03-I-IL-2

Establish a safety management system that addresses process safety at the AB Specialty Waukegan, Illinois facility. Include in that system elements recommended in industry guidance publications, including Center for Chemical Process Safety (CCPS) publications Guidelines for Risk Based Process Safety and Guidelines for Implementing Process Safety Management.


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

2019-03-I-IL-3

Incorporate into operations and activities at AB Specialty the specific elements recommended in CCPS’s Essential Practices for Managing Chemical Reactivity Hazards, which are:

1. Put into place a system to manage chemical reactivity hazards

2. Collect reactivity hazard information

3. Identify chemical reactivity hazards

4. Test for chemical reactivity

5. Assess chemical reactivity risks

6. Identify and implement process controls and risk management options

7. Document chemical reactivity risks and management decisions

8. Communicate and train on chemical reactivity hazards

9. Investigate chemical reactivity incidents

10. Review, audit, manage change in, and improve hazard management practices and programs.


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

Evergreen Packaging Paper Mill - Fire During Hot Work (1 Recommendations)
Universal Blastco (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 24, 2021

2020-07-I-NC-8

Develop a policy and standard operating procedures for the proper use of heat guns in FRP operations. 


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