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

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

Final Report Released On: October 11, 2022

2019-04-I-PA-4

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

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

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

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

Final Report Released On: October 11, 2022

2019-04-I-PA-5

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


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs.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the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

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Environmental Protection Agency (EPA) (3 Recommendations)
Open: 67% | Closed: 33%

Final Report Released On: October 11, 2022

2019-04-I-PA-1

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


Status: Open - 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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2019-04-I-PA-2

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


Status: 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.
 

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2019-04-I-PA-3

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


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

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

Final Report Released On: December 19, 2022

2020-02-I-TX-4

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


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

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2020-02-I-TX-5

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


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

PDF Document Recommendation Status Change Summary

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

Final Report Released On: December 19, 2022

2020-02-I-TX-1

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

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

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

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

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


Status: 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.
 

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2020-02-I-TX-2

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


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

PDF Document Recommendation Status Change Summary

2020-02-I-TX-3

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


Status: 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

Yenkin-Majestic Resin Plant Vapor Cloud Explosion and Fire (7 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: November 30, 2023

2021-04-I-OH-6

Develop specific design, construction, and alteration guidance for low-pressure process vessels in flammable and other highly hazardous chemicals service not exceeding an internal pressure of 15 psig in API 510 Pressure Vessel Inspection Code, API RP 572 Inspection Practices for Pressure Vessels, and/or other appropriate products. At a minimum, include guidance for:

(i) determining and documenting the low-pressure vessel’s design pressure (such as through a data sheet and a nameplate affixed to the vessel);

(ii) determining when or if all or parts of the ASME Boiler and Pressure Vessel Code should be applied;

(iii) acceptable alternative engineering methods, if applicable; and,

(iv) alteration requirements, such as design assessments, inspections, and pressure testing.


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: November 30, 2023

2021-04-I-OH-7

Assist API in developing design, construction, and alteration guidance for low-pressure vessels in flammable and other highly hazardous chemicals service not exceeding an internal pressure of 15 psig. If any new design and construction guidance is specifically developed for pressure vessels in flammable and other highly hazardous chemicals service not exceeding an internal pressure of 15 psig, reference the design and construction guidance in the Section VIII, Division 1 of the ASME Boiler and Pressure Vessel Code (BPVC).


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

Yenkin-Majestic Paint Corporation (5 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: November 30, 2023

2021-04-I-OH-1

Update mechanical integrity procedures for all process vessels in highly hazardous chemicals service, including pressure vessels not exceeding 15 psig, to adopt alteration guidance in API 510 Pressure Vessel Inspection Code or Part 3 of the National Board Inspection Code.


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

2021-04-I-OH-2

Assess and document applicable design, construction, and alteration standards for all pressure vessels in highly hazardous chemicals service in new resin plant designs, including pressure vessels not exceeding 15 psig. At a minimum, adopt PIP VESLP001 Low-Pressure, Welded Vessel Specification as design and construction guidance for pressure vessels not exceeding 15 psig. Implement a program to assess the pressure vessels against updated applicable recognized and generally accepted good engineering practices, such as those published by API, ASME, PIP, and other organizations, at least once every five years, and address the gaps identified. Develop and implement written procedures to document and maintain records of (i) all inspections of, (ii) all alterations to, and (iii) all maintenance and repairs on all pressure vessels in highly hazardous chemicals service.


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

2021-04-I-OH-3

Demonstrate the use of prevention through design using the hierarchy of controls in future resin plant designs. Specifically, prioritize inherently safer design and engineering controls to prevent process safety events. Refer to sources such as Safety Instrumented Systems: A Life-Cycle Approach by P. Gruhn and S. Lucchini, Human Error in Process Plant Design and Operations – A Practitioner’s Guide by J. Robert Taylor, Guidelines for Preventing Human Error in Process Safety by the Center for Chemical Process Safety (CCPS), Guidelines for Inherently Safer Chemical Processes – A Life Cycle Approach by the CCPS, and Guidelines for Risk Based Process Safety by the CCPS for guidance. Demonstration could include documentation of conceptual design safety reviews, hazard analysis and risk assessments of detailed project designs, and a plan to address the recommendations to control the hazards.


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

2021-04-I-OH-4

Identify and document all equipment that could release flammable materials and install LEL detectors in accordance with sources and guidance such as Guidelines for Engineering Design for Process Safety by the Center for Chemical Process Safety and Explosion Hazards in the Process Industries by Rolf K. Eckhoff. Ensure that detection of hazardous conditions automatically triggers both visual and audible alarms to alert plant personnel of the hazard. Develop and implement employee training on actions to take, such as prompt evacuation, when such alarms are activated.


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

2021-04-I-OH-5

Develop and implement requirements for personnel to wear flame-resistant uniforms in all operating areas that process flammable chemicals. Update employee training material to include the requirement for and purpose of PPE use.


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

PDF Document Recommendation Status Change Summary

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

Final Report Released On: September 24, 2021

2019-03-I-IL-1

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


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

PDF Document Recommendation Status Change Summary

2019-03-I-IL-2

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


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

PDF Document Recommendation Status Change Summary

2019-03-I-IL-3

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

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

2. Collect reactivity hazard information

3. Identify chemical reactivity hazards

4. Test for chemical reactivity

5. Assess chemical reactivity risks

6. Identify and implement process controls and risk management options

7. Document chemical reactivity risks and management decisions

8. Communicate and train on chemical reactivity hazards

9. Investigate chemical reactivity incidents

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


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

PDF Document Recommendation Status Change Summary

Acetylene Service Company Gas Explosion (5 Recommendations)
Acetylene Service Company (ASCO) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 25, 2006

2005-3-I-NJ-1

Improve isolation on acetylene generator water lines by incorporating a double-block-and-bleed with a vent to a safe location, or other isolation means of comparable effectiveness.


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).
 

2005-3-I-NJ-2

Implement an effective Process Safety Management program, in accordance with OSHA 1910.119. Include written operating procedures and checklists that are understood by the workers responsible for using them. Train workers on the procedures and periodically confirm that they are being properly followed.


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).
 

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

Final Report Released On: January 25, 2006

2005-3-I-NJ-5

Update the OSHA 1910.102 Acetylene Standard (a. Cylinders, b. Piped Systems, and c. Generators and filling cylinders) to remove the existing references to unavailable and obsolete Compressed Gas Association Pamphlets (CGA G-1-1966, G 1.3-1959, G 1.4-1966). As an alternative, consider incorporating by reference NFPA 51A Standard for Acetylene Cylinder Charging Plants.


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.
 

Rexarc, Inc. (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 25, 2006

2005-3-I-NJ-3

Immediately inform existing acetylene generator users that the check valve did not prevent acetylene gas backflow in this incident. Recommend interim actions be taken to ensure that Rexarc check valves in service on acetylene production equipment will operate reliably.


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.
 

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2005-3-I-NJ-4

Replace check valves of this or similar design supplied by Rexarc with valves that will perform more reliably in recycle water service.


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.
 

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