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 (3 Recommendations)
Wacker Polysilicon (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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.
 

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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

LyondellBasell La Porte Fatal Chemical Release (1 Recommendations)
Turn2 Specialty Companies (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 25, 2023

2021-05-I-TX-3

Update Turn2 policy documents to require that Turn2 employees are provided with written, detailed procedures for safely conducting work on process equipment and are trained on the procedures before the work is authorized to be performed.


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)
National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: January 17, 2013

2011-06-I-HI-8

Once fireworks disposal best practices under recommendation 2011-06-I-HI-R7 is completed, develop and implement an outreach plan to promptly communicate the new NFPA practices to relevant government agencies and private entities that dispose of waste fireworks


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 (7 Recommendations)
American Petroleum Institute (API) (2 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: June 24, 2024

2022-01-I-OH-5

Develop a new publication or revise an existing publication, such as API Recommended Practice 556 Instrumentation, Control, and Protective Systems for Gas Fired Heaters, to incorporate the process hazards associated with Fuel Gas Mix Drum overflow. The publication should include the following at a minimum:

a) Description of the process hazards associated with Fuel Gas Mix Drum overflow and the consequential impacts on equipment using fuel gas,

b) Guidance for Fuel Gas Mix Drum design and sizing criteria which includes consideration of condensation, entrainment, overflow, and draining,

c) Guidance for instrumentation to detect high level to prevent overfilling of Fuel Gas Mix Drums, and

d) Recommended practices for selecting preventive safeguards to prevent overfilling of Fuel Gas Mix Drums.


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

2022-01-I-OH-6

Develop a publication that addresses preventing the overflow of pressure vessels such as towers and drums. The publication should be applicable to both new and existing pressure vessels. Include the following at a minimum:

a) Description of typical overflow events that could result during normal, upset, or transient operations (startup, shutdown, standby) including the formation of a vapor cloud,

b) Recommended practices for instrumentation to monitor and detect a pressure vessel overflow,

c) Process hazard analysis guidance for pressure vessel overflow scenarios,

d) Recommended practices for safeguards to prevent a pressure vessel overflow,

e) Recommended field and board operator process safety training topics and methods to prevent a pressure vessel overflow,

f) Guidelines for process safety assessments to prevent a pressure vessel overflow, and

g) Incorporate lessons learned from this CSB investigation and the CSB’s BP Texas City Refinery investigation throughout the document.


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.
 

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International Society of Automation (ISA) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: June 24, 2024

2022-01-I-OH-7

Revise American National Standard ANSI/ISA 18.2-2016, Management of Alarm Systems for the Process Industries, to include performance targets for short-term alarm flood analysis so that users can evaluate alarm flood performance for a single alarm flood event. The performance targets should include:

a) number of alarm floods,
b) duration of each flood,
c) alarm count in each flood, and
d) peak alarm rate for each flood.

At a minimum, a target peak alarm flood rate should be defined, such as in the guidance provided by the ASM Consortium or Engineering Equipment and Materials Users Association (EEMUA), to establish trigger points that require alarm performance improvement actions.


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

Ohio Refining Company (4 Recommendations)
Open: 100% | Closed: 0%
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 - 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

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 - 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

2022-01-I-OH-3

Develop and implement a policy or revise existing policy that clearly provides employees with the authority to stop work that is perceived to be unsafe until the employer can resolve the matter. This should include detailed procedures and regular training on how employees would exercise their stop work authority. Emphasis should be placed on exercising this authority during abnormal situations, including alarm floods.


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

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: 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

Philadelphia Energy Solutions (PES) Refinery Fire and Explosions (1 Recommendations)
Environmental Protection Agency (EPA) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: October 11, 2022

2019-04-I-PA-1

Develop a program that prioritizes and emphasizes inspections of refinery 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 that HF alkylation units are complying with API RP 751 Safe Operation of Hydrofluoric Acid Alkylation Units, including but not limited to the implementation of a special emphasis inspection program to inspect all individual carbon steel piping components and welds to identify areas of accelerated corrosion; the protection of safety-critical safeguards and associated control system components, including but not limited to wiring and cabling for control systems and primary and backup power supplies, from fire and explosion hazards including radiant heat and flying projectiles (per recommendation 2019-04-I-PA-R4); and the installation of remotely-operated emergency isolation valves on the inlet(s) and outlet(s) of all hydrofluoric acid containing vessels, and hydrocarbon containing vessels meeting defined threshold quantities (per recommendation 2019-04-I-PA-R4).


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

Loy Lange Box Company Pressure Vessel Explosion (2 Recommendations)
Loy Lange Box Company (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 29, 2022

2017-04-I-MO-2

Engage a qualified third-party to conduct a comprehensive review or audit of Loy Lange’s regulatory compliance practices and current compliance status.


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

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2017-04-I-MO-3

Implement an electronic records and data management system that preserves all critical company records, safety policies and procedures, and operational data. Ensure that such records are stored and can be accessed remotely in the event of a catastrophic incident


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 (1 Recommendations)
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 - 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