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

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Status: Closed - No Longer Applicable
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).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

ExxonMobil Refinery Explosion (10 Recommendations)
American Fuel and Petrochemical Manufacturers (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 03, 2017

2015-02-I-CA-10

Facilitate forum(s)—attended by fluid catalytic cracking unit engineers and other relevant personnel from American Fuel and Petrochemical Manufacturers member companies—to discuss the causal factors of the February 18, 2015 ExxonMobil Torrance refinery incident. Encourage participants to share topics such as design, maintenance, and procedural practices that can prevent a similar incident. Topics of discussion should include: (1) Detection of hydrocarbons flowing to an ESP; (2) Isolation strategies to prevent mixing of air and hydrocarbons during standby operations; (3) Safe operation during unit standby; (4) Use of SCSVs as a safeguard during standby operations; (5) Use of reactor steam as a safeguard during standby operations; (6) Measuring reactor / main column differential pressure during standby operations; (7) ESP explosion safeguards; and (8) Preventing ESP explosions. Create documentation that creates institutional knowledge of the information discussed in the forum(s), and share with the member companies and forum attendees.


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

ExxonMobil Corporation (5 Recommendations)
Open: 80% | Closed: 20%

Final Report Released On: May 03, 2017

2015-02-I-CA-1

A Variance to a safety policy or procedure requires robust analysis of the proposed safeguards prior to its approval and implementation. To ensure the proposed methodology described in the Variance is safe and the proposed safeguards are sufficiently robust, revise corporate and U.S. refinery standard(s) to require that a multidisciplinary team reviews the Variance before it is routed to management for their approval. Include knowledgeable personnel on the Variance multidisciplinary team such as: (1) the developer of the Variance; (2) a technical process representative (e.g. process engineer for the applicable unit); (3) an hourly operations representative (e.g. experienced operator in the applicable unit); and (4) a health and safety representative. The role of the multidisciplinary team is to formally meet to review, discuss, and analyze the proposed Variance, and adjust the safety measures as needed to ensure a safe operation. In the event the expert team members do not come to a consensus that the Variance measures can result in a safe operation, require the proposed work to be routed to a higher management level for final approval.


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.
 

2015-02-I-CA-2

ExxonMobil did not have an operating procedure for operating the FCC unit in its Safe Park mode of operation. At all ExxonMobil U.S. refineries, develop a program to ensure operating procedures are written and available for each mode of operation—such as unit standby—for all ExxonMobil U.S. refinery FCC units. Specify in the program that ExxonMobil U.S. refineries develop and train operators on any new procedure.


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.
 

2015-02-I-CA-3

The spent catalyst slide valve, specified as a safety-critical device for normal operation, could not perform its safety-critical function of preventing air and hydrocarbons from mixing while the FCC unit was in its “Safe Park” mode of operation. Also, ExxonMobil Torrance did not operate the FCC unit as if the reactor steam was a safety critical safeguard. Require identification of all safety critical equipment and consequence of failure for each mode of operation and ensure safety critical devices can successfully function when needed. Develop and implement a policy that requires all U.S. ExxonMobil refineries to: (1) specify each safety-critical device’s safety function; (2) identify the consequences of failure of each safety-critical device; (3) specify the testing strategy used to verify whether the safety-critical device can function as intended to perform its required safety function; and (4) maintain target availability (e.g. safe operating life) for each safety-critical device through inspection and maintenance. Require that items (1) through (4) above consider each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation.


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.
 

2015-02-I-CA-4

ExxonMobil extended the maintenance interval of the spent catalyst slide valve and the inspection interval of the pumparound heat exchanger without analyzing whether the extended operation lowered their availability (by operating them beyond their predicted safe operating life) and could result in negative safety consequences. In the event safety-critical equipment is operated beyond its inspection and/or maintenance interval (e.g. extended turnaround interval), require all ExxonMobil U.S. refineries to perform a risk evaluation (e.g. MOC or risk assessment) to identify the safety consequences of the extended operation. Require that each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation is evaluated during the risk evaluation.


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.
 

2015-02-I-CA-5

Electrostatic precipitators create potential ignition sources during normal operation, and have historically caused explosions within the refining industry. At all U.S. ExxonMobil refineries, require a siting risk analysis be performed of all electrostatic precipitators and implement appropriate safeguards to minimize the consequences of an electrostatic precipitator explosion.


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

Torrance Refining Company (4 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: May 03, 2017

2015-02-I-CA-6

Implement protective systems that prevent ignition of flammable gases (including hydrocarbons not in the presence of CO) inside of the electrostatic precipitator, for each mode of operation.


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.
 

2015-02-I-CA-7

The spent catalyst slide valve, specified as a safety-critical device for normal operation, could not perform its safety-critical function of preventing air and hydrocarbons from mixing while the FCC unit was in its “Safe Park” mode of operation. Require identification of all safety critical equipment and consequence of failure for each mode of operation and ensure safety-critical devices can successfully function when needed. Develop and implement a policy that requires the Torrance refinery to: (1) specify each safety-critical device’s safety function; (2) identify the consequences of failure of each safety-critical device; (3) specify the testing strategy used to verify whether the safety-critical device can function as intended to perform its required safety function; and (4) maintain target availability (e.g. safe operating life) for each safety-critical device through inspection and maintenance. Require that items (1) through (4) above consider each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation.


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.
 

2015-02-I-CA-8

The Torrance refinery extended the maintenance interval of the spent catalyst slide valve and the inspection interval of the pumparound heat exchanger without analyzing whether the extended operation lowered their availability (by operating them beyond their predicted safe operating life) and could result in negative safety consequences. In the event safety critical equipment is operated beyond its inspection and/or maintenance interval (e.g. extended turnaround interval), require the Torrance refinery to perform a risk evaluation (e.g. MOC or risk assessment) to identify the safety consequences of the extended operation. Require that each mode of operation, including but not limited to normal operation, start up, shut down, and “Safe Park” modes of operation is evaluated during the risk evaluation.


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.
 

2015-02-I-CA-9

Electrostatic precipitators create potential ignition sources during normal operation, and have historically caused explosions within the refining industry. At the Torrance refinery, require a siting risk analysis be performed of the FCC unit electrostatic precipitator and implement appropriate safeguards to minimize the consequences of an electrostatic precipitator explosion.


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.
 

First Chemical Corp. Reactive Chemical Explosion (15 Recommendations)
American Chemistry Council (ACC) (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 15, 2003

2003-01-I-MS-10

Amend the Technical Specifications guidelines in the Responsible Care Management System to explicitly require facilities to identify findings and lessons learned from process hazard analyses and incident investigations in one unit and apply them to other equipment that processes similar material.


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.
 

2003-01-I-MS-11

Ensure that ACC members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility process safety programs.


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.
 

2003-01-I-MS-12

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.
 

DuPont-First Chemical Pascagoula Facility (6 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 15, 2003

2003-01-I-MS-2

Establish a program for conducting process hazard analyses of processes involving reactive materials.


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

2003-01-I-MS-3

Evaluate the need for layers of protection and install appropriate safeguards, such as alarms and interlocks, to reduce the likelihood of a runaway reaction and catastrophic release of material.


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.
 

2003-01-I-MS-4

Review and revise as necessary procedures for units that process highly energetic material, effectively communicate the updated procedures, and train workers appropriately. Revised procedures should include: Specific steps for isolation of energy sources. Warnings and cautions concerning process chemicals and consequences of deviations from operating limits. Critical operating limits and guidance when the limits are exceeded. Instruction on how to perform a shutdown for all foreseeable causes, to ensure proper isolation, and to continue monitoring critical parameters (such as temperature) while the column is shut down; in addition, review conditions under which material must be deinventoried (such as during extended shutdowns).


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.
 

2003-01-I-MS-5

Conduct a facility-wide survey of pressure vessels to ensure that all equipment that processes reactive materials has appropriate overpressure protection.


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.
 

2003-01-I-MS-6

Identify equipment critical to safe operation of processes containing reactive materials. Upgrade the maintenance program and establish inspection schedules to ensure the integrity of such 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.
 

2003-01-I-MS-7

Survey and take appropriate action to ensure that buildings occupied by plant personnel are of adequate construction and are located so as to protect people inside in the event of an explosion in equipment processing reactive materials.


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

E. I. duPont de Nemours and Company (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 15, 2003

2003-01-I-MS-1

Conduct audits to ensure that the First Chemical Pascagoula facility addresses the issues detailed below. Communicate results of these audits to the workforce.


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

Jackson County Board of Supervisors, Jackson County Emergency Management Agency, Jackson County Local Emergency Planning Committee (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 15, 2003

2003-01-I-MS-8

Update the community notification system to: Immediately alert residents in the Moss Point community when an incident occurs that could affect their health and safety. Determine when a community response should be initiated. Communicate the nature of the incident and the appropriate response by residents. Alert residents when the incident is over (i.e., the all-clear has sounded).


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.
 

2003-01-I-MS-9

Conduct an awareness campaign to educate residents on the proper steps for a shelter-in-place and orderly evacuation.


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.
 

Synthetic Organic Chemical Manufacturers Association (SOCMA) (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 15, 2003

2003-01-I-MS-13

Amend the Technical Specifications in the Responsible Care Management System to explicitly require facilities to identify findings and lessons learned from process hazard analyses and incident investigations in one unit and apply them to other equipment that processes similar material.


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 Download

2003-01-I-MS-14

Ensure that SOCMA members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility process safety programs.


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 Download

2003-01-I-MS-15

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.