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

Xcel Energy Company Hydroelectric Tunnel Fire (20 Recommendations)
American Public Power Association (APPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-17

Publish safety guidance addressing the hazards and controls for using hazardous materials including flammables in confined spaces and the unique hazards of penstocks. At a minimum

a. In controlling hazards in confined spaces, implement a hierarchy of controls by first attempting to eliminate hazards or substitute with a less hazardous material(s) or method(s). Examples include performing work outside of a confined space where reasonably practicable or substituting a flammable material with a non-flammable one.

b. Establish a maximum permissible percentage substantially below the LEL for safe entry and occupancy of permit-required confined spaces.

c. Recommend that confined spaces that are large, or part of a continuous system such as a penstock, always be managed as permit-required as defined in the OSHA Confined Space Standard, and that such spaces always be monitored for hazardous atmospheres both prior to entry and continuously in areas where work is being performed.

d. Ensure that evacuation plans for penstocks that have only one egress point provide for alternative escape routes or refuge chambers.

e. Provide guidance for implementing a written confined space rescue plan. Address staging and methods of rescue for each designated permit space including whether a rescue team is required to stand by outside the space. Require that confined space rescue teams be standing by at the permit spaces where the hazards pose an immediate threat to life or health, including the hazard of a potential flammable atmosphere.


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

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Colorado Division of Emergency Management Director (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-7

Publish a safety communication that will inform fire service and emergency planning organizations in the state about the confined space safety lessons learned from the Cabin Creek incident including
a. The need to train and certify emergency response personnel who perform technical, including confined space, rescue.

b. The importance of a written confined space rescue plan for each designated permit space that includes

i. Methods of rescue and determination of whether a rescue team is required to standby outside the space.
ii. Rescue equipment requirements and plan of action.

c. The importance of treating confined spaces with the potential for flammable atmospheres above 10 percent of the LEL as a hazard immediately dangerous to life or health that requires rescuers to be stationed directly outside the permit space and available for immediate rescue with appropriate fire-extinguishing and rescue equipment.

d. The need for confined space rescue procedures to instruct emergency responders to not enter or occupy a confined space containing a flammable atmosphere 10 percent of the LEL or greater. Personal protective equipment (PPE) will not protect rescuers from an explosion in a confined space.
 


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.
 

Colorado Division of Fire Safety Director (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-7

Publish a safety communication that will inform fire service and emergency planning organizations in the state about the confined space safety lessons learned from the Cabin Creek incident including
a. The need to train and certify emergency response personnel who perform technical, including confined space, rescue.

b. The importance of a written confined space rescue plan for each designated permit space that includes

i. Methods of rescue and determination of whether a rescue team is required to standby outside the space.
ii. Rescue equipment requirements and plan of action.

c. The importance of treating confined spaces with the potential for flammable atmospheres above 10 percent of the LEL as a hazard immediately dangerous to life or health that requires rescuers to be stationed directly outside the permit space and available for immediate rescue with appropriate fire-extinguishing and rescue equipment.

d. The need for confined space rescue procedures to instruct emergency responders to not enter or occupy a confined space containing a flammable atmosphere 10 percent of the LEL or greater. Personal protective equipment (PPE) will not protect rescuers from an explosion in a confined space.
 


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.
 

Colorado Public Utilities Commission (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-4

Revise your rules regulating electric utilities, 4 Code of Colorado Regulations 723-3, to:

a. Require regulated utilities to investigate the facts, conditions, and circumstances of all incidents resulting in death, serious injury or significant property damage as defined in Section 3204

b. Require utilities to submit a written investigation report to the Commission within one year of the incident that contains the investigation findings, root causes and recommendations for preventing future incidents that focus on needed changes to utility safety systems. All reports shall be made public.

c. Authorize the commission to issue orders addressing needed corrective actions to be taken as a result of the incident.

d. Require utilities to submit periodic reports to the Commission detailing action taken on the incident report recommendations and Commission orders. All reports shall be made the public.


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

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2008-01-I-CO-5

Revise your rules regulating electric utilities, 4 Code of Colorado Regulations 723-3, to:

Require all regulated utilities to fully cooperate with all government safety investigations including facilitating access to witnesses, facilities, and equipment; providing copies of requested records; and responding to interrogatories and other investigative requests for information as expeditiously as possible.


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

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2008-01-I-CO-6

Revise your rules regulating electric utilities, 4 Code of Colorado Regulations 723-3, to:

Require that competitive bidding and contractor selection rules for construction, maintenance or repair of regulated utilities include procedures for prequalifying or disqualifying contractors based on specific safety performance measures and qualifications.


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

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Governor of the State of Colorado (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-3

Implement, through the Division of Fire Safety, an accredited firefighter certification program for technical rescue that encompasses appropriate specialty areas including confined space rescue.


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.
 

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

Final Report Released On: August 25, 2010

2008-01-I-CO-1

Amend the OSHA Permit-Required Confined Spaces Rule for general industry (29 CFR 1910.146) to establish a maximum permissible percentage substantially below the lower explosive limit (LEL) for safe entry and occupancy in permit-required confined spaces.


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 Recommendations Status Change Summary

2008-01-I-CO-2

Publish a “Safety and Health Information Bulletin” addressing the hazards and controls when using flammable materials in confined spaces that includes actionable guidance regarding:
 
a. The importance of implementing a hierarchy of controls to address hazards in a confined space that first seeks to eliminate hazards or substitute with a less hazardous material(s) or method(s). Examples include performing work outside of a confined space where reasonably practicable or substituting a flammable material with a non-flammable one.

b. The necessity of establishing a maximum permissible percentage substantially below the lower explosive limit (LEL) for safe entry and occupancy of permit required confined spaces.

c. The need to comprehensively control all potential ignition sources and continuously monitor the confined space at appropriate locations and elevations when work activities involve the use of flammable materials or where flammable atmospheres may be created.

d. The importance of treating confined spaces with the potential for flammable atmospheres above 10 percent of the LEL as a hazard immediately dangerous to life or health (IDLH) that requires rescuers to be stationed directly outside the permit space and available for immediate rescue with appropriate fire-extinguishing and rescue equipment.

e. The requirement that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Such spaces need to be monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working.


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.
 

RPI Coating, Inc. (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-13

Revise your confined space entry program and practices. At a minimum

a. Require continuous monitoring for flammable atmospheres at appropriate locations and elevations within a confined space where work activities involve the use of flammables or where flammable atmospheres may be created.

b. Prohibit entry or require evacuation of a confined space if the atmospheric concentration of flammable vapors is 10 percent of the LEL or higher.

c. Ensure that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Ensure that such spaces are monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working.

d. Ensure that evacuation plans for penstocks that have only one egress point provide for alternative escape routes and/or refuge chambers.

e. Ensure the implementation of a written confined space rescue preplan for each designated permit space. Address staging and methods of rescue for each designated permit space including whether a rescue team is required to standby outside the space. Require that confined space rescue teams be standing by at the permit spaces where the hazards pose an immediate threat to life or health including the hazard of a potential flammable atmosphere.


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

2008-01-I-CO-14

Based on the findings and conclusions of this report, hire a certified safety professional to conduct periodic safety audits at your worksites. At a minimum, assess safety training, confined space safety, safe handling of flammables, emergency response, rescue, and fire prevention.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

PDF Document Recommendations Status Change Summary

2008-01-I-CO-15

Ensure that all journeyman painters have received safety training equivalent in content to that covered in the Joint Apprenticeship program. At a minimum, address confined space safety, safe handling of flammables, emergency response and rescue, and fire prevention.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

PDF Document Recommendations Status Change Summary

Society for Protective Coatings (SSPC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-16

Publish safety guidance addressing the hazards and controls for using hazardous materials including flammables in confined spaces and the unique hazards of penstocks. At a minimum

a. In controlling hazards in confined spaces, implement a hierarchy of controls by first attempting to eliminate hazards or substitute with a less hazardous material(s) or method(s). Examples include performing work outside of a confined space where reasonably practicable or substituting a flammable material with a non-flammable one.

b. Establish a maximum permissible percentage substantially below the LEL for safe entry and occupancy of permit-required confined spaces.

c. Recommend that confined spaces that are large, or part of a continuous system such as a penstock, always be managed as permit-required as defined in the OSHA Confined Space Standard, and that such spaces always be monitored for hazardous atmospheres both prior to entry and continuously in areas where work is being performed.

d. Ensure that evacuation plans for penstocks that have only one egress point provide for alternative escape routes or refuge chambers.

e. Provide guidance for implementing a written confined space rescue plan. Address staging and methods of rescue for each designated permit space including whether a rescue team is required to stand by outside the space. Require that confined space rescue teams be standing by at the permit spaces where the hazards pose an immediate threat to life or health, including the hazard of a potential flammable atmosphere.


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.
 

Southern California Painting and Drywall Industries Joint Apprenticeship and Training Committee (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-18

Require that all journeyman painters who are employees and/or members have received safety training equivalent in content to that covered in the Joint Apprenticeship program. At a minimum, address confined space safety, safe handling of flammables, emergency response and rescue, and fire prevention.


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

2008-01-I-CO-19

Include a safety knowledge and skills component to your journeyman and apprentice evaluation criteria.


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

Xcel Energy, Inc. (5 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-8

Revise your policies for solicitation and procurement of construction services to

a. Ensure that requests for proposals (RFPs) and selection processes include criteria and procedures for prequalifying or disqualifying contractors based on specific safety performance measures and qualifications.

b. Implement written verification procedures for the safety information and documentation submitted by contractors during the bidding and selection process.


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

2008-01-I-CO-9

Revise your contractor safety policies to require a comprehensive review and evaluation of contractor safety policies and procedures such as the permit-required confined space program and safety performance of contractors working in confined spaces to ensure that any bidding contractor meets or exceeds Xcel Energy safety requirements.


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

2008-01-I-CO-10

Conduct periodic safety audits of contractor selection and oversight at your power-generating facilities to ensure adherence to corporate contractor procurement and safety policies.


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

2008-01-I-CO-11

Report key findings, causes and recommendations of the CSB report to Xcel shareholders so that the owners of Xcel are fully informed of the report contents and how Xcel intends to prevent a similar accident in the future.


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

2008-01-I-CO-12

Revise your confined space entry program and practices. At a minimum

a. Require continuous monitoring for flammable atmospheres at appropriate locations and elevations within a confined space where work activities involve the use of flammables or where flammable atmospheres may be created.

b. Prohibit entry or require evacuation of a confined space if the atmospheric concentration of flammable vapors is 10 percent of the LEL or higher.

c. Ensure that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Ensure that such spaces are monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working.

d. Ensure that evacuation plans for penstocks that have only one egress point provide for alternative escape routes and/or refuge chambers.

e. Ensure the implementation of a written confined space rescue preplan for each designated permit space. Address staging and methods of rescue for each designated permit space including whether a rescue team is required to standby outside the space. Require that confined space rescue teams be standing by at the permit spaces where the hazards pose an immediate threat to life or health including the hazard of a potential flammable atmosphere.


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendations Status Change Summary