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.
2024-03-I-VA-3
Reduce the likelihood or mitigate the consequences of liquid or two-phase atmospheric discharges from the ammonia refrigeration emergency pressure relief system at the Sterling plant. At a minimum: a. Identify liquid or two-phase release scenarios, particularly for horizontal surge drums and other vessels containing saturated liquid with little vapor space; b. Implement engineering controls to reduce the likelihood of high liquid level, overfill, or boiling overpressure scenarios; c. Implement engineering controls to mitigate the consequences of these scenarios where their likelihood cannot be acceptably reduced, such as through emergency pressure control systems, atmospheric knockout drums, or automatic shutdown systems; and d. Contract a competent third party to audit the pressure relief systems. The audit should ensure that (i) all relevant relief scenarios have been identified, (ii) preventive and mitigative engineering controls adequately address the hazards, and (iii) engineering controls are maintained in such a way that they function properly when required. Status: Open - Awaiting Response or Evaluation/Approval of Response
Reduce the likelihood or mitigate the consequences of liquid or two-phase atmospheric discharges from the ammonia refrigeration emergency pressure relief system at the Sterling plant. At a minimum:
a. Identify liquid or two-phase release scenarios, particularly for horizontal surge drums and other vessels containing saturated liquid with little vapor space;
b. Implement engineering controls to reduce the likelihood of high liquid level, overfill, or boiling overpressure scenarios;
c. Implement engineering controls to mitigate the consequences of these scenarios where their likelihood cannot be acceptably reduced, such as through emergency pressure control systems, atmospheric knockout drums, or automatic shutdown systems; and
d. Contract a competent third party to audit the pressure relief systems. The audit should ensure that (i) all relevant relief scenarios have been identified, (ii) preventive and mitigative engineering controls adequately address the hazards, and (iii) engineering controls are maintained in such a way that they function properly when required.
2024-03-I-VA-4
Implement an electronic process data historian and management system to ensure that critical process parameters are collected, tracked, and stored. The system should be available to refrigeration technicians so that they can monitor the refrigeration system and respond to and investigate process upsets. Status: Open - Awaiting Response or Evaluation/Approval of Response
Implement an electronic process data historian and management system to ensure that critical process parameters are collected, tracked, and stored. The system should be available to refrigeration technicians so that they can monitor the refrigeration system and respond to and investigate process upsets.
2024-03-I-VA-5
Update the Cuisine Solutions Sterling site’s Emergency Action Plan using guidance such as the IIAR’s Critical Task Guidance for Ammonia Refrigeration System Emergency Planning. At a minimum, the updated plan should: a. Address indoor and outdoor ammonia releases separately, including the distinct alarms and responses to them; b. Clearly specify appropriate evacuation routes and muster points, including alternates; c. Provide guidance for using windsocks to remain upwind of a release during evacuation; d. Implement shelter-in-place strategies, emergency protective equipment, and emergency shutdowns, as appropriate; and e. Include requirements to conduct annual ammonia release drills that include all onsite personnel (including corporate employees). The annual drills should include separate indoor and outdoor ammonia release scenarios and address the use of windsocks to assist with determining evacuation routes, alternate evacuation routes, muster points, and consideration for the decision to shelter-in-place. Additionally, the drills should exercise each evacuation alarm, emergency protective equipment, and emergency shutdowns, where appropriate. Status: Open - Awaiting Response or Evaluation/Approval of Response
Update the Cuisine Solutions Sterling site’s Emergency Action Plan using guidance such as the IIAR’s Critical Task Guidance for Ammonia Refrigeration System Emergency Planning. At a minimum, the updated plan should:
a. Address indoor and outdoor ammonia releases separately, including the distinct alarms and responses to them;
b. Clearly specify appropriate evacuation routes and muster points, including alternates;
c. Provide guidance for using windsocks to remain upwind of a release during evacuation;
d. Implement shelter-in-place strategies, emergency protective equipment, and emergency shutdowns, as appropriate; and
e. Include requirements to conduct annual ammonia release drills that include all onsite personnel (including corporate employees). The annual drills should include separate indoor and outdoor ammonia release scenarios and address the use of windsocks to assist with determining evacuation routes, alternate evacuation routes, muster points, and consideration for the decision to shelter-in-place. Additionally, the drills should exercise each evacuation alarm, emergency protective equipment, and emergency shutdowns, where appropriate.
2024-03-I-VA-6
Add an alarm or alarms specific to ammonia releases, so that workers can properly respond to a release. The alarm response should be documented in the updated Emergency Action Plan, and may include multiple distinct alarms and responses, such as one for shelter-in-place and one for evacuation. Status: Open - Awaiting Response or Evaluation/Approval of Response
Add an alarm or alarms specific to ammonia releases, so that workers can properly respond to a release. The alarm response should be documented in the updated Emergency Action Plan, and may include multiple distinct alarms and responses, such as one for shelter-in-place and one for evacuation.
2024-03-I-VA-1
Update ANSI/IIAR 2 to include guidance for preventing or mitigating liquid or two-phase atmospheric discharges from emergency pressure relief systems, such as the guidance in API Standard 521, Pressure-relieving and Depressuring Systems. At a minimum, the guidance should: a. Identify at-risk scenarios such as horizontal surge vessels and other vessels containing saturated liquid with little vapor space; b. Address design considerations and controls to reduce the likelihood of identified scenarios leading to overpressure or equipment failure and ensure vapor-liquid disengagement (the separation of vapor from liquid) during pressure relief for identified scenarios; and c. Require mitigative safeguards in cases where vapor-liquid disengagement during pressure relief cannot be reliably ensured. This should also include alternative disposal systems where applicable. Status: Open - Awaiting Response or Evaluation/Approval of Response
Update ANSI/IIAR 2 to include guidance for preventing or mitigating liquid or two-phase atmospheric discharges from emergency pressure relief systems, such as the guidance in API Standard 521, Pressure-relieving and Depressuring Systems. At a minimum, the guidance should:
a. Identify at-risk scenarios such as horizontal surge vessels and other vessels containing saturated liquid with little vapor space;
b. Address design considerations and controls to reduce the likelihood of identified scenarios leading to overpressure or equipment failure and ensure vapor-liquid disengagement (the separation of vapor from liquid) during pressure relief for identified scenarios; and
c. Require mitigative safeguards in cases where vapor-liquid disengagement during pressure relief cannot be reliably ensured. This should also include alternative disposal systems where applicable.
2024-03-I-VA-2
Update ANSI/IIAR 2 to include a requirement to assess whether emergency pressure relief devices discharge to a safe location, such as with a dispersion analysis. Status: Open - Awaiting Response or Evaluation/Approval of Response
Update ANSI/IIAR 2 to include a requirement to assess whether emergency pressure relief devices discharge to a safe location, such as with a dispersion analysis.