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 (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 20, 2011

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

Evergreen Packaging Paper Mill - Fire During Hot Work (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 24, 2021

2020-07-I-NC-1

Issue a safety information product (such as a letter of interpretation) addressing the analysis and control of hazards that are not pre-existing but which result from work activities inside permit-required confined spaces. 


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

2020-07-I-NC-2

Require Owner/Operators to ensure the coordination of simultaneous operations involving multiple work groups, including contractors. Include in the requirement for Owner/Operators to ensure the following activities occur:

• Identification of potential simultaneous operations

• Identification of potential hazardous interactions

• Evaluation and implementation of necessary safeguards to allow for safe simultaneous operations

• Coordination, including shared communication methods, between the simultaneous operations

• Inclusion of emergency response personnel or services in the planning and coordination of the simultaneous operations.

As necessary, seek the regulatory authority to promulgate this requirement.


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

Pryor Trust Fatal Gas Well Blowout and Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 12, 2019

2018-01-I-OK-1

Implement one of the three following options regarding regulatory changes:

(a) OPTION 1: Apply the Process Safety Management (PSM) standard (29 CFR 1910.119) to the drilling of oil and gas wells; or

(b) OPTION 2: Apply the Process Safety Management (PSM) standard (29 CFR 1910.119) to the drilling of oil and gas wells as in OPTION 1, and make the necessary modifications to customize it to oil and gas drilling operations; or

(c) OPTION 3: Develop a new standard with a safety management system framework similar to PSM that applies only to the drilling of onshore oil and gas wells that includes but is not limited to the following:

  1. Detailed written operating procedures with specified steps and equipment alignment for all operations;

  2. Written procedures for the management of changes (except replacements in kind) in procedures, the well plan, and equipment;

  3. A risk assessment of hazards associated with the drilling plan;

  4. A requirement to follow Recognized and Generally Accepted Good Engineering Practices (RAGAGEP);

  5. Development of a Well Construction Interface Document between the operator and the drilling contractor prior to the commencement of drilling activities which at a minimum includes a bridging document and well plan specifying barriers and how to manage them;

  6. The performance and documentation of flow checks using acceptable methods at defined points during the operation for a specified duration; and

  7. A requirement for employee participation, similar to the Employee Participation requirement in the OSHA PSM standard.


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

Aghorn Operating Waterflood Station Hydrogen Sulfide Release (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 21, 2021

2020-01-I-TX-8

Issue a safety information product (such as a safety bulletin or safety alert) that addresses the requirements for protecting workers from hazardous air contaminants and from hazardous energy.


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

Barton Solvents Explosions and Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 26, 2008

2007-6-I-KS-1

Revise the "Guidance for Hazard Determination for compliance with the OSHA Hazard Communication Standard" to advise chemical manufacturers and importers that prepare MSDSs to: -Evaluate flammable liquids to determine their potential to accumulate static electricity and form ignitable vapor-air mixtures in storage tanks. -Test the conductivity of the flammable liquid and include the testing results in the MSDS.


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.
 

BP America Refinery Explosion (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: March 20, 2007

2005-4-I-TX-9

2. Amend the OSHA PSM standard to require that a management of change (MOC) review be conducted for organizational changes that may impact process safety including: a. major organizational changes such as mergers, acquisitions, or reorganizations; b. personnel changes, including changes in staffing levels or staff experience; and c. policy changes such as budget cutting.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

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Caribbean Petroleum Refining Tank Explosion and Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: October 21, 2015

2010-02-I-PR-4

a) Revise the Flammable and Combustible Liquids standard (29 CFR§ 1910.106) to require installing, using, and maintaining a high-integrity automatic overfill prevention system with a means of level detection, logic/control equipment, and independent means of flow control for bulk aboveground storage tanks containing gasoline, jet fuel, other fuel mixtures or blends tocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher, to protect against loss of containment. At a minimum, this system
shall meet the following requirements:
1. Separated physically and electronically and independent from the tank gauging system.
2. Engineered, operated, and maintained to achieve an appropriate level of safety integrity in accordance with the rrequirements of Part 1 of International Electro-technical Commission (IEC) 61511-SER ed1.0B-2004, Functional Safety - Safety Instrumented Systems for the Process Industry Sector. Such a system would employ a safety integrity level (SIL) documented in accordance with the principles in Part 3 of IEC 61511-SER ed1.0B-2004, accounting for the following factors:
i. The existence of nearby populations and sensitive environments;
ii. The nature and intensity of facility operations;
iv. The extent/ rigor of operator monitoring.
3. Proof tested in accordance with the validated arrangements and procedures with sufficient frequency to ensure the specified safety integrity level is maintained.
b) Establish hazard analysis, management of change and mechanical integrity management system elements for bulk above ground storage tanks in the revised 1910.106 standard that are similar to those in the Process Safety Management of Highly Hazardous Chemicals standard (29 CFR § 1910.119) and ensure these facilities are subject to Recognized and Generally Accepted Good Engineering Practices (RAGAGEP).

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.
 

Combustible Dust Hazard Investigation (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: November 09, 2006

2006-1-H-1

Issue a standard designed to prevent combustible dust fires and explosions in general industry. Base the standard on current National Fire Protection Association (NFPA) dust explosion standards (including NFPA 654 and NFPA 484), and include at least - hazard assessment, - engineering controls, - housekeeping, - building design, - explosion protection, - operating procedures, and - worker training.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Download

Hoeganaes Corporation Fatal Flash Fires (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 05, 2012

2011-4-I-TN-1

Ensure that the forthcoming OSHA Combustible Dust Standard includes coverage for combustible metal dusts including iron and steel powders.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Download

Improving Reactive Hazard Management (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 17, 2002

2001-01-H-1

Amend the Process Safety Management Standard (PSM), 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 toxic 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: - Literature surveys (e.g., Bretherick's Handbook of Reactive Chemical Hazards, Sax's Dangerous Properties of Industrial Materials). - Information developed from computerized tools (e.g., ASTM's CHETAH, NOAA's The Chemical Reactivity Worksheet). - Chemical reactivity test data produced by employers or obtained from other sources (e.g., differential scanning calorimetry, thermogravimetric analysis, accelerating rate calorimetry). - Relevant incident reports from the plant, the corporation, industry, and government. - Chemical Abstracts Service. · 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 decomposition. - 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 toxic gas evolution.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

Motiva Enterprises Sulfuric Acid Tank Explosion (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: August 28, 2002

2001-05-I-DE-1

Ensure coverage under the Process Safety Management Standard (29 CFR 1910.119) of atmospheric storage tanks that could be involved in a potential catastrophic release as a result of being interconnected to a covered process with 10,000 pounds of a flammable substance.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Download

US Ink Fire (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 15, 2015

2013-01-I-NJ-1

Add North American Industry Classification System (NAICS) Code 325910, Printing Ink Manufacturing, to the list of industries in Appendix D-1 or Appendix D-2 of Combustible Dust National Emphasis Program (NEP), Directive CPL 03-00-008.


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.
 

2013-01-I-NJ-2

Communicate with all OSHA Area Offices to encourage appropriate application of the following existing provisions of the Combustible Dust NEP, Directive CPL 03-00-008:

  • Paragraph IX, Section A2, indicates that area offices may add to their Combustible Dust NEP establishment lists those facilities in their jurisdictions with a Standard Industrial Classification System code, NAICS code, or both (other than those listed in Appendices D-1 and D-2 of the Combustible Dust NEP directive) if those facilities have a known pattern of combustible dust hazards.
  • Paragraph IX, Section B4, indicates that if a fatality or catastrophe investigation is performed at a facility because of a combustible dust deflagration or explosion, the inspector shall use the guidelines in Fatality/Catastrophe Investigation Procedures, Directive CPL 02-00-137, and in the Combustible Dust NEP, Directive CPL 03-00-008.

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.
 

West Fertilizer Explosion and Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2016

2013-02-I-TX-5

Implement one of the following two regulatory changes, either option (a) or (b) below, to address

FGAN hazards:
a. Add FGAN to the OSHA Process Safety Management (PSM) standard List of Highly Hazardous Chemicals, Toxics and Reactives in 29 CFR 1910.119, Appendix A, and establish an appropriate threshold quantity.  Identify National Fire Protection Association (NFPA) 400 as a source of Recognized and Generally Accepted Good Engineering Practices (RAGAGEP) for PSM-covered FGAN equipment and processes.
b. Revise the OSHA Explosives and Blasting Agents standard, 29 CFR 1910.109, to ensure that the title, scope, or both make(s) clear that the standard applies to facilities that store bulk quantities of FGAN.  Revise 1910.109(i), “Storage of Ammonium Nitrate,” to include requirements similar to those in NFPA 400, Hazardous Materials Code (2016

Edition), Chapter 11.  Ensure the following elements are considered:
i. For new construction, prohibit combustible materials of construction for FGAN facilities and FGAN bins. For existing facilities, establish a phase-in requirement for the replacement of wooden bins with bins made of noncombustible materials of construction within a reasonable time period (e.g., 3 to 5 years from the date standard revisions are enacted), based on feedback from the fertilizer industry.

ii. Require automatic fire sprinkler systems and fire detection systems for indoor FGAN storage areas.

iii. Define adequate ventilation for FGAN for indoor storage areas.

iv. Require all FGAN storage areas to be isolated from the storage of combustible, flammable, and other contaminating materials.

v. Establish separation distances between FGAN storage areas and other hazardous chemicals, processes, and facility boundaries.


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.
 

Xcel Energy Company Hydroelectric Tunnel Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: August 25, 2010

2008-01-I-CO-2

Publish a “Safety and Health Information Bulletin” addressing the hazards and controls when using flammable materials in confined spaces that includes actionable guidance regarding:
 
a. The importance of implementing a hierarchy of controls to address hazards in a confined space that first seeks to eliminate hazards or substitute with a less hazardous material(s) or method(s). Examples include performing work outside of a confined space where reasonably practicable or substituting a flammable material with a non-flammable one.

b. The necessity of establishing a maximum permissible percentage substantially below the lower explosive limit (LEL) for safe entry and occupancy of permit required confined spaces.

c. The need to comprehensively control all potential ignition sources and continuously monitor the confined space at appropriate locations and elevations when work activities involve the use of flammable materials or where flammable atmospheres may be created.

d. The importance of treating confined spaces with the potential for flammable atmospheres above 10 percent of the LEL as a hazard immediately dangerous to life or health (IDLH) that requires rescuers to be stationed directly outside the permit space and available for immediate rescue with appropriate fire-extinguishing and rescue equipment.

e. The requirement that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Such spaces need to be monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working.


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.