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

Tesoro Refinery Fatal Explosion and Fire (16 Recommendations)
American Petroleum Institute (API) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2014

2010-08-I-WA-10

Revise American Petroleum Institute API RP 941: Steels for Hydrogen Service at Elevated Temperatures
and Pressures in Petroleum Refineries and Petrochemical Plants
to: 

a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems;

b. Require the use of inherently safer materials to the greatest extent feasible;

c. Require verification of actual operating conditions to confirm that material of construction selection prevents HTHA equipment failure; and

d. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure.


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

2010-08-I-WA-11

Revise American Petroleum Institute API RP 581: Risk-Based Inspection Technology to:

a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems;

b. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure; and

c. Require verification of actual operating conditions to determine potential equipment damage mechanisms.

 


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

Environmental Protection Agency (EPA) (4 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: May 01, 2014

2010-08-I-WA-1

Revise the Chemical Accident Prevention Provisions under 40 CFR Part 68 to require the documented use
of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible when
facilities are establishing safeguards for identified process hazards. The goal shall be to reduce the risk of major accidents to the greatest extent practicable, to be interpreted as equivalent to as low as reasonably practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all management of change, incident investigation, and process hazard analysis reviews and recommendations, prior to the construction of a new process, process unit rebuilds, significant process repairs, and in the development of corrective actions.


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.
 

2010-08-I-WA-2

Until Recommendation 2010-08-I-WA-R1 is in effect, enforce through the Clean Air Act’s General Duty
Clause, section 112(r)(1), 42 U.S.C.§7412(r)(1) the use of inherently safer systems analysis and the
hierarchy of controls to the greatest extent feasible when facilities are establishing safeguards for
identified process hazards.


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 Recommendations Status Change Summary

2010-08-I-WA-3

Develop guidance for the required use of inherently safer systems analysis and the hierarchy of controls for enforcement under 40 CFR Part 68 and the Clean Air Act’s General Duty Clause, section 112(r)(1),42 U.S.C. §7412(r)(1).


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.
 

2010-08-I-WA-4

Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective actions.


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

Governor and Legislature of the State of Washington (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 01, 2014

2010-08-I-WA-5

Based on the findings in this report, augment your existing process safety management regulations for
petroleum refineries in the state of Washington with the following more rigorous goal-setting attributes:

a. A comprehensive process hazard analysis written by the company that includes:

i. Systematic analysis and documentation of all major hazards and safeguards, using the hierarchy of controls to reduce those risks to as low as reasonably practicable (ALARP);

ii. Documentation of the recognized methodologies,rationale and conclusions used to claim that safeguards intended to control hazards will be effective;

iii. Documented damage mechanism hazard review conducted by a diverse team of qualified personnel. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure effective safeguards are in place to control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safer design to the greatest extent feasible into this review; and

iv. Documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.

b. A thorough review of the comprehensive process hazard analysis by technically competent regulatory
personnel;

c. Required preventative audits and preventative inspections by the regulator; 

d. Require that all safety codes, standards, employer internal procedures and recognized and generally
accepted good engineering practices (RAGAGEP) used in the implementation of the regulations contain adequate minimum requirements;

e. Require an increased role for workers in management of process safety by establishing the rights and responsibilities of workers and their representatives on health and safety-related matters, and the election of safety representatives and establishment of safety committees (with equal representation between management and labor) to serve health and safety-related functions. The elected representatives should have a legally recognized role that goes beyond consultation in activities such as the development of the comprehensive process hazard analysis, management of change, incident investigation, audits, and identification and effective control of hazards. The representatives should also have the authority to stop work that is perceived to be unsafe or that presents a serious hazard until the regulator intervenes to resolve the safety concern. Work force participation practices should be documented by the company to the regulator; and

f. Requires reporting of information to the public to the greatest extent feasible such as a summary of the comprehensive process hazard analysis which includes a list of safeguards implemented and standards utilized to reduce risk, and process safety indicators that demonstrate the effectiveness of the safeguards and management systems.

 


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.
 

2010-08-I-WA-6

Establish a well-funded, well-staffed, technically qualified regulator with a compensation system to
ensure the Washington Department of Labor and Industries regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical qualifications. Periodically conduct a market analysis and benchmarking review to ensure the
compensation system remains competitive with Washington petroleum refineries. 


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 Recommendations Status Change Summary

2010-08-I-WA-7

Work with the regulator, the petroleum refining industry, labor, and other relevant stakeholders in the
state of Washington to develop and implement a system that collects, tracks, and analyzes process safety leading and lagging indicators from operators and contractors to promote continuous process safety improvements. At a minimum, this program shall: 

a. Require the use of leading and lagging process safety indicators to actively monitor the effectiveness of process safety management systems and safeguards for major accident prevention. Include leading
and lagging indicators that are measureable, actionable, and standardized. Include indicators that measure safety culture, such as incident reporting and action item implementation culture. Require that the reported data be used for continuous process safety improvement and accident prevention;

b. Analyze data to identify trends and poor performer s and publish annual reports with the data at
facility and corporate levels;

c. Require companies to publicly report required indicators annually at facility and corporate levels;

d. Use process safety indicators (1) to drive continuous improvement for major accident prevention
by using the data to identify industry and facility safety trends and deficiencies and (2) to
determine appropriate allocation of regulator resources and inspections; and

e. Be periodically updated to incorporate new learning from world-wide industry improvements in order to drive continuous major accident process safety improvements in Washington.


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.
 

Tesoro Anacortes Refinery (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2014

2010-08-I-WA-15

Implement a process safety culture continuous improvement program at the Tesoro Anacortes Refinery
including a written procedure for periodic process safety culture surveys across the work force. The
process safety culture program shall be overseen by a tripartite committee of Tesoro management, USW
representatives, Washington State Department of Labor and Industries – Division of Occupational Safety
and Health, and the U.S. Environmental Protection Agency. This oversight committee shall:

a. Select an expert third party that will administer a periodic process safety culture survey;

b. Review and comment on the third party expert report developed from the survey;

c. Oversee the development and effective implementation of action items to address identified process safety culture issues; and

d. Develop process safety culture indicators to measure major accident prevention performance.

The process safety program shall include a focus on items that measure, at a minimum, willingness to
report incidents, normalization of hazardous conditions, burden of proof of safety in plant process safety programs and practices, and management involvement and commitment to process safety. The periodic process safety culture report shall be made available to the plant workforce. The minimum frequency of process safety culture surveys shall be at least once every three years.

 


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

PDF Document Recommendations Status Change Summary

Tesoro Refining & Marketing Company LLC (3 Recommendations)
Open: 33% | Closed: 67%

Final Report Released On: May 01, 2014

2010-08-I-WA-12

Actively participate with API in the completion ofrecommendation 2010-08-I-WA-R10. Document this participation.


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

2010-08-I-WA-13

Once recommendation 2010-08-I-WA-R12 is in effect, develop and implement a plan to meet therequirements established through the acceptable completion of recommendation 2010-08-I-WA-R10. Document the implementation of the plan and the corrective actions taken.


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 Summary

2010-08-I-WA-14

Revise and improve the Process Hazard Analysis (PHA), the Integrity Operating Window (IOW), and the
damage mechanism hazard review (DMHR) programs and cross-linking among these three programs such that all identified hazards are effectively managed in each program. For all Tesoro refineries require:

a. the IOW to review damage mechanism hazards from the most recent PHA and safeguards identified to control these hazards;

b. the IOW review or revalidation to be conducted at least every five years;

c. the IOW to analyze and incorporate applicable industry best practice, the hierarchy of controls, and inherently safer design to the greatest extent reasonably practicable;

d. the DMHR report to be developed by the DMHR team and not just the “corrosion expert;”

e.the DMHR team to review the operating data to verify an accurate understanding of how the data was obtained, what it represents, and that it appropriately addresses both routine and nonroutine operations;

f. the DMHR and/or IOW review to identify and review gaps between current industry best practices and existing Tesoro practices with regard to material selection and process controls and make recommendations that reduce risks from damage mechanism hazards;

g. the DMHR and IOW review to review applicable Tesoro and industry-wide damage mechanism incidents as part of the respective DMHR or IOW review;

h. the DMHR to review relevant MOCs to fully evaluate the impact of the MOC on damage mechanism hazards;

i. the identification of minimum qualifications for the “corrosion expert” and ensure that the DMHR team has the necessary skills to meet these requirements;

j. for sites that have a corrosion/materials engineer, the corrosion/materials engineer shall be a required participant in the DMHR; 

k. the PHA to review the most recent DMHR and IOW reviews in order to contain a complete record of all identified damage mechanism hazards, evaluate existing safeguards, and propose new safeguards to control the identified hazards;

l. the PHA to review the consequence of damage mechanism hazards identified in the risk-based inspection (RBI) program and IOW reviews to ensure effective safeguards are present to control the damage mechanism hazard; and

m. the PHA to use the hierarchy of controls and implement opportunities for inherently safer design
to the greatest extent reasonably practicable.  


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

USW Local 12-591 (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2014

2010-08-I-WA-16

Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight
committee as recommended under recommendation 2010-08-I-WA-R15.  


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 Recommendations Status Change

Washington State Department of Labor & Industries - Division of Occupational Safety and Health (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 01, 2014

2010-08-I-WA-8

Perform a verification audit at all Washington petroleum refineries to ensure: 

a. Prevention of HTHA equipment failure and safe operation of the equipment. Audit HTHA prevention and process condition monitoring techniques used at all Washington petroleum refineries. Verify that all affected equipment in use meets the requirements contained in Recommendation 2010-08-I-WA-R10;

b. For nonroutine work, a written hazard evaluation is performed by a multidisciplinary team and, where feasible, conducted during the job planning process prior to the day of the job execution. Verify that each facility has an effective written decision-making protocol used to determine when it is necessary to shut a process down to safely perform work or conduct repairs. Ensure the program reflects the guidance in the CCPS Risk Based Process Safety book related to hazardous nonroutine work; and

c. Effective programs are in place to control of the number of essential personnel present during all
hazardous nonroutine 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

2010-08-I-WA-9

Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight
committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure
the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective actions.


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.
 

Texas Tech University Chemistry Lab Explosion (4 Recommendations)
American Chemical Society (ACS) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 19, 2011

2011-5-CS-TX-2

Develop good practice guidance that identifies and describes methodologies to assess and control hazards that can be used successfully in a research laboratory.


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: October 19, 2011

2011-5-CS-TX-1

Broadly and explicitly communicate to the target audience of research laboratories the findings and recommendations of the CSB Texas Tech report focusing on the message that while the intent of 29 CFR 1910.1450 (Occupational Exposure to Hazardous Chemicals in Laboratories Standard) is to comprehensively address health hazards of chemicals, organizations also need to effectively implement programs and procedures to control physical hazards of chemicals (as defined in 1910.1450(b)). At a minimum:

a.     Develop a Safety and Health Information Bulletin (SHIB) pertaining to the need to control physical hazards of chemicals; and
b.     Disseminate the SHIB (and any related products) on the OSHA Safety and Health Topics website pertaining to Laboratories (http://www.osha.gov/SLTC/laboratories/index.html)

 


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 Download

Texas Tech University (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 19, 2011

2011-5-CS-TX-3

 

Revise and expand the university chemical hygiene plan (CHP) to ensure that physical safety hazards are addressed and controlled, and develop a verification program that ensures that the safety provisions of the CHP are communicated, followed, and enforced at all levels within the university.


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

2011-5-CS-TX-4

Develop and implement an incident and near-miss reporting system that can be used as an educational resource for researchers, a basis for continuous safety system improvement, and a metric for the university to assess its safety progress. Ensure that the reporting system has a single point of authority with the responsibility of ensuring that remedial actions are implemented in a timely manner.


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

Third Coast Industries Petroleum Products Facility Fire (13 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2009-03-I-TX-7

Communicate the findings of this report to your membership.


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.
 

Brazoria County, Texas (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2002-03-I-TX-4

Adopt a fire code, such as the NFPA Uniform Fire Code or the ICC International Fire Code, for application in unincorporated areas.


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.
 

Independant Lubricant Manufacturers Association (ILMA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2002-03-I-TX-6

Communicate the findings of this report to your membership.


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.
 

International Association of Fire Fighters (IAFF) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2002-03-I-TX-10

Communicate the findings of this report to your membership.


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.
 

International Code Council (ICC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2002-03-I-TX-3

Revise the International Fire Code to address the following issues: For facilities that are not staffed around the clock, specify circumstances where automatic fire detection is needed. Narrow exemptions for Class IIIB liquids. Expand fire protection analysis requirements to include all areas of a facility where there may be flammable or combustible fire 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

National Association of Chemical Distributors (NACD) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2002-03-I-TX-8

Communicate the findings of this report to your membership.


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 Association of Counties (NACo) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2002-03-I-TX-9

Communicate the findings of this report to your membership.


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).
 

National Association of State Fire Marshals (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2002-03-I-TX-12

Communicate the findings of this report to your membership.


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: March 06, 2003

2002-03-I-TX-2

Revise NFPA 30, the Flammable and Combustible Liquids Code, to address the following issues For facilities that are not staffed around the clock, specify circumstances where automatic fire detection is needed. Narrow exemptions for Class IIIB liquids. Expand fire protection analysis requirements to include all areas of a facility where there may be flammable or combustible fire risks.


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

PDF Document Recommendations Status Change Summary

National Volunteer Fire Council (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2002-03-I-TX-11

Communicate the findings of this report to your membership.


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.
 

Petroleum Packaging Council (PPC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2002-03-I-TX-5

Communicate the findings of this report to your membership.


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.
 

Risk and Insurance Management Society (RIMS) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2002-03-I-TX-13

Communicate the findings of this report to your membership.


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.
 

Third Coast Industries (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 06, 2003

2002-03-I-TX-1

Audit the Third Coast Terminals facility in Pearland, Texas, in light of the findings of this report. Take action to ensure that the facility's fire suppression and control procedures meet the relevant requirements of NFPA 30 and OSHA 1910.106.


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.
 

Tosco Avon Refinery Petroleum Naphtha Fire (7 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 21, 2001

1999-014-I-CA-5

Communicate the findings of this report to your membership.


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 Petrochemical and Refiners Association (NPRA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 21, 2001

1999-014-I-CA-5

Communicate the findings of this report to your membership.


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.
 

Paper, Allied-Industrial, Chemical and Energy Workers International Union (PACE) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 21, 2001

1999-014-I-CA-5

Communicate the findings of this report to your membership.


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.
 

Tosco Corporation (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 21, 2001

1999-014-I-CA-1

Conduct periodic safety audits of your oil refinery facilities in light of the findings of this report. At a minimum, ensure that: Audits assess the following: - Safe conduct of hazardous nonroutine maintenance - Management oversight and accountability for safety - Management of change program - Corrosion control program. Audits are documented in a written report that contains findings and recommendations and is shared with the workforce at the facility. Audit recommendations are tracked and implemented.


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.
 

Ultramar Diamond Shammock Golden Eagle Refinery (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 21, 2001

1999-014-I-CA-2

Implement a program to ensure the safe conduct of hazardous nonroutine maintenance. At a minimum, require that: A written hazard evaluation is performed by a multidisciplinary team and, where feasible, conducted during the job planning process prior to the day of job execution. Work authorizations for jobs with higher levels of hazards receive higher levels of management review, approval, and oversight. A written decision-making protocol is used to determine when it is necessary to shut down a process unit to safely conduct repairs. Management and safety personnel are present at the job site at a frequency sufficient to ensure the safe conduct of work. Procedures and permits identify the specific hazards present and specify a course of action to be taken if safety requirements such as controlling ignition sources, draining flammables, and verifying isolation are not met. The program is periodically audited, generates written findings and recommendations, and implements corrective actions.


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.
 

1999-014-I-CA-3

Ensure that MOC reviews are conducted for changes in operating conditions, such as altering feedstock composition, increasing process unit throughput, or prolonged diversion of process flow through manual bypass valves.


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.
 

1999-014-I-CA-4

Ensure that your corrosion management program effectively controls corrosion rates prior to the loss of containment or plugging of process equipment, which may affect 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.
 

Union Carbide Corp. Nitrogen Asphyxiation Incident (6 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 23, 1999

2009-05-I-LA-5

Communicate the findings of this report to your membership.


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.
 

Compressed Gas Association (CGA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 23, 1999

1998-05-I-LA-6

Communicate the findings of this report to your membership.


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 Institute for Occupational Safety and Health (NIOSH) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 23, 1999

1998-05-I-LA-3

Conduct a study concerning the appropriateness and feasibility of odorizing nitrogen in order to warn personnel of the presence of nitrogen when it is used in confined spaces.


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.
 

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

Final Report Released On: February 23, 1999

1998-05-I-LA-4

Issue a safety alert that addresses the hazards and provides safety guidelines for the use of temporary enclosures that are erected around equipment containing hazardous substances.


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.
 

Union Carbide Taft Plant (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 23, 1999

1998-05-I-LA-1

Post signs containing the warning "Danger, Confined Space: Do Not Enter Without Authorization" or similar wording at potential entryways when tanks, vessels, pipes, or other similar chemical industry equipment are opened. When nitrogen is added to a confined space, post an additional sign that warns personnel of the potential nitrogen hazard.


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.
 

1998-05-I-LA-2

Ensure that the plant safety program addresses the control of hazards created by erecting temporary enclosures around equipment that may trap a dangerous atmosphere in the enclosure if the equipment leaks or vents hazardous material.


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.
 

Universal Form Clamp Co. Explosion and Fire (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 10, 2007

2006-8-I-IL-1

Amend 1910.106 Flammable and Combustible Liquids to require facilities that handle flammable and combustible liquids to implement the requirements of 1910.38 Emergency Action Plans.


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

2006-8-I-IL-2

Amend 1910.38 Emergency Action Plans to require employers to conduct practice evacuation drills at least annually, but more frequently if necessary to ensure employees are prepared for emergencies.


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

US Ink Fire (8 Recommendations)
New Jersey Department of Community Affairs (3 Recommendations)
Open: 67% | Closed: 33%

Final Report Released On: January 15, 2015

2013-01-I-NJ-3

Revise the exemption for “manufacturing, production, and process equipment” under the New Jersey Uniform Construction Code (N.J.A.C 5:23-2.2) to require that equipment involved in processing, handling, or conveying combustible dust comply with the design and operating requirements of the current edition of the International Building Code.


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 Status Change Summary

2013-01-I-NJ-4

Develop and implement training for local code officials on the National Fire Protection Association (NFPA) standards referenced in the New Jersey adoption of the International Building Code (IBC) for occupancies with a high hazard classification (Group H); specifically, include training on equipment that handles combustible dust and the hazards involved.


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

2013-01-I-NJ-5

Promulgate a regulation that requires all occupancies handling hazardous materials to inform the local enforcement agency of any type of construction or installation of equipment at an industrial or manufacturing facility. Also require local enforcement agencies to evaluate the information to determine whether a construction permit is required.


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.
 

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

Final Report Released On: January 15, 2015

2013-01-I-NJ-1

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


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

2013-01-I-NJ-2

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

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

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

US Ink/Sun Chemical Corporation (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 15, 2015

2013-01-I-NJ-6

At the US Ink East Rutherford facility, install automatic fire alarm systems consistent with NFPA 72 (the National Fire Alarm Code) in manufacturing areas (such as mixing) where heat generation could occur.


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

2013-01-I-NJ-7

Revise the Capital Appropriations/Asset Request (CAR) form procedure for new installations and modifications to existing equipment to require at a minimum the following:

  • Process hazard analysis (PHA)
  • Management of change (MOC)
  • Review of engineering drawings for permits
  • Safety management of contractors
  • Training of plant operators based on applicable dust collection system guidelines and standards, including NFPA 91 and NFPA 654.

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 Recommendations Status Change Summary

2013-01-I-NJ-8

Develop and implement a management of organizational change protocol to allow for the transfer of knowledge and information to new personnel, at a minimum including initial or refresher training in the following:

  • Safety and health procedures
  • Lessons learned from previous incidents
  • Technical information for equipment
  • Routine plant operations.

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