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.


Quick Search

 
Recommendations Status:
 
 
Expand All

Recommendations

Aghorn Operating Waterflood Station Hydrogen Sulfide Release (9 Recommendations)
Aghorn Operating Inc. (7 Recommendations)
Open: 71% | Closed: 29%

Final Report Released On: May 21, 2021

2020-01-I-TX-1

For all waterflood stations where the potential exists to expose workers or non-employees to H2S concentrations at or above 10 ppm, mandate the use of personal H2S detection devices as an integral part of every employee or visitor personal protective equipment (PPE) kit prior to entering the vicinity of the facility. Ensure detector use is in accordance with manufacturer specifications.


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.
 

PDF Document Recommendation Status Change Summary

2020-01-I-TX-2

For all Aghorn facilities, develop a site-specific, formalized and comprehensive Lockout / Tagout program, to include policies, procedures, and training, to protect workers from energized equipment hazards, such as exposure to H2S. Ensure the program meets the requirements outlined in 29 CFR 1910.147 and includes energy control procedures, training, and periodic 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.
 

PDF Document Recommendation Status Change Summary

2020-01-I-TX-3

For all waterflood stations where the potential exists to expose workers to H2S concentrations at or above 10 ppm, commission an independent and comprehensive analysis of each facility design vis-à-vis ventilation and mitigation systems to ensure that, in the event of an accidental release, workers are protected from exposure to toxic gas levels.


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

2020-01-I-TX-4

For all waterflood stations where the potential exists to expose workers or non-employees to H2S concentrations at or above 10 ppm, develop and demonstrate the use of a safety management program that includes a focus on protecting workers and non-employees from H2S. This program should include risk identification, assessment, mitigation, and monitoring of design, procedures, maintenance and training related to H2S. This program must be in compliance with 29 CFR 1910.1000 – Air Contaminants and 29 CFR 1910.147 – The Control of Hazardous Energy (Lockout / Tagout).


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

2020-01-I-TX-5

For all waterflood stations where the potential exists to expose workers to H2S concentrations at or above 10 ppm, ensure the H2S detection and alarm systems are properly maintained and configured, and develop site-specific detection and alarm programs and associated procedures based on manufacturer specifications, current codes, standards, and industry good practice guidance. The program must address installation, calibration, inspection, maintenance, training and routine 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

2020-01-I-TX-6

For all waterflood stations where the potential exists to expose workers or non-employees within the perimeter of the facility to H2S concentrations at or above 10 ppm, ensure that the H2S detection and alarm system designs employ multiple layers of alerts unique to H2S, such as with the use of both audible and visual mediums, so that workers and non-employees within the perimeter of the facility would be alerted to a significant release. The system design must meet manufacturer specifications, current codes, standards, and industry good practice guidance.


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

2020-01-I-TX-7

For all waterflood stations where the potential exists to expose non-employees to H2S concentrations at or above 10 ppm, develop and implement a formal, written, site-specific security program to prevent unknown and unplanned entrance of those not employed by Aghorn, starting with a requirement for employees to lock access gates upon entering and departing the facility.


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

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

Texas Railroad Commission (RRC) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 21, 2021

2020-01-I-TX-9

Develop and send a Notice to Operators to all oil and gas operators that fall under the jurisdiction of the Railroad Commission of Texas that describes the safety issues described in this report, including: 1. Nonuse of Personal H2S Detector 2. Nonperformance of Lockout / Tagout 3. Confinement of H2S Inside Pump House 4. Lack of Safety Management Program 5. Nonfunctioning H2S Detection and Alarm System 6. Deficient Site Security


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

Evergreen Packaging Paper Mill - Fire During Hot Work (8 Recommendations)
Evergreen Packaging (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 24, 2021

2020-07-I-NC-3

Update all documentation, training, and orientation materials provided to contractors pertaining to hot work to reflect Evergreen Packaging’s internal definition of hot work. The materials should make clear that hot work encompasses any method of work that can serve as a source of ignition.


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-4

Develop and implement a formalized and comprehensive Simultaneous Operations (SIMOPs) program addressing planned work occurring close together in time and place to include policies, procedures, hazards reviews, hazards abatement, training, and shared communication methods, to protect employees and contract workers from the hazards posed by simultaneous operations at its facilities. At a minimum, the program should:

• Identify potential simultaneous operations

• Identify potential hazardous interactions

• Evaluate and implement necessary safeguards to allow for safe simultaneous operations

• Ensure coordination, including shared communication methods, between the simultaneous operations

• Include emergency response personnel or services in the planning and coordination of the simultaneous 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

2020-07-I-NC-5

Develop and implement a policy that requires the involvement of emergency response personnel in planning and coordination of activities involving the use of flammable materials in confined spaces. In the policy, require that emergency response personnel be stationed directly outside the confined space in which flammable materials are used. Ensure that the emergency response personnel are appropriately trained and equipped for confined space entry, confined space rescue and fire 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

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

Universal Blastco (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 24, 2021

2020-07-I-NC-6

Update the Universal Blastco hot work policy and employee training program to specifically identify the use of heat guns as hot work. The policy and programs should make clear that hot work encompasses any method of work that can ignite a fire and not just spark- or flame-producing work 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

2020-07-I-NC-7

Develop a formalized troubleshooting guide and/or standard operating procedure for the usage of resin and fiberglass matting in FRP operations. The procedure should direct employees on acceptable means of addressing cold-weather resin performance.


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-8

Develop a policy and standard operating procedures for the proper use of heat guns in FRP 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

Husky Energy Superior Refinery Explosion and Fire (16 Recommendations)
American Petroleum Institute (API) (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 23, 2022

2018-02-I-WI-13

Using API’s processes to determine the appropriate safety product, develop a publicly available technical publication for the safe operation of fluid catalytic cracking (FCC) units. The document should be applicable to both new and existing units. Include the following topics at a minimum:

a) Description of typical FCC unit hazards, including air leaks into hydrocarbon systems or hydrocarbon leaks into air systems that could form a flammable mixture during transient operation (startup, shutdown, standby, and the actions required to transition between these modes). If needed, include differences between possible reactor/regenerator configurations;

b) Recommended practices for safeguards to control FCC unit hazards;

c) Recommended monitoring for process safety during FCC unit transient operations;

d) Recommended emergency operating procedures for FCC-specific scenarios;

e) PHA guidance for key FCC-specific scenarios, including transient operation;

f) Recommended FCC-specific field and board operator process safety training topics and methods;

g) Guidelines for process safety assessments of FCC units; and

h) Incorporate lessons learned from this CSB investigation and the CSB’s ExxonMobil Torrance Refinery Electrostatic Precipitator Explosion investigation throughout the document and include references in the document’s bibliography.


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

2018-02-I-WI-14

Modify the appropriate existing recommended practice (for example, API RP 553, Refinery Valves and Accessories for Control and Safety Instrumented Systems) to include information about the purpose, design, maintenance, and testing of additional FCC catalyst slide valve components, including the slide valve body. If an API product other than API RP 553 is modified, API RP 553 should guide the reader to that reference.


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

2018-02-I-WI-15

Incorporate lessons learned from the FCC Unit Explosion and Asphalt Fire at Husky Superior Refinery incident into the appropriate API products (for example, API RP 2023, Guide for Safe Storage and Handling of Heated Petroleum-Derived Asphalt Products and Crude Oil Residua, or API RP 2021, Management of Atmospheric Storage Tank Fires). At a minimum, topics shall include the flammability of heated material such as asphalt and the ignition risk of pyrophoric material inside asphalt storage tanks. Include a reference to this CSB investigation in the document’s bibliography.


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

Cenovus Energy, Inc. (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 23, 2022

2018-02-I-WI-8

For all Cenovus operated refineries with FCC units, develop and implement an FCC unit-specific PHA guidance document as part of each FCC unit’s ongoing PHA update/revalidation cycle, including the Cenovus Superior Refinery. The PHA guidance document should be updated with new industry knowledge as it becomes available (for example, from AFPM, CCPS, and API). The PHA guidance document should include a requirement to review available licensor and industry guidance for FCC unit PHA scenarios and recommended safeguards and at a minimum, include information related to transient operation safeguards listed in CSB Recommendation 2018-02-I-WI-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.
 

PDF Document Recommendation Status Change Summary

2018-02-I-WI-9

Develop and implement a technology-specific knowledge-sharing network program across all Cenovus operated refineries, which at a minimum includes an FCC technology peer network. The peer network(s) must include engineers, operations management, and operations staff from each site that uses the technology, including the Cenovus Superior Refinery. The network(s) must meet at least annually to discuss process safety topics in the technology including:

a) Relevant incidents and near-misses at the refineries and/or in industry;
b) Refinery learnings in implementing process safety improvements;
c) Relevant industry tools, bulletins, and knowledge-sharing documents, such as those published by AFPM, CCPS, and API; and
d) Relevant updates to industry publications and standards.


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

2018-02-I-WI-10

Include and maintain the FCC technology licensors’ operating manuals in the process safety information packages for all FCC units, including the FCC unit at Cenovus Superior Refinery.


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

Cenovus Superior Refinery (7 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 23, 2022

2018-02-I-WI-1

Establish safeguards to prevent explosions in the FCC unit during transient operation (including startup, shutdown, standby, and emergency procedures). Incorporate these safeguards into written operating procedures. At a minimum establish the following specific safeguards:

a) Implementation of the reactor steam barrier, or a similar inert gas flow, to maintain an inert barrier at an elevated pressure between the main column (containing hydrocarbon) and the regenerator (containing air);

b) Purging the main column with a non-condensable gas as needed to prevent a dangerous accumulation of oxygen in the main column overhead receiver;

c) Monitoring to ensure that there is a sufficient non-condensable gas purge of the main column to prevent a dangerous accumulation of oxygen in the main column overhead receiver (either through direct measurement of the oxygen concentration and/or through engineering calculation);

d) Monitoring of critical operating parameters for flows, pressures, pressure differences, and catalyst levels;

e) Documentation of consequences of deviating from the transient operation safe operating limits and of predetermined corrective actions; and

f) Inclusion of the above items in the appropriate FCC operator training curricula.


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

2018-02-I-WI-2

Based on licensor input and good industry practices, determine the appropriate point(s) in the FCC unit’s shutdown procedures to shut down all wet gas compressor(s). Incorporate this information into all FCC unit shutdown procedures and operator training material.


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

2018-02-I-WI-3

Develop and implement a slide valve mechanical integrity program that addresses erosion and ensures proper functioning of the slide valves during a shutdown. The program must include, at a minimum:

a) A slide valve mechanical integrity standard that defines monitoring and inspection requirements, with acceptance criteria, required for the safe operation of the FCC unit during transient operation (such as a startup, shutdown, standby, and emergency).

b) Monitoring that includes process data analysis and mechanical preventive activities to evaluate the mechanical condition of the slide valves during the operation of the FCC unit between turnarounds;

c) Quarterly presentations of process data and mechanical preventive maintenance data to refinery operations management and maintenance management to drive key decisions such as shortening the turnaround cycle and/or planning a maintenance outage;

d) During turnarounds and other potential slide valve maintenance outages, evaluate the adequacy of the slide valve mechanical integrity program for the safe operation of the FCC unit during transient operation. If the inspection demonstrates unsuccessful performance, make appropriate corrections.

During the next major FCC unit turnaround at Cenovus Superior Refinery, demonstrate that the slide valve mechanical program is adequate for the safe operation of the FCC unit during transient operation. If the inspection demonstrates unsuccessful performance, make appropriate corrections to the slide valve mechanical integrity program.


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

2018-02-I-WI-4

Develop emergency procedures for responding to a loss of catalyst slide valve function (for example, when it leaks excessively or fails to close on demand).


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

2018-02-I-WI-5

Develop guidance for analyzing operating procedures to improve transient operation hazard evaluations during PHAs. Refer to section Chapter 9.1 in the CCPS publication Guidelines for Hazard Evaluation Procedures, 3rd Ed. or an appropriate equivalent resource to develop the guidance. Incorporate the guidance into the appropriate Cenovus Superior Refinery PHA procedural documents and policies.


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

2018-02-I-WI-6

Develop and implement an FCC unit operator, supervisor, and manager training program based on the licensor’s guidance and on available industry guidance. Elements of the training program shall include:

a) A set of written training materials (such as a manual) consistent with the licensor’s technology information, encompassing:

i) FCC equipment;
ii) Normal operations;
iii) Transient operations (including startup, shutdown, standby, and emergency); and
iv) Case studies of industry FCC industry incidents, including ExxonMobil Torrance (2015) and this incident; and

b) Training delivery methods including:

i) Group and individual training; and
ii) Simulator training for board operators.


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

2018-02-I-WI-7

Incorporate lessons learned from this incident into the appropriate training materials for the Cenovus Superior Refinery Emergency Response Team. At a minimum, topics shall include the proper response to liquids potentially stored above their flash point, such as asphalt, and the ignition risk of pyrophoric material inside asphalt storage tanks.


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

Environmental Protection Agency (EPA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 23, 2022

2018-02-I-WI-12

Develop a program that prioritizes and emphasizes inspections of FCC units in refineries that operate HF alkylation units (for example, under EPA’s National Compliance Initiative called Reducing Risks of Accidental Releases at Industrial and Chemical Facilities). As part of this program, verify FCC unit safeguards that prevent explosions during transient operation (including startup, shutdown, standby, and emergency procedures). At a minimum the program will verify the following specific safeguards:

a) Implementation of the reactor steam barrier, or a similar inert gas flow, to maintain an inert barrier at an elevated pressure between the main column (containing hydrocarbon) and the regenerator (containing air);

b) Purging the main column with a non-condensable gas as needed to prevent a dangerous accumulation of oxygen in the main column overhead receiver;

c) Monitoring to ensure that there is a sufficient non-condensable gas purge of the main column to prevent a dangerous accumulation of oxygen in the main column overhead receiver (either through direct measurement of the oxygen concentration and/or through engineering calculation);

d) Monitoring of critical operating parameters for flows, pressures, pressure differences, and catalyst levels;

e) Documentation of consequences of deviating from the transient operation safe operating parameters and of predetermined corrective actions; and

f) Inclusion of the above items in the appropriate FCC operator training curricula.

This recommendation is in addition to the recommendations to EPA relating to hydrofluoric acid outlined in the CSB’s report on the 2019 fire and explosions at the Philadelphia Energy Solutions refinery. In that report, the CSB recommended (1) that the EPA prioritize inspections of refinery HF alkylation units to ensure units are complying with API good practice guidance, (2) to require petroleum refineries with HF alkylation units to evaluate inherently safer technology, and (3) to initiate prioritization and, as applicable, risk evaluation of HF under the Toxic Substances Control Act.


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

Honeywell UOP (Universal Oil Products) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 23, 2022

2018-02-I-WI-16

Participate in the API committee that develops a technical publication for the safe operation of FCC units.


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

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

Final Report Released On: December 23, 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.
 

PDF Document Recommendation Status Change Summary

Kuraray Pasadena Release and Fire (12 Recommendations)
Kuraray America, Inc. (12 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 21, 2022

2018-03-I-TX-1

Develop and implement an emergency pressure-relief system design standard to ensure that each of these safety systems will discharge to a safe location. Include a requirement to periodically evaluate the site’s emergency pressure-relief systems and make appropriate modifications to ensure that each of these systems discharge to a safe location such that material that could discharge from these safety systems will not harm people.


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

2018-03-I-TX-2

Implement a site-wide system to evacuate nonessential personnel during upset conditions and exclude nonessential workers from being near equipment during transient operating modes, such as startup.


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

2018-03-I-TX-3

Develop and implement a system requiring a periodic evaluation of the adequacy and effectiveness of any safeguard used to mitigate or otherwise lower the risk of process safety hazards. This safeguard protection analysis should be based on the requirements of Cal/OSHA’s Process Safety Management for Petroleum Refineries regulations or an appropriate equivalent methodology.


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

2018-03-I-TX-4

Develop and implement a policy detailing how to effectively address recommendations generated from company process safety management systems, including audits, incident investigations, management of change, and process hazard analysis that is consistent with existing OSHA guidance. Include a periodic training requirement for managers and other employees involved with evaluating and managing proposed recommendations to help ensure proposed safety improvements are effectively evaluated and appropriately implemented.


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

2018-03-I-TX-5

Review the Center for Chemical Process Safety guidance on recognizing catastrophic incident warning signs and then develop and implement a program for the EVAL Plant that incorporates warning signs into its safety management system.


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

2018-03-I-TX-6

Clarify the lower equipment design pressure of the EVAL Reactor 2 within the operator training systems, written procedures, and in the control system interface.


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

2018-03-I-TX-7

Develop and implement a program to ensure that the company’s EVAL Plant nightly operating instructions do not conflict with its written operating procedures. Ensure that employees use the management of change system when changes to the written operating procedures are desired. Additionally, develop and implement a written procedure and conduct training on how to perform the EVAL Reactor methanol flush operation.


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

2018-03-I-TX-8

Strengthen the EVAL Plant’s operator training program by 1) including the known activities, such as bringing ethylene back into the unit, upset conditions like the reactor’s High-High-Pressure alarm, and providing guidance or otherwise clarifying when nonessential personnel should be excluded from being in the unit; 2) including alarm setpoints and actions that operators should take in response to specific process alarms, such as high pressure inside an EVAL Reactor; 3) including directions on when operators should use the emergency open valve; and 4) including safe operating limits, the consequence of deviating beyond the safe operating limits, and the predetermined steps operators need to take to return the process to a safe condition.


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

2018-03-I-TX-9

Complete the alarm management efforts at the EVAL Plant and implement a continual program to meet or be lower than the alarm rate performance targets established in ISA 18.2.


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

2018-03-I-TX-10

Improve the EVAL Plant’s safety management system by 1) controlling when chilled liquid is circulated through the heat exchanger during startup; 2) enhancing recognition of liquid ethylene accumulation and response to low-temperature conditions inside an EVAL Reactor through alarms, written procedures, and operator training; 3) implementing a system to manage abnormal operating conditions effectively by, at a minimum, including appropriate technical representation, performing a hazard analysis of temporary or troubleshooting operations, and providing management oversight of any abnormal condition; 4) updating the written startup procedures to include guidance on the appropriate operator actions to take in response to process alarms; 5) using control system guidance to aid operator response to abnormal or upset conditions to keep the process within the safe operating limits; and 6) removing the physical and procedural controls used at the EVAL Plant to restrict board operators from accessing or using the emergency open valve, and updating the written procedures and operator training to provide guidance on when to open the emergency open valve.


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

2018-03-I-TX-11

Modify the EVAL Plant’s safe operating limits program to prevent operating under conditions that rely upon equipment design safety factors, such as the American Society of Mechanical Engineers (ASME) code material safety factors.


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

2018-03-I-TX-12

Acquire the services of an independent third party to perform a comprehensive assessment of its EVAL Plant’s process safety management systems. In addition to meeting the requirements outlined in Appendix B of this report, this comprehensive assessment should evaluate whether existing policies meet minimum federal process safety regulatory requirements and apply the Center for Chemical Process Safety model to verify both the suitability of these systems and their effective, consistent implementation.


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

Philadelphia Energy Solutions (PES) Refinery Fire and Explosions (5 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: October 12, 2022

2019-04-I-PA-4

Update API RP 751 Safe Operation of Hydrofluoric Acid Alkylation Units to require the following:

  1. Protection of critical safeguards and associated control system components, including but not limited to wiring and cabling for control systems and primary and backup power supplies, from fire and explosion hazards, including radiant heat and flying projectiles; and
  2. Installation of remotely-operated emergency isolation valves on the inlet(s) and outlet(s) of all hydrofluoric acid containing vessels, and hydrocarbon containing vessels meeting defined threshold quantities.

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

American Society for Testing and Materials (ASTM) International (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 12, 2022

2019-04-I-PA-5

Revise ASTM A234 to incorporate supplementary requirements for piping used in HF service, as defined in HF supplementary requirements S9.1 through S9.7 in ASTM A106 version 19a.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

Environmental Protection Agency (EPA) (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: October 12, 2022

2019-04-I-PA-1

Develop a program that prioritizes and emphasizes inspections of refinery HF alkylation units, for example under EPA’s National Compliance Initiative called Reducing Risks of Accidental Releases at Industrial and Chemical Facilities. As part of this program, verify that HF alkylation units are complying with API RP 751 Safe Operation of Hydrofluoric Acid Alkylation Units, including but not limited to the implementation of a special emphasis inspection program to inspect all individual carbon steel piping components and welds to identify areas of accelerated corrosion; the protection of safety-critical safeguards and associated control system components, including but not limited to wiring and cabling for control systems and primary and backup power supplies, from fire and explosion hazards including radiant heat and flying projectiles (per recommendation 2019-04-I-PA-R4); and the installation of remotely-operated emergency isolation valves on the inlet(s) and outlet(s) of all hydrofluoric acid containing vessels, and hydrocarbon containing vessels meeting defined threshold quantities (per recommendation 2019-04-I-PA-R4).


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

2019-04-I-PA-2

Revise 40 C.F.R. Part 68 (EPA Risk Management Plan) to require new and existing petroleum refineries with HF alkylation units to conduct a safer technology and alternatives analysis (STAA) and to evaluate the practicability of any inherently safer technology (IST) identified. Require that these evaluations are performed every 5 years as a part of an initial PHA as well as PHA revalidations.


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

2019-04-I-PA-3

Per the requirements in EPA Rule Procedures for Prioritization of Chemicals for Risk Evaluation Under the Toxic Substances Control Act, initiate prioritization to evaluate whether hydrofluoric acid is a High-Priority Substance for risk evaluation. If it is determined to be a High-Priority Substance, conduct a risk evaluation of hydrofluoric acid to determine whether it presents an unreasonable risk of injury to health or the environment. If it is determined to present an unreasonable risk of injury to health or the environment, apply requirements to hydrofluoric acid to the extent necessary to eliminate or significantly mitigate the risk, for example by using a methodology such as the hierarchy of controls.


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

TPC Port Neches Explosions and Fire (5 Recommendations)
American Chemistry Council (ACC) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 19, 2022

2020-02-I-TX-4

Revise the Butadiene Product Stewardship Guidance Manual to include guidance on identifying and controlling or eliminating dead legs in high-purity butadiene service. Specifically, provide guidance on the potential for dead legs to be formed when equipment, such as primary or spare pumps, is out of service. In the Manual, also provide guidance on method(s) to identify dead legs that could be formed when equipment, such as primary or spare pumps, is temporarily or permanently out of service. Recommend actions to mitigate, control, and prevent hazardous popcorn polymer buildup in these in-process or temporary dead legs, such as through monitoring, use of inhibitor(s), or conducting maintenance activities to minimize the presence of dead legs.


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

2020-02-I-TX-5

Revise the Butadiene Product Stewardship Guidance Manual to provide guidance on a methodology to help identify what should be considered excessive or dangerous amounts of popcorn polymer in a unit. Provide mitigation strategies that describe the actions that owner/operators should take during those polymer excursions to control or eliminate the popcorn polymer to reduce the likelihood of popcorn polymer-induced process loss of containment.


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

TPC Group (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 19, 2022

2020-02-I-TX-1

For all TPC PNO terminal operations in high-purity butadiene service (e.g., greater than 80 percent butadiene concentration), develop and implement a program to identify and control, or eliminate, dead legs. At a minimum, the program must require:

a)   a comprehensive review of equipment configurations in high-purity butadiene service using both Piping and Instrumentation Diagrams (P&IDs) and field evaluations to identify all permanent dead legs. Implement a process to identify changes in operating conditions in high-purity butadiene service that could result in the formation of temporary or new permanent dead legs, such as when primary or spare pumps are temporarily or permanently out of service. Ensure this review is conducted at least every five years;

b)   evaluation and implementation of design strategies, where practical, to prevent dead legs in areas susceptible to popcorn polymer formation;

c)   mitigation, control, or prevention of hazardous popcorn polymer buildup in all identified dead legs in high-purity butadiene service, such as through increased monitoring, flushing of equipment, use of inhibitor(s), or planning maintenance activities to minimize the amount of time that a temporary dead leg is present; and

d)   periodic continual auditing (at a minimum annually) by TPC PNO management to ensure that the process is being implemented.


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

2020-02-I-TX-2

For all TPC PNO terminal operations, passivate all storage vessels, fixed equipment, and associated piping systems in high-purity butadiene service consistent with industry good practice guidance.


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

2020-02-I-TX-3

At the TPC PNO facility, incorporate the recording of any paper-based process performance information into TPC PNO’s existing electronic records management system so that the information can be reliably retained, retrieved, and analyzed in the event of a catastrophic incident. At a minimum, those records shall include Dead Leg Inspection check sheets, Spare Pump Rotation check sheets, and handwritten logs documenting the performance of all critical process instrumentation (e.g., the oxygen analyzer).


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

AB Specialty Silicones, LLC (3 Recommendations)
AB Specialty Silicones, LLC (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 24, 2021

2019-03-I-IL-1

Develop hazardous gas detection and alarm programs and associated procedures based on manufacturer specifications, current codes, standards, and industry good practice guidance, for all hazardous gases that could be released near workers, including hydrogen. The program must address proper installation, calibration, inspection, maintenance, training, and routine operations. Ensure such hazardous gas detection and alarm systems are functional at all times.


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.
 

PDF Document Recommendation Status Change Summary

2019-03-I-IL-2

Establish a safety management system that addresses process safety at the AB Specialty Waukegan, Illinois facility. Include in that system elements recommended in industry guidance publications, including Center for Chemical Process Safety (CCPS) publications Guidelines for Risk Based Process Safety and Guidelines for Implementing Process Safety Management.


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.
 

PDF Document Recommendation Status Change Summary

2019-03-I-IL-3

Incorporate into operations and activities at AB Specialty the specific elements recommended in CCPS’s Essential Practices for Managing Chemical Reactivity Hazards, which are:

1. Put into place a system to manage chemical reactivity hazards

2. Collect reactivity hazard information

3. Identify chemical reactivity hazards

4. Test for chemical reactivity

5. Assess chemical reactivity risks

6. Identify and implement process controls and risk management options

7. Document chemical reactivity risks and management decisions

8. Communicate and train on chemical reactivity hazards

9. Investigate chemical reactivity incidents

10. Review, audit, manage change in, and improve hazard management practices and programs.


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.
 

PDF Document Recommendation Status Change Summary