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

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.
 

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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.
 

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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.
 

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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.
 

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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