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.


Quick Search

 
Recommendations Status:
 
 
Expand All

Recommendations

Arkema Inc. Chemical Plant Fire (5 Recommendations)
Arkema Crosby Facility (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 24, 2018

2017-08-I-TX-1

Reduce flood risk to as low as reasonably practicable (ALARP). Ensure that any safeguards for flooding meet independent layer of protection requirements.


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.
 

Arkema Inc. (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 24, 2018

2017-08-I-TX-2

Within 18 months, develop a policy requiring that Arkema and its subsidiaries that manufacture organic peroxides or that have processes which involve more than the threshold quantities of highly hazardous chemicals (HHC) periodically (corresponding with PHA cycle), analyze such facilities to determine whether they are at risk for extreme weather events such as hurricanes or floods.


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.
 

2017-08-I-TX-3

Establish corporate requirements for its facilities that manufacture organic peroxides or that have processes which involve more than the threshold quantities of highly hazardous chemicals (HHC) to ensure that critical safeguards, such as backup power, function as intended during extreme weather events, including hurricanes or floods.


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.
 

Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 24, 2018

2017-08-I-TX-4

Develop broad and comprehensive guidance to help companies assess their U.S. facility risk from all types of potential extreme weather events. Guidance should address the issues identified in this report and cover actions required to prepare for extreme weather, resiliency and protection of physical infrastructure and personnel during extreme weather, as well as recovery operations following an extreme weather event, where appropriate. Include guidance for each of the following:

• Addressing common mode failures of critical safeguards or equipment that could be caused by extreme weather events, including but not limited to flooding. For flooding scenarios, sufficient independent layers of protection should be available if floodwater heights reach the facility.

• Evaluating facility susceptibility to potential extreme weather events. Relevant safety information such as flood maps should be incorporated as process safety information.

• Involving relevant professional disciplines, including engineering disciplines, to help ensure risk assessments and process hazard analyses are as robust as practicable for any given facility.


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

Harris County, TX (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 24, 2018

2017-08-I-TX-5

Update your emergency operations training using lessons learned from the Arkema incident to help ensure that personnel enforcing evacuation perimeters are not harmed by exposure to hazardous chemical releases. Update existing protocols and revise training curricula to include the use of analytical tools, air monitoring, and personal protective equipment, to provide appropriate protection when emergency equipment or personnel need to be moved through an evacuation zone during a hazardous materials release. Include a process for periodic refresher training.


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

DuPont Corporation Toxic Chemical Releases (14 Recommendations)
American Chemistry Council Phosgene Panel (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 20, 2011

2010-06-I-WV-11

Revise the Phosgene Safe Practice Guidelines Manual  to

  • Advise against the use of hoses for phosgene transfer that are constructed of permeable cores and materials subject to chlorides corrosion.
  • Include guidance for the immediate reporting and prompt investigation of all potential (near-miss) phosgene 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 Recommendations Status Change Summary

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

Final Report Released On: September 20, 2011

2010-06-I-WV-9

Revise CGA P-1, Safe Handling of Compressed Gases in Containers, to include specific requirements for storing and handling highly toxic compressed gas, including enclosure ventilation and alarm requirements at least as protective as Section 7.9, Toxic and Highly Toxic Gases and NFPA 55, Compressed Gases and Cryogenics Fluids Code.


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

2010-06-I-WV-10

Revise CGA P-1, Safe Handling of Compressed Gases in Containers, to incorporate by reference CGA E-9, Standard for Flexible, PTFE-lined Pigtails for Compressed Gas Service.


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

DuPont Belle Plant (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 20, 2011

2010-06-I-WV-3

Improve the existing maintenance management by

  • Supplementing the computerized system with sufficient redundancy to ensure tracking and timely scheduling of preventive maintenance for all PSM-critical equipment.
  • Conducting Management-of-Change (MOC) reviews for all changes to preventive maintenance orders for all PSM-critical equipment in the computerized maintenance management 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 Summary Change

2010-06-I-WV-4

Revise the facility emergency response protocol to require that a responsible and accountable DuPont employee always be available (all shifts, all days) to provide timely and accurate information to the Kanawha County Emergency Ambulance Authority (KCEAA) and Metro 9-1-1 dispatchers.


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 Download

2010-06-I-WV-5

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

  • Ensures employee participation in reporting, investigating, analyzing, and recommending corrective actions as appropriate for all near-misses and disruptions of normal operations.
  • Develops and encourages use of an anonymous electronic and/or hard copy near-miss reporting process for all DuPont Belle site employees.
  • Establishes roles and responsibilities for ownership, management, execution, and resolution of recommendations from incident or near-miss investigations at the DuPont Belle facility.
  • Ensures that the near-miss investigation program requires prompt investigations, as appropriate, and that results are promptly circulated to well-suited recipients throughout the DuPont Corp.
  • Ensures that this program is operational at all times (e.g. nights, weekends, and holiday shifts).

 


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 Download

E. I. duPont de Nemours and Company (6 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 20, 2011

2010-06-I-WV-6

Revise safeguards for phosgene handling at all DuPont facilities by

  • Requiring that all indoor phosgene production and storage areas, as defined in NFPA 55, have secondary enclosures, mechanical ventilation systems, emergency phosgene scrubbers, and automated audible alarms, which are, at a minimum, consistent with the standards of NFPA 55 for highly toxic gases.
  • Prohibiting the use of hoses with permeable cores and materials susceptible to chlorides corrosion for phosgene transfer.
  • Conducting annual phosgene hazard awareness training for all employees who handle phosgene, including the hazards associated with thermal expansion of entrapped liquid phosgene in piping and equipment.

 


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

2010-06-I-WV-7

Review all DuPont units that produce and handle phosgene that, at a minimum, observe and document site-specific practices for engineering controls, construction materials, PPE, procedures, maintenance, emergency response, and release detection and alarms, and use information from external sources to develop and implement consistent company-wide policies for the safe production and handling of phosgene.


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 Summary Change

2010-06-I-WV-8

For each DuPont facility that uses, but does not manufacture, phosgene onsite:

  • Conduct a risk assessment of manufacturing phosgene onsite against the current configuration.
  • Communicate the findings of each assessment to compile recommendations applicable to all DuPont phosgene delivery systems.
  • Implement these recommendations.

 


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

2010-06-I-WV-12

Commission an audit in consultation with operations personnel to establish and identify the conditions that cause nuisance alarms at all DuPont facilities. Establish and implement a corporate alarm management program as part of the DuPont PSM Program, including measures to prevent nuisance alarms and other malfunctions in those systems. Include initial and refresher training as an integral part of this effort.


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 Download

2010-06-I-WV-13

Revise the DuPont PSM standard to require confirmation that all safety alarms/interlocks are in proper working order (e.g., not in an active alarm state) prior to the start-up of all Higher-Hazard Process facilities.


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 Download

2010-06-I-WV-14

Reevaluate and clarify the DuPont corporate MOC policies to ensure that staff can properly identify and use the distinctions between subtle and full changes and train appropriate personnel how to properly apply the distinctions on any changes in the policy.


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 Download

Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: September 20, 2011

2010-06-I-WV-1

Revise OSHA 29 CFR 1910.101, General Industry Standard for Compressed Gases, to require facilities that handle toxic and highly toxic materials in compressed gas cylinders to incorporate provisions that are at least as effective as the 2010 edition of Section 7.9, Toxic and Highly Toxic Gases, in National Fire Protection Association (NFPA) 55, Compressed Gases and Cryogenic Fluids Code, including enclosures, ventilation and treatment systems, interlocked fail-safe shutdown valves, gas detection and alarm systems, piping system components, and similarly relevant layers of protection.


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

2010-06-I-WV-2

Take sustained measures to minimize the exposure of hazards to workers handling highly toxic gases from cylinders and associated regulators, gages, hoses, and appliances. Ensure that OSHA managers, compliance officers, equivalent state OSHA plan personnel, and regulated parties conform, under the Process Safety Management Standard (29 CFR 1910.119) Recognized and Generally Accepted Good Engineering Practices (RAGAGEP) provisions, to industry practices at least as effective as the following:

  1. NFPA 55 - Compressed Gases and Cryogenic Fluids Code (2010)
  2. CGA P-1 Safe Handling of Compressed Gases in Containers (2008)
  3. CGA E-9 Standard for Flexible, PTFE-lined Pigtails for Compressed Gas Service (2010)
  4. ASME B31.3 Process Piping (2008)

 


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

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 - 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

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 - 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

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 - 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

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 - 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

Pryor Trust Fatal Gas Well Blowout and Fire (19 Recommendations)
American Petroleum Institute (API) (5 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 12, 2019

2018-01-I-OK-2

Establish and convene a group of experts with drilling, engineering, and instrumentation expertise to discuss methods to achieve widespread implementation of automatic safety instrumented systems that could bring a well to a safe state in the event other operational barriers fail. Publish a technical bulletin discussing the strategies to implementing Blowout Preventer (BOP) safety instrumented systems.


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

2018-01-I-OK-3

For onshore drilling operations, develop and publish a recommended practice providing guidance on safely tripping drill pipe during (1) overbalanced drilling operations, (2) managed pressure drilling operations, and (3) underbalanced drilling operations. At a minimum, include information on:

(a) Required equipment for tripping operations,

(b) Techniques and procedures for controlling or preventing formation fluid influx, and

(c) Methods to monitor the well and replace the drill pipe displacement volume with drilling fluid (e.g., mud).


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

2018-01-I-OK-4

Develop a recommended practice on alarm management specifically for the drilling industry based on guidance in ANSI/ISA 18.2 Management of Alarm Systems for the Process Industries. The recommended practice will address the unique dynamic environment of the drilling industry and provide guidance on implementing a state-based alarm system for different operating modes (e.g., drilling, circulating, tripping, etc.). Include International Association of Drilling Contractors (IADC) in the development of this recommended practice.


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

2018-01-I-OK-5

Develop a new recommended practice or modify an existing recommended practice (e.g. API RP 54 Recommended Practice for Occupational Safety for Oil and Gas Well Drilling and Servicing Operations) addressing the protection of rig workers on onshore drilling rigs from fire and explosion hazards in the event of a blowout. The recommended practice will specifically address:

(a) Protecting drilling cabin occupants from blowout hazards including heat, blast overpressure, and projectiles, such as requiring an increased fire rating for the driller’s cabin that would allow enough time for occupants to evacuate during a blowout and fire;

(b) Minimum required evacuation methods from the drilling cabin, rig floor, and mast or derrick in the event of a blowout so that personnel can quickly escape in variable hazard location conditions. For example, floor exit hatches and exits on the driller’s cabin wall opposite the rig floor could provide safe evacuation routes during a blowout and fire; and

(c) Proximity of the Blow Out Preventer (BOP) activation controls with the driller.

The above options could be retrofitted on existing drilling rigs. Additionally, formally evaluate alternative locations for the drilling cabin that establishes a safe distance from fire and explosion hazards (e.g., ground level).


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

2018-01-I-OK-6

Update API Bulletin 97 Well Construction Interface Document Guidelines to specify that it applies to both onshore and offshore drilling 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

International Association of Drilling Contractors (IADC) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 12, 2019

2018-01-I-OK-14

Participate in development of the recommended practice describe in recommendation 2018-01-OK-R4 to [American Petroleum Institute] API.


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

National Oilwell Varco (NOV) (2 Recommendations)
Open: 100% | Closed: 0%

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: 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

2018-01-I-OK-18

Design the M/D Totco electronic drilling data system so that alarm information, including alarm set points, alarm activation log, alarm horn status (on or off), and alarm system status (on or off) is provided to customers.


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

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

Final Report Released On: June 12, 2019

2018-01-I-OK-1

Implement one of the three following options regarding regulatory changes:

(a) OPTION 1: Apply the Process Safety Management (PSM) standard (29 CFR 1910.119) to the drilling of oil and gas wells; or

(b) OPTION 2: Apply the Process Safety Management (PSM) standard (29 CFR 1910.119) to the drilling of oil and gas wells as in OPTION 1, and make the necessary modifications to customize it to oil and gas drilling operations; or

(c) OPTION 3: Develop a new standard with a safety management system framework similar to PSM that applies only to the drilling of onshore oil and gas wells that includes but is not limited to the following:

  1. Detailed written operating procedures with specified steps and equipment alignment for all operations;

  2. Written procedures for the management of changes (except replacements in kind) in procedures, the well plan, and equipment;

  3. A risk assessment of hazards associated with the drilling plan;

  4. A requirement to follow Recognized and Generally Accepted Good Engineering Practices (RAGAGEP);

  5. Development of a Well Construction Interface Document between the operator and the drilling contractor prior to the commencement of drilling activities which at a minimum includes a bridging document and well plan specifying barriers and how to manage them;

  6. The performance and documentation of flow checks using acceptable methods at defined points during the operation for a specified duration; and

  7. A requirement for employee participation, similar to the Employee Participation requirement in the OSHA PSM standard.


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

Pason Systems Corp. (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 12, 2019

2018-01-I-OK-15

Design the Pason 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: 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

2018-01-I-OK-16

Design the Pason electronic drilling data system so that alarm information, including alarm set points, alarm activation log, alarm horn status (on or off), and alarm system status (on or off) is provided to customers.


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

Patterson-UTI (5 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 12, 2019

2018-01-I-OK-7

Develop either corporate or rig-specific tripping procedure(s) that detail the required equipment configuration for tripping operations. Require that rig personnel visually verify that equipment is lined up as specified in the procedure before beginning the tripping operation. In the procedure(s), specify well-monitoring requirements for wet versus dry tripping 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

2018-01-I-OK-8

Develop an alarm philosophy and alarm rationalization for rig operations. Based on the alarm philosophy and alarm rationalization, specify necessary alarms, at a minimum, for (1) drilling, (2) tripping, (3) circulating, and (4) rig floor activities (no drill pipe in well). Additionally, develop a policy implementing the alarm philosophy and rationalization.


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

2018-01-I-OK-9

Develop a policy that incorporates recommendations in API RP 59 Recommended Practice for Well Control Operations requiring the regular testing of drillers’ influx detection and response skills through formalized drills, for example by “simulat[ing] a gain in pit drilling fluid volume by raising a float sufficiently to cause an alarm to be activated.” In this policy, require that driller response time is monitored in the spirit of continual improvement.


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

2018-01-I-OK-10

Develop and implement a policy requiring that flow checks be documented, either electronically or with a paper record. At a minimum the documentation will require the reporting of:

  1. Operation during which flow check was performed

  2. Method of performing flow check

  3. Length of time flow check was performed

  4. Result of flow check

Require that the proper authorities (e.g., driller, company man, rig manager) sign or approve the flow check documentation after performing the flow check and before resuming operations. Keep the flow check documentation as part of the well file.


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

2018-01-I-OK-11

Update the Patterson metrics program to track leading and lagging indicators to measure the effectiveness of the overall safety management system. Specifically focus on measuring the effectiveness of the following safety management system components:

(a) The effectiveness of the flow check policy, including the frequency that flow checks are performed when required by Patterson policy;

(b) The frequency that flow checks are documented and approved as recommended in 2018-01-OK-R10;

(c) The effectiveness of the management of change program, for both equipment and procedural changes, including real-time procedure changes;

(d) The frequency that alarms are set at the required set points;

(e) The frequency that drilling rig alarm horns or the entire alarm system is turned off; and

(f) The frequency that trip sheets are filled out properly.


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

Red Mountain Operating (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 12, 2019

2018-01-I-OK-12

Develop a new policy that a well-specific Well Construction Interface Document be in place before drilling operations begin, as specified in API Bulletin 97 Well Construction Interface Document Guidelines. Ensure the policy requires that the Well Construction Interface Document specifies the technical requirements of the rig equipment and technical qualifications of personnel (e.g., conventional drilling, managed pressure drilling, underbalanced drilling) as well as specifies which barriers must be maintained and the expected response if a barrier is lost.


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

2018-01-I-OK-13

Develop a management of change policy governing real-time changes to operations and the drilling plan. As part of this policy, require hazard analysis and consideration of rig equipment, procedures, and personnel training and qualifications.


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

State of Oklahoma/Oklahoma Corporation Commission (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 12, 2019

2018-01-I-OK-19

Establish and implement safety regulations requiring entities who design oil and gas well drilling plans for wells in Oklahoma (e.g., operators) and entities who perform the drilling operation (e.g., drilling contractors) to develop and implement the following prior to conducting drilling operations:

(a) Detailed written operating procedures with specified steps and equipment alignment for all operations;

(b) Written procedures for the management of changes (except replacements in kind) in procedures, the well plan, and equipment;

(c) A risk assessment of hazards associated with the drilling plan;

(d) A requirement to follow Recognized and Generally Accepted Good Engineering Practices (RAGAGEP);

(e) Development of a Well Construction Interface Document between the operator and the drilling contractor prior to the commencement of drilling activities which at a minimum includes a bridging document and well plan specifying barriers and how to manage them;

(f) The performance and documentation of flow checks using acceptable methods at defined points during the operation for a specified duration; and

(g) A requirement for employee participation, similar to the Employee Participation requirement in the OSHA PSM standard.


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