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.
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
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.
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 Note: This recommendation was superseded by 2009-10-I-OH-R6, issued pursuant to the Veolia Environmental Services Flammable Vapor Explosion and Fire Case Study (2010). Status: Closed - Reconsidered/Superseded
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).
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
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).
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
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.
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
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.
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
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.
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
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.
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 - Acceptable Response or Alternate Response
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.
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 - Acceptable Response or Alternate Response
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.
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 - Acceptable Response or Alternate Response
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.
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 - Acceptable Response or Alternate Response
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.
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
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.
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: Closed - Acceptable Action
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.
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: Closed - Acceptable Action
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.
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: Closed - Acceptable Action
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.
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 - Acceptable Response or Alternate Response
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.
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
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.
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
Ensure that ACC members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility process safety programs.
2003-01-I-MS-12
Communicate the findings of this report to your membership. Status: Closed - Acceptable Action
Communicate the findings of this report to your membership.
2003-01-I-MS-2
Establish a program for conducting process hazard analyses of processes involving reactive materials. Status: Closed - Acceptable Action
Establish a program for conducting process hazard analyses of processes involving reactive materials.
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
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.
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
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).
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
Conduct a facility-wide survey of pressure vessels to ensure that all equipment that processes reactive materials has appropriate overpressure protection.
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
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.
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
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.
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
Conduct audits to ensure that the First Chemical Pascagoula facility addresses the issues detailed below. Communicate results of these audits to the workforce.
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
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).
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
Conduct an awareness campaign to educate residents on the proper steps for a shelter-in-place and orderly evacuation.
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
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.
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
Ensure that SOCMA members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility process safety programs.
2003-01-I-MS-15
2006-1-I-TX-6
Incorporate guidance for vehicular traffic protection and remote equipment isolation into the next revision of the Center for Chemical Process Safety?s Guidelines for Hazard Evaluation Procedures. Status: Closed - Acceptable Action
Incorporate guidance for vehicular traffic protection and remote equipment isolation into the next revision of the Center for Chemical Process Safety?s Guidelines for Hazard Evaluation Procedures.
2006-1-I-TX-1
Revise policies and procedures for process hazard analysis and pre-startup safety review to more fully evaluate vehicle impact hazards, passive fire protection, and catastrophic releases. Status: Closed - Acceptable Action
Revise policies and procedures for process hazard analysis and pre-startup safety review to more fully evaluate vehicle impact hazards, passive fire protection, and catastrophic releases.
2006-1-I-TX-2
Require flame resistant clothing for workers in units at the Point Comfort complex where there is a risk of flash fires. Status: Closed - Acceptable Action
Require flame resistant clothing for workers in units at the Point Comfort complex where there is a risk of flash fires.
2006-1-I-TX-3
Communicate the findings and recommendations of this report to all companies that contracted with either M. W. Kellogg or Kellogg, Brown, and Root (KBR) for plant designs similar to the Formosa Olefins II unit. Status: Closed - Exceeds Recommended Action
Communicate the findings and recommendations of this report to all companies that contracted with either M. W. Kellogg or Kellogg, Brown, and Root (KBR) for plant designs similar to the Formosa Olefins II unit.
2006-1-I-TX-4
Communicate the findings and recommendations of this report to your petrochemical process plant design engineers. Emphasize the importance of using current consensus safety standards when designing and constructing petrochemical process plants, including the earlier designs reused for new facilities. Status: Closed - Exceeds Recommended Action
Communicate the findings and recommendations of this report to your petrochemical process plant design engineers. Emphasize the importance of using current consensus safety standards when designing and constructing petrochemical process plants, including the earlier designs reused for new facilities.
2006-1-I-TX-5
Revise KBR petrochemical process plant design procedures to ensure they address the use of current safety standards for new designs and earlier designs reused for new facilities. Status: Closed - Acceptable Action
Revise KBR petrochemical process plant design procedures to ensure they address the use of current safety standards for new designs and earlier designs reused for new facilities.
2004-10-I-IL-8
Develop guidelines for auditing chemical process safety at newly acquired facilities. Emphasize the identification of major hazards, a review of the acquired facility's previous incident history and hazard analyses, the adequacy of management safety systems, and harmonization of the acquired facility's standards and practices with those of the acquiring company. Status: Closed - Acceptable Action
Develop guidelines for auditing chemical process safety at newly acquired facilities. Emphasize the identification of major hazards, a review of the acquired facility's previous incident history and hazard analyses, the adequacy of management safety systems, and harmonization of the acquired facility's standards and practices with those of the acquiring company.
2004-10-I-IL-7
Ensure that the EPA's Enforcement Alert concerning PVC facilities includes the causes and lessons learned from this investigation. Emphasize the importance of analyzing human factors and the need to implement adequate safeguards to minimize the likelihood and consequences of human error that could result in catastrophic incidents. Status: Closed - Acceptable Action
Ensure that the EPA's Enforcement Alert concerning PVC facilities includes the causes and lessons learned from this investigation. Emphasize the importance of analyzing human factors and the need to implement adequate safeguards to minimize the likelihood and consequences of human error that could result in catastrophic incidents.
2004-10-I-IL-1
Review the design and operation of FPC USA manufacturing facilities and implement policies and procedures to ensure that: -Site-wide policies are implemented to address necessary steps and approval levels required to bypass safety interlocks and other critical safety systems. -Chemical processes are designed to minimize the likelihood and consequences of human error that could result in a catastrophic release. -Safety impacts of staffing changes are evaluated. -Risks identified during hazard analyses and near-miss and incident investigations are characterized, prioritized, and that corrective actions are taken promptly. -High-risk hazards are evaluated using layers of protection analysis (LOPA) techniques and that appropriate safeguards are installed to reduce the likelihood of a catastrophic release of material. -All credible consequences are considered in near-miss investigations. -Emergency procedures clearly characterize emergency scenarios, address responsibilities and duties of responders, describe evacuation procedures, and ensure adequate training. Ensure that periodic drills are conducted. -The siting of offices for administrative and support personnel is evaluated to ensure the safety of personnel should an explosion or catastrophic release occur. Status: Closed - Acceptable Action
Review the design and operation of FPC USA manufacturing facilities and implement policies and procedures to ensure that: -Site-wide policies are implemented to address necessary steps and approval levels required to bypass safety interlocks and other critical safety systems. -Chemical processes are designed to minimize the likelihood and consequences of human error that could result in a catastrophic release. -Safety impacts of staffing changes are evaluated. -Risks identified during hazard analyses and near-miss and incident investigations are characterized, prioritized, and that corrective actions are taken promptly. -High-risk hazards are evaluated using layers of protection analysis (LOPA) techniques and that appropriate safeguards are installed to reduce the likelihood of a catastrophic release of material. -All credible consequences are considered in near-miss investigations. -Emergency procedures clearly characterize emergency scenarios, address responsibilities and duties of responders, describe evacuation procedures, and ensure adequate training. Ensure that periodic drills are conducted. -The siting of offices for administrative and support personnel is evaluated to ensure the safety of personnel should an explosion or catastrophic release occur.
2004-10-I-IL-2
Conduct periodic audits of each FPC USA PVC manufacturing facility for implementation of the items in Recommendation R1. Develop written findings and recommendations. Track and promptly implement corrective actions arising from the audit. Share audit findings with the workforce at the facilities and the FPC USA Board of Directors. Status: Closed - Acceptable Action
Conduct periodic audits of each FPC USA PVC manufacturing facility for implementation of the items in Recommendation R1. Develop written findings and recommendations. Track and promptly implement corrective actions arising from the audit. Share audit findings with the workforce at the facilities and the FPC USA Board of Directors.
2004-10-I-IL-3
Design and implement a program requiring audits of newly acquired facilities that address the issues highlighted in this report. Document, track, and promptly address recommended actions arising from the audits. Status: Closed - Acceptable Action
Design and implement a program requiring audits of newly acquired facilities that address the issues highlighted in this report. Document, track, and promptly address recommended actions arising from the audits.
2004-10-I-IL-4
Communicate the contents of this report to all employees of FPC USA PVC facilities. Status: Closed - Acceptable Action
Communicate the contents of this report to all employees of FPC USA PVC facilities.
2004-10-I-IL-5
Revise NFPA 15, Standard for Water Spray Fixed Systems for Fire Protection, to provide additional design guidance for deluge systems designed to prevent or mitigate fires and explosions. Include information concerning the limitations of using deluge systems for this purpose. Status: Closed - Acceptable Action
Revise NFPA 15, Standard for Water Spray Fixed Systems for Fire Protection, to provide additional design guidance for deluge systems designed to prevent or mitigate fires and explosions. Include information concerning the limitations of using deluge systems for this purpose.
2004-10-I-IL-6
Issue a safety alert to your membership highlighting the need to identify design features that may render processes vulnerable to human error and to implement sufficient layers of protection to minimize the likelihood human error causing catastrophic releases of hazardous material. Include lessons from PVC industry industrial accidents (including those described in this report and others highlighted in The Encyclopedia of PVC and elsewhere) that involved human error. Status: Closed - Acceptable Action
Issue a safety alert to your membership highlighting the need to identify design features that may render processes vulnerable to human error and to implement sufficient layers of protection to minimize the likelihood human error causing catastrophic releases of hazardous material. Include lessons from PVC industry industrial accidents (including those described in this report and others highlighted in The Encyclopedia of PVC and elsewhere) that involved human error.