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] 

 

Expand All

Recommendations

Evergreen Packaging Paper Mill - Fire During Hot Work (2 Recommendations)
Universal Blastco (2 Recommendations)
Open: 0% | Closed: 100%

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

Wacker Polysilicon Chemical Release (4 Recommendations)
Tennessee Division of Occupational Safety & Health (TOSHA) (1 Recommendations)
Open: 100% | Closed: 0%

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 (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 15, 2023

2021-01-I-TN-3

Develop detailed maintenance procedures for torquing activities which:

a. Clearly communicate differing equipment torque specifications, such as those for bolts installed at PTFE-to-PTFE and PTFE-to-graphite connections through visual means such as annotated photographs, signage, physical differentiation, and other methods, as appropriate;

b. Include procedural requirements for all torquing activities conducted on equipment containing hazardous material to perform an engineering and risk analysis and implement safeguards as a result of the risk analysis, per American Society of Mechanical Engineers (ASME) PCC-1-2019 Guidelines for Pressure Boundary Bolted Flange Joint Assembly and ANSI/ASSP Z244.1-2016 The Control of Hazardous Energy Lockout, Tagout and Alternative Methods;

c. Ensure that terms such as “hot torque” are clearly defined and that employees and contractors are trained on these terms; and

d. Ensure that procedures and training conform to the mechanical integrity requirements of the Process Safety Management (PSM) standard found in 29 CFR 1910.119(j) and the Risk Management Program (RMP) rule found in 40 CFR 68.73.


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

2021-01-I-TN-4

Develop policy requirements to ensure torquing activities performed on equipment containing hazardous energy are performed safely, such as through de-inventorying equipment or restriction of nonessential personnel and ensuring that essential workers wear proper PPE. Document these requirements in procedures, such as Lock, Tag and Try; First Line Break – Return to Service; or other procedures as applicable. Ensure employees and contractors are trained on these procedures in accordance with the Process Safety Management (PSM) standard requirements found in 29 CFR 1910.119(f)(4) and 29 CFR 1910.119(g) and the Risk Management Program (RMP) rule found in 40 CFR 68.69(d) and 40 CFR 68.71.


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

2021-01-I-TN-5

Develop and implement a formalized Simultaneous Operations (SIMOPs) program addressing planned and/or permitted co-located work tasks including:

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.

Ensure relevant staff are trained on execution of the SIMOPs program.


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

Arkema Inc. Chemical Plant Fire (1 Recommendations)
Harris County, TX (1 Recommendations)
Open: 0% | Closed: 100%

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%

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

Optima Belle Explosion and Fire (6 Recommendations)
Clearon Corporation (5 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 06, 2023

2021-02-I-WV-5

Develop and implement a comprehensive process knowledge management program or evaluate and revise existing process safety management procedures to ensure consistency with industry guidance publications such as the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety. The program should:

a) assign specific responsibilities for compiling content and maintaining robust process technology and safety information packages that incorporate relevant knowledge for all hazardous processes and substances operated, manufactured, and/or handled by Clearon Corporation;

b) ensure that key process personnel are aware of critical reactive chemistry information, including thermal stability and calorimetry data, chemical compatibility information, and descriptions of any past reactive incidents and safety studies involving the materials; and

c) define procedures for the transmittal of such information to toll manufacturers.


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

2021-02-I-WV-6

Update the sodium dichloroisocyanurate dihydrate (CDB-56®) safety data sheet. At a minimum, the document should:

a) provide the underlying reasoning for the storage temperature maximum and the consequences of exceeding that temperature;

b) provide the underlying reasoning for the decomposition temperature and the consequences of exceeding that temperature;

c) explain or make clear the reason(s) for and/or the circumstance(s) resulting in the differences between the decomposition temperature and the lowest temperature at which self-accelerating decomposition may occur; and

d) provide the exothermic decomposition energy in the Physical Properties section.


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

2021-02-I-WV-7

Develop and implement a written program for tolling process design and equipment selection using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety to ensure that:

a) equipment design basis is adequate for any new tolling process or product; and

b) safeguards and ancillary equipment are considered and adequately designed, installed, and function as designed and required.


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

2021-02-I-WV-8

Develop and implement a formalized program for the development of toll manufacturing agreements using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety. Ensure that the program provides for the following:

a) Identification of roles and responsibilities of all parties, including the client, toller, and any third-party technical service providers, for all phases of a proposed arrangement;

b) Evaluation of equipment requirements/specifications to ensure that they are adequate for the intended operation; and

c) Participation by all parties in tolling process development, including process hazards analysis and emergency planning, and appropriate stages of the pre-planning, pre-startup, and production phases.


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

2021-02-I-WV-9

Develop and implement a process safety management system consistent with industry guidance publications such as is contained in the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety. At a minimum, the process safety management system should address hazard identification, risk analysis, and management of risk.


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

Richman Chemical Inc. (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 06, 2023

2021-02-I-WV-10

Develop and implement a formalized program for the development of toll manufacturing agreements using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety. Ensure that the program provides for the following:

a) Identification of roles and responsibilities of all parties, including the client, toller, and any third-party technical service providers, for all phases of a proposed arrangement; and

b) Participation by all parties in tolling process development, including process hazards analysis and emergency planning, and appropriate stages of the pre-planning, pre-startup, and production phases.


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

Philadelphia Energy Solutions (PES) Refinery Fire and Explosions (1 Recommendations)
Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 11, 2022

2019-04-I-PA-2

Revise 40 C.F.R. Part 68 (EPA Risk Management Plan) to require new and existing petroleum refineries with HF alkylation units to conduct a safer technology and alternatives analysis (STAA) and to evaluate the practicability of any inherently safer technology (IST) identified. Require that these evaluations are performed every 5 years as a part of an initial PHA as well as PHA revalidations.


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

TPC Port Neches Explosions and Fire (2 Recommendations)
American Chemistry Council (ACC) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: December 19, 2022

2020-02-I-TX-4

Revise the Butadiene Product Stewardship Guidance Manual to include guidance on identifying and controlling or eliminating dead legs in high-purity butadiene service. Specifically, provide guidance on the potential for dead legs to be formed when equipment, such as primary or spare pumps, is out of service. In the Manual, also provide guidance on method(s) to identify dead legs that could be formed when equipment, such as primary or spare pumps, is temporarily or permanently out of service. Recommend actions to mitigate, control, and prevent hazardous popcorn polymer buildup in these in-process or temporary dead legs, such as through monitoring, use of inhibitor(s), or conducting maintenance activities to minimize the presence of dead legs.


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

PDF Document Recommendation Status Change Summary

2020-02-I-TX-5

Revise the Butadiene Product Stewardship Guidance Manual to provide guidance on a methodology to help identify what should be considered excessive or dangerous amounts of popcorn polymer in a unit. Provide mitigation strategies that describe the actions that owner/operators should take during those polymer excursions to control or eliminate the popcorn polymer to reduce the likelihood of popcorn polymer-induced process loss of containment.


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

PDF Document Recommendation Status Change Summary

CSB Safety Study: Remote Isolation of Process Equipment (3 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 25, 2024

2024-01-H-1

Develop a new publication or revise an existing publication or publications that should be applicable to various facility types such as refineries, chemical and petrochemical facilities, terminals, etc. with major process equipment and atmospheric storage tanks, that details conditions that necessitate the installation of remote isolation devices [use “shall” instead of “should” language] that may be automatically activated or remotely activated from a safe location, particularly during an emergency. When establishing these conditions refer to the guidance published by CCPS entitled Guidelines for Fire Protection in Chemical, Petrochemical, and Hydrocarbon Processing Facilities, Sections 8.1.10 and 8.1.11. At a minimum, the conditions should address major process equipment and atmospheric storage tanks, material volumes/weight as well as flammability, corrosivity, and toxicity


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

Environmental Protection Agency (EPA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 25, 2024

2024-01-H-2

Update the Risk Management Program (RMP) rule by expanding the requirements of 40 CFR Part 68 to include an evaluation of the need for remote isolation devices for major process equipment that can be remotely activated from a safe location or automatically activated during a release. The evaluation should be included in hazard assessments, hazard reviews, and process hazard analyses.


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

Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 25, 2024

2024-01-H-3

Update the Process Safety Management (PSM) standard by expanding the Process Hazard Analysis (PHA) requirements under 29 CFR 1910.119(e)(3) to include an evaluation of the need for remote isolation devices for major process equipment that can be remotely activated from a safe location or automatically activated during a release.


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