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.
2008-08-I-WV-2
Review and revise, as necessary, all Bayer production unit standard operating procedures to ensure they address all operating modes (startup, normal operation, temporary operations, emergency shutdown, emergency operations, normal shutdown, and startup following a turnaround or emergency shutdown), are accurate, and approved. Status: Closed - Acceptable Action
Review and revise, as necessary, all Bayer production unit standard operating procedures to ensure they address all operating modes (startup, normal operation, temporary operations, emergency shutdown, emergency operations, normal shutdown, and startup following a turnaround or emergency shutdown), are accurate, and approved.
2008-08-I-WV-3
Ensure that all facility fire brigade members are trained in the National Incident Management System, consistent with municipal and state emergency response agencies. Status: Closed - Acceptable Action
Ensure that all facility fire brigade members are trained in the National Incident Management System, consistent with municipal and state emergency response agencies.
2008-08-I-WV-4
Evaluate the fenceline air monitor program against federal, state, and local regulations, and Bayer corporate policies, and upgrade and install air monitoring devices as necessary to ensure effective monitoring of potential releases of high-hazard chemicals at the perimeter of the facility. Status: Closed - Acceptable Action
Evaluate the fenceline air monitor program against federal, state, and local regulations, and Bayer corporate policies, and upgrade and install air monitoring devices as necessary to ensure effective monitoring of potential releases of high-hazard chemicals at the perimeter of the facility.
2008-08-I-WV-5
Commission an independent human factors and ergonomics study of all Institute site PSM/RMP covered process control rooms to evaluate the human-control system interface, operator fatigue, and control system familiarity and training. Develop and implement a plan to resolve all recommendations identified in the study that includes assigned responsibilities, required corrective actions, and completion dates. Status: Closed - Acceptable Action
Commission an independent human factors and ergonomics study of all Institute site PSM/RMP covered process control rooms to evaluate the human-control system interface, operator fatigue, and control system familiarity and training. Develop and implement a plan to resolve all recommendations identified in the study that includes assigned responsibilities, required corrective actions, and completion dates.
2008-08-I-WV-1
Revise the corporate PHA policies and procedures to require: a. Validation of all PHA assumptions to ensure that risk analysis of each PHA scenario specifically examines the risk(s) of intentional bypassing or other nullifications of safeguards, b. Addressing all phases of operation and special topics including those cited in chapter 9 of "Guidelines for Hazard Evaluation Procedures" (CCPS, 2008), and c. Training all PHA facilitators on the revised policies and procedures prior to assigning the facilitator to a PHA team. Ensure all PHAs are updated to conform to the revised procedures. Status: Closed - Acceptable Action
Revise the corporate PHA policies and procedures to require: a. Validation of all PHA assumptions to ensure that risk analysis of each PHA scenario specifically examines the risk(s) of intentional bypassing or other nullifications of safeguards, b. Addressing all phases of operation and special topics including those cited in chapter 9 of "Guidelines for Hazard Evaluation Procedures" (CCPS, 2008), and c. Training all PHA facilitators on the revised policies and procedures prior to assigning the facilitator to a PHA team. Ensure all PHAs are updated to conform to the revised procedures.
2008-08-I-WV-12
In light of the findings of this report and the serious potential hazards to workers and the public from chemicals used and stored at the Bayer Institute site (such as phosgene, MIC, and methomyl), conduct a comprehensive Risk Management Program (RMP) inspection of the complex. Coordinate with the Occupational Safety and Health Administration, as appropriate. Status: Closed - No Longer Applicable
In light of the findings of this report and the serious potential hazards to workers and the public from chemicals used and stored at the Bayer Institute site (such as phosgene, MIC, and methomyl), conduct a comprehensive Risk Management Program (RMP) inspection of the complex. Coordinate with the Occupational Safety and Health Administration, as appropriate.
2008-08-I-WV-6
Establish a Hazardous Chemical Release Prevention Program to enhance the prevention of accidental releases of highly hazardous chemicals, and optimize responses in the event of their occurrence. In establishing the program, study and evaluate the possible applicability of the experience of similar programs in the country, such as those summarized in Section 5.3 of this report. As a minimum: a. Ensure that the new program: 1. Implements an effective system of independent oversight and other services to enhance the prevention of accidental releases of highly hazardous chemicals 2. Facilitates the collaboration of multiple stakeholders in achieving common goals of chemical safety; and, 3. Increases the confidence of the community, the workforce, and the local authorities in the ability of the facility owners to prevent and respond to accidental releases of highly hazardous chemicals. b. Define the characteristics of chemical facilities that would be covered by the new Program, such as the hazards and potential risks of their chemicals and processes, their quantities, and similar relevant factors; c. Ensure that covered facilities develop, implement, and submit for review and approval: 1. Applicable hazard and process information and evaluations. 2. Written safety plans with appropriate descriptions of hazard controls, safety culture and human factors programs with employee participation, and consideration of the adoption of inherently safer systems to reduce risks 3. Emergency response plans; and, 4. Performance indicators addressing the prevention of incidents and chemical incidents. d. Ensure that the program has the right to evaluate the documents submitted by the covered facilities, and to require modifications, as necessary e. Ensure that the program has right-of-entry to covered facilities, and access to requisite information to conduct periodic audits of safety systems and investigations of chemical releases; f. Establish a system of fees assessed on covered facilities sufficient to cover the oversight and related services to be provided to the facilities including necessary technical and administrative personnel; and, g. Consistent with applicable law, ensure that the program provides reasonable public participation with the program staff in review of facility programs and access to: 1. The materials submitted by covered facilities (e.g., hazard evaluations, safety plans, emergency response plans); 2. The reviews conducted by program staff and the modifications triggered by those reviews; 3. Records of audits and incident investigations conducted by the program; 4. Performance indicator reports and data submitted by the facilities, and; 5. Other relevant information concerning the hazards and the control methods overseen by the program. h. Ensure that the program will require a periodic review of the designated agency activities and issue a periodic public report of its activities and recommended action items Status: Closed - Unacceptable Action/No Response Received
Establish a Hazardous Chemical Release Prevention Program to enhance the prevention of accidental releases of highly hazardous chemicals, and optimize responses in the event of their occurrence. In establishing the program, study and evaluate the possible applicability of the experience of similar programs in the country, such as those summarized in Section 5.3 of this report. As a minimum: a. Ensure that the new program: 1. Implements an effective system of independent oversight and other services to enhance the prevention of accidental releases of highly hazardous chemicals 2. Facilitates the collaboration of multiple stakeholders in achieving common goals of chemical safety; and, 3. Increases the confidence of the community, the workforce, and the local authorities in the ability of the facility owners to prevent and respond to accidental releases of highly hazardous chemicals. b. Define the characteristics of chemical facilities that would be covered by the new Program, such as the hazards and potential risks of their chemicals and processes, their quantities, and similar relevant factors; c. Ensure that covered facilities develop, implement, and submit for review and approval: 1. Applicable hazard and process information and evaluations. 2. Written safety plans with appropriate descriptions of hazard controls, safety culture and human factors programs with employee participation, and consideration of the adoption of inherently safer systems to reduce risks 3. Emergency response plans; and, 4. Performance indicators addressing the prevention of incidents and chemical incidents. d. Ensure that the program has the right to evaluate the documents submitted by the covered facilities, and to require modifications, as necessary e. Ensure that the program has right-of-entry to covered facilities, and access to requisite information to conduct periodic audits of safety systems and investigations of chemical releases; f. Establish a system of fees assessed on covered facilities sufficient to cover the oversight and related services to be provided to the facilities including necessary technical and administrative personnel; and, g. Consistent with applicable law, ensure that the program provides reasonable public participation with the program staff in review of facility programs and access to: 1. The materials submitted by covered facilities (e.g., hazard evaluations, safety plans, emergency response plans); 2. The reviews conducted by program staff and the modifications triggered by those reviews; 3. Records of audits and incident investigations conducted by the program; 4. Performance indicator reports and data submitted by the facilities, and; 5. Other relevant information concerning the hazards and the control methods overseen by the program. h. Ensure that the program will require a periodic review of the designated agency activities and issue a periodic public report of its activities and recommended action items
2008-08-I-WV-8
Work with the Kanawha and Putnam counties Emergency Response Directors to prepare and issue a revision to the Kanawha Putnam County Emergency Response Plan and Annexes to address facility emergency response and Incident Command when such functions are provided by the facility owner. Status: Closed - Acceptable Action
Work with the Kanawha and Putnam counties Emergency Response Directors to prepare and issue a revision to the Kanawha Putnam County Emergency Response Plan and Annexes to address facility emergency response and Incident Command when such functions are provided by the facility owner.
2008-08-I-WV-10
In light of the findings of this report and the serious potential hazards to workers and the public from chemicals used and stored at the Bayer Institute site (such as phosgene, MIC, and methomyl), conduct a comprehensive Process Safety Management (PSM) inspection of the complex. Coordinate with the Environmental Protection Agency, as appropriate. Status: Closed - No Longer Applicable
In light of the findings of this report and the serious potential hazards to workers and the public from chemicals used and stored at the Bayer Institute site (such as phosgene, MIC, and methomyl), conduct a comprehensive Process Safety Management (PSM) inspection of the complex. Coordinate with the Environmental Protection Agency, as appropriate.
2008-08-I-WV-11
Revise the Chemical National Emphasis Program and the targeting criteria to: a. Expand the coverage to all OSHA regions, b. Include in the targeting criteria from which potential inspections are selected all establishments that have submitted certifications of completions of actions in response to previous PSM citations; c. Require NEP inspections to examine the status of compliance of all previously cited PSM program items for which the company has submitted certifications of completion to OSHA. Status: Closed - Acceptable Action
Revise the Chemical National Emphasis Program and the targeting criteria to: a. Expand the coverage to all OSHA regions, b. Include in the targeting criteria from which potential inspections are selected all establishments that have submitted certifications of completions of actions in response to previous PSM citations; c. Require NEP inspections to examine the status of compliance of all previously cited PSM program items for which the company has submitted certifications of completion to OSHA.
2008-08-I-WV-7
Work with the Director of the Kanawha-Charleston Health Department to ensure the successful planning, fee collection, and implementation of the Hazardous Chemical Release Prevention Program as described in Recommendation 2008-08-WV-R6, above, including the provision of services to all eligible facilities in the State. Status: Closed - No Longer Applicable
Work with the Director of the Kanawha-Charleston Health Department to ensure the successful planning, fee collection, and implementation of the Hazardous Chemical Release Prevention Program as described in Recommendation 2008-08-WV-R6, above, including the provision of services to all eligible facilities in the State.
2008-08-I-WV-9
Revise the Fire Department Evaluation Administrative Section Matrix addressing the periodic inspection of local fire departments to include a requirement for inspectors to examine and identify the status of National Incident Management System fire department personnel training. Status: Closed - Acceptable Action
Revise the Fire Department Evaluation Administrative Section Matrix addressing the periodic inspection of local fire departments to include a requirement for inspectors to examine and identify the status of National Incident Management System fire department personnel training.
2001-02-I-IN-10
Communicate findings of this report to your membership. Status: Closed - Acceptable Action
Communicate findings of this report to your membership.
2001-02-I-IN-10 URGENT!
2001-02-I-IN-7
Conduct periodic audits of work authorization, line and equipment opening, deadleg management programs, and decommissioning and demolition activities at your steelmaking facilities. Share findings with the workforce. Status: Closed - Unacceptable Action/No Response Received
Conduct periodic audits of work authorization, line and equipment opening, deadleg management programs, and decommissioning and demolition activities at your steelmaking facilities. Share findings with the workforce.
2001-02-I-IN-8
Revise the Material Safety Data Sheet (MSDS) for COG condensate to highlight the potential flammability hazard. Ensure that management at your steelmaking facilities trains employees and informs contractors with regard to the potential presence of flammable liquids when working with or opening COG condensate piping and equipment. Status: Closed - Acceptable Action
Revise the Material Safety Data Sheet (MSDS) for COG condensate to highlight the potential flammability hazard. Ensure that management at your steelmaking facilities trains employees and informs contractors with regard to the potential presence of flammable liquids when working with or opening COG condensate piping and equipment.
2001-02-I-IN-9
Communicate findings of this report to the workforce and contractors at Bethlehem Steel's steelmaking facilities. Status: Closed - Reconsidered/Superseded
Communicate findings of this report to the workforce and contractors at Bethlehem Steel's steelmaking facilities.
2001-02-I-IN-1
Implement a work authorization program that requires higher levels of management review, approval, and oversight for jobs that present higher levels of risk, such as opening lines potentially containing flammable liquids where there is no low point drain. Status: Closed - Acceptable Action
Implement a work authorization program that requires higher levels of management review, approval, and oversight for jobs that present higher levels of risk, such as opening lines potentially containing flammable liquids where there is no low point drain.
2001-02-I-IN-2
Monitor the accumulation and flammability of COG condensate throughout the mill. Address potentially hazardous changes in condensate accumulation rates and flammability. Status: Closed - Acceptable Action
Monitor the accumulation and flammability of COG condensate throughout the mill. Address potentially hazardous changes in condensate accumulation rates and flammability.
2001-02-I-IN-3
Survey the mill for deadlegs and implement a program for resolving the hazards. Develop guidance for plant personnel on the risks of deadlegs and their prevention. Include deadlegs in plant winterization planning. Status: Closed - Unacceptable Action/No Response Received
Survey the mill for deadlegs and implement a program for resolving the hazards. Develop guidance for plant personnel on the risks of deadlegs and their prevention. Include deadlegs in plant winterization planning.
2001-02-I-IN-4
Provide drains at low points in piping to allow for the safe draining of potentially flammable material. Status: Closed - Unacceptable Action/No Response Received
Provide drains at low points in piping to allow for the safe draining of potentially flammable material.
2001-02-I-IN-5
Ensure that Burns Harbor and contractor employees are trained with regard to the potential presence of flammable liquids when working with or opening COG or condensate piping and equipment. Status: Closed - Acceptable Action
Ensure that Burns Harbor and contractor employees are trained with regard to the potential presence of flammable liquids when working with or opening COG or condensate piping and equipment.
2001-02-I-IN-6
Establish procedures to ensure that insulation is replaced when removed for maintenance. Status: Closed - Acceptable Action
Establish procedures to ensure that insulation is replaced when removed for maintenance.
2006-3-I-FL-11
Revise CDM policies and procedures to ensure that appropriate quality control measures are applied so that designs specify appropriate materials and comply with applicable safety standards. Ensure that wastewater treatment plant design engineers are aware of the importance of proper material selection as well as the findings and recommendations of this report. Status: Closed - Acceptable Action
Revise CDM policies and procedures to ensure that appropriate quality control measures are applied so that designs specify appropriate materials and comply with applicable safety standards. Ensure that wastewater treatment plant design engineers are aware of the importance of proper material selection as well as the findings and recommendations of this report.
2006-3-I-FL-12
Communicate the findings and recommendations of this report to all companies that contracted with CDM for methanol and other flammable liquid systems that were constructed with aboveground plastic pipe. Recommend replacing plastic pipe with an appropriate material in accordance with NFPA 30 and OSHA 1910.106. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to all companies that contracted with CDM for methanol and other flammable liquid systems that were constructed with aboveground plastic pipe. Recommend replacing plastic pipe with an appropriate material in accordance with NFPA 30 and OSHA 1910.106.
2006-3-I-FL-13
Communicate the findings and recommendations of this report to all companies that contracted with CDM for flammable liquid systems that included a flame arrester. Emphasize the importance of periodic maintenance of the flame arrester to ensure its effective performance. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to all companies that contracted with CDM for flammable liquid systems that included a flame arrester. Emphasize the importance of periodic maintenance of the flame arrester to ensure its effective performance.
2006-3-I-FL-3
Adopt city ordinances to require departments to implement policies, practices, and procedures concerning safety and health in the workplace for city employees that are at least as effective as relevant OSHA standards. Emphasize compliance with chemical standards, including hot work procedures (OSHA Welding, Cutting, and Brazing Standard, Sections 1910.251 and 1910.252) and chemical hazard communication (OSHA Hazard Communication Standard 29 CFR 1910.1200). Implement procedures to ensure compliance with these policies, practices and procedures. Status: Closed - Acceptable Action
Adopt city ordinances to require departments to implement policies, practices, and procedures concerning safety and health in the workplace for city employees that are at least as effective as relevant OSHA standards. Emphasize compliance with chemical standards, including hot work procedures (OSHA Welding, Cutting, and Brazing Standard, Sections 1910.251 and 1910.252) and chemical hazard communication (OSHA Hazard Communication Standard 29 CFR 1910.1200). Implement procedures to ensure compliance with these policies, practices and procedures.
2006-3-I-FL-4
Ensure that flammable liquid storage tanks used throughout the city comply with NFPA 30 and minimum federal standards in 29 CFR 1910.106, including appropriate piping and flame arresters. Status: Closed - Acceptable Action
Ensure that flammable liquid storage tanks used throughout the city comply with NFPA 30 and minimum federal standards in 29 CFR 1910.106, including appropriate piping and flame arresters.
2006-3-I-FL-1
Enact legislation requiring state agencies and each political subdivision (i.e. counties and municipalities) of Florida to implement policies, practices, procedures, including chemical hazards covering the workplace health and safety of Florida public employees that are at least as effective as OSHA. Establish and fund a mechanism to ensure compliance with these standards. Consider legislation providing coverage of Florida public employees under an occupational safety and health program in accordance with Section 18(b) of the Occupational Safety and Health Act of 1970, and Code of Federal Regulations 29 CFR 1956.1. Status: Closed - Unacceptable Action/No Response Received
Enact legislation requiring state agencies and each political subdivision (i.e. counties and municipalities) of Florida to implement policies, practices, procedures, including chemical hazards covering the workplace health and safety of Florida public employees that are at least as effective as OSHA. Establish and fund a mechanism to ensure compliance with these standards. Consider legislation providing coverage of Florida public employees under an occupational safety and health program in accordance with Section 18(b) of the Occupational Safety and Health Act of 1970, and Code of Federal Regulations 29 CFR 1956.1.
2006-3-I-FL-2
Develop and fund a workplace safety and health consultation program for Florida public employees similar to the private sector program currently administered by the Florida Safety Consultation Program at the University of South Florida. Status: Closed - Unacceptable Action/No Response Received
Develop and fund a workplace safety and health consultation program for Florida public employees similar to the private sector program currently administered by the Florida Safety Consultation Program at the University of South Florida.
2006-3-I-FL-9
Work with the Water Environment Federation to prepare and distribute a technical bulletin containing information on the safe receipt, storage, use, and dispensing of methanol in wastewater treatment plants. In addition, include information on basic fire and explosion prevention measures when using bulk methanol (e.g., flame arrester maintenance, hot work programs, electrical classification). Status: Closed - Acceptable Action
Work with the Water Environment Federation to prepare and distribute a technical bulletin containing information on the safe receipt, storage, use, and dispensing of methanol in wastewater treatment plants. In addition, include information on basic fire and explosion prevention measures when using bulk methanol (e.g., flame arrester maintenance, hot work programs, electrical classification).
2006-3-I-FL-10
Work with the Water Environment Federation to prepare safety training materials for wastewater treatment facilities that use methanol. Status: Closed - Acceptable Action
Work with the Water Environment Federation to prepare safety training materials for wastewater treatment facilities that use methanol.
2006-3-I-FL-5
Revise NFPA 30 to specifically exclude the use of thermoplastics in aboveground flammable liquid service. Status: Closed - Acceptable Action
Revise NFPA 30 to specifically exclude the use of thermoplastics in aboveground flammable liquid service.
2006-3-I-FL-6
Revise 29 CFR 1910.106 to specifically exclude the use of thermoplastics in above ground flammable liquid service. Status: Closed - Reconsidered/Superseded
Revise 29 CFR 1910.106 to specifically exclude the use of thermoplastics in above ground flammable liquid service.
2006-3-I-FL-7
Work with the Methanol Institute to prepare and distribute a technical bulletin containing information on the safe receipt, storage, use, and dispensing of methanol in wastewater treatment plants. In addition, include information on basic fire and explosion prevention measures when using bulk methanol (e.g., flame arrester maintenance, hot work programs, electrical classification). Status: Closed - Acceptable Action
Work with the Methanol Institute to prepare and distribute a technical bulletin containing information on the safe receipt, storage, use, and dispensing of methanol in wastewater treatment plants. In addition, include information on basic fire and explosion prevention measures when using bulk methanol (e.g., flame arrester maintenance, hot work programs, electrical classification).
2006-3-I-FL-8
Work with the Methanol Institute to prepare safety training materials for wastewater treatment facilities that use methanol. Status: Closed - Acceptable Action
Work with the Methanol Institute to prepare safety training materials for wastewater treatment facilities that use methanol.
2003-06-I-TX-16
Revise API RP-2219, Safe Operation of Vacuum Trucks in Petroleum Service, and API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities, to discuss the hazards of unloading potentially flammable or flammable liquids onto an open unloading area, such as a concrete pad. Recommend other alternatives for minimizing vapor generation, such as unloading of flammable liquids into a closed piping system. Status: Closed - Acceptable Action
Revise API RP-2219, Safe Operation of Vacuum Trucks in Petroleum Service, and API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities, to discuss the hazards of unloading potentially flammable or flammable liquids onto an open unloading area, such as a concrete pad. Recommend other alternatives for minimizing vapor generation, such as unloading of flammable liquids into a closed piping system.
2003-06-I-TX-17
Communicate the findings and recommendations of this report to your membership. Emphasize that basic sediment and water (BS&W) removed from crude oil and condensate storage tanks requires special handling, in addition to compliance with Occupational Safety and Health Administration (OSHA) or U.S. Department of Transportation (DOT) regulations, if it contains sufficient hydrocarbons (either residual or mixed in during the removal process) to be classified a flammable liquid as defined by each regulation. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to your membership. Emphasize that basic sediment and water (BS&W) removed from crude oil and condensate storage tanks requires special handling, in addition to compliance with Occupational Safety and Health Administration (OSHA) or U.S. Department of Transportation (DOT) regulations, if it contains sufficient hydrocarbons (either residual or mixed in during the removal process) to be classified a flammable liquid as defined by each regulation.
2003-06-I-TX-8
Develop a written Waste Acceptance Plan as recommended by API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities. Require the shipper or carrier to properly classify the flammability hazard of exploration and production (E&P) waste liquids. Require the hauler to provide information that identifies the flammability hazard of the material before accepting the load, such as a material safety data sheet (MSDS). Status: Closed - Acceptable Action
Develop a written Waste Acceptance Plan as recommended by API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities. Require the shipper or carrier to properly classify the flammability hazard of exploration and production (E&P) waste liquids. Require the hauler to provide information that identifies the flammability hazard of the material before accepting the load, such as a material safety data sheet (MSDS).
2003-06-I-TX-9
Develop and implement written procedures and provide training to employees on the safe handling of all waste liquids delivered to the facility in accordance with API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities; and API RP-2219, Safe Operation of Vacuum Trucks in Petroleum Service. Include requirements for proper grounding of trucks and eliminating other sources of ignition (e.g., facility electrical equipment and smoking in unloading areas). Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel. Status: Closed - Acceptable Action
Develop and implement written procedures and provide training to employees on the safe handling of all waste liquids delivered to the facility in accordance with API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities; and API RP-2219, Safe Operation of Vacuum Trucks in Petroleum Service. Include requirements for proper grounding of trucks and eliminating other sources of ignition (e.g., facility electrical equipment and smoking in unloading areas). Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel.
2003-06-I-TX-10
Develop written procedures and provide training to employees on unloading all flammable or potentially flammable E&P waste liquids. Avoid unloading flammable liquids onto an open work area, such as the mud disposal and washout pad. Include alternative unloading method(s), such as using a closed piping system to minimize vapor generation. Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel. Status: Closed - Acceptable Action
Develop written procedures and provide training to employees on unloading all flammable or potentially flammable E&P waste liquids. Avoid unloading flammable liquids onto an open work area, such as the mud disposal and washout pad. Include alternative unloading method(s), such as using a closed piping system to minimize vapor generation. Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel.
2003-06-I-TX-11
Develop written emergency procedures and provide training to employees on response to abnormal or emergency situations, including uncontrolled flammable vapor releases that can result in a fire or explosion hazard. Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel. Status: Closed - Acceptable Action
Develop written emergency procedures and provide training to employees on response to abnormal or emergency situations, including uncontrolled flammable vapor releases that can result in a fire or explosion hazard. Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel.
2003-06-I-TX-12
Publish an information document for exploration and production (E&P) industry employers (including producers/shippers/offerors, motor carriers, and disposal facility operators) involved in the transportation of basic sediment and water (BS&W) and other E&P waste liquids on public highways. (2003-06-I-TX-R12): -Emphasize the importance of, and responsibility for, properly classifying and identifying flammable waste liquids. -Reference the Occupational Safety and Health Administration (OSHA) requirements for obtaining material safety data sheets (MSDS) from the shipper and the required content of DOT shipping papers. -Include specific reference to this CSB Investigation Report and the American Petroleum Institute (API) recommended practices cited in this report. Status: Closed - Acceptable Action
Publish an information document for exploration and production (E&P) industry employers (including producers/shippers/offerors, motor carriers, and disposal facility operators) involved in the transportation of basic sediment and water (BS&W) and other E&P waste liquids on public highways. (2003-06-I-TX-R12): -Emphasize the importance of, and responsibility for, properly classifying and identifying flammable waste liquids. -Reference the Occupational Safety and Health Administration (OSHA) requirements for obtaining material safety data sheets (MSDS) from the shipper and the required content of DOT shipping papers. -Include specific reference to this CSB Investigation Report and the American Petroleum Institute (API) recommended practices cited in this report.
2003-06-I-TX-18
Communicate the findings and recommendations of this report to your membership. Emphasize emergency response to diesel engine overspeed caused by exposure to flammable vapor atmospheres. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to your membership. Emphasize emergency response to diesel engine overspeed caused by exposure to flammable vapor atmospheres.
2003-06-I-TX-1
Provide documentation of the potential flammability hazard of exploration and production (E&P) waste liquids-such as a material safety data sheet (MSDS)- to all employees, contract personnel, and haulers handling waste liquids generated at well sites. Emphasize that mixing condensate with basic sediment and water (BS&W) during the removal process can significantly increase the flammability hazard. The mixture in the transport container should be treated as a flammable liquid absent positive identification to the contrary. Status: Closed - Acceptable Action
Provide documentation of the potential flammability hazard of exploration and production (E&P) waste liquids-such as a material safety data sheet (MSDS)- to all employees, contract personnel, and haulers handling waste liquids generated at well sites. Emphasize that mixing condensate with basic sediment and water (BS&W) during the removal process can significantly increase the flammability hazard. The mixture in the transport container should be treated as a flammable liquid absent positive identification to the contrary.
2003-06-I-TX-2
Review and revise company gauging and waste liquid removal protocols as necessary to minimize the inadvertent removal and subsequent disposal of hydrocarbon product when removing BS&W from product storage tanks. Status: Closed - Acceptable Action
Review and revise company gauging and waste liquid removal protocols as necessary to minimize the inadvertent removal and subsequent disposal of hydrocarbon product when removing BS&W from product storage tanks.
2003-06-I-TX-13
Issue a Safety and Health Information Bulletin on the potential flammability hazard associated with bulk transportation of oilfield exploration and production (E&P) waste liquids. Summarize OSHA requirements for proper hazard classification by the shipper and for the use of material safety data sheets (MSDS). Summarize U.S. Department of Transportation (DOT) requirements for proper hazard classification and manifesting of flammable liquids, approved container design, and periodic testing. Discuss safe handling to minimize the generation of flammable vapor and to control ignition sources from vehicle-mounted equipment and facility equipment. Discuss the need for the employer to provide all worker safety information in languages or formats that are clearly understood by all affected personnel. Summarize the requirements for proper labeling of storage tanks to clearly identify the hazard of the contents to all employees and contractors working at the well site. Status: Closed - Acceptable Action
Issue a Safety and Health Information Bulletin on the potential flammability hazard associated with bulk transportation of oilfield exploration and production (E&P) waste liquids. Summarize OSHA requirements for proper hazard classification by the shipper and for the use of material safety data sheets (MSDS). Summarize U.S. Department of Transportation (DOT) requirements for proper hazard classification and manifesting of flammable liquids, approved container design, and periodic testing. Discuss safe handling to minimize the generation of flammable vapor and to control ignition sources from vehicle-mounted equipment and facility equipment. Discuss the need for the employer to provide all worker safety information in languages or formats that are clearly understood by all affected personnel. Summarize the requirements for proper labeling of storage tanks to clearly identify the hazard of the contents to all employees and contractors working at the well site.
2003-06-I-TX-3
Ensure that the written procedures for hazard identification require that all customers requesting loading and transportation of exploration and production (E&P) waste liquids provide written notification, such as a material safety data sheet (MSDS), listing the potential flammability hazard. Status: Closed - Acceptable Action
Ensure that the written procedures for hazard identification require that all customers requesting loading and transportation of exploration and production (E&P) waste liquids provide written notification, such as a material safety data sheet (MSDS), listing the potential flammability hazard.
2003-06-I-TX-4
Ensure that the written procedures for safe operation of vacuum trucks incorporate applicable good practices, including techniques to minimize the possibility of exposing the diesel engine to flammable vapor, as provided in API RP-2219, Guidelines for Commercial Exploration and Production Waste Management Facilities. Status: Closed - Exceeds Recommended Action
Ensure that the written procedures for safe operation of vacuum trucks incorporate applicable good practices, including techniques to minimize the possibility of exposing the diesel engine to flammable vapor, as provided in API RP-2219, Guidelines for Commercial Exploration and Production Waste Management Facilities.
2003-06-I-TX-5
Develop written operating procedures that incorporate best practices for unloading storage tank waste liquids, such that drivers accurately measure the quantity of liquid removed from the storage tank and minimize removal of product, such as flammable condensate. Status: Closed - Acceptable Action
Develop written operating procedures that incorporate best practices for unloading storage tank waste liquids, such that drivers accurately measure the quantity of liquid removed from the storage tank and minimize removal of product, such as flammable condensate.
2003-06-I-TX-6
Ensure that written emergency procedures address the safe response to abnormal diesel engine operation due to a flammable vapor atmosphere. Explain that the normal engine shutoff method will not function as long as flammable vapor continues to enter the intake system. Status: Closed - Acceptable Action
Ensure that written emergency procedures address the safe response to abnormal diesel engine operation due to a flammable vapor atmosphere. Explain that the normal engine shutoff method will not function as long as flammable vapor continues to enter the intake system.
2003-06-I-TX-7
Conduct and document training for all personnel who handle waste liquids, using languages or formats that are clearly understood by all affected personnel. Address the potential flammability hazard associated with E&P waste liquids, emphasizing how the withdrawal procedure is likely to increase the flammability of the vacuum truck contents through unavoidable mixing of product and basic sediment and water (BS&W). Describe operating and emergency response to diesel engine overspeed caused by a flammable vapor atmosphere. Status: Closed - Acceptable Action
Conduct and document training for all personnel who handle waste liquids, using languages or formats that are clearly understood by all affected personnel. Address the potential flammability hazard associated with E&P waste liquids, emphasizing how the withdrawal procedure is likely to increase the flammability of the vacuum truck contents through unavoidable mixing of product and basic sediment and water (BS&W). Describe operating and emergency response to diesel engine overspeed caused by a flammable vapor atmosphere.
2003-06-I-TX-14
Require that all permitted drillers and producers identify and document (e.g., material safety data sheet [MSDS]) the potential flammability hazard of exploration and production (E&P) waste liquids. Provide the information to workers and contractors in languages clearly understood by the recipients. Status: Closed - Acceptable Action
Require that all permitted drillers and producers identify and document (e.g., material safety data sheet [MSDS]) the potential flammability hazard of exploration and production (E&P) waste liquids. Provide the information to workers and contractors in languages clearly understood by the recipients.
2003-06-I-TX-15
Provide information (e.g., safety bulletin) to industry on the potential flammability hazard associated with basic sediment and water (BS&W) and other E&P waste liquids. Waste liquids can contain sufficient hydrocarbons to be classified as flammable liquids. The waste liquid removal method can result in removing significant quantities of flammable hydrocarbon product such that the mixture in the transport container may require classification as a flammable liquid under Occupational Safety and Health Administration (OSHA) or U.S. Department of Transportation (DOT) regulations. Status: Closed - Acceptable Action
Provide information (e.g., safety bulletin) to industry on the potential flammability hazard associated with basic sediment and water (BS&W) and other E&P waste liquids. Waste liquids can contain sufficient hydrocarbons to be classified as flammable liquids. The waste liquid removal method can result in removing significant quantities of flammable hydrocarbon product such that the mixture in the transport container may require classification as a flammable liquid under Occupational Safety and Health Administration (OSHA) or U.S. Department of Transportation (DOT) regulations.
2022-01-I-OH-5
Develop a new publication or revise an existing publication, such as API Recommended Practice 556 Instrumentation, Control, and Protective Systems for Gas Fired Heaters, to incorporate the process hazards associated with Fuel Gas Mix Drum overflow. The publication should include the following at a minimum: a) Description of the process hazards associated with Fuel Gas Mix Drum overflow and the consequential impacts on equipment using fuel gas, b) Guidance for Fuel Gas Mix Drum design and sizing criteria which includes consideration of condensation, entrainment, overflow, and draining, c) Guidance for instrumentation to detect high level to prevent overfilling of Fuel Gas Mix Drums, and d) Recommended practices for selecting preventive safeguards to prevent overfilling of Fuel Gas Mix Drums. Status: Open - Awaiting Response or Evaluation/Approval of Response
Develop a new publication or revise an existing publication, such as API Recommended Practice 556 Instrumentation, Control, and Protective Systems for Gas Fired Heaters, to incorporate the process hazards associated with Fuel Gas Mix Drum overflow. The publication should include the following at a minimum:
a) Description of the process hazards associated with Fuel Gas Mix Drum overflow and the consequential impacts on equipment using fuel gas,
b) Guidance for Fuel Gas Mix Drum design and sizing criteria which includes consideration of condensation, entrainment, overflow, and draining,
c) Guidance for instrumentation to detect high level to prevent overfilling of Fuel Gas Mix Drums, and
d) Recommended practices for selecting preventive safeguards to prevent overfilling of Fuel Gas Mix Drums.
2022-01-I-OH-6
Develop a publication that addresses preventing the overflow of pressure vessels such as towers and drums. The publication should be applicable to both new and existing pressure vessels. Include the following at a minimum: a) Description of typical overflow events that could result during normal, upset, or transient operations (startup, shutdown, standby) including the formation of a vapor cloud, b) Recommended practices for instrumentation to monitor and detect a pressure vessel overflow, c) Process hazard analysis guidance for pressure vessel overflow scenarios, d) Recommended practices for safeguards to prevent a pressure vessel overflow, e) Recommended field and board operator process safety training topics and methods to prevent a pressure vessel overflow, f) Guidelines for process safety assessments to prevent a pressure vessel overflow, and g) Incorporate lessons learned from this CSB investigation and the CSB’s BP Texas City Refinery investigation throughout the document. Status: Open - Awaiting Response or Evaluation/Approval of Response
Develop a publication that addresses preventing the overflow of pressure vessels such as towers and drums. The publication should be applicable to both new and existing pressure vessels. Include the following at a minimum:
a) Description of typical overflow events that could result during normal, upset, or transient operations (startup, shutdown, standby) including the formation of a vapor cloud,
b) Recommended practices for instrumentation to monitor and detect a pressure vessel overflow,
c) Process hazard analysis guidance for pressure vessel overflow scenarios,
d) Recommended practices for safeguards to prevent a pressure vessel overflow,
e) Recommended field and board operator process safety training topics and methods to prevent a pressure vessel overflow,
f) Guidelines for process safety assessments to prevent a pressure vessel overflow, and
g) Incorporate lessons learned from this CSB investigation and the CSB’s BP Texas City Refinery investigation throughout the document.
2022-01-I-OH-7
Revise American National Standard ANSI/ISA 18.2-2016, Management of Alarm Systems for the Process Industries, to include performance targets for short-term alarm flood analysis so that users can evaluate alarm flood performance for a single alarm flood event. The performance targets should include: a) number of alarm floods, b) duration of each flood, c) alarm count in each flood, and d) peak alarm rate for each flood. At a minimum, a target peak alarm flood rate should be defined, such as in the guidance provided by the ASM Consortium or Engineering Equipment and Materials Users Association (EEMUA), to establish trigger points that require alarm performance improvement actions. Status: Open - Acceptable Response or Alternate Response
Revise American National Standard ANSI/ISA 18.2-2016, Management of Alarm Systems for the Process Industries, to include performance targets for short-term alarm flood analysis so that users can evaluate alarm flood performance for a single alarm flood event. The performance targets should include:
a) number of alarm floods, b) duration of each flood, c) alarm count in each flood, and d) peak alarm rate for each flood.
At a minimum, a target peak alarm flood rate should be defined, such as in the guidance provided by the ASM Consortium or Engineering Equipment and Materials Users Association (EEMUA), to establish trigger points that require alarm performance improvement actions.
2022-01-I-OH-1
Revise the safeguards used in the refinery’s process hazard analyses high level and overflow scenarios. At a minimum, establish effective preventive safeguards that use engineered controls to prevent liquid overfill and do not rely solely on human intervention. Status: Open - Acceptable Response or Alternate Response
Revise the safeguards used in the refinery’s process hazard analyses high level and overflow scenarios. At a minimum, establish effective preventive safeguards that use engineered controls to prevent liquid overfill and do not rely solely on human intervention.
2022-01-I-OH-2
Revise the Abnormal Situation Management policy to incorporate guidance provided by the ASM Consortium and the Center for Chemical Process Safety (CCPS). The revised policy should include, at a minimum: a) A broader definition of abnormal situations, such as that defined by the CCPS, b) Additional predictable abnormal situations and their associated corrective procedures. At a minimum include the following abnormal situations: 1) unplanned crude slate changes, 2) continued operation of the Crude 1 unit with the naphtha hydrotreater unit shut down, and 3) an emergency pressure-relief valve opening. c) Guidance to determine when an abnormal situation is becoming too difficult to manage and the appropriate actions to take, such as shutting down a process, putting it into a circulation mode, or implementing proper procedures for bringing it to a safe state. Status: Closed - Acceptable Alternative Action
Revise the Abnormal Situation Management policy to incorporate guidance provided by the ASM Consortium and the Center for Chemical Process Safety (CCPS). The revised policy should include, at a minimum:
a) A broader definition of abnormal situations, such as that defined by the CCPS,
b) Additional predictable abnormal situations and their associated corrective procedures. At a minimum include the following abnormal situations:
1) unplanned crude slate changes, 2) continued operation of the Crude 1 unit with the naphtha hydrotreater unit shut down, and 3) an emergency pressure-relief valve opening.
c) Guidance to determine when an abnormal situation is becoming too difficult to manage and the appropriate actions to take, such as shutting down a process, putting it into a circulation mode, or implementing proper procedures for bringing it to a safe state.
2022-01-I-OH-3
Develop and implement a policy or revise existing policy that clearly provides employees with the authority to stop work that is perceived to be unsafe until the employer can resolve the matter. This should include detailed procedures and regular training on how employees would exercise their stop work authority. Emphasis should be placed on exercising this authority during abnormal situations, including alarm floods. Status: Closed - Acceptable Action
Develop and implement a policy or revise existing policy that clearly provides employees with the authority to stop work that is perceived to be unsafe until the employer can resolve the matter. This should include detailed procedures and regular training on how employees would exercise their stop work authority. Emphasis should be placed on exercising this authority during abnormal situations, including alarm floods.
2022-01-I-OH-4
Revise the ‘Toledo Alarm Philosophy’ by incorporating the Engineering Equipment and Manufacturers Users Association (EEMUA) guidance for alarm rate following an upset and not limiting alarm performance to a single metric averaged over a month. In addition to including analyzing individual alarm flood events, the revised philosophy document should improve refinery alarm performance to reduce alarm flood duration and peak rate for events similar to the September 20, 2022, incident. Consult EEMUA Publication 191, Chapter 6.5.1, for guidance regarding abnormal condition performance levels. Apply the improved performance levels where applicable, but specifically to the Crude 1 control board alarm performance. Status: Closed - Acceptable Action
Revise the ‘Toledo Alarm Philosophy’ by incorporating the Engineering Equipment and Manufacturers Users Association (EEMUA) guidance for alarm rate following an upset and not limiting alarm performance to a single metric averaged over a month. In addition to including analyzing individual alarm flood events, the revised philosophy document should improve refinery alarm performance to reduce alarm flood duration and peak rate for events similar to the September 20, 2022, incident. Consult EEMUA Publication 191, Chapter 6.5.1, for guidance regarding abnormal condition performance levels. Apply the improved performance levels where applicable, but specifically to the Crude 1 control board alarm performance.