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

Kleen Energy Natural Gas Explosion (18 Recommendations)
American Society of Mechanical Engineers (ASME) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 28, 2010

2010-07-I-CT-3 URGENT!

Make appropriate changes to the 2012 version of Power Piping, ASME B31.1, to require the use of inherently safer fuel gas piping cleaning methodologies rather than natural gas blows. At a minimum, for the cleaning or flushing methods discussed in B31.1 paragraph 122.10, require the use of inherently safer alternatives such as air blows and pigging with air as the motive force in lieu of flammable gas.


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

Electric Power Research Institute (EPRI) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 28, 2010

2010-07-I-CT-18 URGENT!

Work with the six turbine manufacturers identified in this document – General Electric, Siemens, Solar, Mitsubishi Power Systems, Pratt & Whitney, and Rolls-Royce – to publish technical guidance addressing the safe cleaning of fuel gas piping supplying gas turbines. At minimum:

a. For cleaning methodology, require the use of inherently safer alternatives such as air blows and pigging with air in lieu of flammable gas.

b. Provide comprehensive technical guidance on inherently safer methods for cleaning fuel gas piping, such as the use of air or pigging with air.


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 Letter

General Electric (GE) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 28, 2010

2010-07-I-CT-4 URGENT!

Provide to your customers:

a. Comprehensive technical guidance on inherently safer methods for cleaning fuel gas piping, such as the use of air or pigging with air.

b. Comprehensive Cleaning Force Ratio (CFR) guidelines, specifying both the upper and lower limits required to obtain satisfactory cleaning for the fuel gas piping for purposes of the warranties of the turbines.

c. Warnings against the use of fuel gas to clean pipes.


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 Letter

2010-07-I-CT-10 URGENT!

Work with the Electric Power Research Institute to publish technical guidance addressing the safe cleaning of fuel gas piping supplying gas turbines. At minimum:

a. For cleaning methodology, require the use of inherently safer alternatives such as air blows and pigging with air in lieu of flammable gas.

b. Provide technical guidance for the safe and effective use of alternative methods for cleaning such as air and pigging with air.


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 Letter

Governor and Legislature of the State of Connecticut (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 28, 2010

2010-07-I-CT-16 URGENT!

Enact legislation applicable to power plants in the state that prohibits the use of flammable gas that is released to the atmosphere to clean fuel gas piping.


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 Letter

2010-07-I-CT-17 URGENT!

Adopt the current version of NFPA 54 as amended pursuant to 2010-01-I-CT-R2.


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

PDF Document Recommendation Status Change Letter

Mitsubishi Power Systems (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 28, 2010

2010-07-I-CT-7 URGENT!

Provide to your customers:

a. Comprehensive technical guidance on inherently safer methods for cleaning fuel gas piping, such as the use of air or pigging with air.

b. Comprehensive Cleaning Force Ratio (CFR) guidelines, specifying both the upper and lower limits required to obtain satisfactory cleaning for the fuel gas piping for purposes of the warranties of the turbines.

c. Warnings against the use of fuel gas to clean pipes.


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

2010-07-I-CT-13 URGENT!

Work with the Electric Power Research Institute to publish technical guidance addressing the safe cleaning of fuel gas piping supplying gas turbines. At minimum:

a. For cleaning methodology, require the use of inherently safer alternatives such as air blows and pigging with air in lieu of flammable gas.

b. Provide technical guidance for the safe and effective use of alternative methods for cleaning such as air and pigging with air.


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 Letter

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 28, 2010

2010-07-I-CT-2 URGENT!

Enact a Tentative Interim Amendment and permanent changes to the National Fuel Gas Code (NFPA 54/ANSI Z223.1) that address the safe conduct of fuel gas piping cleaning operations. At a minimum:

a. Remove the existing NFPA 54 fuel gas piping exemptions for power plants and systems with an operating pressure of 125 pounds per square inch gauge (psig) or more.

b. For cleaning methodology, require the use of inherently safer alternatives such as air blows or pigging with air in lieu of flammable gas.


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

PDF Document Recommendation Status Change Summary

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

Final Report Released On: June 28, 2010

2010-07-I-CT-1 URGENT!

Promulgate regulations that address fuel gas safety for both construction and general industry. At a minimum:

a. Prohibit the release of flammable gas to the atmosphere for the purpose of cleaning fuel gas piping.

b. Prohibit flammable gas venting or purging indoors. Prohibit venting or purging outdoors where fuel gas may form a flammable atmosphere in the vicinity of workers and/or ignition sources.

c. Prohibit any work activity in areas where the concentration of flammable gas exceeds a fixed low percentage of the lower explosive limit (LEL) determined by appropriate combustible gas monitoring.

d. Require that companies develop flammable gas safety procedures and training that involves contractors, workers, and their representatives in decision-making.


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendation Status Change Summary

Pratt & Whitney (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 28, 2010

2010-07-I-CT-8 URGENT!

Provide to your customers:

a. Comprehensive technical guidance on inherently safer methods for cleaning fuel gas piping, such as the use of air or pigging with air.

b. Comprehensive Cleaning Force Ratio (CFR) guidelines, specifying both the upper and lower limits required to obtain satisfactory cleaning for the fuel gas piping for purposes of the warranties of the turbines.

c. Warnings against the use of fuel gas to clean pipes.


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 Letter

2010-07-I-CT-14 URGENT!

Work with the Electric Power Research Institute to publish technical guidance addressing the safe cleaning of fuel gas piping supplying gas turbines. At minimum:

a. For cleaning methodology, require the use of inherently safer alternatives such as air blows and pigging with air in lieu of flammable gas.

b. Provide technical guidance for the safe and effective use of alternative methods for cleaning such as air and pigging with air.


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 Letter

Rolls-Royce (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 28, 2010

2010-07-I-CT-9 URGENT!

Provide to your customers:

a. Comprehensive technical guidance on inherently safer methods for cleaning fuel gas piping, such as the use of air or pigging with air.

b. Comprehensive Cleaning Force Ratio (CFR) guidelines, specifying both the upper and lower limits required to obtain satisfactory cleaning for the fuel gas piping for purposes of the warranties of the turbines.

c. Warnings against the use of fuel gas to clean pipes.


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

2010-07-I-CT-15 URGENT!

Work with the Electric Power Research Institute to publish technical guidance addressing the safe cleaning of fuel gas piping supplying gas turbines. At minimum:

a. For cleaning methodology, require the use of inherently safer alternatives such as air blows and pigging with air in lieu of flammable gas.

b. Provide technical guidance for the safe and effective use of alternative methods for cleaning such as air and pigging with air.


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 Letter

Siemens (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 28, 2010

2010-07-I-CT-5 URGENT!

Provide to your customers:

a. Comprehensive technical guidance on inherently safer methods for cleaning fuel gas piping, such as the use of air or pigging with air.

b. Comprehensive Cleaning Force Ratio (CFR) guidelines, specifying both the upper and lower limits required to obtain satisfactory cleaning for the fuel gas piping for purposes of the warranties of the turbines.

c. Warnings against the use of fuel gas to clean pipes.


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

2010-07-I-CT-12 URGENT!

Work with the Electric Power Research Institute to publish technical guidance addressing the safe cleaning of fuel gas piping supplying gas turbines. At minimum:

a. For cleaning methodology, require the use of inherently safer alternatives such as air blows and pigging with air in lieu of flammable gas.

b. Provide technical guidance for the safe and effective use of alternative methods for cleaning such as air and pigging with air.


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 Letter

Solar Turbines (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 28, 2010

2010-07-I-CT-6 URGENT!

Provide to your customers:

a. Comprehensive technical guidance on inherently safer methods for cleaning fuel gas piping, such as the use of air or pigging with air.

b. Comprehensive Cleaning Force Ratio (CFR) guidelines, specifying both the upper and lower limits required to obtain satisfactory cleaning for the fuel gas piping for purposes of the warranties of the turbines.

c. Warnings against the use of fuel gas to clean pipes.


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

2010-07-I-CT-11 URGENT!

Work with the Electric Power Research Institute to publish technical guidance addressing the safe cleaning of fuel gas piping supplying gas turbines. At minimum:

a. For cleaning methodology, require the use of inherently safer alternatives such as air blows and pigging with air in lieu of flammable gas.

b. Provide technical guidance for the safe and effective use of alternative methods for cleaning such as air and pigging with air.


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 Letter

Little General Store Propane Explosion (12 Recommendations)
Association of Public-Safety Communications Officials (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 25, 2008

2007-4-I-WV-6

Develop a guide card for propane emergencies to assist 911 operators in the collection of pertinent information on propane emergencies. The questionnaire in Section 1.9.1 in the Propane Education and Research Council's Certified Employee Training Program may be used as a model.


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.
 

Ferrellgas (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 25, 2008

2007-4-I-WV-12

Establish and implement a comprehensive safety management system that includes at a minimum: -An auditing program developed in accordance with generally accepted methodologies to monitor the performance and effectiveness of safety management systems and personnel at all levels; -An inspection program that uses NFPA 58 as a guide to systematically inspect all customer propane systems and identify all deficiencies; -A means of tracking audits and inspections and identified deficiencies; -A means of tracking corrective actions; -A means of collecting and using audit and inspection data for trend analysis and organizational learning; -A means of periodically reporting audit and inspection trends to the Board of Directors and Managing Board, and; -A provision for periodic safety management system audits conducted by a third party competent in the requirements of NFPA 58.


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.
 

Governor and Legislature of the State of West Virginia (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 25, 2008

2007-4-I-WV-1

Require training and qualification of individuals who operate bulk propane plants, dispense and deliver propane, install and service propane systems, and install propane appliances. The training and qualification requirements should be comparable to those of existing propane industry programs such as the Certified Employee Training Program.


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

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 25, 2008

2007-4-I-WV-5

In the Liquefied Petroleum Gas Code (NFPA 58) "Qualifications for Personnel" section, specify training requirements (including supervised on-the-job training), training curricula, competencies, and testing through written examination and performance evaluation, or reference a nationally recognized curriculum for these requirements.


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

National Propane Gas Association (NPGA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 25, 2008

2007-4-I-WV-9

Submit a request to the United States Occupational Safety and Health Administration for a letter of interpretation to determine if the Certified Employee Training Program curriculum meets the training requirements in 29 CFR 1910.110.


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.
 

2007-4-I-WV-10

Work with the West Virginia E911 Council with development of propane emergency guidance by providing the Council with the customer leak questionnaire located in Section 1.9.1 of the Certified Employee Training Program and technical assistance.


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.
 

Propane Education and Research Council (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 25, 2008

2007-4-I-WV-7

Revise the Certified Employee Training Program to include: -Procedures for transfer of liquid propane from tank to tank, or -The prohibition of the transfer of liquid propane from tank to tank.


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.
 

2007-4-I-WV-8

Revise the Certified Employee Training Program to include emergency response guidance for propane service technicians who respond to propane emergencies similar to guidance provided to emergency responders in the Propane Emergencies program.


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

West Virginia 911 Council (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 25, 2008

2007-4-I-WV-11

Work with the National Propane Gas Association to develop and distribute propane emergency guidance for use by all county and municipal 911 communication centers in West Virginia.


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.
 

West Virginia Fire Commission (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 25, 2008

2007-4-I-WV-2

Revise the Fire Commission rules and codes to require annual hazardous materials response refresher training for all firefighters in West Virginia.


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.
 

2007-4-I-WV-3

Revise the Fire Commission rules and codes to require that all West Virginia fire departments perform at least one hazardous material response drill annually.


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.
 

West Virginia Office of Emergency Medical Services (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 25, 2008

2007-4-I-WV-4

Revise the Office of Emergency Medical Services rules and codes to require annual hazardous materials response refresher training for all emergency medical personnel in West Virginia.


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 Status Change Summary

Loy Lange Box Company Pressure Vessel Explosion (8 Recommendations)
Arise, Inc (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 29, 2022

2017-04-I-MO-7

Update company policies and/or procedures by including prescriptive elements in the boiler and pressure vessel repair and alteration inspection and acceptance process that would prevent the acceptance of a non-conforming repair or alteration.


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

Board of Aldermen, City of St. Louis, MO (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 29, 2022

2017-04-I-MO-4

Revise the City of St. Louis Mechanical Code to adopt a national consensus standard such as NBIC Part 2 to govern the requirements for inservice inspection of boilers and pressure vessels.


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

PDF Document Recommendation Status Change Summary

2017-04-I-MO-5

Revise the City of St. Louis Mechanical Code to require pressure vessel inspections be performed by a National Board of Boiler and Pressure Vessel Inspectors (NBBI) inservice (IS) commissioned inspector.


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

PDF Document Recommendation Status Change Summary

Loy Lange Box Company (3 Recommendations)
Open: 67% | Closed: 33%

Final Report Released On: July 29, 2022

2017-04-I-MO-1

Develop and implement a comprehensive safety management system. Include in that system process safety elements recommended in industry guidance publications, such as the Center for Chemical Process Safety (CCPS) publication Guidelines for Risk Based Process Safety.


Status: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendation Status Change Summary

2017-04-I-MO-2

Engage a qualified third-party to conduct a comprehensive review or audit of Loy Lange’s regulatory compliance practices and current compliance status.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

PDF Document Recommendation Status Change Summary

2017-04-I-MO-3

Implement an electronic records and data management system that preserves all critical company records, safety policies and procedures, and operational data. Ensure that such records are stored and can be accessed remotely in the event of a catastrophic incident


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

Mayor, City of St. Louis, MO (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 29, 2022

2017-04-I-MO-6

Distribute and communicate the findings of this report to all licensed stationary engineers and all registered boiler and pressure vessel owning/operating entities in the City of St. Louis. 


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

PDF Document Recommendation Status Change Summary

National Board of Boiler and Pressure Vessel Inspectors (NBBI) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 29, 2022

2017-04-I-MO-8

Update NB-263 Rules for Commissioned Inspectors to include prescriptive elements in the boiler and pressure vessel repair and alteration inspection and acceptance process that would prevent the acceptance of a non-conforming repair.


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

LyondellBasell La Porte Fatal Chemical Release (6 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 25, 2023

2021-05-I-TX-5

Revise API Standard 599 Metal Plug Valves—Flanged, Threaded, and Welding Ends as follows:

a. State that there have been multiple incidents in which workers have inadvertently removed pressure-retaining components from plug valves while workers were attempting to remove the valve’s actuator or gearbox.

b. Recommend that facilities using plug valves establish written procedures detailing the correct way to remove the plug valve actuator or gearbox for each specific plug valve design at the facility.

c. For existing plug valves, require facilities to clearly mark all pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with ASME and VMA to ensure a consistent methodology is specified across both API and ASME standards.

d. Require that new plug valves be designed, consistent with Prevention through Design principles, to prevent the inadvertent removal of pressure-retaining components when removing the actuator or gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those incidents, when formulating a new plug valve design. Work with ASME and VMA to ensure a consistent methodology is specified across both API and ASME 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

American Society of Mechanical Engineers (ASME) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 25, 2023

2021-05-I-TX-4

Revise American Society of Mechanical Engineers (ASME) Standard B16.34 Valves—Flanged, Threaded, and Welding End as follows:

a. For existing plug valves, require facilities to clearly mark all pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with American Petroleum Institute (API) and the Valve Manufacturers Association of America (VMA) to ensure a consistent methodology is specified across both API and ASME standards.

b. Require that new plug valves be designed, consistent with Prevention through Design principles, to prevent the inadvertent removal of pressure-retaining components when removing the actuator or gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those incidents, when formulating a new plug valve design. Work with API and VMA to ensure a consistent methodology is specified across both API and ASME 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

LyondellBasell Industries (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 25, 2023

2021-05-I-TX-1

Update LyondellBasell policy documents to require that procedures are developed for properly removing actuating equipment from plug valves. Require that the procedures clearly identify which non-pressure-retaining components are safe to remove and pressure-retaining components that shall not be removed, as well as ensure LyondellBasell personnel are trained on these procedures. Ensure that hazardous energy is controlled when performing these procedures, as required by 29 C.F.R. 1910.147. Require in the policy document that risk assessments for process safety are conducted before the actuating equipment removal work is authorized. Ensure that sufficient procedures and safeguards are in place to prevent worker exposure to process fluid.


Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

PDF Document Recommendation Status Change Summary

2021-05-I-TX-2

Update LyondellBasell policy documents to require that LyondellBasell competent employee(s), as defined by 29 C.F.R. 1926.32(f), verify that contractors are competent, adequately trained, and qualified to perform the required work. To make this determination and to ensure work on process equipment is conducted in a safe manner, LyondellBasell competent employees may be required to oversee the work conducted by contractors on the process equipment. In the updated policy documents, include requirements to ensure that contract employees are informed of relevant process hazards and relevant details about the process equipment and are provided with equipment-specific procedures necessary to safely conduct their work.


Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

PDF Document Recommendation Status Change Summary

Turn2 Specialty Companies (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 25, 2023

2021-05-I-TX-3

Update Turn2 policy documents to require that Turn2 employees are provided with written, detailed procedures for safely conducting work on process equipment and are trained on the procedures before the work is authorized to be performed.


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

Valve Manufacturers Association of America (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 25, 2023

2021-05-I-TX-6

Work with ASME and API and develop a white paper to the Valve Manufacturers Association of America addressing the issue of plug valve design with a focus on the following:

a. Recommend as an industry good practice that facilities using plug valves establish written procedures detailing the correct way to remove the plug valve actuator or gearbox for each specific plug valve design.

b. For existing plug valves, recommend as an industry good practice for facilities to clearly mark all pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with ASME and API to ensure a consistent methodology is specified to the industry.

c. Recommend new plug valves be designed, consistent with Prevention through Design principles, to prevent the inadvertent removal of pressure-retaining components when removing the actuator or gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those incidents, when formulating a new plug valve design recommendation. Work with ASME and API to ensure a consistent design is recommended to the industry.


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

Macondo Blowout and Explosion (16 Recommendations)
American Petroleum Institute (API) (3 Recommendations)
Open: 67% | Closed: 33%

Final Report Released On: April 20, 2016

2010-10-I-OS-3

Publish an offshore exploration and production safety standard for the identification and effective management of safety critical elements (SCEs)— technical, operational, and organizational— with the goal of reducing major accident risk to As Low As Reasonably Practicable (ALARP), including but not limited to:
a. development and implementation of a SCE management system that includes the minimum necessary “shall” requirements in the standard to establish and maintain effective safety barriers to prevent major accidents;
b. methodologies for (1) the identification of SCEs and (2) the development of performance standards of each SCE, including its functionality, availability, reliability, survivability, and interactions with other systems;
c. establishment of assurance schemes for continuous active monitoring of all identified SCEs throughout each SCE’s lifecycle;
d. fulfillment of independent verification requirements and use of those verification activities to demonstrate robustness of the SCE management process;
e. development of process safety key performance indicators pertaining to the effective management of SCEs to drive continuous improvement.


Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

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2010-10-I-OS-4

Revise Blowout Preventer Equipment System for Drilling Wells (API Standard-53, 4th edition) to establish additional testing or monitoring requirements that verify the reliability of those individual redundant blowout prevention systems that are separate from the integrated system tests currently recommended.


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

2010-10-I-OS-5

Based on the analysis presented in the CSB Macondo investigation report, Volumes 3 and 4, and the requirements listed in R11, revise Recommended Practice 75, Development of a Safety and Environmental Management Program for Offshore Operations and Facilities, 3rd ed., May 2004 (reaffirmed May 2008), to require a specific focus on major accident prevention and address the following issues:
a.    Incorporate the following listed safety management system issues as explicit program elements and include language throughout API 75 regarding each element’s explicit and defined applicability to all of the other existing program elements:
1.    Human factors program requirements for the design, planning, execution, management, assessment, and decommissioning of well operations for the prevention of major accidents, as well as in the investigation of accidents and near-misses;
2.    Corporate governance and Board of Director responsibilities for major accident risk management;
3.    Workforce involvement and engagement in all aspects of the SEMS program;
4.    Contractor oversight and effective coordination for major accident prevention; and
5.    Leading and lagging key performance indicators that drive major accident prevention.
b.    Define and expand the roles and responsibilities for major accident prevention among the primary parties engaged in offshore drilling and production (i.e., the leaseholder/operator and owner/drilling contractor) by expanding applicability of this standard to the parties with primary control over major hazard operations and day-to-day activities and thus best positioned to implement and oversee a safety and environmental management system (SEMS) program to control major accident hazards.
c.    Incorporate into the Principles section of the document, as well as within the Setting Objectives and Goals section, as overarching provisions for the overall successful implementation and execution of a SEMS program:
1.    Management of major accident risk to As Low As Reasonably Practicable or similar risk-reduction target;
2.    Use the hierarchy of controls for identifying, establishing, and implementing barriers meant to prevent or mitigate major accident hazards.


Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

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Bureau of Safety and Environmental Enforcement (BSEE) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2016

2010-10-I-OS-1

Augment 30 C.F.R §250 Subpart S to require the responsible parties, including the lessee, operator, and drilling contractor, to effectively manage all safety critical elements (SCEs)— technical, operational, and organizational—thereby ensuring their effective operation and reducing major accident risk to As Low As Reasonably Practicable (ALARP).  At a minimum, require the following improvements:

a. Written identification of all safety critical elements for offshore operations through hazard analysis. This list will be made available for audits and inspections performed by the responsible parties, external entities (e.g., independent competent parties, third-party auditors), and the regulator, and it will be shared among the lessee, operator, and drilling contractor. Identifying all safety critical elements shall ensure the establishment and maintenance of effective safety barriers to prevent major accidents;

b. Documented performance standards (as defined in Section 5.2 of the CSB Macondo Investigation Report Volume 2) describing the required performance of each SCE, including its functionality, availability, reliability, survivability, and interactions with other systems;

c. Augmentation of 30 C.F.R §250.1916 to include requirements for all responsible parties, including contractors, to conduct monitoring for continuous active assurance of all identified SCEs through each SCE’s lifecycle (as described in Section 5.0 of the CSB Macondo Investigation Report Volume 2);

d. Documented independent verification scheme for the identified SCEs reported to and subject to review by the regulator (as described in Section 5.5 of the CSB Macondo Investigation Report Volume 2), where:

1. the independent party meets BSEE criteria that guarantees its competence and independence from the company or facility for which it is providing verification;
2. the independent verification occurs prior to commencement of the offshore drilling or production activity and periodically, as defined by BSEE;
3. all resulting assessments of the independent verification activities will be tracked in a formal records management system; and
4. corrective action shall be taken to address negative verification findings and non-compliance. Verified noncompliance shall be tracked by the responsible party as a process safety key performance indicator and be used to drive continuous improvement.


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.
 

2010-10-I-OS-2

Publish safety guidance to assist the responsible parties in fulfillment of regulatory obligations stipulated in R1 for the identification and effective management of safety critical elements (SCEs)—technical, operational, and organizational— with the goal of reducing major accident risk to As Low As Reasonably Practicable (ALARP), including but not limited to each of the identified minimum requirements (See R1, items a-d).


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.
 

Department of the Interior (DOI) [delegated to DOI-BSEE] (9 Recommendations)
Open: 33% | Closed: 67%

Final Report Released On: April 20, 2016

2010-10-I-OS-6

Drawing upon best available global standards and practices, develop guidance to assist industry in the incorporation of human factors principles into the systematic analysis of their major accident hazards, development of their SEMS programs, and in the preparation of their major hazards report documentation. This standard shall provide guidance on topics including, but not limited to, safety critical task assessment and the development and verification of non-technical skills. Include the participation of diverse expertise in the development of the standard including industry, workforce, and subject matter expert representatives.


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

2010-10-I-OS-7

Drawing upon best available global standards and practices, develop guidance addressing the roles and responsibilities of corporate board of directors and executives for effective major accident prevention. Among other topics, this standard shall provide specific guidance on how boards and executives could best communicate major accident safety risks to their stakeholders, as well as corporate level strategies to effectively manage those risks.


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendations Status Change Summary

2010-10-I-OS-8

Expand upon the principles of the BSEE Safety Culture policy and establish a process safety culture improvement program for responsible parties as defined in R11(a) that periodically administers process safety culture assessments and implements identified major accident prevention improvements. The process safety culture improvement program shall include a focus on items that measure, at a minimum, willingness to report incidents and near-misses, effectiveness of workforce participation efforts, organizational drift from safety policies and procedures, and management involvement and commitment to process safety.


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

2010-10-I-OS-11

Revise and augment the offshore safety regulations, including the SEMS Rule (C.F.R. 250 subpart S), and issue guidance as it relates to those revisions/augmentations, to:
a.    Establish clear and consistent safety and environmental management responsibilities to prevent major accidents for the companies having primary control over the hazardous activities being undertaken (e.g., the owner/drilling contractor for a non-production installation and the leaseholder/operator for the production installation);
b.    Require all responsible parties as defined in R11(a) to develop documentation for each hazardous operation/facility it maintains primary control over, where the documentation demonstrates the party’s systematic analysis that risks posed by all identifiable major accident hazards are reduced to As Low As Reasonably Practicable (ALARP) or similar risk-reduction target. The documentation shall include:
1.    Identification of major hazards and the barriers and safety management systems controls (including augmented SEMS elements) that will be used to reduce risk to ALARP or similar risk reduction target;
2.    Use of the hierarchy of controls to the greatest extent feasible in establishing safety barriers and controls;
3.    Identification of safety critical elements and tasks to establish and maintain safety barriers and controls, in fulfillment of R1 (See Volume 2);
4.    Demonstrate use of established qualitative, quantitative and semi-quantitative methods in determining (1) the barriers and safety management systems necessary to achieve ALARP risk reduction levels and (2) the performance requirements of those barriers and controls (e.g., reliability, functionality, and availability) to ensure their effectiveness;
5.    Identification of all US and international standards that have been applied, or will be applied, in relation to the facility, hazardous operation, or equipment used on/in connection with the operation for which required documentation is submitted. Should the responsible party wish to use standards other than well-recognized US or international consensus safety standards developed by a representative committee of diverse stakeholders, a detailed technical justification that those standards achieve risk-reduction to ALARP must accompany submitted documentation. The regulator may challenge or reject the technical justification. Remove from the US offshore safety regulatory scheme the provisions that allow companies to substitute requirements to use the best available and safest technology with a showing of compliance with BSEE regulations.
c.    Require responsible parties as defined by R11(a) to fully implement all aspects of the documentation stipulated in R11(b) and establish a documented process to verify that all methods to manage, reduce, and control those hazards are effectively maintained throughout the lifecycle of the operation/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.
 

2010-10-I-OS-12

Augment the capabilities and functioning of BSEE to incorporate the following proactive oversight mechanisms:
a.    Review of the documentation required to be submitted under CSB 2010-I-OS-R11(b) by technically qualified regulatory personnel who have the capability and authority to require modifications and improvements to the major hazards report as necessary, either before an acceptance process and commencement of the major hazards operation(s) or during periodic proactive review by the regulator;
b.    Establish a program for preventive, comprehensive inspections and audits with technically qualified staff as described in R13(a) to ensure that the responsible party as defined in R11(a) can demonstrate the risk reduction commitments stipulated in its major hazards report.


Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

2010-10-I-OS-13

Further enhance the qualifications, professional competency, and diversity of BSEE staff to implement major accident prevention programs by:
a.    Continuing efforts to enhance recruiting and retention of sufficient staff with a diversity of expertise, professional backgrounds and skill sets, such that BSEE has staff competencies in a variety of safety-critical and technical areas, including petroleum, chemical, and mechanical engineering; human and organizational factors; well design and control; and process safety, as well as those with industry experience to perform an even more expanded mission as envisioned in this report;  
b.    Retaining the services of a human resources consulting firm to complement BSEE’s efforts to date on human capital management and workforce planning issues, in light of documented difficulties in recruiting and retaining necessary staff, including the development of a plan with respect to large numbers of retirements facing the agency in the coming decade, as well as a compensation analysis (and a plan for subsequent periodic market analyses and benchmarking) to ensure BSEE remains competitive with other employers in the offshore industry. Augment the agency’s compensation system as necessary to enable BSEE to attract and retain the level of staffing needed to perform BSEE’s mission.
c.    Continuing to assess, expand, and improve ongoing BSEE training programs for new hires to provide all employees with robust skill sets, including appropriate technical training as well as interpersonal skills such as communications, negotiation and advocacy.

If funding, legislative authority, or other approvals are required to implement the recommended regulatory provisions in Recommendation R11 – R13, the Secretary of the Interior shall seek such authority from Congress or expedited hiring authority from the Office of Personnel Management.


Status: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendation Status Change Summary

2010-10-I-OS-14

Expand the offshore safety regulatory program that collects, tracks, and analyzes safety performance indicators from industry to further influence industry efforts in reducing major accident risks to ALARP. At a minimum, this program shall:
a.    Require the reporting of safety indicator data by all responsible parties, as defined in R11(a);
b.    Emphasize the greater preventive value of using leading indicators to actively monitor the health and performance of major accident safety barriers and the management systems meant to ensure their effectiveness, and work with industry to develop leading indicators that are measurable, actionable, normalized across industry, and that occur with sufficient frequency to allow for meaningful trending and analysis at the facility and corporate levels;
c.    Augment current reporting requirements to include leading safety performance indicators;
d.    Use the safety performance indicator data to:
1.    identify industrywide, companywide, and facility-specific safety trends and deficiencies;
2.    set annual process safety goals or targets for the industry, company and/or facility, as appropriate, based upon those identified safety trends and deficiencies;
3.    issue, at a minimum, annual reports that publicly communicate those trends, deficiencies, targets, and goals; and
4.    determine future appropriate allocations of BSEE resources and the prioritization of BSEE inspections;
e.    Include use of significant lagging indicators data (including those already mandated by 30 C.F.R. 250.188(a) and (b), such as major events like explosions, fires, gas releases, fatalities, INCs) as qualification criteria in the lease-approval and permit-to-drill decision-making processes by the regulator.


Status: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendation Status Change Summary

2010-10-I-OS-15

Issue participation regulations and training requirements for workers and their representatives that include the following:
a.    Worker-elected safety representatives and safety committees for each staffed offshore facility chosen under procedures overseen by the regulator; these safety representatives will have the authority to interact with employers (such as operators and drillers) and regulators on issues of worker health and safety risks and the development and implementation of the major hazard report documentation;
b.    The elected worker representative has the right to issue an enforceable stop-work order if an operation or task is perceived as unsafe; all efforts should be made to resolve the issue at the workplace level, but if the issue remains unresolved, BSEE shall establish mechanisms such that the worker representative has the right and ability to seek regulator intervention to resolve the issue, and the regulator must respond in a timely fashion;
c.    The regulator will host an annual tripartite forum for workforce representatives, industry management, and the regulator to promote opportunities for interaction by all three entities on safety matters and to advance initiatives for major accident prevention.
d.    Protections for workers participating in safety activities with a specific and effective process that workers can use to seek redress from retaliatory action with the goal to provide a workplace free from fear that encourages discussion and resolution of safety issues and concerns. Protected activities include, but are not limited to reporting unsafe working conditions, near misses, and situations where stop work authority is used.


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 Recommendations Status Change Summary

2010-10-I-OS-16

Incorporate by reference into the offshore safety regulations the revised version of Recommended Practice 75, Development of a Safety and Environmental Management Program for Offshore Operations and Facilities, 3rd Ed., May 2004 (reaffirmed May 2008) upon the inclusion of the CSB recommendations in R11 by API.


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.
 

Ocean Energy Safety Institute (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 20, 2016

2010-10-I-OS-10

Conduct further study on riser gas unloading scenarios, testing, and modeling and publish a white paper containing technical guidance that communicates findings and makes recommendations for industry safety improvements.


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

Sustainability Accounting Standards Board (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 20, 2016

2010-10-I-OS-9

Update, strengthen, and finalize the SASB’s provisional Oil & Gas Exploration & Production Sustainability Accounting Standard by enhancing standard NR0101-18. Expand recommended coverage of “Process Safety Event rates for Loss of Primary Containment of greater consequences” in accordance with the findings of this report. Specifically, this expanded coverage shall:
a.    Recommend the disclosure of additional leading and lagging indicators and emphasize the greater preventive value of disclosure of a company’s use of leading indicators to actively monitor the health and performance of major accident safety barriers and the management systems for ensuring their effectiveness. Specifically add:
1.    Indicators addressing the health of safety barriers to be communicated to the workforce, and to shareholders in required SEC disclosures, and also to be made readily available to the regulator.  
2.    Guidance emphasizing and promoting the concept that personal safety metrics such as those captured in NR0101-17 (total recordable injury rate, fatality rate, near-miss frequency rate) are important but separate from leading and lagging process safety performance indicators, which better correlate to major accident prevention.
•    Accomplish this communication within NR0101-18.
•    Supplement this effort within the SASB’s Oil & Gas Exploration & Production Research Briefs, based on the findings of this report as well other current safety scholarship that demonstrates the lack of correlation between personal safety efforts and process safety and major accident prevention initiatives.


Status: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendation Status Change Summary