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

Valero Refinery Asphyxiation Incident (8 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-6

Revise Guidelines for Safe Work in Inert Confined Spaces in the Petroleum and Petrochemical Industries (API, 2005) to clearly address the following: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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

American Society of Safety Engineers (ASSE) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-7

Revise Safety Requirements for Confined Spaces, ANSI/ASSE Z117.1 to emphasize that: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


Status: Closed - Exceeds Recommended Action
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

PDF Document Recommendations Status Change Summary

Compressed Gas Association (CGA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-8

Issue a safety alert to address nitrogen/inert gas hazards in confined spaces. Emphasize that: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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.
 

Matrix Service Industrial Contractors, Inc. (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-5

Conduct confined space control and inert gas purge procedure refresher training for all affected personnel. Emphasize: - The requirements to maintain posted warnings at all access points to confined space temporary openings. - The need to maintain posted warnings, barricades, and access controls as required by the client. - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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.
 

Valero Delaware City Refinery (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-1

Conduct safe work permit refresher training for all permit-preparers and approvers and affected refinery personnel and contractors. Emphasize: - All proposed work requires a jobsite visit by the requestor and a unit operator to identify special precautions, equipment status, and personal safety equipment requirements. - The conditions for marking the "nitrogen purge or inerted" (Yes/No/NA) status box. - The permit must clearly identify all hazards and special personal protective equipment requirements. - "Fresh Air" work restrictions apply to "Set up only" permits whenever an IDLH atmosphere is suspected or known to be present in the work area.


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.
 

2006-2-I-DE-2

Conduct confined space control and inert gas purge procedure refresher training for all affected refinery personnel and contractors. Emphasize: - The requirements to maintain posted warnings at all access points to confined space temporary openings. - The requirements to maintain posted warnings, barricades, and access control log at equipment during purging. - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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.
 

Valero Energy Corporation (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-3

Audit work permit procedures and nitrogen purge safety procedures at each Valero U.S. refinery. Determine if issues identified in this Case Study are occurring elsewhere. Implement corrective action, including training, where necessary.


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.
 

2006-2-I-DE-4

Require Valero U.S. refineries to revise and conduct nitrogen hazards awareness training. Emphasize: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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.