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

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Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).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Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).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

PDF Document Download

AirGas Facility Fatal Explosion (6 Recommendations)
ACD, LLC (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 20, 2017

2016-04-I-FL-5

Provide effective warning about nitrous oxide decomposition hazards

Modify nitrous oxide pump product literature to include warnings about nitrous oxide decomposition hazards, illustrated by examples from historical incidents, and refer users to this CSB investigation report for additional information.


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

Air Liquide (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2017

2016-04-I-FL-1

The goal of 2016-04-I-FL-R1 is to prevent all nitrous oxide explosions at its facilities, while preventing harm to workers and the public.

Following the August 28, 2016, incident, the company began a comprehensive initiative to review its nitrous oxide production facilities, trucking fleet, and cylinder-filling operations.  The scope of the ongoing Air Liquide initiative is shown in Table 1. 

Complete the development and implementation of the company’s nitrous oxide business process safety initiative as shown in Table 1, consistent with the findings, conclusions, and recommendations contained in this report. 


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

Compressed Gas Association (CGA) (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: April 20, 2017

2016-04-I-FL-2

Safety Management System for Nitrous Oxide Manufacturing

Develop and implement a safety management system standard for nitrous oxide manufacturing, to manage known process safety hazards, including nitrous oxide decomposition, which includes appropriate elements based on chemical industry good practice guidance, such as CCPS Guidelines for Risk Based Process Safety, Essential Practices for Managing Chemical Reactivity Hazards, and Guidelines for Implementing Process Safety Management.


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

2016-04-I-FL-3

Ensure Effective Flame Arrestor Design

Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to require testing of safety devices, such as strainers used as flame arrestors, for applications where a safety device is used to quench a nitrous oxide decomposition reaction.  To ensure that these safety devices meet the intended purpose, the user should test the safety device by simulating conditions of use.  In addition, require users to document the required performance standard or test protocol followed. 


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

2016-04-I-FL-4

Require Pump Run-Dry Safety Interlocks Apply ISA-84

Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to reference and require applying International Society of Automation (ISA) standard ISA-84, Functional Safety: Safety Instrumented Systems for the Process Industry Sector to safety interlocks such as the nitrous oxide pump “run-dry” shutdown.


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

Cryostar USA, LLC (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 20, 2017

2016-04-I-FL-6

Provide effective warning about nitrous oxide decomposition hazards

Modify nitrous oxide pump product literature to include warnings about nitrous oxide decomposition hazards, illustrated by examples from historical incidents, and refer users to this CSB investigation report for additional information.


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

AL Solutions Fatal Dust Explosion (4 Recommendations)
AL Solutions, Inc. (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 16, 2014

2011-3-I-WV-1

For all new and existing equipment and operations at AL Solutions facilities that process combustible dusts or powders, apply the following chapters of NFPA 484-2012, Standard for Combustible Metals:

  • Chapter 12, Titanium
  • Chapter 13, Zirconium
  • Chapter 15, Fire Prevention, Fire Protection, and Emergency Response
  • Chapter 16, Combustible Metal Recycling Facilities

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

2011-3-I-WV-2

Develop training materials that address combustible dust hazards and plant-specific metal dust hazards and then train all employees and contractors.  Require periodic (e.g., annual) refresher training for all employees and contractors.


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

AL Solutions, Inc. facility in Burgettstown, PA (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 16, 2014

2011-3-I-WV-3

Prohibit the use of sprinkler systems and water deluge systems in all buildings that process or store combustible metals.


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

2011-3-I-WV-4

Conduct a process hazard analysis as defined in NFPA 484-2012, Section 12.2.5, and submit a copy to the local fire department or the enforcing authority for the fire 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 Recommendation Status Change Summary

Allied Terminals Fertilizer Tank Collapse (10 Recommendations)
Allied Terminals Inc. (5 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 26, 2009

2009-3-I-VA-1 URGENT!

Take immediate action to reduce the risk of a catastrophic failure of Tanks 202, 205, and 209 at the Allied Terminals Hill Street facility including but not limited to significantly reducing the maximum liquid levels ("safe fill height") based on sound engineering principles. Report the actions taken to the City of Chesapeake.


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

2009-3-I-VA-2 URGENT!

Select and retain a qualified, independent tank engineering firm to evaluate Tanks 202, 205, and 209 and determine their fitness for continued service. The evaluation should be based on recognized and generally accepted good engineering practices, such as API 653 - Tank Inspection, Repair Alteration, and Reconstruction and API 579 - Fitness for Service.


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

2009-3-I-VA-3 URGENT!

Within 30 days, provide the report prepared by the independent tank engineering firm to the City of Chesapeake, together with a comprehensive action plan and schedule to address any identified deficiencies.


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

2009-3-I-VA-6

Hire a qualified independent reviewer to verify that maximum liquid levels for all tanks at Allied’s Norfolk and Chesapeake terminals meet the requirements of American Petroleum Institute Standard 653, Tank Inspection, Repair, Alteration, and Reconstruction. At a minimum, the review should verify that all requirements for welding, inspection of welds, and In-Service and Out-of-Service tank inspections are met. Make the complete review report for both terminals available to the Cities of Norfolk, Chesapeake, and Portsmouth, Virginia, as well as the Virginia Department of Environmental Quality.


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

2009-3-I-VA-7

Develop and implement worker safety procedures for initial filling of tanks following major modification or change-in-service. At a minimum, require the exclusion of all personnel from secondary containment during the initial filling.


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

Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 26, 2009

2009-3-I-VA-4

Revise and reissue the Chemical Emergency Preparedness and Prevention Office Rupture Hazard from Liquid Storage Tanks Chemical Safety Alert. At a minimum, revise the alert to: 1) Include the Allied Terminals tank failure, 2) Discuss the increased rupture hazard during first fill or hydrostatic testing, and 3) List The Fertilizer Institute fertilizer tank inspection guidelines in the reference section.


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.
 

Fertilizer Institute (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 26, 2009

2009-3-I-VA-10

Formally recommend to all member companies the incorporation of The Fertilizer Institute tank inspection guidelines into contracts for the storage of liquid fertilizer at terminals.


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.
 

Govenor and Legislature of the Commonwealth of Virginia (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 26, 2009

2009-3-I-VA-5

Require state regulation of 100,000-gallon and larger fertilizer storage tanks (which presently are located solely along and in the area of the Elizabeth River) or authorize local jurisdictions to regulate these tanks. The regulations should: 1) Address design, construction, maintenance, and inspection of 100,000-gallon and larger liquid fertilizer storage tanks, and 2) Incorporate generally recognized and accepted good engineering practice.


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

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

Final Report Released On: May 26, 2009

2009-3-I-VA-8

Implement The Fertilizer Institute’s inspection guidelines as part of tank inspector training and inspection procedures for fertilizer tank inspection.


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.
 

2009-3-I-VA-9

Revise company procedures to require tank inspectors to verify that radiography required as part of the calculation for a maximum liquid level has been performed.


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.
 

Barton Solvents Explosions and Fire (9 Recommendations)
American Chemistry Council (ACC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-4

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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.
 

American National Standards Institute (ANSI) Z400.1 Committee (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-3

Revise ANSI Z400.1 to advise chemical manufacturers and importers that prepare MSDSs to: -Identify and include a warning for materials that are static-accumulators and that may form ignitable vapor-air mixtures in storage tanks; -Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)); and -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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.
 

American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-5

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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

Final Report Released On: June 26, 2008

2007-6-I-KS-6

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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 Paint and Coatings Association (NPCA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-7

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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: June 26, 2008

2007-6-I-KS-8

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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

Final Report Released On: June 26, 2008

2007-6-I-KS-1

Revise the "Guidance for Hazard Determination for compliance with the OSHA Hazard Communication Standard" to advise chemical manufacturers and importers that prepare MSDSs to: -Evaluate flammable liquids to determine their potential to accumulate static electricity and form ignitable vapor-air mixtures in storage tanks. -Test the conductivity of the flammable liquid and include the testing results in the MSDS.


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.
 

2007-6-I-KS-2

Prior to the next revision, communicate to the Sub-Committee on the Globally Harmonized System of Classification and Labeling of Chemicals (SCEGHS) the need to amend the GHS to advise chemical manufacturers and importers that prepare MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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.
 

Society for Chemical Hazard Communication (SCHC) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 26, 2008

2007-6-I-KS-9

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.


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.