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

Optima Belle Explosion and Fire (15 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-15

Update Guidelines for Process Safety in Outsourced Manufacturing Operations or develop a new tolling guidance document to supplement existing guidelines. The publication should include current best practices, introduce guidance specific to tolling brokers and/or project managing companies such as Richman Chemical Inc., and cross-reference and align with the comprehensive management systems framework and terminology contained in Guidelines for Risk Based Process Safety and other contemporary industry good practice guidance.


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.
 

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Clearon Corporation (5 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-5

Develop and implement a comprehensive process knowledge management program or evaluate and revise existing process safety management procedures to ensure consistency with industry guidance publications such as the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety. The program should:

a) assign specific responsibilities for compiling content and maintaining robust process technology and safety information packages that incorporate relevant knowledge for all hazardous processes and substances operated, manufactured, and/or handled by Clearon Corporation;

b) ensure that key process personnel are aware of critical reactive chemistry information, including thermal stability and calorimetry data, chemical compatibility information, and descriptions of any past reactive incidents and safety studies involving the materials; and

c) define procedures for the transmittal of such information to toll manufacturers.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

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2021-02-I-WV-6

Update the sodium dichloroisocyanurate dihydrate (CDB-56®) safety data sheet. At a minimum, the document should:

a) provide the underlying reasoning for the storage temperature maximum and the consequences of exceeding that temperature;

b) provide the underlying reasoning for the decomposition temperature and the consequences of exceeding that temperature;

c) explain or make clear the reason(s) for and/or the circumstance(s) resulting in the differences between the decomposition temperature and the lowest temperature at which self-accelerating decomposition may occur; and

d) provide the exothermic decomposition energy in the Physical Properties section.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

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2021-02-I-WV-7

Develop and implement a written program for tolling process design and equipment selection using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety to ensure that:

a) equipment design basis is adequate for any new tolling process or product; and

b) safeguards and ancillary equipment are considered and adequately designed, installed, and function as designed and required.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

PDF Document Recommendation Status Change Summary

2021-02-I-WV-8

Develop and implement a formalized program for the development of toll manufacturing agreements using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety. Ensure that the program provides for the following:

a) Identification of roles and responsibilities of all parties, including the client, toller, and any third-party technical service providers, for all phases of a proposed arrangement;

b) Evaluation of equipment requirements/specifications to ensure that they are adequate for the intended operation; and

c) Participation by all parties in tolling process development, including process hazards analysis and emergency planning, and appropriate stages of the pre-planning, pre-startup, and production phases.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

PDF Document Recommendation Status Change Summary

2021-02-I-WV-9

Develop and implement a process safety management system consistent with industry guidance publications such as is contained in the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety. At a minimum, the process safety management system should address hazard identification, risk analysis, and management of risk.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

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National Center for Biotechnology Information (NCBI) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-14

Update the safety information in PubChem for sodium dichloroisocyanurate (NaDCC) dihydrate, to include publicly available reactivity and decomposition information including but not limited to the Self Accelerating Decomposition Temperature (SADT), the explosion hazard when heating metal containers containing NaDCC dihydrate, and the Differential Scanning Calorimetry (DSC) and Accelerating Rate Calorimetry (ARC) results presented in this report. When compiling this information, review sources including the Registration, Evaluation, Authorization, and Restriction of Chemicals Regulation (REACH) dossier and other publications.


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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Occupational Safety and Health Administration (OSHA) (3 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-11

Update the Chemical Reactivity Hazards website (https://www.osha.gov/chemical-reactivity) to include various reactivity assessment tools developed since the 2002 Index-Based Method for Assessing Exothermic Runaway Risk and the 2004 Preliminary Screening Method. Mathematical methods, thermal analysis methods (e.g., Accelerating Rate Calorimeter (ARC) testing), ASTM E1231-19 Standard Practice for Calculation of Hazard Potential Figures of Merit for Thermally Unstable Materials, Stoessel Criticality, and the O.R.E.O.S. Method (an assessment that combines Oxygen balance calculations, the Rule of 6, and the Explosive functional group list with Onset decomposition and scale) are tools that could be considered for the update. The “Additional Resources” section of the website should also be evaluated for necessary changes and updates.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

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2021-02-I-WV-12

Following the implementation of CSB recommendation 2021-02-I-WV-R11, ensure that the chemical industry is aware of the Chemical Reactivity Hazards website (https://www.osha.gov/chemical-reactivity) by developing and implementing a comprehensive outreach plan that actively targets the chemical industry and related trade associations. The outreach plan may include such means as a national news release and OSHA’s “QuickTakes” newsletter and/or Safety and Health Information Bulletins. This outreach plan should be coordinated with OSHA’s On-Site Consultation Program partners.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

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2021-02-I-WV-13

Amend the Process Safety Management (PSM) Standard, 29 CFR 1910.119, to achieve more comprehensive control of reactive hazards that could have catastrophic consequences.

  • Broaden the application to cover reactive hazards resulting from process-specific conditions and combinations of chemicals. Additionally, broaden coverage of hazards from self-reactive chemicals. In expanding PSM coverage, use objective criteria. Consider criteria such as the North American Industry Classification System (NAICS), a reactive hazard classification system (e.g., based on heat of reaction or hazardous gas evolution), incident history, or catastrophic potential.
  • In the compilation of process safety information, require that multiple sources of information be sufficiently consulted to understand and control potential reactive hazards. Useful sources include but are not limited to:

- Literature surveys (e.g., Bretherick’s Handbook of Reactive Chemical Hazards, Sax’s Dangerous Properties of Industrial Materials, CAS SciFinder).

- Information developed from computerized tools (e.g., ASTM’s CHETAH, CCPS’s Chemical Reactivity Worksheet).

- Chemical property data compiled in PubChem and the REACH (Registration, Evaluation, and Authorization of Chemicals) dossiers maintained by the European Chemicals Agency (ECHA).

- Chemical reactivity test data produced by employers or obtained from other sources following established standards such as:

- ASTM E537-20, Standard Test Method for Chemicals by Differential Scanning Calorimetry;

- ASTM E1981-22, Standard Guide for Assessing Thermal Stability of Materials by Methods of Accelerating Rate Calorimetry;

- ASTM E2550-21, Standard Test Method for Thermal Stability by Thermogravity; and

- ASTM E1231-19, Standard Practice for Calculation of Hazard Potential Figures of Merit for Thermally Unstable Materials.

- Relevant incident data from the plant, the corporation, industry, and government.

  • Augment the process hazard analysis (PHA) element to explicitly require an evaluation of reactive hazards. In revising this element, evaluate the need to consider relevant factors, such as:

- Rate and quantity of heat or gas generated.

- Maximum operating temperature to avoid a runaway reaction from decomposition.

- Time to Maximum Rate under Adiabatic Conditions (TMRad).

- Thermal stability of reactants, reaction mixtures, byproducts, waste streams, and products.

- Effect of variables such as charging rates, catalyst addition, and possible contaminants.

- Understanding the consequences of runaway reactions or hazardous gas evolution.

(Superseded 2001-01-H-XX-R1)


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

PDF Document Recommendation Status Change Summary

Optima Belle LLC (4 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-1

Develop and implement a written thermal and reactive hazards evaluation and management program. The program should adhere to industry guidance provided in publications such as the Center for Chemical Process Safety’s Essential Practices for Managing Chemical Reactivity Hazards. At a minimum, the program should identify the process that Optima Belle will use to manage chemical reactivity hazards, resources for collecting and assessing reactivity hazards, steps for determining how and when to test for chemical reactivity, documentation requirements, and training.


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

2021-02-I-WV-2

Develop and implement a written program for tolling process design and equipment selection using guidance from the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety and Guidelines for Process Safety in Outsourced Manufacturing Operations to ensure that:

a) equipment design basis is adequate for any new tolling process or product;

b) safeguards and ancillary equipment are considered and adequately designed, installed, and function as designed and required; and

c) new processes are evaluated for potential process hazards at the laboratory and/or pilot scale before production scale.

This written program should incorporate the information developed in Optima Belle’s thermal and reactive hazards evaluation program (see CSB recommendation 2021-02-I-WV-R1) to ensure that chemical hazards are fully understood and controlled.

 


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

2021-02-I-WV-3

Develop and implement a formalized program for the development of toll manufacturing agreements using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety. Ensure that the program provides for the following:

a) Identification of roles and responsibilities of all parties, including the client, toller, and any third-party technical service providers, for all phases of a proposed arrangement; 

b) Evaluation of equipment requirements/specifications to ensure that they are adequate for intended operation; and

c) Participation by all parties in the tolling process development, including process hazards analysis and emergency planning, and appropriate stages of the pre-planning, pre-startup, and production phases.


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

2021-02-I-WV-4

Develop and implement a process safety management system consistent with industry guidance publications such as is contained in the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety. At a minimum, the process safety management system should address hazard identification, risk analysis, and management of risk.


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

Richman Chemical Inc. (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-10

Develop and implement a formalized program for the development of toll manufacturing agreements using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety. Ensure that the program provides for the following:

a) Identification of roles and responsibilities of all parties, including the client, toller, and any third-party technical service providers, for all phases of a proposed arrangement; and

b) Participation by all parties in tolling process development, including process hazards analysis and emergency planning, and appropriate stages of the pre-planning, pre-startup, and production phases.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

PDF Document Recommendation Status Change Summary