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

Sierra Chemical Co. High Explosives Accident (16 Recommendations)
Department of Defense (DOD) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 23, 1998

1998-001-I-NV-15

Develop a program to ensure that reclaimed, demilitarized explosives sold by the Department of Defense are free of foreign materials that can present hazards during subsequent manufacturing of explosives.


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.
 

1998-001-I-NV-16

Provide access to explosives incident reports and lessons learned information to managers and workers involved in explosives manufacturing, associations such as IME, government agencies, and safety researchers.


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.
 

Institute of Makers of Explosives (IME) (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 23, 1998

1998-001-I-NV-11

Develop and disseminate process and safety training guidelines for personnel involved in the manufacture of explosives that include methods for the demonstration and maintenance of proficiency.


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.
 

1998-001-I-NV-12

Distribute the CSB report on the incident at Sierra to IME member companies.


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.
 

1998-001-I-NV-13

Develop safety guidelines for the screening of reclaimed explosive materials.


Status: Closed - Exceeds Recommended Action
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

Nevada Occupational Safety and Health Enforcement Section (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 23, 1998

1998-001-I-NV-14

Increase the frequency of safety inspections of explosives manufacturing facilities due to their potential for catastrophic incidents. (Note: Nevada Governor Bob Miller signed an Executive Order on June 10, 1998, that will require inspections at least twice a year.)


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.
 

Sierra and Explosives Manufacturers (10 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 23, 1998

1998-001-I-NV-1

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - Process hazard analyses include examination of quantity-distance requirements, building, design, human factors, incident reports, and lessons learned from explosives manufacturers.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

1998-001-I-NV-2

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - Written operating procedures are specific to the process being controlled and address all phases of the operation.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

1998-001-I-NV-3

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - Procedures, chemical hazards, and process safety information are communicated in the language(s) understood by personnel involved in manufacturing or handling of explosives.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

1998-001-I-NV-4

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: Explosives training and certification programs for workers and line managers provide and require demonstration of a basic understanding of explosives safety principles and job specific knowledge.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

1998-001-I-NV-5

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - Process changes, such as the construction or modification of buildings, or changes in explosive ingredients, equipment, or procedures are analyzed and PSM elements are updated to address these changes.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

1998-001-I-NV-6

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - Pre-startup safety reviews are performed to verify operational readiness when changes are made.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

1998-001-I-NV-7

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - All elements of OSHA's Process Safety Management Standard are verified by performing periodic assessments and audits of safety programs.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

1998-001-I-NV-8

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - The employee participation program effectively includes workers and resolves their safety issues.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

1998-001-I-NV-9

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - Explosives safety programs provide an understanding of the hazards and control of detonation sources. These include: · foreign objects in raw materials; · use of substitute raw materials; · specific handling requirements for raw materials; · impact by tools or equipment; · impingement; · friction; · sparking; and · static discharge.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

1998-001-I-NV-10

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - The following issues are addressed in plant design or modification: · Operations in explosives manufacturing plants are separated by adequate intraplant distances to reduce the risk of propagation. · Unrelated chemical or industrial operations or facilities are separated from explosives facilities using quantity-distance guidelines. · Facilities are designed to reduce secondary fragmentation that could result in the propagation of explosions.


Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

Sonat Exploration Co. Catastrophic Vessel Overpressurization (5 Recommendations)
American Petroleum Institute (API) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 21, 2000

1998-002-I-LA-4

Develop and issue recommended practice guidelines governing the safe start-up and operation of oil and gas production facilities. Ensure that the guidelines address, at a minimum, the following: project design review processes, including hazard analyses; written operating procedures; employee and contractor training; and pressure-relief requirements for all equipment exposed to pressure hazards.


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.
 

1998-002-I-LA-5

Communicate the findings of this report to your membership.


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.
 

El Paso Production Company (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 21, 2000

1998-002-I-LA-1

Institute a formal engineering design review process for all oil and gas production facilities,following good engineering practices and including analyses of process hazards.


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.
 

1998-002-I-LA-2

Implement a program to ensure that all oil and gas production equipment that is potentially subject to overpressurization is equipped with adequate pressure-relief systems, and audit compliance with the program.


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.
 

1998-002-I-LA-3

Develop written operating procedures for oil and gas production facilities and implement programs to ensure that all workers, including contract employees, are trained in the use of the procedures. Ensure the procedures address, at a minimum, purging and start-up operations and provide information on process-related hazards.


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.
 

Sterigenics Ethylene Oxide Explosion (17 Recommendations)
California Air Resources Board (CARB) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 30, 2006

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

California Occupational Safety and Health Administration (Cal/OSHA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 30, 2006

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
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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Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 30, 2006

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Ethylene Oxide Sterilization Association (EOSA) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 30, 2006

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Institute of Clean Air Companies (ICAC) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 30, 2006

2004-11-I-CA-17

Communicate the findings and recommendations of this report to your membership.


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.
 

National Fire Protection Association (NFPA) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 30, 2006

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.


    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.
     

    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.


    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.
     

National Institute for Occupational Safety and Health (NIOSH) (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 30, 2006

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Sterigenics International (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 30, 2006

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Sterigenics International - Ontario Facility (5 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 30, 2006

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.