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

BP America Refinery Explosion (26 Recommendations)
American Petroleum Institute (API) (5 Recommendations)
Open: 40% | Closed: 60%
View Investigation
Final Report Released On: March 20, 2007

2005-4-I-TX-2 URGENT!

In light of the findings concerning the March 23rd incident at BP's Texas City refinery, revise your Recommended Practice 752, Management of Hazards Associated with Location of Process Plant Buildings or issue a new Recommended Practice to ensure the safe placement of occupied trailers and similar temporary structures away from hazardous areas of process plants. Ensure that the new recommended practice: - Protects occupants from accident hazards such as heat, blast overpressure, and projectiles; - Establishes minimum safe distances for trailers and similar temporary structures away from hazardous areas of process plants; - Evaluates the siting of trailers under a separate methodology from permanent structures, since trailers are more susceptible to damage, are more readily relocated, and likely do not need to be placed near hazardous areas.


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

2005-4-I-TX-3 URGENT!

Issue a safety alert to your membership to take prompt action to ensure the safe placement of occupied trailers away from hazardous areas of process 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.
 

2005-4-I-TX-4

Revise API Recommended Practice 521, Guide for Pressure Relieving and Depressurizing Systems to ensure that the guidelines: - Identifies overfilling vessels as a potential hazard for evaluation in selecting and designing pressure relief and disposal systems; - Addresses the need to adequately size disposal drums for credible worse-case liquid relief scenarios, based on accurate relief valve and disposal collection piping studies; - Warns against the use of atmospheric blowdown drums and stacks attached to collection piping systems that receive flammable discharges from multiple relief valves and urges the use of appropriate inherently safer alternatives such as a flare 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 Recommendations Status Change Summary

2005-4-I-TX-6

Work together to develop two new consensus American National Standards Institute (ANSI) standards. a. In the first standard, create performance indicators for process safety in the refinery and petrochemical industries. Ensure that the standard identifies leading and lagging indicators for nationwide public reporting as well as indicators for use at individual facilities. Include methods for the development and use of the performance indicators. (CSB2005-04-I-TX-R6A) In the development of each standard, ensure that a. the committees are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


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 Download

2005-4-I-TX-7

Work together to develop two new consensus American National Standards Institute (ANSI) standards. b. In the second standard, develop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. (CSB2005-04-I-TX-R7a) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


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

BP Global Executive Board of Directors (4 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 20, 2007

2005-4-I-TX-1 URGENT!

1. Commission an independent panel to assess and report on the effectiveness of BP North America's corporate oversight of safety management systems at its refineries and its corporate safety culture. Provide the panel with necessary funding, resources, and authority - including full access to relevant data, corporate records, and employee interviews - in order to conduct a thorough, independent, and credible inquiry. 2. Ensure that, at a minimum, the panel report examines and recommends any needed improvements to: Corporate safety oversight, including the safe management of refineries obtained through mergers and acquisitions; Corporate safety culture, including the degree to which: - Corporate officials exercise appropriate leadership to promote adherence to safety management systems; - Process safety is effectively incorporated into management decisionmaking at all levels; - Employees at all levels are empowered to promote improved process safety; - Process safety programs receive adequate resources and are appropriately positioned within organizational structures; Corporate and site safety management systems, specifically: - Near-miss reporting and investigation programs; - Mechanical integrity programs; - Hazard analysis programs, management-of-change programs, and up-todate operating procedures for processes with catastrophic potential; - Siting policies for occupied structures near hazardous operating units. 3. Ensure that the panel has a diverse makeup, including an external chairperson; employee representatives; and outside safety experts, such as experts in process safety; experts in corporate culture, organizational behavior, and human factors; and experts from other high-risk sectors such as aviation, space exploration, nuclear energy, and the undersea navy. 4. Ensure that the report and recommendations of the independent panel, which should be completed within 12 months, are made available to the BP workforce and to the public.


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.
 

2005-4-I-TX-11

1. Appoint an additional non-executive member of the Board of Directors with specific professional expertise and experience in refinery operations and process safety. Appoint this person to be a member of the Board Ethics and Environmental Assurance Committee.


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

PDF Document Recommendations Status Change Summary

2005-4-I-TX-12

2. Ensure and monitor that senior executives implement an incident reporting program throughout your refinery organization that a. encourages the reporting of incidents without fear of retaliation; b. requires prompt corrective actions based on incident reports and recommendations, and tracks closure of action items at the refinery where the incident occurred and other affected facilities; and c. requires communication of key lessons learned to management and hourly employees as well as to the industry.


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.
 

2005-4-I-TX-13

3. Ensure and monitor that senior executives use leading and lagging process safety indicators to measure and strengthen safety performance in your refineries.


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

BP Texas City Refinery (8 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 20, 2007

2005-4-I-TX-14

1. Evaluate your refinery process units to ensure that critical process equipment is safely designed. At a minimum, a. Ensure that distillation towers have effective instrumentation and control systems to prevent overfilling such as multiple level indicators and appropriate automatic controls. b. Configure control board displays to clearly indicate material balance for distillation towers.


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.
 

2005-4-I-TX-16

3. Work with the United Steelworkers Union and Local 13-1 to establish a joint program that promotes the reporting, investigation, and analysis of incidents, near-misses, process upsets, and major plant hazards without fear of retaliation. Ensure that the program tracks recommendations to completion and shares lessons learned with the workforce.


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.
 

2005-4-I-TX-15

2. Ensure that instrumentation and process equipment necessary for safe operation is properly maintained and tested. At a minimum, a. Establish an equipment database that captures the history of testing, inspections, repair, and successful work order completion. b. Analyze repair trends and adjust maintenance and testing intervals to prevent breakdowns. c. Require repair of malfunctioning process equipment prior to unit startups.


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.
 

2005-4-I-TX-17

4. Improve the operator training program. At a minimum, require a. face-to-face training conducted by personnel with process-specific knowledge and experience who can assess trainee competency, and; b. training on recognizing and handling abnormal situations including the use of simulators or similar training tools.


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.
 

2005-4-I-TX-18

5. Require additional board operator staffing during the startup of process units. Ensure that hazard reviews address staffing levels during abnormal conditions such as startups, shutdowns, and unit upsets.


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.
 

2005-4-I-TX-19

6. Require knowledgeable supervisors or technically trained personnel to be present during especially hazardous operation phases such as unit startup.


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.
 

2005-4-I-TX-20

7. Ensure that process startup procedures are updated to reflect actual process conditions.


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.
 

2005-4-B-TX-1

Revise the maintenance quality control program to require positive material identification testing or another suitable material verification process for all critical service alloy steel piping components removed and reinstalled during maintenance and inform work crews of special material handling precautions.


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.
 

Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 20, 2007

2005-4-I-TX-10

Issue management of change guidelines that address the safe control of the following: a. major organizational changes including mergers, acquisitions, and reorganizations; b. changes in policies and budgets; c. personnel changes; d. staffing during process startups, shutdowns and other abnormal conditions.


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.
 

JV Industrial Companies (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 20, 2007

2005-4-B-TX-2

Develop / update the written piping component installation quality control procedure to require positive material identification testing or other suitable verification or tracking process for all alloy steel piping components removed during maintenance.


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%
View Investigation
Final Report Released On: March 20, 2007

2005-4-I-TX-3 URGENT!

Issue a safety alert to your membership to take prompt action to ensure the safe placement of occupied trailers away from hazardous areas of process 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.
 

PDF Document Download

Occupational Safety and Health Administration (OSHA) (3 Recommendations)
Open: 33% | Closed: 67%
View Investigation
Final Report Released On: March 20, 2007

2005-4-I-TX-5

1. Implement a national emphasis program for all oil refineries that focuses on: - The hazards of blowdown drums and stacks that release flammables to the atmosphere instead of to an inherently safer disposal system such as a flare. Particular attention should be paid to blowdown drums attached to collection piping systems servicing multiple relief valves; - The need for adequately sized disposal knockout drums to safely contain discharged flammable liquid based on accurate relief valve and disposal collection piping studies 2. Urge states that administer their own OSHA plan to implement comparable emphasis programs within their respective jurisdictions.


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

2005-4-I-TX-8

1. Strengthen the planned comprehensive enforcement of the OSHA Process Safety Management (PSM) standard. At a minimum: a. Identify those facilities at greatest risk of a catastrophic accident by using available indicators of process safety performance and information gathered by the EPA under its Risk Management Program (RMP). b. Conduct, or have conducted, comprehensive inspections, such as those under your Program Quality Verification (PQV) program at facilities identified as presenting the greatest risk. c. Establish the capacity to conduct more comprehensive PSM inspections by hiring or developing a sufficient cadre of highly trained and experienced inspectors. d. Expand the PSM training offered to inspectors at the OSHA National Training Institute.


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

PDF Document Recommendation Status Change Summary

2005-4-I-TX-9

2. Amend the OSHA PSM standard to require that a management of change (MOC) review be conducted for organizational changes that may impact process safety including: a. major organizational changes such as mergers, acquisitions, or reorganizations; b. personnel changes, including changes in staffing levels or staff experience; and c. policy changes such as budget cutting.


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 Download

United Steelworkers of America (USWA) (2 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: March 20, 2007

2005-4-I-TX-6

Work together to develop two new consensus American National Standards Institute (ANSI) standards. a. In the first standard, create performance indicators for process safety in the refinery and petrochemical industries. Ensure that the standard identifies leading and lagging indicators for nationwide public reporting as well as indicators for use at individual facilities. Include methods for the development and use of the performance indicators.(CSB2005-04-I-TX-R6b) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


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 Download

2005-4-I-TX-7

Work together to develop two new consensus American National Standards Institute (ANSI) standards. b. In the second standard, develop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. (CSB2005-04-I-TX-R7b) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.


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

PDF Document Recommendation Status Change Summary

USW Local 13-1 (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 20, 2007

2005-4-I-TX-21

Work with BP to establish a joint program that promotes reporting, investigating, and analyzing incidents, near-misses, process upsets, and major plant hazards without fear of retaliation. Ensure that the program tracks recommendations to completion and shares lessons learned with the workforce.


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.
 

BP Amoco Thermal Decomposition Incident (11 Recommendations)
American Chemistry Council (ACC) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 20, 2002

2001-03-I-GA-10

Communicate the findings of this report to your membership.


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

BP Chemicals Group (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 20, 2002

2001-03-I-GA-9

Communicate the findings of this report to your chemical and plastics manufacturing facilities in North America.


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.
 

Society of Plastics Engineers (SPE) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 20, 2002

2009-03-I-GA-11

Communicate the findings of this report to your membership.


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

Solvay Advanced Polymers, LLC (8 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 20, 2002

2001-03-I-GA-1

Examine the manufacturing businesses acquired from BP Amoco Performance Polymers and ensure that a systematic safety review procedure is developed and implemented for identifying and controlling hazards from unintended chemical reactions. Additionally, ensure that reactive hazards are identified and evaluated: - During product R&D, during conceptual design of a new process, and during detailed design of a new process. - Before changes are made to existing equipment or process chemistry. - Communicate the results of this review to the workforce.


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.
 

2001-03-I-GA-2

Ensure that a program is in place at facilities acquired from BP Amoco Performance Polymers to systematically review the hazards associated with new and modified processes and equipment as operating experience accrues. Ensure that facilities correct all identified design, operation, and maintenance deficiencies. Verify that operating experience does not invalidate the design basis for equipment.


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.
 

2001-03-I-GA-3

Revise the Material Safety Data Sheet (MSDS) for Amodel to warn of the hazards of accumulating large masses of molten polymer. Communicate the MSDS changes to current and past customers (who may retain inventories of this product).


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.
 

2001-03-I-GA-4

Implement a program to conduct periodic management reviews of incidents and near-miss incidents. Look for trends and patterns among incidents. Address root causes and implement and track corrective measures.


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.
 

2001-03-I-GA-5

Revise process safety information to include: - Information regarding the decomposition reactions of Amodel. - Design intent, basis, capacity, and limitations of equipment. - Hazards and consequences of deviations from design intent and operating limits.


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.
 

2001-03-I-GA-6

Revalidate hazard analyses for the Amodel process to address: - Credible deviations from process intent and their consequences. - Hazards associated with startup and shutdown operations. - Prevention of accumulations of potentially hazardous masses of polymer.


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.
 

2001-03-I-GA-7

Revise your lockout/tagout program to ensure that equipment is rendered safe prior to opening for maintenance. At a minimum, ensure that equipment opening procedures contain a stop work provision that requires higher levels of management review and approval when safe opening conditions, such as equipment depressurization, cannot be verified.


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.
 

2001-03-I-GA-8

Ensure that your management of change policy applies to operational and procedural modifications.


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.
 

CAI / Arnel Chemical Plant Explosion (11 Recommendations)
CAI, Inc. (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 13, 2008

2007-03-I-MA-8

Develop a written safety program to manage hazardous process operations. The program should : -Prohibit heating flammable or combustible liquids above their flashpoints in tanks inside buildings unless the tanks are sealed and vented to the building exterior. -Require safety controls to prevent overheating of flammable or combustible liquids. - Apply the process safety management program elements as contained in the American Institute of Chemical Engineers (AIChE) Center for Chemical Process Safety (CCPS) Guidelines for Implementing Process Safety Management Systems to all processes that use flammable, toxic, or reactive chemicals. -Comply with the following, as applicable: OSHA Flammable and Combustible Liquids standard (29 CFR 1910.106), OSHA Process Safety Management standard (29 CFR 1910.119), National Fire Protection Association Flammable and Combustible Liquids Code (NFPA 30), and National Fire Protection Association Standard for the Manufacture of Organic Coatings (NFPA 35).


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.
 

Commonwealth of Massachusetts Office of Public Safety, Department of Fire Services (4 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 13, 2008

2007-03-I-MA-3

Incorporate the Flammable and Combustible Liquids Code (NFPA 30) and Standard for the Manufacture of Organic Coatings (NFPA 35) into the Massachusetts Board of Fire Prevention Regulations.


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

2007-03-I-MA-4

Revise 527 CMR 14 to specify the maximum interval (such as annually) for local fire departments to conduct inspections of manufacturing facilities holding one or more licenses and permits to store and handle flammable materials.


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

2007-03-I-MA-5

Develop mandatory written inspection criteria to be used by the local fire departments when performing manufacturing facility inspections. Develop inspection training material and provide training to the local fire departments.


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

2007-03-I-MA-6

Revise the license and registration forms (FP-2 and FP-5) to require listing each hazardous material type and quantity. Identify the requirement that a separate license and permit are required for each of the eight classes of flammable material when the facility possesses more than the listed threshold quantity specified in 527 CMR 14.03 (2).


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

General Court of the Commonwealth of Massachusetts (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 13, 2008

2007-03-I-MA-1

Revise the General Laws of Massachusetts addressing flammable materials licensing and registration: - As part of the annual registration renewal, require new and existing product manufacturing registrants to submit written certification to local governments stating that the facility complies with, at a minimum, all state and local fire codes and hazardous chemical regulations. -Require all companies holding a license and current registration to apply for an amended license and re-register the facility before increasing any flammable material quantity above the licensed amount or adding a different regulated chemical. Include a requirement in the approval process to solicit input from affected landowners, similar to the requirement for obtaining the original license and registration.


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

2007-03-I-MA-2

Amend the General Laws of Massachusetts to require the Office of the State Fire Marshal to audit local governments for compliance with the flammable materials licensing regulation and audit fire departments for compliance with permit issuance and inspection of manufacturing facilities licensed to store and handle flammable liquids and solids. The audits should be conducted at least once every five years.


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

PDF Document Status Change Summary

International Code Council (ICC) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 13, 2008

2007-03-I-MA-11

Revise the International Fire Code: Chapter 20: - Specifically include "printing inks" in the definition of "organic coating." - Define equipment specifically discussed in the standard, such as open and closed kettles. - Require heated tanks and vessels containing flammable and combustible liquids to have equipment to prevent overheating, such as: devices to stop the heating process if the temperature exceeds the safe operating limits; devices to stop the heating process if the flammable vapor control equipment malfunctions (e.g., building ventilation system or heated tank vent); and a heating medium that is unable to heat the tank above safe operating temperatures. Chapters 20, 27, and 34: -Define "open", "closed", and "sealed and vented" process tanks. -Define "non-listed" process tanks. -Prohibit heating flammable and combustible liquids above their flashpoints in tanks inside buildings unless the tanks are sealed and vented to the building exterior.


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

PDF Document Recommendations Status Change Summary

National Fire Protection Association (NFPA) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 13, 2008

2007-03-I-MA-9

Revise Flammable and Combustible Liquids Code (NFPA 30): - Prohibit heating flammable and combustible liquids above their flashpoints in tanks inside buildings, unless the tanks are sealed and vented to the building exterior. - Require heated tanks and vessels containing flammable and combustible liquids to have equipment to prevent overheating, such as: devices to stop the heating process if the temperature exceeds the safe operating limits; devices to stop the heating process if the flammable vapor control equipment malfunctions (e.g., building ventilation system or heated tank vent); and a heating medium that is unable to heat the tank above safe operating temperatures.


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

2007-03-I-MA-10

Revise The Standard for the Manufacture of Organic Coatings (NFPA 35): -Define equipment specifically discussed in the standard, such as kettles and thin-down tanks. -Define the terms "open, "closed", and "sealed" and "vented." -Prohibit heating flammable and combustible liquids above their flashpoints in tanks inside buildings unless the tanks are sealed and vented to the building exterior. -Require heated tanks and vessels containing flammable and combustible liquids to have equipment to prevent overheating, such as: Devices to stop the heating process if the temperature exceeds the safe operating limits; Devices to stop the heating process if the flammable vapor control equipment malfunctions (e.g., building ventilation system or heated tank vent); and a heating medium that is unable to heat the tank above safe operating temperatures.


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

Town of Danvers (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 13, 2008

2007-03-I-MA-7

Pending revision of the Massachusetts Fire Safety Code (527 CMR), revise the town bylaws addressing 527 CMR 14 requirements applicable to facility licensing and annual registration to: -Require new and current product manufacturing registrants to certify in writing that the facility complies with, at a minimum, all state and local fire codes and hazardous chemical regulations as part of the annual registration renewal. -Require companies holding a license and current registration for any of the eight classes of flammable materials specified in 527 CMR 14.03 (2) to re-register the facility before increasing any chemical quantity above the registered amount or adding a different regulated chemical at the facility. Include a requirement in the approval process to solicit input from affected landowners, similar to the requirement for obtaining the original license and registration. -Revise the license and registration forms to require listing each hazardous material type and quantity, and require a separate license and permit for each of the eight classes of flammable materials specified in 527 CMR 14.03 (2) . -Require the fire department to annually inspect licensed manufacturing facilities for compliance with the fire code.


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

PDF Document Recommendations Status Change Summary

Carbide Industries Fire and Explosion (3 Recommendations)
Carbide Industries (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 07, 2013

2011-5-I-KY-2

Modify the design and procedures for the electric arc furnace and related structures including the control room to comply with the NFPA standard developed per R1 of this case study.  


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

PDF Document Recommendations Status Change Summary

2011-5-I-KY-3

Implement a mechanical integrity program for the electric arc furnace and cover, including preventive maintenance based on periodic inspections, and timely replacement of the furnace cover. At a minimum, the program should include factors such as leak detection and repair and refractory lining wear.


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

PDF Document Recommendation Status Change Summary

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 07, 2013

2011-5-I-KY-1

Establish a committee to evaluate and develop a standard that defines the safety requirements for electric arc furnaces operated with flammable materials and low oxygen atmospheres. At a minimum, establish requirements that electric arc furnaces containing flammables have: • Adequate safety instrumentation and controls to prevent explosions and overpressure events; • Mechanical integrity and inspection programs; • A documented siting analysis to ensure that control rooms and other occupied areas are adequately protected.  


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

PDF Document Recommendations Status Change Summary

Caribbean Petroleum Refining Tank Explosion and Fire (9 Recommendations)
American Petroleum Institute (API) (3 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: October 21, 2015

2010-02-I-PR-7

Revise ANSI/API 2350, Overfill Protection for Storage Tanks in Petroleum Facilities (2015), to require the installation of an automatic overfill prevention systems for existing and new facilities at bulk aboveground storage tanks storing gasoline, jet fuel, other fuel mixtures or blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher. At a minimum, this system shall meet the following requirements:
a. Separated physically and independent from the level control and monitoring system.
b. Engineered, operated, and maintained to achieve an appropriate safety integrity level in accordance with the requirements of Part 1 of International Electrotechnical Commission (IEC) 61511-SER ed1-2004, Functional Safety – Safety Instrumented Systems for the Process Industry Sector.
c. Specified to achieve the necessary risk reduction as determined by a documented risk assessment methodology set in accordance with Center for Chemical Process Safety Guidelines for Hazard Evaluation Procedures, 3rd Edition, accounting for the following factors:
1. The existence of nearby populations and contamination of nearby environmental resources;
2. The nature and intensity of facility operations;
3. Realistic reliability for the tank gauging system; and
4. The extent/rigor of operator monitoring.
d. Proof tested with sufficient frequency in accordance with the validated arrangements and procedures to maintain the required safety integrity level.
e. Ensure that the above changes are not subject to grandfathering provisions in the standard.

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

2010-02-I-PR-8

Develop detailed guidance on conducting a risk assessment for onsite and offsite impacts of a potential tank overfill during transfer operations involving one and multiple tanks and for determining the Safety Integrity Level of the required overfill prevention safeguard to replace Annex E of ANSI/API 2350, Overfill Protection for Storage Tanks in Petroleum Facilities (2015).

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

2010-02-I-PR-9

Develop a single publication or resource describing all API standards and other relevant codes, standards, guidance, and information for filling operations of aboveground storage tanks in petroleum facilities that describes:
a. The required design and management practices for control of filling operations;
b. The minimum set of independent overfill prevention safeguards if the control fails; and
c. Operational challenges (e.g., monitoring/calculating flow rates, ability to maintain constant line pressures, and influences of valve cracking) related to loading multiple tanks concurrently from a single product source.

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.
 

Environmental Protection Agency (EPA) (3 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: October 21, 2015

2010-02-I-PR-1

Revise where necessary the Spill Prevention, Control and Countermeasure (SPCC); Facility Response Plan (FRP); and/or Accidental Release Prevention Program (40 CFR Part 68) rules to prevent impacts to the environment and/or public from spills, releases, fires, and explosions that can occur at bulk aboveground storage facilities storing gasoline, jet fuels, blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher.
 
At a minimum, these revisions shall incorporate the following provisions:
 
a) Ensure bulk above ground storage facilities conduct and document a risk assessment that takes into account the following factors:
1. The existence of nearby populations and sensitive environmenls;
2. The nature and intensity of facility operations;
3. Realistic reliability of the tank gauging system; and
4. The extent/rigor of operator monitoring
b) Equip bulk aboveground storage containers/tanks with automatic overfill prevention systems that are physically separate and independent from the lank level control systems.
c) Ensure these automatic overfill prevention systems follow good engineering practices.
d) Engineer, operate, and maintain automatic overfill prevention systems to achieve appropriate safety integrity levels in accordance with good engineering practices, such as Part 1 of lnternational Electro-technical Commission (IEC) 61511-SER ed1.0B-2004, Functional Safety - Safety Instrumented Systems for the Process Industry Sector.
e) Regularly inspect and test automatic overfill prevention systems to ensure their proper operation in accordance with good engineering 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.
 

2010-02-I-PR-2

Conduct a survey of randomly selected bulk aboveground storage containers storing gasoline or other flammable liquids with a NFPA 704 flammability rating of 3 or higher, at terminals in high risk locations (such as near population centers or sensitive environments) that are already subject to the Spill Prevention, Control and Countermeasure (SPCC) and/or Facility Response Plan (FRP) rules to determine:
a) The nature of the safety management systems in place to prevent overfilling a storage tank during loading operations. Analysis of the safety management systems should include equipment, training, staffing, operating procedures and preventative maintenance programs.
b) The extent to which terminals use independent high level alarms, automated shutoff/diversion systems, redundant level alarms or other technical means to prevent overfilling a tank
c) The history of overfilling incidents at the facilities, with or without consequence
d) Whether additional reporting requirements are needed to understand the types of incidents leading to overfilling spills that breach secondary containment and have the potential to impact the environment and/or the public, as well as the number of safeguards needed to prevent them.

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

2010-02-I-PR-3

As an interim measure, until the rule changes in CSB Recommendation No. 2009-02-I-PR-R1 are adopted and go into effect: issue appropriate guidance or an alert, similar to EPA’s previously issued Chemical Safety Alert addressing Rupture Hazard from Liquid Storage Tanks, to illustrate the hazards posed by spills, releases, fires and explosions due to overfilling bulk aboveground storage containers storing gasoline, jet fuel, blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher.

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.
 

International Code Council (ICC) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: October 21, 2015

2010-02-I-PR-5

Revise the Section 5704.2.7.5.8 (2015), Overfill Prevention of the International Fire Code (IFC) to require an automatic overfill prevention system (AOPS) for bulk aboveground storage tank terminals storing gasoline, jet fuel, other fuel mixtures or blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher, or equivalent designation. These safeguards shall meet the following requirements:
a) Engineered, operated, and maintained to achieve an appropriate safety integrity level in accordance with the requirements of Part 1 of International Electrotechnical Commission (IEC) 61511-SER ed1-2004, Functional Safety – Safety Instrumented Systems for the Process Industry Sector.
b) Specified to achieve the necessary risk reduction as determined by a documented risk assessment methodology in accordance with Center for Chemical Process Safety Guidelines for Hazard Evaluation Procedures, 3rd Edition, accounting for the following factors:
i. The existence of nearby populations and sensitive environments;
ii. The nature and intensity of facility operations;
iii. Realistic reliability for the tank gauging system; and
iv. The extent/rigor of operator monitoring.
c) Proof tested in accordance with the validated arrangements and procedures with sufficient frequency to maintain the specified safety integrity level.
d) Ensure that the above changes are not subject to grandfathering provisions in the codes.

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.
 

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: October 21, 2015

2010-02-I-PR-6

Revise NFPA 30, Storage of Flammable and Combustible Liquids, Section 21.7.1.1 (2015) for bulk aboveground storage tank terminals storing gasoline, jet fuel, other fuel mixtures or blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or greater. This modification shall meet the following requirements:
a. More than one safeguard to prevent a tank overfill, all within an automatic overfill prevention system as described in ANSI/API Standard 2350 (2015) Overfill Protection for Storage Tanks in Petroleum Facilities with an independent level alarm as one of the safeguards. The safeguards should meet the following standards:
1. Separated physically and electronically and independent from the tank gauging system;
2. Engineered, operated, and maintained for an appropriate level of safety based on the predetermined risk level after considering part b of this recommendation; and
3. Proof tested with sufficient frequency in accordance with the validated arrangements and procedures.
b. Specified to achieve the necessary risk reduction as determined by a documented risk assessment methodology conducted in accordance with Center for Chemical Process Safety Guidelines for Hazard Evaluation Procedures, 3rd Edition, accounting for the following factors:
1. The existence of nearby populations and contamination of nearby environmental resources;
2. The nature and intensity of facility operations;
3. Realistic reliability for the tank gauging system; and
4. The extent/rigor of operator monitoring.
c. Ensure that the above changes not subject to grandfathering provisions in the 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.
 

Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: October 21, 2015

2010-02-I-PR-4

a) Revise the Flammable and Combustible Liquids standard (29 CFR§ 1910.106) to require installing, using, and maintaining a high-integrity automatic overfill prevention system with a means of level detection, logic/control equipment, and independent means of flow control for bulk aboveground storage tanks containing gasoline, jet fuel, other fuel mixtures or blends tocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher, to protect against loss of containment. At a minimum, this system
shall meet the following requirements:
1. Separated physically and electronically and independent from the tank gauging system.
2. Engineered, operated, and maintained to achieve an appropriate level of safety integrity in accordance with the rrequirements of Part 1 of International Electro-technical Commission (IEC) 61511-SER ed1.0B-2004, Functional Safety - Safety Instrumented Systems for the Process Industry Sector. Such a system would employ a safety integrity level (SIL) documented in accordance with the principles in Part 3 of IEC 61511-SER ed1.0B-2004, accounting for the following factors:
i. The existence of nearby populations and sensitive environments;
ii. The nature and intensity of facility operations;
iv. The extent/ rigor of operator monitoring.
3. Proof tested in accordance with the validated arrangements and procedures with sufficient frequency to ensure the specified safety integrity level is maintained.
b) Establish hazard analysis, management of change and mechanical integrity management system elements for bulk above ground storage tanks in the revised 1910.106 standard that are similar to those in the Process Safety Management of Highly Hazardous Chemicals standard (29 CFR § 1910.119) and ensure these facilities are subject to Recognized and Generally Accepted Good Engineering Practices (RAGAGEP).

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.
 

Chevron Refinery Fire (37 Recommendations)
American Petroleum Institute (API) (6 Recommendations)
Open: 83% | Closed: 17%
View Investigation
Final Report Released On: January 28, 2015

2012-03-I-CA-26

Revise API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries to establish minimum requirements for preventing catastrophic rupture of low-silicon carbon steel piping.  At a minimum: 

a.       Require users to identify carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components.  These circuits have the potential to contain carbon steel components that were not manufactured to the American Society for Testing and Materials (ASTM) A106 specification and may contain less than 0.10 weight percent silicon content. 

b.      For piping circuits identified to meet the specifications detailed in 2012-03-I-CA-R26(a), require users to either (1) enact a program to inspect every component within the piping circuit once, known as 100 percent component inspection (per the requirements established pursuant to recommendation 2012-03-I-CA-R28(c)), or (2) replace the identified at-risk carbon steel piping with a steel alloy that is more resistant to sulfidation corrosion. 

c.       If low-silicon components or components with accelerated corrosion are identified in a carbon steel piping circuit meeting the specifications detailed in 2012-03-I-CA-R26(a), require designation of these components as permanent Condition Monitoring Locations (CMLs) until the piping components are replaced.


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.
 

2012-03-I-CA-27

Revise API RP 571: Damage Mechanisms Affecting Fixed Equipment in the Refining Industry to:

a.       Describe the potential for increased rates of sulfidation corrosion occurring in low-silicon carbon steel in Section 4.4.2.3 Critical Factors; 

b.      Specify that sulfidation corrosion rates in carbon steel piping can be significantly faster in a few, individual piping components in section 4.4.2.5 Appearance or Morphology of Damage; and

c.       Refer the reader to the 100 percent component inspection or pipe replacement requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to recommendation 2012-03-I-CA-R26)  and API 570: Piping Inspection Code:  In-service Inspection, Rating, Repair, and Alteration of Piping Systems (pursuant to 2012-03-I-CA-R28(c)) for carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components.  


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.
 

2012-03-I-CA-28

Revise API 570: Piping Inspection Code:  In-service Inspection, Rating, Repair, and Alteration of Piping Systems to:   

 

a.       Use terminology consistent with API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries and other API standards and recommended practices discussed in this report.  Replace the terminology “high-temperature sulfur corrosion” with “sulfidation corrosion”;

b.      Specify that sulfidation corrosion rates in carbon steel piping can be significantly faster in some individual piping components than in others;

c.       Establish a new section that details inspection requirements to identify low-silicon piping components in carbon steel circuits susceptible to sulfidation corrosion.  This section shall require users to identify carbon steel piping circuits at risk to contain low-silicon components by following the requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to 2012-03-I-CA-R26(a)) and API RP 578: Material Verification Program for New and Existing Alloy Piping Systems (pursuant to 2012-03-I-CA-R29).  At a minimum, require users to either:

                                                              i.      Inspect every component within all carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components once.  The purpose of this practice is to identify any low-silicon components that are corroding at accelerated rates.  Inspection may be performed through ultrasonic thickness measurements to establish corrosion rates for each component, destructive laboratory analysis, or other methods.  Following the inspection, require users to follow the low-silicon corrosion rate monitoring requirements established in 2012-03-I-CA-R26(c); or    

                                                            ii.      Replace the identified at-risk carbon steel piping with a steel alloy that is more resistant to sulfidation corrosion.

 

d.      Incorporate as a “normative reference” API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries; and

e.       Require users to follow the minimum leak response guidance establishedinAPI RP 2001: Fire Protection in Refineries, developed in response to recommendation 2012-03-I-CA-R31.


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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2012-03-I-CA-29

Revise API RP 578: Material Verification Program for New and Existing Alloy Piping Systems, to require users to establish and implement a program to identify carbon steel piping circuits that are susceptible to sulfidation corrosionand may contain low-silicon components.  These circuits have the potential to contain carbon steel components that were not manufactured to the American Society for Testing and Materials (ASTM) A106 specification and may contain less than 0.10 weight percent silicon content.  Refer the reader to the 100 percent component inspection or pipe replacement requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to recommendation 2012-03-I-CA-26(b))  and API 570: Piping Inspection Code:  In-service Inspection, Rating, Repair, and Alteration of Piping Systems (pursuant to 2012-03-I-CA-28(c)) for carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components.


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.
 

2012-03-I-CA-30

Revise API RP 574: Inspection Practices for Piping System Components (3rd edition) to: 

a.       Incorporate as a normative reference API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries;

b.      Reference API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries when discussing that nonsilicon-killed carbon steel is susceptible to sulfidation corrosion; and

c.       In Section 9.3 Investigation of Leaks, require users to follow the leak response protocol requirements established in API RP 2001: Fire Protection in Refineries (pursuant to 2012-03-I-CA-R31).


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 Recommendations Status Change Summary

2012-03-I-CA-31

Revise API RP 2001: Fire Protection in Refineries to require users to develop a process fluid leak response protocol specific to their own facility that must be followed when a process fluid leak is discovered.  Recommend users to incorporate the following actions into their leak response protocol: 

a.       Establish an Incident Command structure upon identification of a process fluid leak;

b.      Conduct a pre-response meeting with personnel with specific technical expertise (e.g., inspectors, operators, metallurgists, engineers, and management) and the Incident Commander to determine pressure, temperature, remaining inventory of process fluids, potential damage mechanisms that caused the leak, and worst-case leak scenario;

c.       Establish a hot zone that identifies the area of risk of exposure or injuries due to flame contact, radiant heat, or contact to hazardous materials, taking into consideration the worst-case leak scenario;

d.      Limit site access around leak location to essential personnel only;

e.       Isolate the leaking piping or vessel, or if isolation is not possible, shutdown of the unit when the leaking process fluid poses immediate danger to safety, health, or the environment—such as piping fluid that is toxic or near the autoignition temperature.


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.
 

American Society of Mechanical Engineers (ASME) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: January 28, 2015

2012-03-I-CA-32

Revise ASME PCC-2-2011: Repair of Pressure Equipment and Piping to require users to follow the minimum process fluid leak response requirements established in API RP 2001: Fire Protection in Refineries, developed in response to recommendation 2012-03-I-CA-R31, before conducting process fluid leak repair.


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 Recommendations Status Change Summary

Board of Supervisors, Contra Costa County, CA (6 Recommendations)
Open: 17% | Closed: 83%
View Investigation
Final Report Released On: January 28, 2015

2012-03-I-CA-6

Revise the Industrial Safety Ordinance (ISO) to require that Process Hazard Analyses include documentation of the recognized methodologies, rationale and conclusions used to claim that safeguards intended to control hazards will be effective. This process shall use established qualitative, quantitative, and/or semi-quantitative methods such as Layers of Protection Analysis (LOPA).


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-7

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


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-8

Monitor and confirm the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R1 and 2012-03-I-CA-R2), so that all necessary mechanical integrity work at the Chevron Richmond Refinery is identified and recommendations are completed in a timely way.


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

2012-03-I-CA-16

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.


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

PDF Document Status Change Summary

2012-03-I-CA-25

Implement a compensation system to ensure the regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical competency at all levels of process safety regulatory oversight and policy development in Contra Cost County, California. A market analysis and benchmarking review should be periodically conducted to ensure the compensation system remains competitive with California petroleum refineries.


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-36

Revise the Industrial Safety Ordinance (ISO) regulations for petroleum refineries to require a process safety culture continuous improvement program including a written procedure for periodic process safety culture surveys across the work force. Require an oversight committee comprised of the regulator, the company, the company’s workforce and their representatives, and community representatives. This oversight committee shall:

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

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

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

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

The periodic process safety culture report shall be made available to the plant workforce.


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.
 

California Air Quality Management Divisions (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: January 28, 2015

2012-03-I-CA-18

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.


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

PDF Document Status Change Summary

California Environment Protection Agency (Cal/EPA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: January 28, 2015

2012-03-I-CA-20

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.


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

PDF Document Status Change Summary

Chevron USA (5 Recommendations)
Open: 20% | Closed: 80%
View Investigation
Final Report Released On: January 28, 2015

2012-03-I-CA-1 URGENT!

At all Chevron U.S. refineries, engage a diverse team of qualified personnel to perform a documented damage mechanism hazard review. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure safeguards are in place to control hazards presented by those damage mechanisms. Analyze and incorporate into this review applicable industry best practices, Chevron Energy Technology Company findings and recommendations, and inherently safer systems to the greatest extent feasible.


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-2 URGENT!

At all California Chevron U.S. refineries, report leading and lagging process safety indicators, such as the action item completion status of recommendations from damage mechanism hazard reviews, to the federal, state, and local regulatory agencies that have chemical release prevention authority.


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

2012-03-I-CA-33

Develop a method to assign accountability at Chevron to determine whether any whether any new Energy Technology Company (ETC) recommended program or industry best practice, such as API guidance must be followed to ensure process safety or employee personal safety.  This method shall include monitoring of these practices and guidance at a refining system level and at the refinery level.  Develop a tracking system to monitor the progress of implementing these selected practices and guidance to completion.


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-34

Develop an auditable process to be available for all recommended turnaround work items necessary to address mechanical integrity deficiencies or inspection recommendations that are denied or deferred.  This process shall provide the submitter of the denied or deferred recommendation with the option to seek further review by his or her manager, who can further elevate and discuss the recommendation with higher level management, such as the Area Business Unit Manager.  Maintain an auditable log of each of these potential turnaround work items, including the ultimate determination of approval, deferral, or rejection, justification determination, and the person or team responsible for that decision.


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-35

Develop an approval process that includes a technical review that must be implemented prior to resetting the minimum alert thickness to a lower value in the inspection database.


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

PDF Document Recommendations Status Change Summary

Environmental Protection Agency (EPA) (2 Recommendations)
Open: 50% | Closed: 50%
View Investigation
Final Report Released On: January 28, 2015

2012-03-I-CA-15

Jointly plan and conduct inspections with Cal/OSHA, California EPA and other state and local regulatory agencies with chemical accident prevention responsibilities to monitor the effective implementation of the damage mechanism hazard review and disclosure requirements under 2012-03-I-CA-R9 and R10 above.


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.
 

2012-03-I-CA-19

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.


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

PDF Document Status Change Summary

Governor and Legislature of the State of California (9 Recommendations)
Open: 33% | Closed: 67%
View Investigation
Final Report Released On: January 28, 2015

2012-03-I-CA-9

Revise the California Code of Regulations, Title 8, Section 5189, Process Safety Management of Acutely Hazardous Materials, to require improvements to mechanical integrity and process hazard analysis programs for all California oil refineries. These improvements shall include engaging a diverse team of qualified personnel to perform a documented damage mechanism hazard review. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure safeguards are in place to control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safety systems to the greatest extent feasible into this review.


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-10

For all California oil refineries, identify and require the reporting of leading and lagging process safety indicators, such as the action item completion status of recommendations from damage mechanism hazard reviews, to state and local regulatory agencies that have chemical release prevention authority. These indicators shall be used to ensure that requirements described in 2012-03-I-CA-R9 are effective at improving mechanical integrity and process hazard analysis performance at all California oil refineries and preventing major chemical incidents.


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-11

Establish a multi-agency process safety regulatory program for all California oil refineries to improve the public accountability, transparency, and performance of chemical accident prevention and mechanical integrity programs. This program shall:

  1. Establish a system to report to the regulator the recognized methodologies, findings, conclusions and corrective actions related to refinery mechanical integrity inspection and repair work arising from Process Hazard Analyses, California oil refinery turnarounds and maintenance-related shutdowns;
  2. Require reporting of information such as damage mechanism hazard reviews, notice of upcoming maintenance-related shutdowns, records related to proposed and completed mechanical integrity work lists, and the technical rationale for any delay in work proposed but not yet completed;
  3. Establish procedures for greater workforce and public participation including the public reporting of information; and
  4. Provide mechanisms for federal, state and local agency operational coordination, sharing of data (including safety indicator data), and joint accident prevention activities. The California Department of Industrial Relations will be designated as the lead state agency for establishing a repository of joint investigative and inspection data, coordinating the sharing of data and joint accident prevention activities.

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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-12

Require that Process Hazard Analyses required under California Code of Regulations, Title 8, Section 5189 Section (e) include documentation of the recognized methodologies, rationale and conclusions used to claim that safeguards intended to control hazards will be effective. This process shall use established qualitative, quantitative, and/or semi-quantitative methods such as Layers of Protection Analysis (LOPA).


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-13

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


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-14

Monitor and confirm the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R9 and 2012-03-I-CA-R10), so that all necessary mechanical integrity work at all California Chevron Refineries is identified and recommendations are completed in a timely way.


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-21

Based on the findings in this report, enhance and restructure California’s process safety management (PSM) regulations for petroleum refineries by including the following goal-setting attributes:

a. Require a comprehensive process hazard analysis (PHA) written by the company that includes:

i. Systematic analysis and documentation of all major hazards and safeguards, using the hierarchy of controls to identify hazards and significantly reduce risks to a goal of as low as reasonably practicable (ALARP) or similar;

ii. Documentation of the recognized methodologies, rationale and conclusions used to claim that inherently safer systems have been implemented to as low as reasonably practicable (ALARP) or similar, and that additional safeguards intended to control remaining hazards will be effective;

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

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

b. Require a thorough review of the comprehensive process hazard an alysis by technically competent regulatory personnel;

c. Require preventative audits and preventative inspections by the regulator to ensure the effective implementation of the comprehensive process hazard analysis (PHA);

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

e. Require mechanisms for the regulator, the refinery, and workers and their representatives to play an equal and essential role in the direction of preventing major incidents. Require an expanded role for workers in management of process safety by establishing the rights and responsibilities of workers and their representatives on health and safety-related matters, and the election of safety representatives and establishment of safety committees (with equal representation between management and labor) to serve health and safety-related functions. The elected representatives should have a legally recognized role that goes beyond consultation in activities such as the development of the comprehensive process hazard analysis, implementation of corrective actions generated from hierarchy of control analyses, management of change, incident investigation, audits, and the identification, prevention, and control of all processhazards. The regulation should provide workers and their representatives with the authority to stop work that is perceived to be unsafe until the employer resolves the matter or the regulator intervenes.  Workforce participation practices should be documented by the refinery to the regulator;

f. Require reporting of information to the public to the greatest extent feasible, such as a summary of the comprehensive process hazard analysis (PHA) which should include a list of inherently safer systems implemented; safeguards implemented for remaining hazards; standards utilized to reduce risks to As Low As Reasonably Practicable (ALARP) or similar; and process safety indicators that demonstrate the effectiveness of the safeguards and management systems;

g. Implement an approach or system that determines when new or improved industry standards and practices are needed and initiate programs and other activities, such as an advisory committee or forum, toprompt the timely development and implementation of such standards and practices; and

h. Ensure that a means of sustained funding is established to support an independent, well-funded, well-staffed, technically competent regulator.


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.
 

2012-03-I-CA-22

Implement a compensation system to ensure the regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical competency at all levels of process safety regulatory oversight and policy development in California. A market analysis and benchmarking review should be periodically conducted to ensure the compensation system remains competitive with California petroleum refineries.

 


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

PDF Document Recommendation Status Change Summary

2012-03-I-CA-23

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

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

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

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

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

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


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.
 

Mayor and City Council, City of Richmond, CA (6 Recommendations)
Open: 17% | Closed: 83%
View Investigation
Final Report Released On: January 28, 2015

2012-03-I-CA-3

Revise the Industrial Safety Ordinance (ISO) to require that Process Hazard Analyses include documentation of the recognized methodologies, rationale and conclusions used to claim that safeguards intended to control hazards will be effective. This process shall use established qualitative, quantitative, and/or semi-quantitative methods such as Layers of Protection Analysis (LOPA).


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-4

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


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-5

Ensure the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R1 and 2012-03-I-CA-R2), so that all necessary mechanical integrity work at the Chevron Richmond Refinery is identified and recommendations are completed in a timely way


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

PDF Document Recommendations Status Change Summary

2012-03-I-CA-17

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.


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

PDF Document Status Change Summary

2012-03-I-CA-24

Implement or cause to be implemented a compensation system to ensure the regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical competency at all levels of process safety regulatory oversight and policy development in Richmond, California. A market analysis and benchmarking review should be periodically conducted to ensure the compensation system remains competitive with California petroleum refineries.

 


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

2012-03-I-CA-37

Revise the Richmond Industrial Safety Ordinance (RISO) regulations for petroleum refineries to require a process safety culture continuous improvement program including a written procedure for periodic process safety culture surveys across the work force. Require an oversight committee comprised of the regulator, the company, the company’s workforce and their representatives, and community representatives. This oversight committee shall:

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

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

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

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

The periodic process safety culture report shall be made available to the plant workforce.


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.