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

Husky Energy Superior Refinery Explosion and Fire (16 Recommendations)
American Petroleum Institute (API) (3 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 29, 2022

2018-02-I-WI-13

Using API’s processes to determine the appropriate safety product, develop a publicly available technical publication for the safe operation of fluid catalytic cracking (FCC) units. The document should be applicable to both new and existing units. Include the following topics at a minimum:

a) Description of typical FCC unit hazards, including air leaks into hydrocarbon systems or hydrocarbon leaks into air systems that could form a flammable mixture during transient operation (startup, shutdown, standby, and the actions required to transition between these modes). If needed, include differences between possible reactor/regenerator configurations;

b) Recommended practices for safeguards to control FCC unit hazards;

c) Recommended monitoring for process safety during FCC unit transient operations;

d) Recommended emergency operating procedures for FCC-specific scenarios;

e) PHA guidance for key FCC-specific scenarios, including transient operation;

f) Recommended FCC-specific field and board operator process safety training topics and methods;

g) Guidelines for process safety assessments of FCC units; and

h) Incorporate lessons learned from this CSB investigation and the CSB’s ExxonMobil Torrance Refinery Electrostatic Precipitator Explosion investigation throughout the document and include references in the document’s bibliography.


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.
 

PDF Document Recommendation Status Change Summary

2018-02-I-WI-14

Modify the appropriate existing recommended practice (for example, API RP 553, Refinery Valves and Accessories for Control and Safety Instrumented Systems) to include information about the purpose, design, maintenance, and testing of additional FCC catalyst slide valve components, including the slide valve body. If an API product other than API RP 553 is modified, API RP 553 should guide the reader to that reference.


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.
 

PDF Document Recommendation Status Change Summary

2018-02-I-WI-15

Incorporate lessons learned from the FCC Unit Explosion and Asphalt Fire at Husky Superior Refinery incident into the appropriate API products (for example, API RP 2023, Guide for Safe Storage and Handling of Heated Petroleum-Derived Asphalt Products and Crude Oil Residua, or API RP 2021, Management of Atmospheric Storage Tank Fires). At a minimum, topics shall include the flammability of heated material such as asphalt and the ignition risk of pyrophoric material inside asphalt storage tanks. Include a reference to this CSB investigation in the document’s bibliography.


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.
 

PDF Document Recommendation Status Change Summary

Cenovus Energy, Inc. (3 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 29, 2022

2018-02-I-WI-8

For all Cenovus operated refineries with FCC units, develop and implement an FCC unit-specific PHA guidance document as part of each FCC unit’s ongoing PHA update/revalidation cycle, including the Cenovus Superior Refinery. The PHA guidance document should be updated with new industry knowledge as it becomes available (for example, from AFPM, CCPS, and API). The PHA guidance document should include a requirement to review available licensor and industry guidance for FCC unit PHA scenarios and recommended safeguards and at a minimum, include information related to transient operation safeguards listed in CSB Recommendation 2018-02-I-WI-R1.


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.
 

PDF Document Recommendation Status Change Summary

2018-02-I-WI-9

Develop and implement a technology-specific knowledge-sharing network program across all Cenovus operated refineries, which at a minimum includes an FCC technology peer network. The peer network(s) must include engineers, operations management, and operations staff from each site that uses the technology, including the Cenovus Superior Refinery. The network(s) must meet at least annually to discuss process safety topics in the technology including:

a) Relevant incidents and near-misses at the refineries and/or in industry;
b) Refinery learnings in implementing process safety improvements;
c) Relevant industry tools, bulletins, and knowledge-sharing documents, such as those published by AFPM, CCPS, and API; and
d) Relevant updates to industry publications and standards.


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.
 

PDF Document Recommendation Status Change Summary

2018-02-I-WI-10

Include and maintain the FCC technology licensors’ operating manuals in the process safety information packages for all FCC units, including the FCC unit at Cenovus Superior Refinery.


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.
 

PDF Document Recommendation Status Change Summary

Cenovus Superior Refinery (7 Recommendations)
Open: 14% | Closed: 86%
View Investigation
Final Report Released On: December 29, 2022

2018-02-I-WI-1

Establish safeguards to prevent explosions in the FCC unit during transient operation (including startup, shutdown, standby, and emergency procedures). Incorporate these safeguards into written operating procedures. At a minimum establish the following specific safeguards:

a) Implementation of the reactor steam barrier, or a similar inert gas flow, to maintain an inert barrier at an elevated pressure between the main column (containing hydrocarbon) and the regenerator (containing air);

b) Purging the main column with a non-condensable gas as needed to prevent a dangerous accumulation of oxygen in the main column overhead receiver;

c) Monitoring to ensure that there is a sufficient non-condensable gas purge of the main column to prevent a dangerous accumulation of oxygen in the main column overhead receiver (either through direct measurement of the oxygen concentration and/or through engineering calculation);

d) Monitoring of critical operating parameters for flows, pressures, pressure differences, and catalyst levels;

e) Documentation of consequences of deviating from the transient operation safe operating limits and of predetermined corrective actions; and

f) Inclusion of the above items in the appropriate FCC operator training curricula.


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 Recommendation Status Change Summary

2018-02-I-WI-2

Based on licensor input and good industry practices, determine the appropriate point(s) in the FCC unit’s shutdown procedures to shut down all wet gas compressor(s). Incorporate this information into all FCC unit shutdown procedures and operator training 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.
 

PDF Document Recommendation Status Change Summary

2018-02-I-WI-3

Develop and implement a slide valve mechanical integrity program that addresses erosion and ensures proper functioning of the slide valves during a shutdown. The program must include, at a minimum:

a) A slide valve mechanical integrity standard that defines monitoring and inspection requirements, with acceptance criteria, required for the safe operation of the FCC unit during transient operation (such as a startup, shutdown, standby, and emergency).

b) Monitoring that includes process data analysis and mechanical preventive activities to evaluate the mechanical condition of the slide valves during the operation of the FCC unit between turnarounds;

c) Quarterly presentations of process data and mechanical preventive maintenance data to refinery operations management and maintenance management to drive key decisions such as shortening the turnaround cycle and/or planning a maintenance outage;

d) During turnarounds and other potential slide valve maintenance outages, evaluate the adequacy of the slide valve mechanical integrity program for the safe operation of the FCC unit during transient operation. If the inspection demonstrates unsuccessful performance, make appropriate corrections.

During the next major FCC unit turnaround at Cenovus Superior Refinery, demonstrate that the slide valve mechanical program is adequate for the safe operation of the FCC unit during transient operation. If the inspection demonstrates unsuccessful performance, make appropriate corrections to the slide valve mechanical integrity program.


Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

PDF Document Recommendation Status Change Summary

2018-02-I-WI-4

Develop emergency procedures for responding to a loss of catalyst slide valve function (for example, when it leaks excessively or fails to close on demand).


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 Recommendation Status Change Summary

2018-02-I-WI-5

Develop guidance for analyzing operating procedures to improve transient operation hazard evaluations during PHAs. Refer to section Chapter 9.1 in the CCPS publication Guidelines for Hazard Evaluation Procedures, 3rd Ed. or an appropriate equivalent resource to develop the guidance. Incorporate the guidance into the appropriate Cenovus Superior Refinery PHA procedural documents and 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.
 

PDF Document Recommendation Status Change Summary

2018-02-I-WI-6

Develop and implement an FCC unit operator, supervisor, and manager training program based on the licensor’s guidance and on available industry guidance. Elements of the training program shall include:

a) A set of written training materials (such as a manual) consistent with the licensor’s technology information, encompassing:

i) FCC equipment;
ii) Normal operations;
iii) Transient operations (including startup, shutdown, standby, and emergency); and
iv) Case studies of industry FCC industry incidents, including ExxonMobil Torrance (2015) and this incident; and

b) Training delivery methods including:

i) Group and individual training; and
ii) Simulator training for board operators.


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 Recommendation Status Change Summary

2018-02-I-WI-7

Incorporate lessons learned from this incident into the appropriate training materials for the Cenovus Superior Refinery Emergency Response Team. At a minimum, topics shall include the proper response to liquids potentially stored above their flash point, such as asphalt, and the ignition risk of pyrophoric material inside asphalt storage tanks.


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 Recommendation Status Change Summary

Environmental Protection Agency (EPA) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 29, 2022

2018-02-I-WI-12

Develop a program that prioritizes and emphasizes inspections of FCC units in refineries that operate HF alkylation units (for example, under EPA’s National Compliance Initiative called Reducing Risks of Accidental Releases at Industrial and Chemical Facilities). As part of this program, verify FCC unit safeguards that prevent explosions during transient operation (including startup, shutdown, standby, and emergency procedures). At a minimum the program will verify the following specific safeguards:

a) Implementation of the reactor steam barrier, or a similar inert gas flow, to maintain an inert barrier at an elevated pressure between the main column (containing hydrocarbon) and the regenerator (containing air);

b) Purging the main column with a non-condensable gas as needed to prevent a dangerous accumulation of oxygen in the main column overhead receiver;

c) Monitoring to ensure that there is a sufficient non-condensable gas purge of the main column to prevent a dangerous accumulation of oxygen in the main column overhead receiver (either through direct measurement of the oxygen concentration and/or through engineering calculation);

d) Monitoring of critical operating parameters for flows, pressures, pressure differences, and catalyst levels;

e) Documentation of consequences of deviating from the transient operation safe operating parameters and of predetermined corrective actions; and

f) Inclusion of the above items in the appropriate FCC operator training curricula.

This recommendation is in addition to the recommendations to EPA relating to hydrofluoric acid outlined in the CSB’s report on the 2019 fire and explosions at the Philadelphia Energy Solutions refinery. In that report, the CSB recommended (1) that the EPA prioritize inspections of refinery HF alkylation units to ensure units are complying with API good practice guidance, (2) to require petroleum refineries with HF alkylation units to evaluate inherently safer technology, and (3) to initiate prioritization and, as applicable, risk evaluation of HF under the Toxic Substances Control Act.


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.
 

PDF Document Recommendation Status Change Summary

Honeywell UOP (Universal Oil Products) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 29, 2022

2018-02-I-WI-16

Participate in the API committee that develops a technical publication for the safe operation of FCC units.


Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

PDF Document Recommendation Status Change Summary

Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 29, 2022

2018-02-I-WI-11

Develop guidance documents for performing process hazard analysis on operating procedures to address transient operation hazards in facilities with Process Safety Management (PSM) covered processes.


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.
 

PDF Document Recommendation Status Change Summary