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

Optima Belle Explosion and Fire (15 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-15

Update Guidelines for Process Safety in Outsourced Manufacturing Operations or develop a new tolling guidance document to supplement existing guidelines. The publication should include current best practices, introduce guidance specific to tolling brokers and/or project managing companies such as Richman Chemical Inc., and cross-reference and align with the comprehensive management systems framework and terminology contained in Guidelines for Risk Based Process Safety and other contemporary industry good practice guidance.


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

Clearon Corporation (5 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-5

Develop and implement a comprehensive process knowledge management program or evaluate and revise existing process safety management procedures to ensure consistency with industry guidance publications such as the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety. The program should:

a) assign specific responsibilities for compiling content and maintaining robust process technology and safety information packages that incorporate relevant knowledge for all hazardous processes and substances operated, manufactured, and/or handled by Clearon Corporation;

b) ensure that key process personnel are aware of critical reactive chemistry information, including thermal stability and calorimetry data, chemical compatibility information, and descriptions of any past reactive incidents and safety studies involving the materials; and

c) define procedures for the transmittal of such information to toll manufacturers.


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

2021-02-I-WV-6

Update the sodium dichloroisocyanurate dihydrate (CDB-56®) safety data sheet. At a minimum, the document should:

a) provide the underlying reasoning for the storage temperature maximum and the consequences of exceeding that temperature;

b) provide the underlying reasoning for the decomposition temperature and the consequences of exceeding that temperature;

c) explain or make clear the reason(s) for and/or the circumstance(s) resulting in the differences between the decomposition temperature and the lowest temperature at which self-accelerating decomposition may occur; and

d) provide the exothermic decomposition energy in the Physical Properties section.


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

2021-02-I-WV-7

Develop and implement a written program for tolling process design and equipment selection using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety to ensure that:

a) equipment design basis is adequate for any new tolling process or product; and

b) safeguards and ancillary equipment are considered and adequately designed, installed, and function as designed and required.


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

2021-02-I-WV-8

Develop and implement a formalized program for the development of toll manufacturing agreements using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety. Ensure that the program provides for the following:

a) Identification of roles and responsibilities of all parties, including the client, toller, and any third-party technical service providers, for all phases of a proposed arrangement;

b) Evaluation of equipment requirements/specifications to ensure that they are adequate for the intended operation; and

c) Participation by all parties in tolling process development, including process hazards analysis and emergency planning, and appropriate stages of the pre-planning, pre-startup, and production phases.


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

2021-02-I-WV-9

Develop and implement a process safety management system consistent with industry guidance publications such as is contained in the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety. At a minimum, the process safety management system should address hazard identification, risk analysis, and management of risk.


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 Center for Biotechnology Information (NCBI) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-14

Update the safety information in PubChem for sodium dichloroisocyanurate (NaDCC) dihydrate, to include publicly available reactivity and decomposition information including but not limited to the Self Accelerating Decomposition Temperature (SADT), the explosion hazard when heating metal containers containing NaDCC dihydrate, and the Differential Scanning Calorimetry (DSC) and Accelerating Rate Calorimetry (ARC) results presented in this report. When compiling this information, review sources including the Registration, Evaluation, Authorization, and Restriction of Chemicals Regulation (REACH) dossier and other publications.


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

Occupational Safety and Health Administration (OSHA) (3 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-11

Update the Chemical Reactivity Hazards website (https://www.osha.gov/chemical-reactivity) to include various reactivity assessment tools developed since the 2002 Index-Based Method for Assessing Exothermic Runaway Risk and the 2004 Preliminary Screening Method. Mathematical methods, thermal analysis methods (e.g., Accelerating Rate Calorimeter (ARC) testing), ASTM E1231-19 Standard Practice for Calculation of Hazard Potential Figures of Merit for Thermally Unstable Materials, Stoessel Criticality, and the O.R.E.O.S. Method (an assessment that combines Oxygen balance calculations, the Rule of 6, and the Explosive functional group list with Onset decomposition and scale) are tools that could be considered for the update. The “Additional Resources” section of the website should also be evaluated for necessary changes and updates.


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

PDF Document Recommendation Status Change Summary

2021-02-I-WV-12

Following the implementation of CSB recommendation 2021-02-I-WV-R11, ensure that the chemical industry is aware of the Chemical Reactivity Hazards website (https://www.osha.gov/chemical-reactivity) by developing and implementing a comprehensive outreach plan that actively targets the chemical industry and related trade associations. The outreach plan may include such means as a national news release and OSHA’s “QuickTakes” newsletter and/or Safety and Health Information Bulletins. This outreach plan should be coordinated with OSHA’s On-Site Consultation Program partners.


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

PDF Document Recommendation Status Change Summary

2021-02-I-WV-13

Amend the Process Safety Management (PSM) Standard, 29 CFR 1910.119, to achieve more comprehensive control of reactive hazards that could have catastrophic consequences.

  • Broaden the application to cover reactive hazards resulting from process-specific conditions and combinations of chemicals. Additionally, broaden coverage of hazards from self-reactive chemicals. In expanding PSM coverage, use objective criteria. Consider criteria such as the North American Industry Classification System (NAICS), a reactive hazard classification system (e.g., based on heat of reaction or hazardous gas evolution), incident history, or catastrophic potential.
  • In the compilation of process safety information, require that multiple sources of information be sufficiently consulted to understand and control potential reactive hazards. Useful sources include but are not limited to:

- Literature surveys (e.g., Bretherick’s Handbook of Reactive Chemical Hazards, Sax’s Dangerous Properties of Industrial Materials, CAS SciFinder).

- Information developed from computerized tools (e.g., ASTM’s CHETAH, CCPS’s Chemical Reactivity Worksheet).

- Chemical property data compiled in PubChem and the REACH (Registration, Evaluation, and Authorization of Chemicals) dossiers maintained by the European Chemicals Agency (ECHA).

- Chemical reactivity test data produced by employers or obtained from other sources following established standards such as:

- ASTM E537-20, Standard Test Method for Chemicals by Differential Scanning Calorimetry;

- ASTM E1981-22, Standard Guide for Assessing Thermal Stability of Materials by Methods of Accelerating Rate Calorimetry;

- ASTM E2550-21, Standard Test Method for Thermal Stability by Thermogravity; and

- ASTM E1231-19, Standard Practice for Calculation of Hazard Potential Figures of Merit for Thermally Unstable Materials.

- Relevant incident data from the plant, the corporation, industry, and government.

  • Augment the process hazard analysis (PHA) element to explicitly require an evaluation of reactive hazards. In revising this element, evaluate the need to consider relevant factors, such as:

- Rate and quantity of heat or gas generated.

- Maximum operating temperature to avoid a runaway reaction from decomposition.

- Time to Maximum Rate under Adiabatic Conditions (TMRad).

- Thermal stability of reactants, reaction mixtures, byproducts, waste streams, and products.

- Effect of variables such as charging rates, catalyst addition, and possible contaminants.

- Understanding the consequences of runaway reactions or hazardous gas evolution.

(Superseded 2001-01-H-XX-R1)


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

PDF Document Recommendation Status Change Summary

Optima Belle LLC (4 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-1

Develop and implement a written thermal and reactive hazards evaluation and management program. The program should adhere to industry guidance provided in publications such as the Center for Chemical Process Safety’s Essential Practices for Managing Chemical Reactivity Hazards. At a minimum, the program should identify the process that Optima Belle will use to manage chemical reactivity hazards, resources for collecting and assessing reactivity hazards, steps for determining how and when to test for chemical reactivity, documentation requirements, and training.


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

2021-02-I-WV-2

Develop and implement a written program for tolling process design and equipment selection using guidance from the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety and Guidelines for Process Safety in Outsourced Manufacturing Operations to ensure that:

a) equipment design basis is adequate for any new tolling process or product;

b) safeguards and ancillary equipment are considered and adequately designed, installed, and function as designed and required; and

c) new processes are evaluated for potential process hazards at the laboratory and/or pilot scale before production scale.

This written program should incorporate the information developed in Optima Belle’s thermal and reactive hazards evaluation program (see CSB recommendation 2021-02-I-WV-R1) to ensure that chemical hazards are fully understood and controlled.

 


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

2021-02-I-WV-3

Develop and implement a formalized program for the development of toll manufacturing agreements using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety. Ensure that the program provides for the following:

a) Identification of roles and responsibilities of all parties, including the client, toller, and any third-party technical service providers, for all phases of a proposed arrangement; 

b) Evaluation of equipment requirements/specifications to ensure that they are adequate for intended operation; and

c) Participation by all parties in the tolling process development, including process hazards analysis and emergency planning, and appropriate stages of the pre-planning, pre-startup, and production phases.


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

2021-02-I-WV-4

Develop and implement a process safety management system consistent with industry guidance publications such as is contained in the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety. At a minimum, the process safety management system should address hazard identification, risk analysis, and management of risk.


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

Richman Chemical Inc. (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-10

Develop and implement a formalized program for the development of toll manufacturing agreements using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety. Ensure that the program provides for the following:

a) Identification of roles and responsibilities of all parties, including the client, toller, and any third-party technical service providers, for all phases of a proposed arrangement; and

b) Participation by all parties in tolling process development, including process hazards analysis and emergency planning, and appropriate stages of the pre-planning, pre-startup, and production phases.


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

Packaging Corporation of America Hot Work Explosion (1 Recommendations)
Packaging Corporation of America (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: April 24, 2018

2017-03-I-LA-1

Apply the CSB safety guidance to PCA pulp and paper mills that produce NCG and operate NCG systems, which includes all foul condensate tanks. For these NCG systems:

  • Apply effective process safety management elements using good practice guidance, such as CCPS Guidelines for Risk Based Process Safety, and Guidelines for Implementing Process Safety Management;
  • Consider further expanding process safety management program boundaries beyond the minimum legal requirements to provide heightened coverage of process safety hazards;
  • Apply NFPA 69, Standard on Explosion Prevention Systems, to provide effective explosion prevention;
  • Where explosions cannot be prevented in accordance with NFPA 69, apply NFPA 68, Standard on Explosion Protection by Deflagration Venting, to provide explosion protection;
  • Ensure safety instrumented systems (safety interlocks) achieve desired risk reduction by applying the life-cycle approach provided in ISA-84, Functional Safety: Safety Instrumented Systems for the Process Industry Sector;
  • Apply TIP 0416-09, Collection and burning of concentrated noncondensible gases: regulations, design and operation, for effective NCG system design and operation;
  • Provide workers with periodic training to ensure they have an understanding of all process safety hazards applicable to areas of their responsibility and job tasks, including the safety conditions needed to permit hot work.

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

Partridge Raleigh Oilfield Explosion and Fire (4 Recommendations)
Mississippi State Oil & Gas Board (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2007

2006-7-I-MS-3

Establish a program to identify and refer to the federal Occupational Safety and Health Administration (OSHA) potentially unsafe health and safety conditions observed during board field inspections of well sites and drilling operations. Ensure that the program includes: -Written procedures that define how the referrals will be implemented; and, -Training of field inspectors so that they are able to recognize the potentially unsafe health and safety conditions that should be referred to OSHA.


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.
 

Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2007

2006-7-I-MS-4

Implement a Local Emphasis Program (LEP) to inspect companies in the oil and gas production and extraction sector.


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

PDF Document Download

Partridge-Raleigh, LLC (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2007

2006-7-I-MS-2

Establish written health and safety performance standards and performance metrics such as those found in Recommended Practice for Occupational Safety for Onshore Oil and Gas Production, API RP-74.


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).
 

Stringer's Oil Field Services, Inc. (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2007

2006-7-I-MS-1

Develop and implement written procedures to ensure safe work practices during hot work, tank cleaning, and work at elevated locations.


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.
 

Praxair Flammable Gas Cylinder Fire (2 Recommendations)
Compressed Gas Association (CGA) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 15, 2006

2005-5-I-MO-1

Communicate with your members who operate gas repackaging facilities the details of this incident and the best practices for handling and storing cylinders.


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.
 

2005-5-I-MO-2

Revise CGA standards for the CG-7 relief valves used in propylene service to require: 1) a greater margin between vapor pressure and relief valve set point (similar to propane); and 2) that valves be capable of multiple operations within the specified setpoint tolerance or be furnished with an indicator that alerts users that the valve has operated.


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.
 

Pryor Trust Fatal Gas Well Blowout and Fire (19 Recommendations)
American Petroleum Institute (API) (5 Recommendations)
Open: 40% | Closed: 60%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-2

Establish and convene a group of experts with drilling, engineering, and instrumentation expertise to discuss methods to achieve widespread implementation of automatic safety instrumented systems that could bring a well to a safe state in the event other operational barriers fail. Publish a technical bulletin discussing the strategies to implementing Blowout Preventer (BOP) safety instrumented systems.


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

2018-01-I-OK-3

For onshore drilling operations, develop and publish a recommended practice providing guidance on safely tripping drill pipe during (1) overbalanced drilling operations, (2) managed pressure drilling operations, and (3) underbalanced drilling operations. At a minimum, include information on:

(a) Required equipment for tripping operations,

(b) Techniques and procedures for controlling or preventing formation fluid influx, and

(c) Methods to monitor the well and replace the drill pipe displacement volume with drilling fluid (e.g., mud).


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

PDF Document Recommendation Status Change Summary

2018-01-I-OK-4

Develop a recommended practice on alarm management specifically for the drilling industry based on guidance in ANSI/ISA 18.2 Management of Alarm Systems for the Process Industries. The recommended practice will address the unique dynamic environment of the drilling industry and provide guidance on implementing a state-based alarm system for different operating modes (e.g., drilling, circulating, tripping, etc.). Include International Association of Drilling Contractors (IADC) in the development of this recommended practice.


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

PDF Document Recommendation Status Change Summary

2018-01-I-OK-5

Develop a new recommended practice or modify an existing recommended practice (e.g. API RP 54 Recommended Practice for Occupational Safety for Oil and Gas Well Drilling and Servicing Operations) addressing the protection of rig workers on onshore drilling rigs from fire and explosion hazards in the event of a blowout. The recommended practice will specifically address:

(a) Protecting drilling cabin occupants from blowout hazards including heat, blast overpressure, and projectiles, such as requiring an increased fire rating for the driller’s cabin that would allow enough time for occupants to evacuate during a blowout and fire;

(b) Minimum required evacuation methods from the drilling cabin, rig floor, and mast or derrick in the event of a blowout so that personnel can quickly escape in variable hazard location conditions. For example, floor exit hatches and exits on the driller’s cabin wall opposite the rig floor could provide safe evacuation routes during a blowout and fire; and

(c) Proximity of the Blow Out Preventer (BOP) activation controls with the driller.

The above options could be retrofitted on existing drilling rigs. Additionally, formally evaluate alternative locations for the drilling cabin that establishes a safe distance from fire and explosion hazards (e.g., ground level).


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

2018-01-I-OK-6

Update API Bulletin 97 Well Construction Interface Document Guidelines to specify that it applies to both onshore and offshore drilling operations.


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

PDF Document Recommendation Status Change Summary

International Association of Drilling Contractors (IADC) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-14

Participate in development of the recommended practice describe in recommendation 2018-01-OK-R4 to [American Petroleum Institute] 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.
 

PDF Document Recommendation Status Change Summary

National Oilwell Varco (NOV) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-17

Design the M/D Totco user interface to allow drilling contractors to pre-set different alarms for different operations (e.g., different alarm configurations for drilling, tripping, circulating, and surface operations in a “state-based” alarm system).


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

2018-01-I-OK-18

Design the M/D Totco electronic drilling data system so that alarm information, including alarm set points, alarm activation log, alarm horn status (on or off), and alarm system status (on or off) is provided to customers.


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

Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-1

Implement one of the three following options regarding regulatory changes:

(a) OPTION 1: Apply the Process Safety Management (PSM) standard (29 CFR 1910.119) to the drilling of oil and gas wells; or

(b) OPTION 2: Apply the Process Safety Management (PSM) standard (29 CFR 1910.119) to the drilling of oil and gas wells as in OPTION 1, and make the necessary modifications to customize it to oil and gas drilling operations; or

(c) OPTION 3: Develop a new standard with a safety management system framework similar to PSM that applies only to the drilling of onshore oil and gas wells that includes but is not limited to the following:

  1. Detailed written operating procedures with specified steps and equipment alignment for all operations;

  2. Written procedures for the management of changes (except replacements in kind) in procedures, the well plan, and equipment;

  3. A risk assessment of hazards associated with the drilling plan;

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

  5. Development of a Well Construction Interface Document between the operator and the drilling contractor prior to the commencement of drilling activities which at a minimum includes a bridging document and well plan specifying barriers and how to manage them;

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

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


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

Pason Systems Corp. (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-15

Design the Pason user interface to allow drilling contractors to pre-set different alarms for different operations (e.g., different alarm configurations for drilling, tripping, circulating, and surface operations in a “state-based” alarm system).


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

PDF Document Recommendation Status Change Summary

2018-01-I-OK-16

Design the Pason electronic drilling data system so that alarm information, including alarm set points, alarm activation log, alarm horn status (on or off), and alarm system status (on or off) is provided to customers.


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

Patterson-UTI (5 Recommendations)
Open: 20% | Closed: 80%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-7

Develop either corporate or rig-specific tripping procedure(s) that detail the required equipment configuration for tripping operations. Require that rig personnel visually verify that equipment is lined up as specified in the procedure before beginning the tripping operation. In the procedure(s), specify well-monitoring requirements for wet versus dry tripping 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 Recommendation Status Change Summary

2018-01-I-OK-8

Develop an alarm philosophy and alarm rationalization for rig operations. Based on the alarm philosophy and alarm rationalization, specify necessary alarms, at a minimum, for (1) drilling, (2) tripping, (3) circulating, and (4) rig floor activities (no drill pipe in well). Additionally, develop a policy implementing the alarm philosophy and rationalization.


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

PDF Document Recommendation Status Change Summary

2018-01-I-OK-9

Develop a policy that incorporates recommendations in API RP 59 Recommended Practice for Well Control Operations requiring the regular testing of drillers’ influx detection and response skills through formalized drills, for example by “simulat[ing] a gain in pit drilling fluid volume by raising a float sufficiently to cause an alarm to be activated.” In this policy, require that driller response time is monitored in the spirit of continual improvement.


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

2018-01-I-OK-10

Develop and implement a policy requiring that flow checks be documented, either electronically or with a paper record. At a minimum the documentation will require the reporting of:

  1. Operation during which flow check was performed

  2. Method of performing flow check

  3. Length of time flow check was performed

  4. Result of flow check

Require that the proper authorities (e.g., driller, company man, rig manager) sign or approve the flow check documentation after performing the flow check and before resuming operations. Keep the flow check documentation as part of the well file.


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

2018-01-I-OK-11

Update the Patterson metrics program to track leading and lagging indicators to measure the effectiveness of the overall safety management system. Specifically focus on measuring the effectiveness of the following safety management system components:

(a) The effectiveness of the flow check policy, including the frequency that flow checks are performed when required by Patterson policy;

(b) The frequency that flow checks are documented and approved as recommended in 2018-01-OK-R10;

(c) The effectiveness of the management of change program, for both equipment and procedural changes, including real-time procedure changes;

(d) The frequency that alarms are set at the required set points;

(e) The frequency that drilling rig alarm horns or the entire alarm system is turned off; and

(f) The frequency that trip sheets are filled out properly.


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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Red Mountain Operating (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-12

Develop a new policy that a well-specific Well Construction Interface Document be in place before drilling operations begin, as specified in API Bulletin 97 Well Construction Interface Document Guidelines. Ensure the policy requires that the Well Construction Interface Document specifies the technical requirements of the rig equipment and technical qualifications of personnel (e.g., conventional drilling, managed pressure drilling, underbalanced drilling) as well as specifies which barriers must be maintained and the expected response if a barrier is lost.


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.
 

2018-01-I-OK-13

Develop a management of change policy governing real-time changes to operations and the drilling plan. As part of this policy, require hazard analysis and consideration of rig equipment, procedures, and personnel training and qualifications.


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.
 

State of Oklahoma/Oklahoma Corporation Commission (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-19

Establish and implement safety regulations requiring entities who design oil and gas well drilling plans for wells in Oklahoma (e.g., operators) and entities who perform the drilling operation (e.g., drilling contractors) to develop and implement the following prior to conducting drilling operations:

(a) Detailed written operating procedures with specified steps and equipment alignment for all operations;

(b) Written procedures for the management of changes (except replacements in kind) in procedures, the well plan, and equipment;

(c) A risk assessment of hazards associated with the drilling plan;

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

(e) Development of a Well Construction Interface Document between the operator and the drilling contractor prior to the commencement of drilling activities which at a minimum includes a bridging document and well plan specifying barriers and how to manage them;

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

(g) A requirement for employee participation, similar to the Employee Participation requirement in the OSHA PSM standard.


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

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