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

West Fertilizer Explosion and Fire (3 Recommendations)
Environmental Protection Agency (EPA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 28, 2016

2013-02-I-TX-1

Develop a guidance document on Emergency Planning and Community Right-to-Know Act (EPCRA) requirements that is issued annually to State Emergency Response Commissions(SERCs) and Local Emergency Planning Committees (LEPCs) and ensure that the guidance focuses on the following:

a. Explains which chemicals are exempt and which must be reported.

b. Describes how emergency responders should use Tier I and Tier II inventory reports and Safety Data Sheets, such as in safety training, practice drills, and for emergency planning.

c. Includes comprehensive LEPC planning requirements, with an emphasis on annual training exercises and drills for local emergency response agencies.


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

PDF Document Recommendation Status Change Summary

2013-02-I-TX-3

Revise the Risk Management Program rule to include fertilizer grade ammonium nitrate (FGAN) at an appropriate threshold quantity on the List of Regulated Substances.

a. Ensure that the calculation for the offsite consequence analysis considers the unique explosive characteristics of FGAN explosions to determine the endpoint for explosive effects and overpressure levels.  Examples of such analyses include that adopted by the 2014 Fire Protection Research Foundation report, “Separation Distances in NFPA Codes and Standards,” Great Britain’s Health and Safety Executive, and other technical guidance.

b. Develop Risk Management Program rule guidance document(s) for regulated FGAN facilities.


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

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

Final Report Released On: January 28, 2016

2013-02-I-TX-4

Develop and issue a Regional Emphasis Program for Section (i) of the Explosives and Blasting Agent standard, 29 CFR 1910.109(i), in appropriate regions (such as Regions IV, VI, and VII) where fertilizer grade ammonium nitrate (FGAN) facilities similar to the West Fertilizer Company facility are prevalent.  Establish a minimum number of emphasis program inspections per region for each fiscal year.  Work with regional offices to communicate information about the emphasis program to potential inspection recipients. 


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

Macondo Blowout and Explosion (2 Recommendations)
Sustainability Accounting Standards Board (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 20, 2016

2010-10-I-OS-9

Update, strengthen, and finalize the SASB’s provisional Oil & Gas Exploration & Production Sustainability Accounting Standard by enhancing standard NR0101-18. Expand recommended coverage of “Process Safety Event rates for Loss of Primary Containment of greater consequences” in accordance with the findings of this report. Specifically, this expanded coverage shall:
a.    Recommend the disclosure of additional leading and lagging indicators and emphasize the greater preventive value of disclosure of a company’s use of leading indicators to actively monitor the health and performance of major accident safety barriers and the management systems for ensuring their effectiveness. Specifically add:
1.    Indicators addressing the health of safety barriers to be communicated to the workforce, and to shareholders in required SEC disclosures, and also to be made readily available to the regulator.  
2.    Guidance emphasizing and promoting the concept that personal safety metrics such as those captured in NR0101-17 (total recordable injury rate, fatality rate, near-miss frequency rate) are important but separate from leading and lagging process safety performance indicators, which better correlate to major accident prevention.
•    Accomplish this communication within NR0101-18.
•    Supplement this effort within the SASB’s Oil & Gas Exploration & Production Research Briefs, based on the findings of this report as well other current safety scholarship that demonstrates the lack of correlation between personal safety efforts and process safety and major accident prevention initiatives.


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

PDF Document Recommendation Status Change Summary

U.S. Department of the Interior (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 20, 2016

2010-10-I-OS-6

Drawing upon best available global standards and practices, develop guidance to assist industry in the incorporation of human factors principles into the systematic analysis of their major accident hazards, development of their SEMS programs, and in the preparation of their major hazards report documentation. This standard shall provide guidance on topics including, but not limited to, safety critical task assessment and the development and verification of non-technical skills. Include the participation of diverse expertise in the development of the standard including industry, workforce, and subject matter expert representatives.


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

ExxonMobil Refinery Explosion (4 Recommendations)
ExxonMobil Corporation (4 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 03, 2017

2015-02-I-CA-1

A Variance to a safety policy or procedure requires robust analysis of the proposed safeguards prior to its approval and implementation. To ensure the proposed methodology described in the Variance is safe and the proposed safeguards are sufficiently robust, revise corporate and U.S. refinery standard(s) to require that a multidisciplinary team reviews the Variance before it is routed to management for their approval. Include knowledgeable personnel on the Variance multidisciplinary team such as: (1) the developer of the Variance; (2) a technical process representative (e.g. process engineer for the applicable unit); (3) an hourly operations representative (e.g. experienced operator in the applicable unit); and (4) a health and safety representative. The role of the multidisciplinary team is to formally meet to review, discuss, and analyze the proposed Variance, and adjust the safety measures as needed to ensure a safe operation. In the event the expert team members do not come to a consensus that the Variance measures can result in a safe operation, require the proposed work to be routed to a higher management level for final approval.


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

2015-02-I-CA-2

ExxonMobil did not have an operating procedure for operating the FCC unit in its Safe Park mode of operation. At all ExxonMobil U.S. refineries, develop a program to ensure operating procedures are written and available for each mode of operation—such as unit standby—for all ExxonMobil U.S. refinery FCC units. Specify in the program that ExxonMobil U.S. refineries develop and train operators on any new procedure.


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

2015-02-I-CA-3

The spent catalyst slide valve, specified as a safety-critical device for normal operation, could not perform its safety-critical function of preventing air and hydrocarbons from mixing while the FCC unit was in its “Safe Park” mode of operation. Also, ExxonMobil Torrance did not operate the FCC unit as if the reactor steam was a safety critical safeguard. Require identification of all safety critical equipment and consequence of failure for each mode of operation and ensure safety critical devices can successfully function when needed. Develop and implement a policy that requires all U.S. ExxonMobil refineries to: (1) specify each safety-critical device’s safety function; (2) identify the consequences of failure of each safety-critical device; (3) specify the testing strategy used to verify whether the safety-critical device can function as intended to perform its required safety function; and (4) maintain target availability (e.g. safe operating life) for each safety-critical device through inspection and maintenance. Require that items (1) through (4) above consider each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation.


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

2015-02-I-CA-4

ExxonMobil extended the maintenance interval of the spent catalyst slide valve and the inspection interval of the pumparound heat exchanger without analyzing whether the extended operation lowered their availability (by operating them beyond their predicted safe operating life) and could result in negative safety consequences. In the event safety-critical equipment is operated beyond its inspection and/or maintenance interval (e.g. extended turnaround interval), require all ExxonMobil U.S. refineries to perform a risk evaluation (e.g. MOC or risk assessment) to identify the safety consequences of the extended operation. Require that each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation is evaluated during the risk evaluation.


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

Veolia Environmental Services Flammable Vapor Explosion and Fire (1 Recommendations)
Environmental Technology Council (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 21, 2010

2009-10-I-OH-7

Supersedes 2007-01-I-NC-R3, issued pursuant to EQ Hazardous Waste Plant Explosions and Fire

Develop and issue standardized guidance for the processing, handling and storage of hazardous waste to reduce the likelihood of fires, explosions, and releases at hazardous waste treatment storage and disposal facilities. Include the incident findings, consequences, conclusions, and recommendations from the CSB investigations of the Environmental Quality facility and the Veolia ES Technical Solutions.


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

NDK Crystal Inc. Explosion with Offsite Fatality (1 Recommendations)
American Society of Mechanical Engineers (ASME) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: November 14, 2013

2010-04-I-IL-1

Revise the ASME Boiler and Pressure Vessel Code to include specific material thickness limitations for the design of pressure-containing components to ensure proper heat treatment and avoid environmentally induced damage mechanisms. Clarify required vessel wall thickness limitations for SA-723 steel in the following code sections:
a) ASME BPVC Section II, Part A, Material Requirements
b) ASME BPVC Section VIII, Division III, Article KM-400, Material Design Data


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

Enterprise Pascagoula Gas Plant Explosion and Fire (5 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: February 13, 2019

2016-02-I-MS-1

Develop a new informational product or incorporate into the next revision of Brazed Aluminum Plate-Fin Heat Exchangers for General Refinery Services 1st ed.; ANSI/API Standard 668 (formerly Standard 662, Part 2), guidance focused on the safe operation, maintenance, and repair of brazed aluminum heat exchangers (BAHX) to advance understanding of thermal fatigue hazards and how to mitigate them. At a minimum the informational product/incorporated material must include:

a. Information on the potential for both minor leaks and catastrophic failure as a result of accumulated thermal fatigue (beyond a single cyclic thermal shock event);

b. Clarification on the optimal placement of BAHX temperature and pressure sensors to effectively monitor the operating conditions for the potential impact of accumulated thermal fatigue on BAHX, including temperature rates of change; and

c. Clarification on the need to safely vent layers that have been blocked off as part of the repair process for interpass leaks in all BAHX configurations, as well as information describing the consequences when safe venting does not occur.

d. Should applicable data from CSB Recommendation No. 2016-02-I-MS-R4 (R4) be available prior to finalizing the requirements of this recommendation, then the data from R4 will be considered for inclusion and/or incorporation by reference in the product required by this recommendation. If the decision is made not to include/incorporate by reference the data from R4, then a detailed explanation for the exclusion will be provided.


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.
 

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 - 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.
 

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 - 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.
 

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 - 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.
 

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 - 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.
 

BP America Refinery Explosion (2 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: March 20, 2007

2005-4-I-TX-7

Work together to develop two new consensus American National Standards Institute (ANSI) standards. b. In the second standard, develop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. (CSB2005-04-I-TX-R7a) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


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

United Steelworkers of America (USWA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: March 20, 2007

2005-4-I-TX-7

Work together to develop two new consensus American National Standards Institute (ANSI) standards. b. In the second standard, develop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. (CSB2005-04-I-TX-R7b) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


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

CAI / Arnel Chemical Plant Explosion (1 Recommendations)
Town of Danvers (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 13, 2008

2007-03-I-MA-7

Pending revision of the Massachusetts Fire Safety Code (527 CMR), revise the town bylaws addressing 527 CMR 14 requirements applicable to facility licensing and annual registration to: -Require new and current product manufacturing registrants to certify in writing that the facility complies with, at a minimum, all state and local fire codes and hazardous chemical regulations as part of the annual registration renewal. -Require companies holding a license and current registration for any of the eight classes of flammable materials specified in 527 CMR 14.03 (2) to re-register the facility before increasing any chemical quantity above the registered amount or adding a different regulated chemical at the facility. Include a requirement in the approval process to solicit input from affected landowners, similar to the requirement for obtaining the original license and registration. -Revise the license and registration forms to require listing each hazardous material type and quantity, and require a separate license and permit for each of the eight classes of flammable materials specified in 527 CMR 14.03 (2) . -Require the fire department to annually inspect licensed manufacturing facilities for compliance with the fire code.


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 Recommendations Status Change Summary