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

Wacker Polysilicon Chemical Release (2 Recommendations)
Tennessee Division of Occupational Safety & Health (TOSHA) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: June 15, 2023

2021-01-I-TN-7

Promulgate a standard or modify existing standards to require employers to ensure the coordination of simultaneous operations (SIMOPs) involving multiple work groups, including contractors. Ensure that the requirements of this standard or standards apply to both general industry and construction activities and are not limited to activities occurring within confined spaces. Include in the standard requirements for Employers to ensure that the following activities occur:

a. Identification of potential SIMOPs;

b. Identification of potential hazardous interactions;

c. Evaluation and implementation of necessary safeguards to allow for safe SIMOPs;

d. Coordination, including shared communication methods, between the SIMOPs; and

e. Inclusion of emergency response personnel or services in the planning and coordination of the SIMOPs.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Recommendation Status Change Summary

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

Kuraray Pasadena Release and Fire (2 Recommendations)
Kuraray America, Inc. (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: December 21, 2022

2018-03-I-TX-3

Develop and implement a system requiring a periodic evaluation of the adequacy and effectiveness of any safeguard used to mitigate or otherwise lower the risk of process safety hazards. This safeguard protection analysis should be based on the requirements of Cal/OSHA’s Process Safety Management for Petroleum Refineries regulations or an appropriate equivalent methodology.


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

2018-03-I-TX-4

Develop and implement a policy detailing how to effectively address recommendations generated from company process safety management systems, including audits, incident investigations, management of change, and process hazard analysis that is consistent with existing OSHA guidance. Include a periodic training requirement for managers and other employees involved with evaluating and managing proposed recommendations to help ensure proposed safety improvements are effectively evaluated and appropriately implemented.


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

Williams Olefins Plant Explosion and Fire (2 Recommendations)
American Petroleum Institute (API) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 19, 2016

2013-3-I-LA-4

To help prevent future major incidents such as a rupture of a pressure vessel in a special operating status, strengthen API Standard 521, Pressure-relieving and Depressuring Systems, by defining the various types of equipment operating statuses. Include definitions for “standby” and “out-of-service.” Specify pressure relief requirements for each type of equipment operating status.


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

PDF Document Recommendation Status Change Summary

2013-3-I-LA-5

To help prevent future major incidents such as pressure vessel rupture from ineffective or failed administrative controls, clarify API Standard 521, Pressure-relieving and Depressuring Systems, to require a pressure relief device for overpressure scenarios where internal vessel pressure can exceed what is allowed by the design code. Although some portions of API Standard 521 already require a pressure relief device for these scenarios, other areas, such as Section 4.4.12 Hydraulic Expansion, are not as protective. Section 4.4.12 Hydraulic Expansion (the failure mode that caused the Williams overpressure incident) permits omitting a pressure relief device and allows the exclusive use of administrative controls.


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

PDF Document Recommendation Status Change Summary

Caribbean Petroleum Refining Tank Explosion and Fire (2 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

Loy Lange Box Company Pressure Vessel Explosion (1 Recommendations)
National Board of Boiler and Pressure Vessel Inspectors (NBBI) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 29, 2022

2017-04-I-MO-8

Update NB-263 Rules for Commissioned Inspectors to include prescriptive elements in the boiler and pressure vessel repair and alteration inspection and acceptance process that would prevent the acceptance of a non-conforming repair.


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

Evergreen Packaging Paper Mill - Fire During Hot Work (5 Recommendations)
Evergreen Packaging (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 24, 2021

2020-07-I-NC-3

Update all documentation, training, and orientation materials provided to contractors pertaining to hot work to reflect Evergreen Packaging’s internal definition of hot work. The materials should make clear that hot work encompasses any method of work that can serve as a source of ignition.


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

2020-07-I-NC-4

Develop and implement a formalized and comprehensive Simultaneous Operations (SIMOPs) program addressing planned work occurring close together in time and place to include policies, procedures, hazards reviews, hazards abatement, training, and shared communication methods, to protect employees and contract workers from the hazards posed by simultaneous operations at its facilities. At a minimum, the program should:

• Identify potential simultaneous operations

• Identify potential hazardous interactions

• Evaluate and implement necessary safeguards to allow for safe simultaneous operations

• Ensure coordination, including shared communication methods, between the simultaneous operations

• Include emergency response personnel or services in the planning and coordination of the simultaneous operations.


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

2020-07-I-NC-5

Develop and implement a policy that requires the involvement of emergency response personnel in planning and coordination of activities involving the use of flammable materials in confined spaces. In the policy, require that emergency response personnel be stationed directly outside the confined space in which flammable materials are used. Ensure that the emergency response personnel are appropriately trained and equipped for confined space entry, confined space rescue and fire response.


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

Universal Blastco (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 24, 2021

2020-07-I-NC-7

Develop a formalized troubleshooting guide and/or standard operating procedure for the usage of resin and fiberglass matting in FRP operations. The procedure should direct employees on acceptable means of addressing cold-weather resin 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

2020-07-I-NC-8

Develop a policy and standard operating procedures for the proper use of heat guns in FRP operations. 


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

Husky Energy Superior Refinery Explosion and Fire (3 Recommendations)
Cenovus Energy, Inc. (3 Recommendations)
Open: 33% | Closed: 67%
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: 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-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: 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

Arkema Inc. Chemical Plant Fire (1 Recommendations)
Harris County, TX (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 24, 2018

2017-08-I-TX-5

Update your emergency operations training using lessons learned from the Arkema incident to help ensure that personnel enforcing evacuation perimeters are not harmed by exposure to hazardous chemical releases. Update existing protocols and revise training curricula to include the use of analytical tools, air monitoring, and personal protective equipment, to provide appropriate protection when emergency equipment or personnel need to be moved through an evacuation zone during a hazardous materials release. Include a process for periodic refresher training.


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

PDF Document Recommendation Status Change Summary

Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire (1 Recommendations)
Department of the Treasury - Office of the Procurement Executive (OPE) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: January 17, 2013

2011-06-I-HI-4

When the NFPA guidance developed by the National Fire Protection Association for the safe disposal of fireworks as recommended under recommendation 2011-06-I-HI-R7 is completed, incorporate this document by reference into the formal policies established by 2011-06-I-HI-R2 and 2011-06-I-HI-R3.


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