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Recommendations

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

Aghorn Operating Inc. Waterflood Station Hydrogen Sulfide Release (9 Recommendations)

Aghorn Operating Inc. (7 Recommendations)

Open: 71% | Closed: 29%

View Investigation

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.

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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.

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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.

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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).

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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.

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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.

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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.

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Recommendation Status Change Summary

Occupational Safety and Health Administration (OSHA) (1 Recommendations)

Texas Railroad Commission (RRC) (1 Recommendations)

Bio-Lab Lake Charles Chemical Fire and Release (6 Recommendations)

Bio-Lab Lake Charles (4 Recommendations)

Open: 100% | Closed: 0%

View Investigation

Final Report Released On: April 24, 2023

2020-05-I-LA-1

Evaluate the hazards to the Bio-Lab Lake Charles facility from hurricanes and accompanying wind, rainwater, floodwater, or storm surge forces. Implement processes and safeguards for protection against those hazards, such as through:

a. Constructing new and maintaining existing buildings and structures to withstand hurricane winds and flooding, with a particular focus on those containing hazardous materials;

b. Implementing safeguards and processes to ensure hazardous chemicals are not compromised and released during extreme weather events; and

c. Following the guidance presented in the Center for Chemical Process Safety Monograph Assessment of and Planning for Natural Hazards.

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Recommendation Status Change Summary

2020-05-I-LA-2

Develop and implement an improved Process Hazard Analysis (PHA) action item management system. At a minimum the PHA action item management system should:

a. Ensure that each PHA action item or recommendation is assigned to an appropriate person with a deadline for initial evaluation;

b. Document and maintain the rationale if the action item or recommendation is modified or rejected; and

c. Track the status of all PHA action items or recommendations until they are resolved.

Additionally, periodic audits must be conducted on the PHA action item management system to ensure its effectiveness.

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Recommendation Status Change Summary

2020-05-I-LA-3

Perform process hazard analyses (PHAs) on all buildings and units processing or storing trichloroisocyanuric acid. Ensure that the PHAs are revalidated at least every five years. Also include the building design basis as process safety information for the PHA team to reference during their analysis.

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2020-05-I-LA-4

Revise the Bio-Lab Lake Charles emergency response plan to require the following:

a. The site’s fire protection system is properly maintained and routinely function-tested in accordance with published industry guidance and NFPA requirements. Require in the emergency response plan that any equipment identified as nonfunctional must be repaired in a timely manner in accordance with NFPA requirements;

b. Emergency and fire protection equipment (in particular fire water pumps) must be checked regularly to ensure it is in good working order one month before the start of the U.S. hurricane season, as recommended by the Center for Chemical Process Safety Monograph Assessment of and Planning for Natural Hazards; and

c. Site personnel must be trained on the use of all emergency generators and other emergency equipment at least one month before the start of the U.S. hurricane season.

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Environmental Protection Agency (EPA) (1 Recommendations)

Open: 100% | Closed: 0%

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Final Report Released On: April 24, 2023

2020-05-I-LA-6

Implement the five open recommendations issued in the 2022 U.S. Government Accountability Office Report titled Chemical Accident Prevention: EPA Should Ensure Regulated Facilities Consider Risks from Climate Change, which are:

a. The U.S. Environmental Protection Agency (EPA) should provide additional compliance assistance to Risk Management Program (RMP) facilities related to risks from natural hazards and climate change;

b. The EPA should design an information system to track common deficiencies found during inspections, including any related to natural hazards and climate change, and use this information to target compliance assistance;

c. The EPA should issue regulations, guidance, or both, as appropriate, to clarify requirements and provide direction for RMP facilities on how to incorporate risks from natural hazards and climate change into their risk management programs;

d. The EPA should develop a method for inspectors to assess the sufficiency of RMP facilities’ incorporation of risks from natural hazards and climate change into risk management programs and provide related guidance and training to inspectors; and

e. The EPA should incorporate the vulnerability of RMP facilities to natural hazards and climate change as criteria when selecting facilities for inspection.

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Recommendation Status Change Summary

Louisiana Governor and Legislature/Secretary of the Louisiana Department of Environmental Quality (1 Recommendations)

Open: 100% | Closed: 0%

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Final Report Released On: April 24, 2023

2020-05-I-LA-5

Under existing statutory or regulatory authority or through the establishment of new authority by executive or legislative action, for all existing chemical manufacturing and storage facilities that:

(1) Are located in a hurricane-prone region as defined by the International Building Code, and

(2) Manufacture or store or can inadvertently or otherwise produce (e.g., by chemical reaction) regulated substances inside equipment or building(s) built before more current wind design requirements came into effect

Require the facility operators to evaluate the hazards to their facilities from hurricanes and accompanying wind, rainwater, floodwater, or storm surge forces. Require the facility operators to implement processes and safeguards for protection against those hazards, such as through:

a. Ensuring that buildings and structures (both new and existing) can withstand hurricane winds and flooding, with a particular focus on buildings and structures containing hazardous materials;

b. Implementing safeguards and processes to ensure that hazardous chemicals are not compromised and released during extreme weather events; and/or

c. Following the guidance presented in the Center for Chemical Process Safety Monograph Assessment of and Planning for Natural Hazards.

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Recommendation Status Change Summary

Evergreen Packaging Paper Mill - Fire During Hot Work (8 Recommendations)

Evergreen Packaging (3 Recommendations)

Open: 0% | Closed: 100%

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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.

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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.

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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.

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Recommendation Status Change Summary

Occupational Safety and Health Administration (OSHA) (2 Recommendations)

Open: 0% | Closed: 100%

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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.

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2020-07-I-NC-2

(Superseded by 2021-01-I-TN-R1 from the Wacker report)

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.

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Recommendation Status Change Summary

Universal Blastco (3 Recommendations)

Foundation Food Group Fatal Chemical Release (12 Recommendations)

Compressed Gas Association (CGA) (2 Recommendations)

Open: 100% | Closed: 0%

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Final Report Released On: December 11, 2023

2021-03-I-GA-9

Develop a comprehensive standard for the safe storage, handling, and use of liquid nitrogen in stationary applications, comparable to the guidance presented in CGA G-6.5 Standard for Small Stationary Insulated Carbon Dioxide Systems. At a minimum, the standard should include:

a) requirements for and guidance on the location, the maintenance, and the functional testing of atmospheric monitoring devices;

b) requirements for visible and audible alarm indication distinct from the building’s fire alarm system and at a continuously attended location;

c) guidance on the design, function, periodic maintenance and testing, and location of room and emergency ventilation systems; and,

d) requirements for and guidance on the location of emergency shutdown devices including E-stops.

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Recommendation Status Change Summary

2021-03-I-GA-10

Update P-76 Hazards of Oxygen-Deficient Atmospheres. At a minimum, the updated standard should:

a) require that atmospheric monitoring systems shall be utilized with processes, equipment, and piping systems capable of producing oxygen-deficient atmospheres;

b) require that atmospheric monitoring systems provide both visible and audible alarm indication distinct from a building’s fire alarm system and at a continuously attended location;

c) require that processes, equipment, and piping systems capable of producing oxygen-deficient atmospheres shall be equipped with remotely operated emergency isolation valves (ROEIVs); and

d) include guidance on the adequate safe location of emergency stop devices. At a minimum this guidance should be harmonized with the requirements of ISO 13850 Safety of machinery – Emergency stop function – Principles for design. As necessary, augment the general guidance of ISO 13850 with guidance specific to processes, equipment, and piping using cryogenic asphyxiants and inert gases.

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Recommendation Status Change Summary

Gold Creek Foods (1 Recommendations)

Open: 0% | Closed: 100%

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Final Report Released On: December 11, 2023

2021-03-I-GA-1

Include in the emergency action program provisions for proactively interacting with and informing local emergency response resources of all emergencies at the former FFG Plant 4 facility to which Gold Creek expects them to respond. At a minimum, Gold Creek should:

a) inform local emergency responders of the existence, nature, and location of hazardous substances at its facilities, including liquid nitrogen;

b) inform local emergency responders of the location of emergency-critical equipment such as bulk storage tanks, points of use, isolation valves, E-stop switches, and any other emergency equipment or systems with which emergency responders may need to interact; and,

c) provide local emergency responders with information, such as facility plot plans, engineering drawings, or other information needed to mount an effective emergency response.

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Recommendation Status Change Summary

International Code Council (ICC) (1 Recommendations)

Open: 100% | Closed: 0%

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Final Report Released On: December 11, 2023

2021-03-I-GA-12

Update the International Fire Code to:

a) require the use of atmospheric monitoring with cryogenic asphyxiants in accordance with industry guidance such as is contained in CGA P-76 Hazards of Oxygen-Deficient Atmospheres and CGA P-12 Safe Handling of Cryogenic Liquids in addition to CGA P-18 Standard for Bulk Inert Gas Systems; and,

b) include guidance on the adequate safe location of manual shutoff valves and devices such as emergency push buttons used to activate remotely operated emergency isolation valves (ROEIVs) in cryogenic fluid service. At a minimum this guidance should be harmonized with the requirements of ISO 13850 Safety of machinery – Emergency stop function – Principles for design.

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Recommendation Status Change Summary

Messer LLC (2 Recommendations)

Open: 100% | Closed: 0%

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Final Report Released On: December 11, 2023

2021-03-I-GA-2

Update the company product stewardship policy to:

a) include participation by Messer in customers’ process hazard analyses (PHAs). The policy should require that these PHAs be conducted in a manner which conforms with CCPS Guidelines for Hazard Evaluation Procedures prior to the startup of a cryogenic freezing process;

b) require verification that proper signage, in accordance with CGA P-76 Hazards of Oxygen-Deficient Atmospheres, is displayed on and/or near equipment; and,

c) require a facility and/or equipment siting review to ensure that emergency shutoff devices, including E-stops, are located such that they can be safely actuated during a release of liquid nitrogen.

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Recommendation Status Change Summary

2021-03-I-GA-3

Create an informational product that provides Messer customers with information on the safety issues described in this report. In this informational product, recommend that Messer customers develop and implement effective safety management systems to control asphyxiation hazards from inert gases based on the guidance published in CGA P-86 Guideline for Process Safety Management, CGA P-12 Guideline for Safe Handling of Cryogenic and Refrigerated Liquids, CGA P-18 Standard for Bulk Inert Gas Systems, and CGA P-76 Hazards of Oxygen-Deficient Atmospheres.

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Recommendation Status Change Summary

National Fire Protection Association (NFPA) (1 Recommendations)

Open: 100% | Closed: 0%

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Final Report Released On: December 11, 2023

2021-03-I-GA-11

Update NFPA 55 Compressed Gases and Cryogenic Fluids Code to:

a) require the use of atmospheric monitoring with cryogenic asphyxiants in accordance with industry guidance such as is contained in CGA P-76 Hazards of Oxygen-Deficient Atmospheres and CGA P-12 Safe Handling of Cryogenic Liquids in addition to CGA P-18 Standard for Bulk Inert Gas Systems; and,

b) include guidance on the adequate safe location of manual shutoff valves and devices such as emergency push buttons used to activate remotely operated emergency isolation valves (ROEIVs). At a minimum this guidance should be harmonized with the requirements of ISO 13850 Safety of machinery – Emergency stop function – Principles for design.

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Recommendation Status Change Summary

Occupational Safety and Health Administration (OSHA) (5 Recommendations)

Open: 100% | Closed: 0%

View Investigation

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.

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Recommendation Status Change Summary

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:

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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:

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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.

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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:

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Recommendation Status Change Summary

Husky Energy Superior Refinery Explosion and Fire (16 Recommendations)

American Petroleum Institute (API) (3 Recommendations)

Open: 67% | Closed: 33%

View Investigation

Final Report Released On: December 29, 2022

2018-02-I-WI-13

The American Fuel & Petrochemical Manufacturers (AFPM) implemented this recommendation on behalf of API.

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.

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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.

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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.

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Recommendation Status Change Summary

Cenovus Energy, Inc. (3 Recommendations)

Cenovus Superior Refinery (7 Recommendations)

Open: 14% | Closed: 86%

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Final Report Released On: December 29, 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:

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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.

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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.

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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).

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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.

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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.

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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.

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Recommendation Status Change Summary

Environmental Protection Agency (EPA) (1 Recommendations)

Open: 100% | Closed: 0%

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Final Report Released On: December 29, 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.

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Honeywell UOP (Universal Oil Products) (1 Recommendations)

Occupational Safety and Health Administration (OSHA) (1 Recommendations)

Kuraray Pasadena Release and Fire (12 Recommendations)

Kuraray America, Inc. (12 Recommendations)