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.
2005-4-I-TX-2 URGENT!
In light of the findings concerning the March 23rd incident at BP's Texas City refinery, revise your Recommended Practice 752, Management of Hazards Associated with Location of Process Plant Buildings or issue a new Recommended Practice to ensure the safe placement of occupied trailers and similar temporary structures away from hazardous areas of process plants. Ensure that the new recommended practice: - Protects occupants from accident hazards such as heat, blast overpressure, and projectiles; - Establishes minimum safe distances for trailers and similar temporary structures away from hazardous areas of process plants; and - Evaluates the siting of trailers under a separate methodology from permanent structures, since trailers are more susceptible to damage, are more readily relocated, and likely do not need to be placed near hazardous areas. Status: Closed - Acceptable Action
In light of the findings concerning the March 23rd incident at BP's Texas City refinery, revise your Recommended Practice 752, Management of Hazards Associated with Location of Process Plant Buildings or issue a new Recommended Practice to ensure the safe placement of occupied trailers and similar temporary structures away from hazardous areas of process plants. Ensure that the new recommended practice:
- Protects occupants from accident hazards such as heat, blast overpressure, and projectiles;
- Establishes minimum safe distances for trailers and similar temporary structures away from hazardous areas of process plants; and
- Evaluates the siting of trailers under a separate methodology from permanent structures, since trailers are more susceptible to damage, are more readily relocated, and likely do not need to be placed near hazardous areas.
2005-4-I-TX-3 URGENT!
Issue a safety alert to your membership to take prompt action to ensure the safe placement of occupied trailers away from hazardous areas of process plants. Status: Closed - Acceptable Action
Issue a safety alert to your membership to take prompt action to ensure the safe placement of occupied trailers away from hazardous areas of process plants.
2005-4-I-TX-4
Revise API Recommended Practice 521, Guide for Pressure Relieving and Depressurizing Systems to ensure that the guidelines: - Identifies overfilling vessels as a potential hazard for evaluation in selecting and designing pressure relief and disposal systems; - Addresses the need to adequately size disposal drums for credible worse-case liquid relief scenarios, based on accurate relief valve and disposal collection piping studies; and - Warns against the use of atmospheric blowdown drums and stacks attached to collection piping systems that receive flammable discharges from multiple relief valves and urges the use of appropriate inherently safer alternatives such as a flare system Status: Closed - Acceptable Action
Revise API Recommended Practice 521, Guide for Pressure Relieving and Depressurizing Systems to ensure that the guidelines:
- Identifies overfilling vessels as a potential hazard for evaluation in selecting and designing pressure relief and disposal systems;
- Addresses the need to adequately size disposal drums for credible worse-case liquid relief scenarios, based on accurate relief valve and disposal collection piping studies; and
- Warns against the use of atmospheric blowdown drums and stacks attached to collection piping systems that receive flammable discharges from multiple relief valves and urges the use of appropriate inherently safer alternatives such as a flare system
2005-4-I-TX-6
Develop a new consensus American National Standards Institute (ANSI) standard that creates performance indicators for process safety in the refinery and petrochemical industries. Ensure that the standard identifies leading and lagging indicators for nationwide public reporting as well as indicators for use at individual facilities. Include methods for the development and use of the performance indicators. Ensure that: a. the committees are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines. Status: Closed - Acceptable Alternative Action
Develop a new consensus American National Standards Institute (ANSI) standard that creates performance indicators for process safety in the refinery and petrochemical industries. Ensure that the standard identifies leading and lagging indicators for nationwide public reporting as well as indicators for use at individual facilities. Include methods for the development and use of the performance indicators. Ensure that:
a. the committees are accredited and conform to ANSI principles of openness, balance, due process, and consensus;
b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.
2005-4-I-TX-7
Develop a new consensus American National Standards Institute (ANSI) standard with fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. In the development of the standard, ensure that the committees: a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines. Status: Closed - Acceptable Action
Develop a new consensus American National Standards Institute (ANSI) standard with fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. In the development of the standard, ensure that the committees:
a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus;
2005-4-I-TX-1 URGENT!
Commission an independent panel to assess and report on the effectiveness of BP North America's corporate oversight of safety management systems at its refineries and its corporate safety culture. Provide the panel with necessary funding, resources, and authority - including full access to relevant data, corporate records, and employee interviews - in order to conduct a thorough, independent, and credible inquiry. Ensure that, at a minimum, the panel report examines and recommends any needed improvements to: Corporate safety oversight, including the safe management of refineries obtained through mergers and acquisitions; Corporate safety culture, including the degree to which: - Corporate officials exercise appropriate leadership to promote adherence to safety management systems; - Process safety is effectively incorporated into management decisionmaking at all levels; - Employees at all levels are empowered to promote improved process safety; - Process safety programs receive adequate resources and are appropriately positioned within organizational structures; Corporate and site safety management systems, specifically: - Near-miss reporting and investigation programs; - Mechanical integrity programs; - Hazard analysis programs, management-of-change programs, and up-todate operating procedures for processes with catastrophic potential; - Siting policies for occupied structures near hazardous operating units. Ensure that the panel has a diverse makeup, including an external chairperson; employee representatives; and outside safety experts, such as experts in process safety; experts in corporate culture, organizational behavior, and human factors; and experts from other high-risk sectors such as aviation, space exploration, nuclear energy, and the undersea navy. Ensure that the report and recommendations of the independent panel, which should be completed within 12 months, are made available to the BP workforce and to the public. Status: Closed - Acceptable Action
Commission an independent panel to assess and report on the effectiveness of BP North America's corporate oversight of safety management systems at its refineries and its corporate safety culture. Provide the panel with necessary funding, resources, and authority - including full access to relevant data, corporate records, and employee interviews - in order to conduct a thorough, independent, and credible inquiry. Ensure that, at a minimum, the panel report examines and recommends any needed improvements to:
- Corporate officials exercise appropriate leadership to promote adherence to safety management systems;
- Process safety is effectively incorporated into management decisionmaking at all levels;
- Employees at all levels are empowered to promote improved process safety;
- Process safety programs receive adequate resources and are appropriately positioned within organizational structures;
- Near-miss reporting and investigation programs;
- Mechanical integrity programs;
- Hazard analysis programs, management-of-change programs, and up-todate operating procedures for processes with catastrophic potential;
- Siting policies for occupied structures near hazardous operating units.
Ensure that the panel has a diverse makeup, including an external chairperson; employee representatives; and outside safety experts, such as experts in process safety; experts in corporate culture, organizational behavior, and human factors; and experts from other high-risk sectors such as aviation, space exploration, nuclear energy, and the undersea navy. Ensure that the report and recommendations of the independent panel, which should be completed within 12 months, are made available to the BP workforce and to the public.
2005-4-I-TX-11
Appoint an additional non-executive member of the Board of Directors with specific professional expertise and experience in refinery operations and process safety. Appoint this person to be a member of the Board Ethics and Environmental Assurance Committee. Status: Closed - Acceptable Alternative Action
Appoint an additional non-executive member of the Board of Directors with specific professional expertise and experience in refinery operations and process safety. Appoint this person to be a member of the Board Ethics and Environmental Assurance Committee.
2005-4-I-TX-12
Ensure and monitor that senior executives implement an incident reporting program throughout your refinery organization that: a. encourages the reporting of incidents without fear of retaliation; b. requires prompt corrective actions based on incident reports and recommendations, and tracks closure of action items at the refinery where the incident occurred and other affected facilities; and c. requires communication of key lessons learned to management and hourly employees as well as to the industry. Status: Closed - Acceptable Action
Ensure and monitor that senior executives implement an incident reporting program throughout your refinery organization that:
a. encourages the reporting of incidents without fear of retaliation;
b. requires prompt corrective actions based on incident reports and recommendations, and tracks closure of action items at the refinery where the incident occurred and other affected facilities; and
c. requires communication of key lessons learned to management and hourly employees as well as to the industry.
2005-4-I-TX-13
Ensure and monitor that senior executives use leading and lagging process safety indicators to measure and strengthen safety performance in your refineries. Status: Closed - Acceptable Action
Ensure and monitor that senior executives use leading and lagging process safety indicators to measure and strengthen safety performance in your refineries.
2005-4-I-TX-14
Evaluate your refinery process units to ensure that critical process equipment is safely designed. At a minimum: a. Ensure that distillation towers have effective instrumentation and control systems to prevent overfilling such as multiple level indicators and appropriate automatic controls. b. Configure control board displays to clearly indicate material balance for distillation towers. Status: Closed - Acceptable Action
Evaluate your refinery process units to ensure that critical process equipment is safely designed. At a minimum:
a. Ensure that distillation towers have effective instrumentation and control systems to prevent overfilling such as multiple level indicators and appropriate automatic controls.
b. Configure control board displays to clearly indicate material balance for distillation towers.
2005-4-I-TX-16
Work with the United Steelworkers Union and Local 13-1 to establish a joint program that promotes the reporting, investigation, and analysis of incidents, near-misses, process upsets, and major plant hazards without fear of retaliation. Ensure that the program tracks recommendations to completion and shares lessons learned with the workforce. Status: Closed - Acceptable Action
Work with the United Steelworkers Union and Local 13-1 to establish a joint program that promotes the reporting, investigation, and analysis of incidents, near-misses, process upsets, and major plant hazards without fear of retaliation. Ensure that the program tracks recommendations to completion and shares lessons learned with the workforce.
2005-4-I-TX-15
Ensure that instrumentation and process equipment necessary for safe operation is properly maintained and tested. At a minimum: a. Establish an equipment database that captures the history of testing, inspections, repair, and successful work order completion. b. Analyze repair trends and adjust maintenance and testing intervals to prevent breakdowns. c. Require repair of malfunctioning process equipment prior to unit startups. Status: Closed - Acceptable Action
Ensure that instrumentation and process equipment necessary for safe operation is properly maintained and tested. At a minimum:
a. Establish an equipment database that captures the history of testing, inspections, repair, and successful work order completion.
b. Analyze repair trends and adjust maintenance and testing intervals to prevent breakdowns.
c. Require repair of malfunctioning process equipment prior to unit startups.
2005-4-I-TX-17
Improve the operator training program. At a minimum, require: a. face-to-face training conducted by personnel with process-specific knowledge and experience who can assess trainee competency, and; b. training on recognizing and handling abnormal situations including the use of simulators or similar training tools. Status: Closed - Acceptable Action
Improve the operator training program. At a minimum, require:
a. face-to-face training conducted by personnel with process-specific knowledge and experience who can assess trainee competency, and;
b. training on recognizing and handling abnormal situations including the use of simulators or similar training tools.
2005-4-I-TX-18
Require additional board operator staffing during the startup of process units. Ensure that hazard reviews address staffing levels during abnormal conditions such as startups, shutdowns, and unit upsets. Status: Closed - Acceptable Action
Require additional board operator staffing during the startup of process units. Ensure that hazard reviews address staffing levels during abnormal conditions such as startups, shutdowns, and unit upsets.
2005-4-I-TX-19
Require knowledgeable supervisors or technically trained personnel to be present during especially hazardous operation phases such as unit startup. Status: Closed - Acceptable Action
Require knowledgeable supervisors or technically trained personnel to be present during especially hazardous operation phases such as unit startup.
2005-4-I-TX-20
Ensure that process startup procedures are updated to reflect actual process conditions. Status: Closed - Acceptable Action
Ensure that process startup procedures are updated to reflect actual process conditions.
2005-4-B-TX-1
Revise the maintenance quality control program to require positive material identification testing or another suitable material verification process for all critical service alloy steel piping components removed and reinstalled during maintenance and inform work crews of special material handling precautions. Status: Closed - Acceptable Action
Revise the maintenance quality control program to require positive material identification testing or another suitable material verification process for all critical service alloy steel piping components removed and reinstalled during maintenance and inform work crews of special material handling precautions.
2005-4-I-TX-10
Issue management of change guidelines that address the safe control of the following: a. major organizational changes including mergers, acquisitions, and reorganizations; b. changes in policies and budgets; c. personnel changes; and d. staffing during process startups, shutdowns and other abnormal conditions. Status: Closed - Acceptable Action
Issue management of change guidelines that address the safe control of the following:
a. major organizational changes including mergers, acquisitions, and reorganizations;
b. changes in policies and budgets;
c. personnel changes; and
d. staffing during process startups, shutdowns and other abnormal conditions.
2005-4-B-TX-2
Develop / update the written piping component installation quality control procedure to require positive material identification testing or other suitable verification or tracking process for all alloy steel piping components removed during maintenance. Status: Closed - Acceptable Action
Develop / update the written piping component installation quality control procedure to require positive material identification testing or other suitable verification or tracking process for all alloy steel piping components removed during maintenance.
2005-4-I-TX-5
Implement a national emphasis program for all oil refineries that focuses on: - The hazards of blowdown drums and stacks that release flammables to the atmosphere instead of to an inherently safer disposal system such as a flare. Particular attention should be paid to blowdown drums attached to collection piping systems servicing multiple relief valves; - The need for adequately sized disposal knockout drums to safely contain discharged flammable liquid based on accurate relief valve and disposal collection piping studies Urge states that administer their own OSHA plan to implement comparable emphasis programs within their respective jurisdictions. Status: Closed - Acceptable Action
Implement a national emphasis program for all oil refineries that focuses on:
- The hazards of blowdown drums and stacks that release flammables to the atmosphere instead of to an inherently safer disposal system such as a flare. Particular attention should be paid to blowdown drums attached to collection piping systems servicing multiple relief valves;
- The need for adequately sized disposal knockout drums to safely contain discharged flammable liquid based on accurate relief valve and disposal collection piping studies
Urge states that administer their own OSHA plan to implement comparable emphasis programs within their respective jurisdictions.
2005-4-I-TX-8
Strengthen the planned comprehensive enforcement of the OSHA Process Safety Management (PSM) standard. At a minimum: a. Identify those facilities at greatest risk of a catastrophic accident by using available indicators of process safety performance and information gathered by the EPA under its Risk Management Program (RMP). b. Conduct, or have conducted, comprehensive inspections, such as those under your Program Quality Verification (PQV) program at facilities identified as presenting the greatest risk. c. Establish the capacity to conduct more comprehensive PSM inspections by hiring or developing a sufficient cadre of highly trained and experienced inspectors. d. Expand the PSM training offered to inspectors at the OSHA National Training Institute. Status: Closed - Acceptable Alternative Action
Strengthen the planned comprehensive enforcement of the OSHA Process Safety Management (PSM) standard. At a minimum:
a. Identify those facilities at greatest risk of a catastrophic accident by using available indicators of process safety performance and information gathered by the EPA under its Risk Management Program (RMP).
b. Conduct, or have conducted, comprehensive inspections, such as those under your Program Quality Verification (PQV) program at facilities identified as presenting the greatest risk.
c. Establish the capacity to conduct more comprehensive PSM inspections by hiring or developing a sufficient cadre of highly trained and experienced inspectors.
d. Expand the PSM training offered to inspectors at the OSHA National Training Institute.
2005-4-I-TX-9
Amend the OSHA PSM standard to require that a management of change (MOC) review be conducted for organizational changes that may impact process safety including: a. major organizational changes such as mergers, acquisitions, or reorganizations; b. personnel changes, including changes in staffing levels or staff experience; and c. policy changes such as budget cutting. Status: Open - Unacceptable Response/No Response Received
Amend the OSHA PSM standard to require that a management of change (MOC) review be conducted for organizational changes that may impact process safety including:
a. major organizational changes such as mergers, acquisitions, or reorganizations;
b. personnel changes, including changes in staffing levels or staff experience; and
c. policy changes such as budget cutting.
Work with API to develop a new consensus American National Standards Institute (ANSI) standard that creates performance indicators for process safety in the refinery and petrochemical industries. Ensure that the standard identifies leading and lagging indicators for nationwide public reporting as well as indicators for use at individual facilities. Include methods for the development and use of the performance indicators. Status: Closed - Acceptable Action
Work with API to develop a new consensus American National Standards Institute (ANSI) standard that creates performance indicators for process safety in the refinery and petrochemical industries. Ensure that the standard identifies leading and lagging indicators for nationwide public reporting as well as indicators for use at individual facilities. Include methods for the development and use of the performance indicators.
Work with API to develop a new consensus American National Standards Institute (ANSI) standard with fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. Status: Closed - Acceptable Action
Work with API to develop a new consensus American National Standards Institute (ANSI) standard with fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work.
2005-4-I-TX-21
Work with BP to establish a joint program that promotes reporting, investigating, and analyzing incidents, near-misses, process upsets, and major plant hazards without fear of retaliation. Ensure that the program tracks recommendations to completion and shares lessons learned with the workforce. Status: Closed - Acceptable Action
Work with BP to establish a joint program that promotes reporting, investigating, and analyzing incidents, near-misses, process upsets, and major plant hazards without fear of retaliation. Ensure that the program tracks recommendations to completion and shares lessons learned with the workforce.