Recent Recommendation Status Updates

Each recommendation the CSB issues is monitored by CSB staff from the time it is issued to closing. CSB staff evaluate recipient responses, and the Board votes to assign status designations to recommendations based on staff evaluation. This page highlights recommendations for which the Board has recently voted to change the status of the recommendation. For more information on how the CSB defines its recommendation statuses, please visit the Recommendations Frequently Asked Questions page.

To contact CSB Recommendations Staff please email [email protected] 

 

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Recommendations

Pryor Trust Fatal Gas Well Blowout and Fire (1 Recommendations)
Patterson-UTI (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-11

Update the Patterson metrics program to track leading and lagging indicators to measure the effectiveness of the overall safety management system. Specifically focus on measuring the effectiveness of the following safety management system components:

(a) The effectiveness of the flow check policy, including the frequency that flow checks are performed when required by Patterson policy;

(b) The frequency that flow checks are documented and approved as recommended in 2018-01-OK-R10;

(c) The effectiveness of the management of change program, for both equipment and procedural changes, including real-time procedure changes;

(d) The frequency that alarms are set at the required set points;

(e) The frequency that drilling rig alarm horns or the entire alarm system is turned off; and

(f) The frequency that trip sheets are filled out properly.


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

BP - Husky Oregon Chemical Release and Fire (3 Recommendations)
Ohio Refining Company (3 Recommendations)
Open: 67% | Closed: 33%
View Investigation
Final Report Released On: June 24, 2024

2022-01-I-OH-1

Revise the safeguards used in the refinery’s process hazard analyses high level and overflow scenarios. At a minimum, establish effective preventive safeguards that use engineered controls to prevent liquid overfill and do not rely solely on human intervention.


Status: Open - Acceptable Response or Alternate Response
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

2022-01-I-OH-2

Revise the Abnormal Situation Management policy to incorporate guidance provided by the ASM Consortium and the Center for Chemical Process Safety (CCPS). The revised policy should include, at a minimum:

a) A broader definition of abnormal situations, such as that defined by the CCPS,

b) Additional predictable abnormal situations and their associated corrective procedures. At a minimum include the following abnormal situations:

1) unplanned crude slate changes,
2) continued operation of the Crude 1 unit with the naphtha hydrotreater unit shut down, and
3) an emergency pressure-relief valve opening.

c) Guidance to determine when an abnormal situation is becoming too difficult to manage and the appropriate actions to take, such as shutting down a process, putting it into a circulation mode, or implementing proper procedures for bringing it to a safe state.


Status: 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

2022-01-I-OH-4

Revise the ‘Toledo Alarm Philosophy’ by incorporating the Engineering Equipment and Manufacturers Users Association (EEMUA) guidance for alarm rate following an upset and not limiting alarm performance to a single metric averaged over a month. In addition to including analyzing individual alarm flood events, the revised philosophy document should improve refinery alarm performance to reduce alarm flood duration and peak rate for events similar to the September 20, 2022, incident. Consult EEMUA Publication 191, Chapter 6.5.1, for guidance regarding abnormal condition performance levels. Apply the improved performance levels where applicable, but specifically to the Crude 1 control board alarm performance.


Status: Closed - Acceptable Action
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

Caribbean Petroleum Refining Tank Explosion and Fire (3 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 21, 2015

2010-02-I-PR-7

Revise ANSI/API 2350, Overfill Protection for Storage Tanks in Petroleum Facilities (2015), to require the installation of an automatic overfill prevention systems for existing and new facilities at bulk aboveground storage tanks storing gasoline, jet fuel, other fuel mixtures or blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher. At a minimum, this system shall meet the following requirements:
a. Separated physically and independent from the level control and monitoring system.
b. Engineered, operated, and maintained to achieve an appropriate safety integrity level in accordance with the requirements of Part 1 of International Electrotechnical Commission (IEC) 61511-SER ed1-2004, Functional Safety – Safety Instrumented Systems for the Process Industry Sector.
c. Specified to achieve the necessary risk reduction as determined by a documented risk assessment methodology set in accordance with Center for Chemical Process Safety Guidelines for Hazard Evaluation Procedures, 3rd Edition, accounting for the following factors:
1. The existence of nearby populations and contamination of nearby environmental resources;
2. The nature and intensity of facility operations;
3. Realistic reliability for the tank gauging system; and
4. The extent/rigor of operator monitoring.
d. Proof tested with sufficient frequency in accordance with the validated arrangements and procedures to maintain the required safety integrity level.
e. Ensure that the above changes are not subject to grandfathering provisions in the standard.

Status: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendation Status Change Summary

Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 21, 2015

2010-02-I-PR-3

As an interim measure, until the rule changes in CSB Recommendation No. 2010-02-I-PR-R1 are adopted and go into effect: issue appropriate guidance or an alert, similar to EPA’s previously issued Chemical Safety Alert addressing Rupture Hazard from Liquid Storage Tanks, to illustrate the hazards posed by spills, releases, fires and explosions due to overfilling bulk aboveground storage containers storing gasoline, jet fuel, blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher.

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

International Code Council (ICC) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 21, 2015

2010-02-I-PR-5

Revise the Section 5704.2.7.5.8 (2015), Overfill Prevention of the International Fire Code (IFC) to require an automatic overfill prevention system (AOPS) for bulk aboveground storage tank terminals storing gasoline, jet fuel, other fuel mixtures or blendstocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher, or equivalent designation. These safeguards shall meet the following requirements:
a) Engineered, operated, and maintained to achieve an appropriate safety integrity level in accordance with the requirements of Part 1 of International Electrotechnical Commission (IEC) 61511-SER ed1-2004, Functional Safety – Safety Instrumented Systems for the Process Industry Sector.
b) Specified to achieve the necessary risk reduction as determined by a documented risk assessment methodology in accordance with Center for Chemical Process Safety Guidelines for Hazard Evaluation Procedures, 3rd Edition, accounting for the following factors:
i. The existence of nearby populations and sensitive environments;
ii. The nature and intensity of facility operations;
iii. Realistic reliability for the tank gauging system; and
iv. The extent/rigor of operator monitoring.
c) Proof tested in accordance with the validated arrangements and procedures with sufficient frequency to maintain the specified safety integrity level.
d) Ensure that the above changes are not subject to grandfathering provisions in the codes.

Status: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendations Status Change Summary

Husky Energy Superior Refinery Explosion and Fire (2 Recommendations)
Cenovus Energy, Inc. (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: December 29, 2022

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: 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-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: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendation Status Change Summary

Chevron Richmond Refinery Fire (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: January 28, 2015

2012-03-I-CA-31

Revise API RP 2001: Fire Protection in Refineries to require users to develop a process fluid leak response protocol specific to their own facility that must be followed when a process fluid leak is discovered.  Recommend users to incorporate the following actions into their leak response protocol: 

a.       Establish an Incident Command structure upon identification of a process fluid leak;

b.      Conduct a pre-response meeting with personnel with specific technical expertise (e.g., inspectors, operators, metallurgists, engineers, and management) and the Incident Commander to determine pressure, temperature, remaining inventory of process fluids, potential damage mechanisms that caused the leak, and worst-case leak scenario;

c.       Establish a hot zone that identifies the area of risk of exposure or injuries due to flame contact, radiant heat, or contact to hazardous materials, taking into consideration the worst-case leak scenario;

d.      Limit site access around leak location to essential personnel only;

e.       Isolate the leaking piping or vessel, or if isolation is not possible, shutdown of the unit when the leaking process fluid poses immediate danger to safety, health, or the environment—such as piping fluid that is toxic or near the autoignition temperature.


Status: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)
 

PDF Document Recommendations Status Change Summary

Wacker Polysilicon Chemical Release (1 Recommendations)
Wacker Polysilicon (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 15, 2023

2021-01-I-TN-6

Install additional means of egress for the T230 desorption tower platforms and other multi-floor equipment structures on-site. After completing these installations, ensure workers are made aware of exit locations from the structure platforms through training, drills, or other techniques as appropriate.


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

Didion Milling Company Explosion and Fire (1 Recommendations)
National Fire Protection Association (NFPA) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 06, 2023

2017-07-I-WI-13

Update NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, or a successor standard, to incorporate, at a minimum, the following elements:

1. Unify the requirements for performing dust hazard analyses to remove equipment exemptions and require the assessment of all processes, such as cyclones, as required in:

a. The 2019 edition of NFPA 652, Standard on the Fundamentals of Combustible Dust

b. Chapters 3, 5, and 6 of the CCPS’s Guidelines for Combustible Dust Hazard Analysis.

2. Incorporate the additional guidance for Management of Change to include but not limited to:

a. Harmonize the 2019 edition of NFPA 652, Standard on the Fundamentals of Combustible Dust, requirements for section 8.12.2.4, modifications to operating and maintenance procedures, and section 8.12.2.4, employee training requirements.

b. Chapter 3 and Appendix B of the CCPS’s Guidelines for the Management of Change for Process Safety, such as addressing temporary changes, operating and maintenance procedures, employee training, and dust testing results, to standardize MOC requirements across all industries that handle combustible dust.

3. Update the requirements for incident investigation management systems, to include but not limited to:

a. Incorporate the optional guidance of the 2019 edition of NFPA 652, Standard on the Fundamentals of Combustible Dust, as a mandatory requirement.

b. Chapters 4 and 10 of CCPS’s Guidelines for Investigating Process Safety Incidents (3rd Edition).  


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