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.
2024-06-I-KY-12
Alert association members who manufacture corn syrup of the November 12, 2024, Givaudan incident and its causes, including but not limited to the sugar ingredient decomposition reaction that led to Reactor 6’s rupture. Request that they update their corn syrup safety data sheets to include: the decomposition temperature, the consequences of exceeding that temperature, and the decomposition products produced (for example, carbon dioxide). Status: Open - Awaiting Response or Evaluation/Approval of Response
Alert association members who manufacture corn syrup of the November 12, 2024, Givaudan incident and its causes, including but not limited to the sugar ingredient decomposition reaction that led to Reactor 6’s rupture. Request that they update their corn syrup safety data sheets to include: the decomposition temperature, the consequences of exceeding that temperature, and the decomposition products produced (for example, carbon dioxide).
2024-06-I-KY-8
Create and fill a corporate senior leadership position responsible for overseeing process safety at all Givaudan caramel coloring facilities or identify a current senior leader who is competent in process safety management concepts to fill this role. Establish this senior leader’s job duties to oversee the process safety management system implementation at all Givaudan caramel coloring facilities. Assign this individual to develop corporate-level process safety management system policies to ensure consistent development and implementation of process safety management systems at all Givaudan caramel coloring facilities. One of the policies will address training operations personnel on defined safe operating limits and actions to take if those limits are exceeded. Status: Open - Awaiting Response or Evaluation/Approval of Response
Create and fill a corporate senior leadership position responsible for overseeing process safety at all Givaudan caramel coloring facilities or identify a current senior leader who is competent in process safety management concepts to fill this role. Establish this senior leader’s job duties to oversee the process safety management system implementation at all Givaudan caramel coloring facilities. Assign this individual to develop corporate-level process safety management system policies to ensure consistent development and implementation of process safety management systems at all Givaudan caramel coloring facilities. One of the policies will address training operations personnel on defined safe operating limits and actions to take if those limits are exceeded.
2024-06-I-KY-1
Contract a third party to analyze the reactivity of the sugar ingredients in the caramel coloring product manufacturing process by, at a minimum: a. Conducting calorimetry testing on at least one representative recipe for all caramel coloring product types to determine their temperature and pressure behavior upon heating. b. Testing the composition of any produced non-condensable gases. Maintain this information for use during future equipment design efforts and hazard analyses. Status: Open - Awaiting Response or Evaluation/Approval of Response
Contract a third party to analyze the reactivity of the sugar ingredients in the caramel coloring product manufacturing process by, at a minimum:
a. Conducting calorimetry testing on at least one representative recipe for all caramel coloring product types to determine their temperature and pressure behavior upon heating.
b. Testing the composition of any produced non-condensable gases.
Maintain this information for use during future equipment design efforts and hazard analyses.
2024-06-I-KY-2
Contract a third party to conduct a hazard analysis of each caramel coloring facility. Require this analysis to address reactivity hazards and include a review of the reactivity data obtained from implementing CSB Recommendation 2024-06-I-KY-R1. Implement the recommendations issued by the third party as a result of the hazard analyses. Status: Open - Awaiting Response or Evaluation/Approval of Response
Contract a third party to conduct a hazard analysis of each caramel coloring facility. Require this analysis to address reactivity hazards and include a review of the reactivity data obtained from implementing CSB Recommendation 2024-06-I-KY-R1. Implement the recommendations issued by the third party as a result of the hazard analyses.
2024-06-I-KY-3
Contract a third party to develop a process safety management system to be used at each caramel coloring facility. This third party shall: a. Ensure the process safety management system is in alignment with current industry guidance such as the CCPS’s Guidelines for Risk Based Process Safety. b. Ensure that the process safety management system requires hazard reviews/analyses to be conducted at prescribed intervals and include: (1) the review/incorporation of reactivity data from CSB Recommendation 2024-06-I-KY-R1 and any additional reactivity data obtained during the course of operating any caramel coloring facility, (2) the review/analysis of any process changes that could affect relief system designs, and (3) the review/updating of the facility siting study from CSB Recommendation 2024-06-I-KY-R7, as appropriate. Status: Open - Awaiting Response or Evaluation/Approval of Response
Contract a third party to develop a process safety management system to be used at each caramel coloring facility. This third party shall:
a. Ensure the process safety management system is in alignment with current industry guidance such as the CCPS’s Guidelines for Risk Based Process Safety.
b. Ensure that the process safety management system requires hazard reviews/analyses to be conducted at prescribed intervals and include:
(1) the review/incorporation of reactivity data from CSB Recommendation 2024-06-I-KY-R1 and any additional reactivity data obtained during the course of operating any caramel coloring facility,
(2) the review/analysis of any process changes that could affect relief system designs, and
(3) the review/updating of the facility siting study from CSB Recommendation 2024-06-I-KY-R7, as appropriate.
2024-06-I-KY-4
At each caramel coloring facility, hire a new or identify a current employee who is competent in process safety management concepts. Establish this employee’s job duties to specifically include overseeing the caramel coloring facility’s process safety management system established in 2024-06-I-KY-R3, its implementation, and personnel training on the system’s elements. Status: Open - Awaiting Response or Evaluation/Approval of Response
At each caramel coloring facility, hire a new or identify a current employee who is competent in process safety management concepts. Establish this employee’s job duties to specifically include overseeing the caramel coloring facility’s process safety management system established in 2024-06-I-KY-R3, its implementation, and personnel training on the system’s elements.
2024-06-I-KY-5
For each caramel coloring facility, contract a third party to design adequate emergency pressure relief systems for the vessels involved in caramel coloring manufacturing. Ensure the third party reviews/incorporates all reactivity data obtained from the testing required by CSB Recommendation 2024-06-I-KY-R1 when designing the emergency pressure relief systems. Document and maintain each vessel’s relief system design basis for the service life of the vessel. Status: Open - Awaiting Response or Evaluation/Approval of Response
For each caramel coloring facility, contract a third party to design adequate emergency pressure relief systems for the vessels involved in caramel coloring manufacturing. Ensure the third party reviews/incorporates all reactivity data obtained from the testing required by CSB Recommendation 2024-06-I-KY-R1 when designing the emergency pressure relief systems. Document and maintain each vessel’s relief system design basis for the service life of the vessel.
2024-06-I-KY-6
For each caramel coloring facility, establish automatic alerts, such as alarms or control screen indications, to notify operators when a safe operating limit has been reached. Follow industry guidance, such as the guidance presented in the Center for Chemical Process Safety Book Guidelines for Engineering Design for Process Safety (2nd Edition), Chapter 5 General Design. Provide initial and refresher training for operations personnel on the established safe operating limits including the actions to take if these limits are exceeded. Status: Open - Awaiting Response or Evaluation/Approval of Response
For each caramel coloring facility, establish automatic alerts, such as alarms or control screen indications, to notify operators when a safe operating limit has been reached. Follow industry guidance, such as the guidance presented in the Center for Chemical Process Safety Book Guidelines for Engineering Design for Process Safety (2nd Edition), Chapter 5 General Design. Provide initial and refresher training for operations personnel on the established safe operating limits including the actions to take if these limits are exceeded.
2024-06-I-KY-7
Contract a third party to conduct a facility siting study before constructing caramel coloring facility(ies) to help protect facility occupants and critical equipment from hazards created by explosion, fire, or toxic material release, using published industry guidance, such as that in the Center for Chemical Process Safety book, Guidelines for Siting and Layout of Facilities. Status: Open - Awaiting Response or Evaluation/Approval of Response
Contract a third party to conduct a facility siting study before constructing caramel coloring facility(ies) to help protect facility occupants and critical equipment from hazards created by explosion, fire, or toxic material release, using published industry guidance, such as that in the Center for Chemical Process Safety book, Guidelines for Siting and Layout of Facilities.
2024-06-I-KY-11
Update all invert sugar safety data sheets to include: the decomposition temperature, the consequences of exceeding that temperature, and the decomposition products produced (for example, carbon dioxide). Status: Open - Awaiting Response or Evaluation/Approval of Response
Update all invert sugar safety data sheets to include: the decomposition temperature, the consequences of exceeding that temperature, and the decomposition products produced (for example, carbon dioxide).
2024-06-I-KY-9
Publish a technical safety bulletin for caramel coloring manufacturing that encourages caramel color manufacturers to ensure known hazards, including sugar ingredient decomposition, are addressed. Emphasize the importance of obtaining information on calorimetric properties of sugar ingredients and ensuring appropriately sized emergency pressure relief systems to safely vent pressure and gases that could be produced by sugar ingredient decomposition reactions, as well as other overpressure scenarios identified in hazard analyses. Refer caramel color manufacturers to the CSB’s investigation report for additional details. Recommend in the technical safety bulletin that caramel coloring manufacturers implement, as appropriate, process safety management systems that are in alignment with local requirements and chemical industry good practice guidance, such as the Center for Chemical Process Safety Guidelines for Risk Based Process Safety, Essential Practices for Managing Chemical Reactivity Hazards, and Guidelines for Implementing Process Safety Management. Status: Open - Awaiting Response or Evaluation/Approval of Response
Publish a technical safety bulletin for caramel coloring manufacturing that encourages caramel color manufacturers to ensure known hazards, including sugar ingredient decomposition, are addressed. Emphasize the importance of obtaining information on calorimetric properties of sugar ingredients and ensuring appropriately sized emergency pressure relief systems to safely vent pressure and gases that could be produced by sugar ingredient decomposition reactions, as well as other overpressure scenarios identified in hazard analyses. Refer caramel color manufacturers to the CSB’s investigation report for additional details. Recommend in the technical safety bulletin that caramel coloring manufacturers implement, as appropriate, process safety management systems that are in alignment with local requirements and chemical industry good practice guidance, such as the Center for Chemical Process Safety Guidelines for Risk Based Process Safety, Essential Practices for Managing Chemical Reactivity Hazards, and Guidelines for Implementing Process Safety Management.
2024-06-I-KY-10
Alert association members that manufacture caramel coloring of the November 12, 2024, Givaudan incident and its causes, including but not limited to the sugar ingredient decomposition reaction that led to Reactor 6’s rupture. Status: Open - Awaiting Response or Evaluation/Approval of Response
Alert association members that manufacture caramel coloring of the November 12, 2024, Givaudan incident and its causes, including but not limited to the sugar ingredient decomposition reaction that led to Reactor 6’s rupture.