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

CITGO Refinery Hydrofluoric Acid Release and Fire (2 Recommendations)
CITGO, Inc. (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: December 09, 2009

2009-14-I-TX-1 URGENT!

  • Within 30 days, develop and initiate actions to ensure adequate water supply to the CITGO HF mitigation system.  Actions could include, but are not limited to, increasing onsite storage capacity, installing a permanent backup system, and developing procedures and training for water management in an emergency.
  • Every 30 days, report actions planned or completed to the Refinery Terminal Fire Company and Local Emergency Planning Committee.  Continue the 30-day periodic reporting until all planned actions are fully implemented.


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

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2009-14-I-TX-2 URGENT!

  • Within 60 days, complete a third-party audit of all (Corpus Christi, TX and Lemont, IL) CITGO HF alkylation unit operations in the United States as recommended by API Recommended Practice 751, Safe Operation of Hydrofluoric Acid Alkylation Units, Third Edition June 2007. The selected lead auditor shall have extensive knowledge of HF hazards, HF alkylation units, and API 751. 
  • Consistent with the employee participation requirements of the Process Safety Management Standard for Highly Hazardous Chemicals (29 CFR 1910.119(c)), share all audit results and actions planned or completed to correct deficiencies in each refinery with all CITGO and contract employees whose work area includes that refinery’s alkylation unit.


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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Combustible Dust Hazard Investigation (6 Recommendations)
American National Standards Institute (ANSI) Z400.1 Committee (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: November 09, 2006

2006-1-H-6

Modify ANSI Z400.1 American National Standard for Hazardous Industrial Chemicals--Material Safety Data Sheets to recommend that MSDSs include information on: - combustible dust hazards, safe handling practices, and references to relevant fire codes in MSDS; - hazard information about the by-products of materials that may generate combustible dusts due to processing or handling; - identification of combustible dust hazards and selection of physical properties to include in MSDS.


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

Occupational Safety and Health Administration (OSHA) (5 Recommendations)
Open: 20% | Closed: 80%
View Investigation
Final Report Released On: November 09, 2006

2006-1-H-1

Issue a standard designed to prevent combustible dust fires and explosions in general industry. Base the standard on current National Fire Protection Association (NFPA) dust explosion standards (including NFPA 654 and NFPA 484), and include at least - hazard assessment, - engineering controls, - housekeeping, - building design, - explosion protection, - operating procedures, and - worker training.


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

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2006-1-H-2

Revise the Hazard Communication Standard (HCS) (1910.1200) to: - Clarify that the HCS covers combustible dusts, including those materials that may reasonably be anticipated to generate combustible dusts through downstream processing or handling. - Require Material Safety Data Sheets (MSDSs) to include the hazards and physical properties of combustible dusts, as well as clear information on safe handling practices and references to relevant consensus standards.


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

2006-1-H-3

Communicate to the United Nations Economic Commission for Europe (UNECE) the need to amend the Globally Harmonized System (GHS) to address combustible dust hazards by: - defining combustible dusts, - specifying the hazards that must be addressed in chemical information sheets, and - addressing the physical properties that must be included on a chemical information sheet pertinent to combustible dusts.


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.
 

2006-1-H-4

Provide training through the OSHA Training Institute (OTI) on recognizing and preventing combustible dust explosions.


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.
 

2006-1-H-5

While a standard is being developed, identify manufacturing industries at risk and develop and implement a national Special Emphasis Program (SEP) on combustible dust hazards in general industry. Include in the SEP an outreach program focused on the information in the Safety and Health Information Bulletin (SHIB), Combustible Dust in Industry: Preventing and Mitigating the Effects of Fire and Explosions.


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.
 

ConAgra Natural Gas Explosion and Ammonia Release (4 Recommendations)
American Gas Association (AGA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 04, 2010

2010-12-I-NC-1 URGENT!

Enact a Tentative Interim Amendment as well as permanent changes to the National Fuel Gas Code (NFPA 54/ANSI Z223.1) to require that during the purging of fuel gas piping at industrial, commercial, and public facilities: (a) Purged fuel gases shall be directly vented to a safe location outdoors, away from personnel and ignition sources 

(b) If it is not possible to vent purged gases outdoors, purging gas to the inside of a building shall be allowed only upon approval by the authority having jurisdiction of a documented risk evaluation and hazard control plan. The evaluation and plan shall establish that indoor purging is necessary and that adequate safeguards are in place such as:

     • Evacuating nonessential personnel from the vicinity of the purging;      • Providing adequate ventilation to maintain the gas concentration at an established safe level, substantially below   
     the lower explosive limit; and

     • Controlling or eliminating potential ignition sources (c) Combustible gas detectors are used to continuously monitor the gas concentration at appropriate locations in the vicinity where purged gases are released

(d) Personnel are trained about the problems of odor fade and odor fatigue and warned against relying on odor alone for detecting releases of fuel gases


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

ICC International Fuel Gas Code Committee Chair (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 04, 2010

2010-12-I-NC-2 URGENT!

Incorporate the revised gas purging provisions of the National Fuel Gas Code, consistent with CSB recommendation 2009-12-I-NC-R1, into the International Fuel Gas Code


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

International Code Council (ICC) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 04, 2010

2010-12-I-NC-2 URGENT!

Incorporate the revised gas purging provisions of the National Fuel Gas Code, consistent with CSB recommendation 2009-12-I-NC-R1, into the International Fuel Gas Code


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

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 04, 2010

2010-12-I-NC-1 URGENT!

Enact a Tentative Interim Amendment as well as permanent changes to the National Fuel Gas Code (NFPA 54/ANSI Z223.1) to require that during the purging of fuel gas piping at industrial, commercial, and public facilities: (a) Purged fuel gases shall be directly vented to a safe location outdoors, away from personnel and ignition sources 

(b) If it is not possible to vent purged gases outdoors, purging gas to the inside of a building shall be allowed only upon approval by the authority having jurisdiction of a documented risk evaluation and hazard control plan. The evaluation and plan shall establish that indoor purging is necessary and that adequate safeguards are in place such as:

     • Evacuating nonessential personnel from the vicinity of the purging;      • Providing adequate ventilation to maintain the gas concentration at an established safe level, substantially below   
     the lower explosive limit; and

     • Controlling or eliminating potential ignition sources (c) Combustible gas detectors are used to continuously monitor the gas concentration at appropriate locations in the vicinity where purged gases are released

(d) Personnel are trained about the problems of odor fade and odor fatigue and warned against relying on odor alone for detecting releases of fuel gases


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

CTA Acoustics Dust Explosion and Fire (22 Recommendations)
American Chemistry Council (ACC) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 15, 2005

2003-09-I-KY-19

Communicate the findings and recommendations of this report to your membership. Emphasize that dusts from phenolic resins can explode


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.
 

Borden Chemical, Inc. (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 15, 2005

2003-09-I-KY-11

Ensure MSDSs for phenolic resins include, at a minimum, warnings that dust from these products can be explosive.


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.
 

2003-09-I-KY-12

Develop and distribute educational material, in addition to MSDSs, to inform customers of the explosion hazard of phenolic resin dust.


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.
 

2003-09-I-KY-13

Communicate the findings and recommendations of this report to your customers that purchase phenolic resin.


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.
 

CertainTeed Corporation (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 15, 2005

2003-09-I-KY-9

Evaluate your facilities that handle combustible dusts and ensure that good practice guidelines such as NFPA 654 are followed.


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.
 

2003-09-I-KY-10

Ensure that company design standard's applicable to facilities that handle combustible dust's incorporate good engineering practices to prevent dust explosions, such as NFPA 654.


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

CTA Acoustics, Inc. (8 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 15, 2005

2003-09-I-KY-1

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Minimize surfaces where combustible dust could accumulate in the design or modification of the plant.


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.
 

2003-09-I-KY-2

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Ensure phenolic resin-handling facilities are designed to prevent the spread of fires or explosions involving combustible dust. Options include measures such as the use of firewalls and blast-resistant construction.


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.
 

2003-09-I-KY-3

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Prevent the unsafe accumulation and dispersion of combustible dust by frequently cleaning process areas, including locations above production lines.


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.
 

2003-09-I-KY-4

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Minimize the dispersion of combustible dust by using appropriate dust-cleaning methods and 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.
 

2003-09-I-KY-5

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Address the dangers of combustible dust and the prevention of dust explosions in the hazard communication training program.


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.
 

2003-09-I-KY-6

Conduct hazard assessments of ovens to ensure that fire detection and suppression systems are adequate, using good practice guidelines such as NFPA 86, Standard for Ovens and Furnaces.


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.
 

2003-09-I-KY-7

Develop procedures to maintain safety during nonroutine operating conditions, such as the loss of oven temperature control.


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.
 

2003-09-I-KY-8

Revise the incident investigation program to ensure that the underlying causes of incidents such as fires are identified and corrective actions implemented.


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

FM Global (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 15, 2005

2003-09-I-KY-16

Incorporate the findings and recommendations of this report in your training of employees who conduct inspections at facilities that may handle combustible dusts.


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

International Code Council (ICC) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 15, 2005

2003-09-I-KY-20

Communicate the findings and recommendations 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.
 

Kentucky Office of Housing, Buildings, and Construction (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 15, 2005

2003-09-I-KY-17

Incorporate the findings and recommendations of this report in your continuing training of inspectors, plan reviewers, technical advisors, and fire marshal general inspectors who interface with facilities that may handle combustible dusts.


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.
 

2003-09-I-KY-18

Identify sites that handle combustible dusts when facilities apply for new or modified construction permits, and use this information to help prioritize establishments that will be inspected by the fire marshal.


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

Kentucky Office of Occupational Safety and Health (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 15, 2005

2003-09-I-KY-14

Develop and distribute an educational bulletin on the prevention of combustible dust explosions.


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.
 

2003-09-I-KY-15

Enhance the training program for compliance officers regarding the recognition and prevention of combustible dust explosion hazards.


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

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 15, 2005

2003-09-I-KY-21

Communicate the findings and recommendations 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.
 

Society of the Plastics Industry- Phenolic Division (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 15, 2005

2003-09-I-KY-22

Communicate the findings and recommendations 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.
 

D.D. Williamson & Co. Catastrophic Vessel Failure (10 Recommendations)
Commonwealth of Kentucky (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 12, 2004

2003-11-I-KY-7

Communicate to the owners of pressure vessels, mechanical contractors, engineering consulting companies, and insurance companies doing business in Kentucky that used pressure vessels are not exempt from registration and initial inspection before being placed in service in Kentucky.


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.
 

D.D. Williamson and Co., Inc. (6 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 12, 2004

2003-11-I-KY-1

Institute procedures to ensure that pressure vessels are designed, fabricated, and operated according to applicable codes and standards.


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.
 

2003-11-I-KY-2

Audit all vessels at all D. D. Williamson facilities and ensure that they are: Equipped with adequate overpressure protection, as warranted. Equipped with alarms or interlocks, as warranted.


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.
 

2003-11-I-KY-3

Implement a program to review existing equipment when it is used for new purposes and when safety devices are removed or altered.


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.
 

2003-11-I-KY-4

Implement a hazard evaluation procedure to determine the potential for catastrophic incidents and necessary safeguards.


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.
 

2003-11-I-KY-5

Audit manual control of process conditions, such as temperature and pressure, and determine if safeguards are needed.


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.
 

2003-11-I-KY-6

Upgrade written operating procedures and train operators on the revised procedures.


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.
 

Mechanical Contractors Association of Kentucky (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 12, 2004

2003-11-I-KY-8

Communicate to your members that used pressure vessels are not exempt from registration and initial inspection before being placed in service in Kentucky.


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 Board of Boiler and Pressure Vessel Inspectors (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 12, 2004

2003-11-I-KY-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.
 

Risk and Insurance Management Society (RIMS) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: March 12, 2004

2003-11-I-KY-9

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.