The CSB issues safety recommendations to prevent the recurrence or reduce the likelihood or consequences of similar incidents or hazards in the future. Recommendations are issued to a variety of parties, including government entities, safety organizations, trade unions, trade associations, corporations, emergency response organizations, educational institutions, and public interest groups. Recommendations are published in CSB reports and are closed only by vote of the Board. The CSB tracks all recommendations and communicates regularly with recommendations recipients to ensure that the recommended corrective actions are implemented.

For more information, see Frequently Asked Questions about CSB recommendations.


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Recommendations

Aghorn Operating Inc. Waterflood Station Hydrogen Sulfide Release (9 Recommendations)
Aghorn Operating Inc. (7 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 21, 2021

2020-01-I-TX-1

For all waterflood stations where the potential exists to expose workers or non-employees to H2S concentrations at or above 10 ppm, mandate the use of personal H2S detection devices as an integral part of every employee or visitor personal protective equipment (PPE) kit prior to entering the vicinity of the facility. Ensure detector use is in accordance with manufacturer specifications.


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

2020-01-I-TX-2

For all Aghorn facilities, develop a site-specific, formalized and comprehensive Lockout / Tagout program, to include policies, procedures, and training, to protect workers from energized equipment hazards, such as exposure to H2S. Ensure the program meets the requirements outlined in 29 CFR 1910.147 and includes energy control procedures, training, and periodic inspections.


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

2020-01-I-TX-3

For all waterflood stations where the potential exists to expose workers to H2S concentrations at or above 10 ppm, commission an independent and comprehensive analysis of each facility design vis-à-vis ventilation and mitigation systems to ensure that, in the event of an accidental release, workers are protected from exposure to toxic gas levels.


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

PDF Document Recommendation Status Change Summary

2020-01-I-TX-4

For all waterflood stations where the potential exists to expose workers or non-employees to H2S concentrations at or above 10 ppm, develop and demonstrate the use of a safety management program that includes a focus on protecting workers and non-employees from H2S. This program should include risk identification, assessment, mitigation, and monitoring of design, procedures, maintenance and training related to H2S. This program must be in compliance with 29 CFR 1910.1000 – Air Contaminants and 29 CFR 1910.147 – The Control of Hazardous Energy (Lockout / Tagout).


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

2020-01-I-TX-5

For all waterflood stations where the potential exists to expose workers to H2S concentrations at or above 10 ppm, ensure the H2S detection and alarm systems are properly maintained and configured, and develop site-specific detection and alarm programs and associated procedures based on manufacturer specifications, current codes, standards, and industry good practice guidance. The program must address installation, calibration, inspection, maintenance, training and routine operations.


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

2020-01-I-TX-6

For all waterflood stations where the potential exists to expose workers or non-employees within the perimeter of the facility to H2S concentrations at or above 10 ppm, ensure that the H2S detection and alarm system designs employ multiple layers of alerts unique to H2S, such as with the use of both audible and visual mediums, so that workers and non-employees within the perimeter of the facility would be alerted to a significant release. The system design must meet manufacturer specifications, current codes, standards, and industry good practice 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

2020-01-I-TX-7

For all waterflood stations where the potential exists to expose non-employees to H2S concentrations at or above 10 ppm, develop and implement a formal, written, site-specific security program to prevent unknown and unplanned entrance of those not employed by Aghorn, starting with a requirement for employees to lock access gates upon entering and departing the facility.


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

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

Final Report Released On: May 21, 2021

2020-01-I-TX-8

Issue a safety information product (such as a safety bulletin or safety alert) that addresses the requirements for protecting workers from hazardous air contaminants and from hazardous energy.


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

Texas Railroad Commission (RRC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 21, 2021

2020-01-I-TX-9

Develop and send a Notice to Operators to all oil and gas operators that fall under the jurisdiction of the Railroad Commission of Texas that describes the safety issues described in this report, including: 1. Nonuse of Personal H2S Detector 2. Nonperformance of Lockout / Tagout 3. Confinement of H2S Inside Pump House 4. Lack of Safety Management Program 5. Nonfunctioning H2S Detection and Alarm System 6. Deficient Site Security


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

Bio-Lab Lake Charles Chemical Fire and Release (6 Recommendations)
Bio-Lab Lake Charles (4 Recommendations)
Open: 25% | Closed: 75%

Final Report Released On: April 24, 2023

2020-05-I-LA-1

Evaluate the hazards to the Bio-Lab Lake Charles facility from hurricanes and accompanying wind, rainwater, floodwater, or storm surge forces. Implement processes and safeguards for protection against those hazards, such as through:

a. Constructing new and maintaining existing buildings and structures to withstand hurricane winds and flooding, with a particular focus on those containing hazardous materials;

b. Implementing safeguards and processes to ensure hazardous chemicals are not compromised and released during extreme weather events; and

c. Following the guidance presented in the Center for Chemical Process Safety Monograph Assessment of and Planning for Natural Hazards.


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

2020-05-I-LA-2

Develop and implement an improved Process Hazard Analysis (PHA) action item management system. At a minimum the PHA action item management system should:

a. Ensure that each PHA action item or recommendation is assigned to an appropriate person with a deadline for initial evaluation;

b. Document and maintain the rationale if the action item or recommendation is modified or rejected; and

c. Track the status of all PHA action items or recommendations until they are resolved.

Additionally, periodic audits must be conducted on the PHA action item management system to ensure its effectiveness.


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

2020-05-I-LA-3

Perform process hazard analyses (PHAs) on all buildings and units processing or storing trichloroisocyanuric acid. Ensure that the PHAs are revalidated at least every five years. Also include the building design basis as process safety information for the PHA team to reference during their analysis.


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

2020-05-I-LA-4

Revise the Bio-Lab Lake Charles emergency response plan to require the following:

a. The site’s fire protection system is properly maintained and routinely function-tested in accordance with published industry guidance and NFPA requirements. Require in the emergency response plan that any equipment identified as nonfunctional must be repaired in a timely manner in accordance with NFPA requirements;

b. Emergency and fire protection equipment (in particular fire water pumps) must be checked regularly to ensure it is in good working order one month before the start of the U.S. hurricane season, as recommended by the Center for Chemical Process Safety Monograph Assessment of and Planning for Natural Hazards; and

c. Site personnel must be trained on the use of all emergency generators and other emergency equipment at least one month before the start of the U.S. hurricane season.


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

Environmental Protection Agency (EPA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 24, 2023

2020-05-I-LA-6

Implement the five open recommendations issued in the 2022 U.S. Government Accountability Office Report titled Chemical Accident Prevention: EPA Should Ensure Regulated Facilities Consider Risks from Climate Change, which are:

a. The U.S. Environmental Protection Agency (EPA) should provide additional compliance assistance to Risk Management Program (RMP) facilities related to risks from natural hazards and climate change;

b. The EPA should design an information system to track common deficiencies found during inspections, including any related to natural hazards and climate change, and use this information to target compliance assistance;

c. The EPA should issue regulations, guidance, or both, as appropriate, to clarify requirements and provide direction for RMP facilities on how to incorporate risks from natural hazards and climate change into their risk management programs;

d. The EPA should develop a method for inspectors to assess the sufficiency of RMP facilities’ incorporation of risks from natural hazards and climate change into risk management programs and provide related guidance and training to inspectors; and

e. The EPA should incorporate the vulnerability of RMP facilities to natural hazards and climate change as criteria when selecting facilities for inspection.


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

Louisiana Governor and Legislature/Secretary of the Louisiana Department of Environmental Quality (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 24, 2023

2020-05-I-LA-5

Under existing statutory or regulatory authority or through the establishment of new authority by executive or legislative action, for all existing chemical manufacturing and storage facilities that:

(1) Are located in a hurricane-prone region as defined by the International Building Code, and

(2) Manufacture or store or can inadvertently or otherwise produce (e.g., by chemical reaction) regulated substances inside equipment or building(s) built before more current wind design requirements came into effect

Require the facility operators to evaluate the hazards to their facilities from hurricanes and accompanying wind, rainwater, floodwater, or storm surge forces. Require the facility operators to implement processes and safeguards for protection against those hazards, such as through:

a. Ensuring that buildings and structures (both new and existing) can withstand hurricane winds and flooding, with a particular focus on buildings and structures containing hazardous materials;

b. Implementing safeguards and processes to ensure that hazardous chemicals are not compromised and released during extreme weather events; and/or

c. Following the guidance presented in the Center for Chemical Process Safety Monograph Assessment of and Planning for Natural Hazards.


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

Cuisine Solutions Ammonia Release (6 Recommendations)
Cuisine Solutions Inc. Sterling Site (4 Recommendations)
Open: 75% | Closed: 25%

Final Report Released On: September 25, 2025

2024-03-I-VA-3

Reduce the likelihood or mitigate the consequences of liquid or two-phase atmospheric discharges from the ammonia refrigeration emergency pressure relief system at the Sterling plant. At a minimum:

a. Identify liquid or two-phase release scenarios, particularly for horizontal surge drums and other vessels containing saturated liquid with little vapor space;

b. Implement engineering controls to reduce the likelihood of high liquid level, overfill, or boiling overpressure scenarios;

c. Implement engineering controls to mitigate the consequences of these scenarios where their likelihood cannot be acceptably reduced, such as through emergency pressure control systems, atmospheric knockout drums, or automatic shutdown systems; and

d. Contract a competent third party to audit the pressure relief systems. The audit should ensure that (i) all relevant relief scenarios have been identified, (ii) preventive and mitigative engineering controls adequately address the hazards, and (iii) engineering controls are maintained in such a way that they function properly when required.


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

2024-03-I-VA-4

Implement an electronic process data historian and management system to ensure that critical process parameters are collected, tracked, and stored. The system should be available to refrigeration technicians so that they can monitor the refrigeration system and respond to and investigate process upsets.


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

2024-03-I-VA-5

Update the Cuisine Solutions Sterling site’s Emergency Action Plan using guidance such as the IIAR’s Critical Task Guidance for Ammonia Refrigeration System Emergency Planning. At a minimum, the updated plan should:

a. Address indoor and outdoor ammonia releases separately, including the distinct alarms and responses to them;

b. Clearly specify appropriate evacuation routes and muster points, including alternates;

c. Provide guidance for using windsocks to remain upwind of a release during evacuation;

d. Implement shelter-in-place strategies, emergency protective equipment, and emergency shutdowns, as appropriate; and

e. Include requirements to conduct annual ammonia release drills that include all onsite personnel (including corporate employees). The annual drills should include separate indoor and outdoor ammonia release scenarios and address the use of windsocks to assist with determining evacuation routes, alternate evacuation routes, muster points, and consideration for the decision to shelter-in-place. Additionally, the drills should exercise each evacuation alarm, emergency protective equipment, and emergency shutdowns, where appropriate.


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

2024-03-I-VA-6

Add an alarm or alarms specific to ammonia releases, so that workers can properly respond to a release. The alarm response should be documented in the updated Emergency Action Plan, and may include multiple distinct alarms and responses, such as one for shelter-in-place and one for evacuation.


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

International Institute of All-Natural Refrigeration (IIAR) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 25, 2025

2024-03-I-VA-1

Update ANSI/IIAR 2 to include guidance for preventing or mitigating liquid or two-phase atmospheric discharges from emergency pressure relief systems, such as the guidance in API Standard 521, Pressure-relieving and Depressuring Systems. At a minimum, the guidance should:

a. Identify at-risk scenarios such as horizontal surge vessels and other vessels containing saturated liquid with little vapor space;

b. Address design considerations and controls to reduce the likelihood of identified scenarios leading to overpressure or equipment failure and ensure vapor-liquid disengagement (the separation of vapor from liquid) during pressure relief for identified scenarios; and

c. Require mitigative safeguards in cases where vapor-liquid disengagement during pressure relief cannot be reliably ensured. This should also include alternative disposal systems where applicable.


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

2024-03-I-VA-2

Update ANSI/IIAR 2 to include a requirement to assess whether emergency pressure relief devices discharge to a safe location, such as with a dispersion analysis.


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 (8 Recommendations)
Evergreen Packaging (3 Recommendations)
Open: 0% | Closed: 100%

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

Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 24, 2021

2020-07-I-NC-1

Issue a safety information product (such as a letter of interpretation) addressing the analysis and control of hazards that are not pre-existing but which result from work activities inside permit-required confined spaces. 


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

2020-07-I-NC-2

(Superseded by 2021-01-I-TN-R1 from the Wacker report)

Require Owner/Operators to ensure the coordination of simultaneous operations involving multiple work groups, including contractors. Include in the requirement for Owner/Operators to ensure the following activities occur:

• Identification of potential simultaneous operations

• Identification of potential hazardous interactions

• Evaluation and implementation of necessary safeguards to allow for safe simultaneous operations

• Coordination, including shared communication methods, between the simultaneous operations

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

As necessary, seek the regulatory authority to promulgate this requirement.


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

Universal Blastco (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 24, 2021

2020-07-I-NC-6

Update the Universal Blastco hot work policy and employee training program to specifically identify the use of heat guns as hot work. The policy and programs should make clear that hot work encompasses any method of work that can ignite a fire and not just spark- or flame-producing work methods.


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

2020-07-I-NC-7

Develop a formalized troubleshooting guide and/or standard operating procedure for the usage of resin and fiberglass matting in FRP operations. The procedure should direct employees on acceptable means of addressing cold-weather resin performance.


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

2020-07-I-NC-8

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


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 (12 Recommendations)
Compressed Gas Association (CGA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 11, 2023

2021-03-I-GA-9

Develop a comprehensive standard for the safe storage, handling, and use of liquid nitrogen in stationary applications, comparable to the guidance presented in CGA G-6.5 Standard for Small Stationary Insulated Carbon Dioxide Systems. At a minimum, the standard should include:

a) requirements for and guidance on the location, the maintenance, and the functional testing of atmospheric monitoring devices;

b) requirements for visible and audible alarm indication distinct from the building’s fire alarm system and at a continuously attended location;

c) guidance on the design, function, periodic maintenance and testing, and location of room and emergency ventilation systems; and,

d) requirements for and guidance on the location of emergency shutdown devices including E-stops.


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

2021-03-I-GA-10

Update P-76 Hazards of Oxygen-Deficient Atmospheres. At a minimum, the updated standard should:

a) require that atmospheric monitoring systems shall be utilized with processes, equipment, and piping systems capable of producing oxygen-deficient atmospheres;

b) require that atmospheric monitoring systems provide both visible and audible alarm indication distinct from a building’s fire alarm system and at a continuously attended location;

c) require that processes, equipment, and piping systems capable of producing oxygen-deficient atmospheres shall be equipped with remotely operated emergency isolation valves (ROEIVs); and

d) include guidance on the adequate safe location of emergency stop devices. At a minimum this guidance should be harmonized with the requirements of ISO 13850 Safety of machinery – Emergency stop function – Principles for design. As necessary, augment the general guidance of ISO 13850 with guidance specific to processes, equipment, and piping using cryogenic asphyxiants and inert gases.


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

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

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: 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

International Code Council (ICC) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 11, 2023

2021-03-I-GA-12

Update the International Fire 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) in cryogenic fluid service. 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 - 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

Messer LLC (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 11, 2023

2021-03-I-GA-2

Update the company product stewardship policy to:

a) include participation by Messer in customers’ process hazard analyses (PHAs). The policy should require that these PHAs be conducted in a manner which conforms with CCPS Guidelines for Hazard Evaluation Procedures prior to the startup of a cryogenic freezing process;

b) require verification that proper signage, in accordance with CGA P-76 Hazards of Oxygen-Deficient Atmospheres, is displayed on and/or near equipment; and,

c) require a facility and/or equipment siting review to ensure that emergency shutoff devices, including E-stops, are located such that they can be safely actuated during a release of liquid nitrogen.


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

2021-03-I-GA-3

Create an informational product that provides Messer customers with information on the safety issues described in this report. In this informational product, recommend that Messer customers develop and implement effective safety management systems to control asphyxiation hazards from inert gases based on the guidance published in CGA P-86 Guideline for Process Safety Management, CGA P-12 Guideline for Safe Handling of Cryogenic and Refrigerated Liquids, CGA P-18 Standard for Bulk Inert Gas Systems, and CGA P-76 Hazards of Oxygen-Deficient Atmospheres.


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

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 100% | Closed: 0%

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

Occupational Safety and Health Administration (OSHA) (5 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 11, 2023

2021-03-I-GA-4

Update the Region 4 Poultry Processing Facilities Regional Emphasis Program to explicitly cover liquid nitrogen freezing processes. At a minimum, the update should encourage practices applicable to managing the hazards of using liquid nitrogen and other cryogenic asphyxiants, including process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.


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

2021-03-I-GA-5

Update the Region 5 Regional Emphasis Program for Food Manufacturing Industry to explicitly cover liquid nitrogen freezing processes. At a minimum, the update should encourage practices applicable to managing the hazards of using liquid nitrogen and other cryogenic asphyxiants, including process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.


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

2021-03-I-GA-6

Update the Region 6 Poultry Processing Facilities Regional Emphasis Program to explicitly cover liquid nitrogen freezing processes. At a minimum, the update should encourage practices applicable to managing the hazards of using liquid nitrogen and other cryogenic asphyxiants, including process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.


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

2021-03-I-GA-7

Promulgate a standard specific to cryogenic asphyxiants. The purpose of this standard shall be the prevention and/or mitigation of hazards arising from the storage, use, and/or handling of these substances. The new standard shall reference applicable national consensus standards such as those published by the Compressed Gas Association and others, as appropriate. At a minimum the new standard shall:

a) Address requirements for the design, construction, and installation of process equipment storing or using cryogenic asphyxiants;

b) Require atmospheric monitoring where equipment storing or using cryogenic asphyxiants is located indoors;

c) Require emergency shutdown systems such that equipment storing or using cryogenic asphyxiants may be isolated during a release without endangerment;

d) Address requirements for employee training and hazard awareness specific to cryogenic asphyxiants;

e) Require an emergency action plan in accordance with 29 CFR 1910.38; and,

f) Address requirements for the use of process safety management elements such as process hazard analysis, management of change, procedures, and others deemed necessary through the rulemaking process to prevent and/or mitigate these hazards.


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

2021-03-I-GA-8

Develop and publish a Guidance Document (similar to OSHA 3912-03 Process Safety Management for Explosives and Pyrotechnics Manufacturing) for process safety management practices applicable to processes handling compressed gases and cryogenic asphyxiants, including (at a minimum) the practices highlighted in this report.


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