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

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