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

Foundation Food Group Fatal Chemical Release (5 Recommendations)
Occupational Safety and Health Administration (OSHA) (5 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 11, 2023

2021-03-I-GA-4

Update the Region 4 Poultry Processing Facilities Regional Emphasis Program to explicitly cover liquid nitrogen freezing processes. At a minimum, the update should encourage practices applicable to managing the hazards of using liquid nitrogen and other cryogenic asphyxiants, including process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.


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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2021-03-I-GA-5

Update the Region 5 Regional Emphasis Program for Food Manufacturing Industry to explicitly cover liquid nitrogen freezing processes. At a minimum, the update should encourage practices applicable to managing the hazards of using liquid nitrogen and other cryogenic asphyxiants, including process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.


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

2021-03-I-GA-6

Update the Region 6 Poultry Processing Facilities Regional Emphasis Program to explicitly cover liquid nitrogen freezing processes. At a minimum, the update should encourage practices applicable to managing the hazards of using liquid nitrogen and other cryogenic asphyxiants, including process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.


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

2021-03-I-GA-7

Promulgate a standard specific to cryogenic asphyxiants. The purpose of this standard shall be the prevention and/or mitigation of hazards arising from the storage, use, and/or handling of these substances. The new standard shall reference applicable national consensus standards such as those published by the Compressed Gas Association and others, as appropriate. At a minimum the new standard shall:

a) Address requirements for the design, construction, and installation of process equipment storing or using cryogenic asphyxiants;

b) Require atmospheric monitoring where equipment storing or using cryogenic asphyxiants is located indoors;

c) Require emergency shutdown systems such that equipment storing or using cryogenic asphyxiants may be isolated during a release without endangerment;

d) Address requirements for employee training and hazard awareness specific to cryogenic asphyxiants;

e) Require an emergency action plan in accordance with 29 CFR 1910.38; and,

f) Address requirements for the use of process safety management elements such as process hazard analysis, management of change, procedures, and others deemed necessary through the rulemaking process to prevent and/or mitigate these hazards.


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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2021-03-I-GA-8

Develop and publish a Guidance Document (similar to OSHA 3912-03 Process Safety Management for Explosives and Pyrotechnics Manufacturing) for process safety management practices applicable to processes handling compressed gases and cryogenic asphyxiants, including (at a minimum) the practices highlighted in this report.


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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Husky Energy Superior Refinery Explosion and Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 29, 2022

2018-02-I-WI-11

Develop guidance documents for performing process hazard analysis on operating procedures to address transient operation hazards in facilities with Process Safety Management (PSM) covered processes.


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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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 (Texas City) 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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Didion Milling Company Explosion and Fire (3 Recommendations)
Occupational Safety and Health Administration (OSHA) (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 06, 2023

2017-07-I-WI-10

Promulgate a standard for all industries that handle combustible dust, which should be based on the requirements of current NFPA combustible dust standards, including NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, NFPA 484, Standard for Combustible Metals, NFPA 652, Standard on the Fundamentals of Combustible Dust, NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids, NFPA 655, Standard for Prevention of Sulfur Fires and Explosions, NFPA 664, Standard for the Prevention of Fires and Explosions in Wood Processing and Woodworking Facilities, or a successor standard. At a minimum, the standard should include the following elements:

a. Hazard Recognition;

b. Dust Hazard Analysis;

c. Management of Change;

d. Incident Investigation;

e. Engineering Controls;

f. Building Design;

g. Fugitive Dust Management;

h. Operating Procedures;

i. Process Safety Information; 

j. External Audit Management;

k. Training;

l. Emergency Response; and

m. Personal Protective Equipment.

(Superseded the following recommendations: 2006-1-H-R1 from the Combustible Dust Hazard investigation, 2008-05-I-GA-R11 from the Imperial Sugar investigation, and 2011-04-I-TN-R1 and 2011-04-I-TN-R2 from the Hoeganaes Corporation investigation)


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

2017-07-I-WI-11

Following implementation of CSB Recommendation No. 2017-07-I-WI-R10, update the Grain Handling Facilities Standard to clarify grain handling facilities with combustible dust are covered by the new Combustible Dust 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

2017-07-I-WI-12

Develop a program to trigger follow-up inspections when hazard alert letters are issued for combustible dust hazards and there is insufficient evidence to demonstrate that those hazards have been abated.


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

DuPont Belle 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

Intercontinental Terminals Company (ITC) Tank Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 06, 2023

2019-01-I-TX-7

Eliminate the atmospheric storage tank exemption from the PSM standard.

(Superseded 2001-05-I-DE-R1 from the Motiva report and 2010-02-I-PR-R4 from the Caribbean Petroleum (CAPECO) report)


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 Explosion and Fire (3 Recommendations)
Occupational Safety and Health Administration (OSHA) (3 Recommendations)
Open: 100% | Closed: 0%

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.
 

PDF Document Recommendation Status Change Summary

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.
 

PDF Document Recommendation Status Change Summary

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.
 

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Wacker Polysilicon Chemical Release (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 15, 2023

2021-01-I-TN-1

Promulgate a standard or modify existing standards to require employers to ensure the coordination of simultaneous operations (SIMOPs) involving multiple work groups, including contractors. Ensure that the requirements of this standard or standards apply to both general industry and construction activities and are not limited to activities occurring within confined spaces. Include in the standard requirements for Employers to ensure that the following activities occur:

a. Identification of potential SIMOPs;

b. Identification of potential hazardous interactions;

c. Evaluation and implementation of necessary safeguards to allow for safe SIMOPs;

d. Coordination, including shared communication methods, between the SIMOPs; and

e. Inclusion of emergency response personnel or services in the planning and coordination of the SIMOPs.

(Superseded 2020-7-I-NC-R2 from the Evergreen report)


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

2021-01-I-TN-2

Develop a safety product providing guidance on the coordination of simultaneous operations (SIMOPs) involving multiple work groups, including contractors, that is not limited to confined space or construction. Provide guidance on the following activities:

a. Identification of potential SIMOPs;

b. Identification of potential hazardous interactions;

c. Evaluation and implementation of necessary safeguards to allow for safe SIMOPs;

d. Coordination, including shared communication methods, between the SIMOPs; and

e. Inclusion of emergency response personnel or services in the planning and coordination of the SIMOPs.


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

Wendland 1H Well Fatal Explosion (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 26, 2023

2020-04-I-TX-3

Remove the exemption for oil and gas drilling and well servicing from the Control of Hazardous Energy standard (29 CFR 1910.147) and expand its applicability to cover oil and gas production and workover operations.


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

2020-04-I-TX-4

Promulgate a new standard with prescriptive requirements, similar to the Control of Hazardous Energy Standard, as well as a performance-based safety management system framework, similar to the OSHA Process Safety Management (PSM) Standard, that applies to the drilling, production, and servicing/workover activities surrounding onshore oil and gas wells. At a minimum, this standard should include the following:

1. Prescriptively address requirements for primary and secondary barriers for well control;

2. Detailed written drilling, production, and servicing procedures with specified steps and equipment alignment for all operations;

3. Management of change requirements (except replacements in kind) that, at a minimum, address procedures, the well plan, and equipment;

4. A risk assessment of hazards associated with the drilling, production, and servicing/workover plans;

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

6. Development of a Well Construction Interface Document between the operator and the drilling contractor prior to the commencement of drilling and servicing activities and an equivalent document for production and workover contractors which, at a minimum, includes a bridging document and well plans specifying barriers and how to manage them;

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

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

9. A requirement for maintaining critical well information, similar to the Process Safety Information requirement in the OSHA PSM standard, which at a minimum includes well history and documented well control methods during workovers;

10. A requirement for analyzing and assessing the hazards during all phases and steps for well servicing, similar to the Process Hazard Analysis requirement in the OSHA PSM standard;

11. A requirement for developing, executing, communicating, and maintaining procedures for drilling, production, and servicing operations on a well, similar to the Operating Procedures requirement in the OSHA PSM standard; and

12. The documentation of well control plans for drilling, production, and servicing/workover operations for a well utilizing acceptable methods for monitoring the effectiveness of well control methods.


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

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.