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

DPC Enterprises Glendale Chlorine Release (14 Recommendations)
Chlorine Institute (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 28, 2007

2004-2-I-AZ-14

Clarify the chemistry involved in over-chlorination incidents so that "Chlorine Scrubbing Systems, Pamphlet 89," and other pertinent publications: -Ensure that the recommended practices and safeguards prevent, mitigate, and control hazardous releases due to bleach decomposition. -Provide sufficient detail on the safety and environmental consequences of over-chlorination to enable companies to provide emergency responders with information on the potential characteristics of over-chlorination events, and on the best means of mitigating the bleach decomposition reaction following a release.


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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DPC Enterprises, L.P. (6 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 28, 2007

2004-2-I-AZ-1

Establish and implement DPC corporate engineering standards that include adequate layers of protection on chlorine scrubbers at DPC facilities, including: -additional interlocks and shutdowns, such as automatically stopping chlorine flow to the scrubber upon oxidation-reduction potential alarm; -mitigation measures, such as systems to automatically add caustic to over-chlorinated scrubbers, or back-up scrubbing capability to treat emissions from over-chlorinated scrubbers; -increases in the final caustic concentration in the scrubbers to eight percent or higher to provide a substantial safety margin against over-chlorination; and -use of the site's continuous bleach manufacturing system to convert scrubber solution to saleable bleach.


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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2004-2-I-AZ-2

Revise scrubber SOPs to include: -clearly described operating limits and warnings about the consequences of exceeding those limits, and -the safety and environmental hazards associated with scrubber over-chlorination.


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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2004-2-I-AZ-3

Train employees on the revised SOPs and include a test to verify understanding. Periodically review operator understanding of and conformance to the scrubber SOPs.


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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2004-2-I-AZ-4

Include scrubber operation in facility PHAs. Ensure that they: -include lessons learned from this incident and other DPC scrubber incidents, as well as industry experience with over-chlorination, and -consider off-site consequences when evaluating the adequacy of existing 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.
 

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2004-2-I-AZ-5

Use a qualified, independent auditor to evaluate DPC's PSM and RMP programs against best practices. Implement audit recommendations in a timely manner at all DPC chlorine repackaging sites.


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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2004-2-I-AZ-6

Implement a recognized safety management system, including third party verification and certification, to achieve documented continuous improvement in safety performance at Glendale and the other DPC chlorine repackaging sites.


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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Glendale, AZ Fire Department (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 28, 2007

2004-2-I-AZ-7

Work with the Glendale Police Department to integrate them into the incident command structure during hazardous material incidents, and address communications issues, such as radio interoperability, to ensure the timely transmission of critical safety information to responding officers.


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.
 

2004-2-I-AZ-8

Conduct hazardous materials exercises with the Glendale Police Department to identify and resolve police/fire integration issues. Coordinate exercise planning with the Arizona Division of Emergency Management Exercise Officer and with the Maricopa County LEPC. Schedule periodic hazardous materials incident drills to ensure safe and effective responses to future hazardous materials incidents.


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.
 

Glendale, AZ Police Department (4 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 28, 2007

2004-2-I-AZ-9

Work with the Glendale Fire Department to integrate the Glendale Police Department into the command structure during hazardous material incidents, and address communications issues, such as radio interoperability, to ensure the timely transmission of critical safety information to responding officers.


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.
 

2004-2-I-AZ-10

Ensure that police officers responding to hazardous material incidents are briefed on specific incident conditions, and are equipped with and trained on the proper use, capabilities, and limitations of appropriate protective 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.
 

2004-2-I-AZ-11

Ensure that police officers receive hazardous materials - operations level training, and annual hazardous materials and air purifying respirator (APR) refresher training.


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.
 

2004-2-I-AZ-12

Conduct exercises with the Glendale Fire Department to identify and resolve police/fire integration issues. Coordinate exercise planning with the Arizona Division of Emergency Management Exercise Officer and with the Maricopa County LEPC. Schedule periodic hazardous materials incident drills to ensure safe and effective responses to future hazardous materials incidents.


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.
 

Maricopa County Department of Air Quality (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 28, 2007

2004-2-I-AZ-13

Revise DPC's permitted operating conditions to specify a minimum scrubber caustic concentration of 8 percent or more, as determined by laboratory measurement, with measurements taken daily and upon completion of each scrubber batch.


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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DuPont La Porte Facility Toxic Chemical Release (9 Recommendations)
DuPont LaPorte, Texas Chemical Facility (7 Recommendations)
Open: 14% | Closed: 86%

Final Report Released On: June 25, 2019

2015-01-I-TX-1

Prior to resuming Insecticide Business Unit (IBU) manufacturing operations, conduct a comprehensive
engineering analysis of the manufacturing building and the discharge of pressure relief systems with toxic
chemical scenarios to assess potential inherently safer design options. At a minimum, evaluate the use of
an open building structure, and the direction of toxic chemical leaks and the discharge of pressure relief
systems with toxic chemical scenarios to a destruction system. Implement inherently safer design
principles to the greatest extent feasible and effectively apply the hierarchy of controls such that neither
workers nor the public are harmed from potential highly toxic chemical releases. Detail the analysis,
findings, and corrective actions in a written report and make this report available to DuPont La Porte
employees, their representatives, and the CSB.

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

2015-01-I-TX-2

Prior to resuming Insecticide Business Unit (IBU) manufacturing operations, conduct a robust
engineering evaluation of the manufacturing building and the dilution air ventilation system that includes
the implementation of corrective action(s) to the greatest extent feasible in order to ensure a safe
environment for all workers. Develop a documented design basis for the manufacturing building and the
air dilution ventilation system that identifies effective controls for highly toxic, asphyxiation, and
flammability hazards and implement these controls to the greatest extent feasible. Address nonroutine
operations and emergency response activities in the design basis. The design basis for the manufacturing
building and the dilution air ventilation system must use the hierarchy of controls and inherently safer
design principles to the greatest extent feasible.

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

2015-01-I-TX-3

Prior to resuming manufacturing operations, ensure all Insecticides Business Unit (IBU) pressure relief
systems are routed to a safe location and effectively apply the hierarchy of controls to protect workers and
the public. Commission a pressure relief device analysis, consistent with API Standard 521 and the
ASME Code, including a field review. Include an evaluation of relief system discharge location to ensure
that relief systems are discharged to a safe location that will prevent toxic exposure, flammability, or
asphyxiation hazards in order to ensure public and worker health and safety to the greatest extent feasible.
Include an evaluation of relief scenarios consistent with API Standard 521.

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

2015-01-I-TX-4

Develop and implement an expedited schedule to perform more robust process hazard analyses (PHAs)
consistent with R1, R2, and R3 for all units within the Insecticides Business Unit (IBU). At a minimum,
the PHAs must effectively identify and control the hazards referenced in this document utilizing the
hierarchy of controls. The PHA schedule must be prioritized based on anticipated risks to the public and
workers in order to ensure that the highest risk areas receive priority consideration. At a minimum, the
more robust PHAs must be consistent with the approach applied to post-incident reviews described above
in paragraph 10.

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

2015-01-I-TX-5

Work together with the International Chemical Workers Union Council of the United Food and
Commercial Workers (ICWUC/UFCW) Local 900C and the ICWUC/UFCW staff (at the request of the
local) to develop and implement a plan to ensure active participation of the workforce and their
representatives in the implementation of Recommendations R1 through R4. In addition, provide a copy
of DuPont’s integrated plan for restart to La Porte workers and their local union representatives.

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

2015-01-I-TX-6

Make publicly available (on a website) a summary of the DuPont November 15, 2014 incident
investigation report, the integrated plan for restart, and actions to be taken for the implementation of
Recommendations R1 through R5. This website must be periodically updated to accurately reflect the
integrated plan for restart and implementation of Recommendations R1 through R5.

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

2015-01-I-TX-8

Work together with emergency response team (ERT) member companies (DuPont, Chemours, Kuraray, and Invista), the International Chemical Workers Union Council of the United Food and Commercial Workers (ICWUC/UFCW) Local 900C, and the ICWUC/UFCW staff (if requested by the Local 900C) to update the DuPont La Porte emergency response plan. The emergency response program should ensure that periodic exercises or drills are performed on new procedures developed to address key lessons to strengthen ERT capabilities. The emergency response program should address the following:

  • Preidentifying unit experts as technical support personnel and ensuring that backup capability is available in the event the primary technical support personnel become unavailable. (Section 4.2: Process Coordinator Was Missing)
  • Clearly detailing in plant emergency procedures the alerting and notification protocols for different types of plant emergencies. Provide initial training to new plant personnel and periodic training to all plant personnel on these emergency communication procedures. These procedures should also include guidance for emergency responders when there is insufficient initial information to effectively assess the nature of the problem and the level of ERT resources required. (Section 4.3.1: Call for ERT Response)
  • Developing and applying regular maintenance schedules for emergency response vehicles consistent with the National Fire Protection Association’s Standard for the Inspection, Maintenance, Testing, and Retirement of In-Service Emergency Vehicles (NFPA 1911), which requires weekly visual and operational checks of emergency vehicles and has example checklists to use when performing preventive maintenance on emergency vehicles. (Section 4.3.2: ERT Mini-Pumper Truck Not Operational)
  • Ensuring that ERTs have reliable means to characterize hazardous atmospheres, for example equipment that monitors toxicity, explosivity, and oxygen levels. Additionally, ensure that ERT members know where the equipment is stored, can access it, and are trained on its proper use. (Section 4.4.1: Entry into Potentially Explosive Atmosphere)
  • Evaluating high-hazard areas, including PSM covered processes, to determine whether detectors and alarms are necessary to identify chemical releases (or other types of emergencies). Additionally, consider equipping high-hazard areas with surveillance technology to identify personnel in the field. (Section 4.4.2: No Technology to Locate Missing Workers)
  • Developing and implementing written policy and procedures to update emergency response plan documents when hazards are identified. For example, personnel can identify these types of hazards in process hazard analyses, facility siting studies, management of change reviews, and incident investigations. Changes to emergency planning documents should be effectively communicated to the site ERT as soon as possible after identifying the hazard. (Section 4.4.3: Unrecognized Manufacturing Building Collapse Hazard)
  • Ensuring that emergency response planning accounts for difficulties in conducting response efforts, including (1) maps included in emergency response plans to show the layout of buildings containing hazardous chemicals, for use by emergency responders and to aid evacuation and rescue efforts; (2) coordination of periodic (at least annual) site tours for plant and external emergency responders; (3) training emergency responders to help ensure familiarity with facility access points, hazards, emergency response issues, and site or facility layout; and (4) building teamwork by having members (from the different companies) of the ERT field train (by conducting drills) together when practicable. (Section 4.5: Difficulties Navigating Manufacturing Building)
  • Assigning knowledgeable personnel the responsibility to analyze process data to assess the source, scope, and magnitude of any incident. (Section 4.6: No Analysis of Process Data to Identify Source of Leak)
  • Training emergency response team members to (1) physically designate the hot zone; (2) communicate the location of the hot zone and entry control points to all personnel assisting with the emergency response, including operations personnel; and (3) control entry and exit points of the hot zone. (Section 4.7: Inadequate Control of Hot Zone)
  • Addressing in the emergency response plan how to characterize (including size, concentration, location, and direction of release) hazardous chemical releases and providing guidance on how and where people should take protective action (e.g., sheltering-in-place) in the event of a chemical release. (Section 4.8.1: Release Modeling)
  • Developing a procedure in the emergency response plan to effectively monitor for hazardous gases along the fence line at chemical facilities during the release to help workers understand and clearly communicate the extent of a release. (Section 4.8.4: Air Monitoring)

In addition, provide a copy of the emergency response plan to the Emergency Response Team and their local union representatives.


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 Chemical Workers Union Council (ICWUC) of the United Food and Commercial Workers (UFCW) and Local 900C (2 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: June 25, 2019

2015-01-I-TX-7

Work together with DuPont to develop and implement a plan to ensure active participation of the
workforce and their representatives in the implementation of Recommendations R1 through R4.

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

2015-01-I-TX-9

Work together with DuPont to develop and implement the emergency response plan described in Recommendation R8 (2015-01-I-TX-R8).


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.
 

E. I. DuPont De Nemours Co. Fatal Hotwork Explosion (4 Recommendations)
E. I. duPont de Nemours and Company (4 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 19, 2012

2011-01-I-NY-1

Develop and enforce corporate-directed policies and procedures which will require all DuPont facilities to audit their hot work permitting systems prior to initiating hot work to ensure that:

  • All potential explosion hazards associated with hot work activities are identified and mitigated
  • All relevant forms required for permits are completed in accordance with corporate policies and industry standards (including NFPA 326 and NFPA 51B)
  • Appropriate DuPont personnel officially approve hot work permits, by signature or equivalent, consistent with DuPont policies

 


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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2011-01-I-NY-2

Revise corporate policies and procedures to require that all process piping, or similar connections to tanks or vessels be positively isolated, (using closed valves, blind flanges or pancake blanks) and the equipment appropriately vented before authorizing any hot work.


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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2011-01-I-NY-3

Revise corporate policies and procedures to require that the atmosphere inside the container be monitored for flammable vapor prior to performing any welding, cutting, or grinding on the container surface.


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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2011-01-I-NY-4

Revise corporate policies and procedures to require air monitoring for flammable vapor inside the container for the duration of the hot work consistent with industry standards (NFPA 326, NFPA 51B). Create a policy for determining criteria for requiring continuous or periodic testing for the duration of hot work.


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

Emergency Shutdown Systems for Chlorine Transfer (1 Recommendations)
U.S. Department of Transportation (DOT) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 14, 2007

2005-06-I-LA-1

Expand the scope of DOT regulatory coverage to include chlorine railcar unloading operations. Ensure the regulations specifically require remotely operated emergency isolation devices that will quickly isolate a leak in any of the flexible hoses (or piping components) used to unload a chlorine railcar. The shutdown system must be capable of stopping a chlorine release from both the railcar and the facility chlorine receiving equipment. Require the emergency isolation system be periodically maintained and operationally tested to ensure it will function in the event of an unloading system chlorine leak.


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

PDF Document Recommendation Status Change Summary

EQ Hazardous Waste Plant Explosions and Fire (6 Recommendations)
Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 16, 2008

2007-1-I-NC-1

Ensure that the emergency response planning required for permitted hazardous waste treatment, storage, and disposal facilities (40 CFR 264.37) includes providing written information to state and local emergency response officials on the type, approximate quantities, and locations of materials within the facility (similar to reporting requirements of the Emergency Planning and Community Right-to-Know Act). Additionally, ensure that permit holders periodically update this information throughout the ten-year permit period.


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.
 

Environmental Technology Council (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 16, 2008

2007-1-I-NC-2

Petition the National Fire Protection Association, following the guidelines of their "Codes and Standards Development Process" (http://www.nfpa.org/index.asp), to develop a fire protection standard (occupancy standard) specific to hazardous waste treatment, storage, and disposal facilities. This standard should address fire prevention, detection, control, and suppression requirements.

Note:  This recommendation was superseded by 2009-10-I-OH-R6, issued pursuant to the Veolia Environmental Services Flammable Vapor Explosion and Fire Case Study (2010).

 


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.
 

2007-1-I-NC-3

Develop standardized guidance for the handling and storage of hazardous waste to reduce the likelihood of releases and fires at hazardous waste treatment, storage, and disposal facilities.

Note:  This recommendation was superseded by 2009-10-I-OH-R7, issued pursuant to the Veolia Environmental Services Flammable Vapor Explosion and Fire Case Study (2010).


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.
 

Mobile Aerospace Engineering, Inc. (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 16, 2008

2007-1-I-NC-1 URGENT!

Revise and or develop company procedures and policies to require and ensure that unspent chemical oxygen generators that have exceeded their service life be actuated so that the chemical core is expended before shipping by any transport mode.


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

2007-1-I-NC-2 URGENT!

Review and revise as necessary company procedures and policies for transporting hazardous waste to ensure that hazardous waste is correctly characterized on the shipping manifest.


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.
 

2007-1-I-NC-3 URGENT!

Communicate to all of your waste brokers and treatment, storage, and disposal facilities to which unspent oxygen generators were shipped: - the hazards associated with unspent chemical oxygen generators and - that the incorrect shipping name and UN code was, or might have been used, for unspent chemical oxygen generators shipped from your facility.


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.