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

Kuraray Pasadena Release and Fire (2 Recommendations)
Kuraray America, Inc. (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: December 21, 2022

2018-03-I-TX-3

Develop and implement a system requiring a periodic evaluation of the adequacy and effectiveness of any safeguard used to mitigate or otherwise lower the risk of process safety hazards. This safeguard protection analysis should be based on the requirements of Cal/OSHA’s Process Safety Management for Petroleum Refineries regulations or an appropriate equivalent methodology.


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

2018-03-I-TX-4

Develop and implement a policy detailing how to effectively address recommendations generated from company process safety management systems, including audits, incident investigations, management of change, and process hazard analysis that is consistent with existing OSHA guidance. Include a periodic training requirement for managers and other employees involved with evaluating and managing proposed recommendations to help ensure proposed safety improvements are effectively evaluated and appropriately 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

Williams Olefins Plant Explosion and Fire (2 Recommendations)
American Petroleum Institute (API) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 19, 2016

2013-3-I-LA-4

To help prevent future major incidents such as a rupture of a pressure vessel in a special operating status, strengthen API Standard 521, Pressure-relieving and Depressuring Systems, by defining the various types of equipment operating statuses. Include definitions for “standby” and “out-of-service.” Specify pressure relief requirements for each type of equipment operating status.


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

PDF Document Recommendation Status Change Summary

2013-3-I-LA-5

To help prevent future major incidents such as pressure vessel rupture from ineffective or failed administrative controls, clarify API Standard 521, Pressure-relieving and Depressuring Systems, to require a pressure relief device for overpressure scenarios where internal vessel pressure can exceed what is allowed by the design code. Although some portions of API Standard 521 already require a pressure relief device for these scenarios, other areas, such as Section 4.4.12 Hydraulic Expansion, are not as protective. Section 4.4.12 Hydraulic Expansion (the failure mode that caused the Williams overpressure incident) permits omitting a pressure relief device and allows the exclusive use of administrative controls.


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

PDF Document Recommendation Status Change Summary

Loy Lange Box Company Pressure Vessel Explosion (1 Recommendations)
National Board of Boiler and Pressure Vessel Inspectors (NBBI) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 29, 2022

2017-04-I-MO-8

Update NB-263 Rules for Commissioned Inspectors to include prescriptive elements in the boiler and pressure vessel repair and alteration inspection and acceptance process that would prevent the acceptance of a non-conforming repair.


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

Evergreen Packaging Paper Mill - Fire During Hot Work (3 Recommendations)
Evergreen Packaging (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 24, 2021

2020-07-I-NC-3

Update all documentation, training, and orientation materials provided to contractors pertaining to hot work to reflect Evergreen Packaging’s internal definition of hot work. The materials should make clear that hot work encompasses any method of work that can serve as a source of ignition.


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

2020-07-I-NC-4

Develop and implement a formalized and comprehensive Simultaneous Operations (SIMOPs) program addressing planned work occurring close together in time and place to include policies, procedures, hazards reviews, hazards abatement, training, and shared communication methods, to protect employees and contract workers from the hazards posed by simultaneous operations at its facilities. At a minimum, the program should:

• Identify potential simultaneous operations

• Identify potential hazardous interactions

• Evaluate and implement necessary safeguards to allow for safe simultaneous operations

• Ensure coordination, including shared communication methods, between the simultaneous operations

• Include emergency response personnel or services in the planning and coordination of the simultaneous operations.


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

2020-07-I-NC-5

Develop and implement a policy that requires the involvement of emergency response personnel in planning and coordination of activities involving the use of flammable materials in confined spaces. In the policy, require that emergency response personnel be stationed directly outside the confined space in which flammable materials are used. Ensure that the emergency response personnel are appropriately trained and equipped for confined space entry, confined space rescue and fire response.


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