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.
2004-11-I-CA-7
In collaboration with other state/regional agencies as necessary, such as California Occupational Safety and Health Administration, recommend to facilities that treat ethylene oxide backvent emissions with oxidizing emissions control devices to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices. Status: Closed - Acceptable Action
In collaboration with other state/regional agencies as necessary, such as California Occupational Safety and Health Administration, recommend to facilities that treat ethylene oxide backvent emissions with oxidizing emissions control devices to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices.
2004-11-I-CA-8
In collaboration with other state/regional agencies as necessary, such as California Environmental Protection Agency, identify the ethylene oxide sterilization facilities in California that utilize oxidizing emissions control devices and conduct inspections of those facilities (including the Sterigenics Ontario facility) in terms of the findings of this report. Ensure prompt correction of all violations identified during these inspections. Status: Closed - Acceptable Action
In collaboration with other state/regional agencies as necessary, such as California Environmental Protection Agency, identify the ethylene oxide sterilization facilities in California that utilize oxidizing emissions control devices and conduct inspections of those facilities (including the Sterigenics Ontario facility) in terms of the findings of this report. Ensure prompt correction of all violations identified during these inspections.
2004-11-I-CA-16
Communicate the findings and recommendations of this report to the states that require EO backvent emissions treatment. Emphasize the need for facilities to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to the states that require EO backvent emissions treatment. Emphasize the need for facilities to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices.
2004-11-I-CA-14
Coordinate with NIOSH to revise and reissue Appendix C of the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically, remove the portion of paragraph D that states, "[t]he accuracy, reliability, resolution, and availability of current ethylene oxide measurement devices is questionable." Status: Closed - Acceptable Action
Coordinate with NIOSH to revise and reissue Appendix C of the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically, remove the portion of paragraph D that states, "[t]he accuracy, reliability, resolution, and availability of current ethylene oxide measurement devices is questionable."
2004-11-I-CA-15
Conduct outreach to communicate the findings and recommendations of this report, and the contents of the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities, to your membership. Status: Closed - Acceptable Action
Conduct outreach to communicate the findings and recommendations of this report, and the contents of the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities, to your membership.
2004-11-I-CA-17
Communicate the findings and recommendations of this report to your membership. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to your membership.
2004-11-I-CA-9
Review and revise NFPA 560, Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation in terms of the findings of this report. Specifically: Include references to the following: NFPA 69, Standard on Explosion Prevention Systems. NFPA 86, Ovens and Furnaces. NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions in Industrial Ethylene Oxide Sterilization Facilities.
Review and revise NFPA 560, Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation in terms of the findings of this report. Specifically:
2004-11-I-CA-10
Review and revise NFPA 560, Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation in terms of the findings of this report. Specifically: Include requirements for appropriate safeguards, such as: Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. Post-ignition deflagration detection and damage control devices.
2004-11-I-CA-11
Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Include industry guidance materials on Process Hazard Analysis (PHA), such as those published by the Center for Chemical Process Safety (CCPS). Status: Closed - Acceptable Action
Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Include industry guidance materials on Process Hazard Analysis (PHA), such as those published by the Center for Chemical Process Safety (CCPS).
2004-11-I-CA-12
Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Add references to NFPA 68 Guide for Venting of Deflagrations; NFPA 69 Standard on Explosion Prevention Systems; NFPA 86 Ovens and Furnaces; and NFPA 560 Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation. Status: Closed - Acceptable Action
Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Add references to NFPA 68 Guide for Venting of Deflagrations; NFPA 69 Standard on Explosion Prevention Systems; NFPA 86 Ovens and Furnaces; and NFPA 560 Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation.
2004-11-I-CA-13
Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Coordinate with the Ethylene Oxide Sterilization Association (EOSA) to remove the portion of paragraph D of Appendix C that states, ?[t]he accuracy, reliability, resolution, and availability of current ethylene oxide measurement devices is questionable.? Status: Closed - Acceptable Action
Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Coordinate with the Ethylene Oxide Sterilization Association (EOSA) to remove the portion of paragraph D of Appendix C that states, ?[t]he accuracy, reliability, resolution, and availability of current ethylene oxide measurement devices is questionable.?
2004-11-I-CA-1
Audit all Sterigenics ethylene oxide sterilization facilities using oxidizing emissions control devices. Ensure that audits assess the issues detailed below, under "Sterigenics International - Ontario Facility," and that necessary corrective measures are promptly implemented. Communicate results of these audits to your workforce. Status: Closed - Acceptable Action
Audit all Sterigenics ethylene oxide sterilization facilities using oxidizing emissions control devices. Ensure that audits assess the issues detailed below, under "Sterigenics International - Ontario Facility," and that necessary corrective measures are promptly implemented. Communicate results of these audits to your workforce.
2004-11-I-CA-2
Review and revise the Process Hazard Analysis (PHA) program to ensure that: - Hazardous scenarios are identified, evaluated, and documented. - Lessons learned from past incidents are applied, where appropriate. Status: Closed - Acceptable Action
Review and revise the Process Hazard Analysis (PHA) program to ensure that: - Hazardous scenarios are identified, evaluated, and documented. - Lessons learned from past incidents are applied, where appropriate.
2004-11-I-CA-3
Evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices. Status: Closed - Acceptable Action
Evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices.
2004-11-I-CA-4
Ensure that all employees with passwords capable of modifying the sterilization cycle sequence have process experience and training that enables them to make safe process decisions. Training should emphasize flammability hazards and the need for gas washes when the chamber is empty of products to be sterilized. Status: Closed - Acceptable Action
Ensure that all employees with passwords capable of modifying the sterilization cycle sequence have process experience and training that enables them to make safe process decisions. Training should emphasize flammability hazards and the need for gas washes when the chamber is empty of products to be sterilized.
2004-11-I-CA-5
Ensure that the control room, and any other room where employees congregate in dangerous proximity to the sterilization area, is located and/or designed to protect workers from an explosion. Status: Closed - Acceptable Action
Ensure that the control room, and any other room where employees congregate in dangerous proximity to the sterilization area, is located and/or designed to protect workers from an explosion.
2004-11-I-CA-6
Communicate the findings and recommendations of this report to all employees, including operators and maintenance staff. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to all employees, including operators and maintenance staff.