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

Aghorn Operating Waterflood Station Hydrogen Sulfide Release (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 21, 2021

2020-01-I-TX-8

Issue a safety information product (such as a safety bulletin or safety alert) that addresses the requirements for protecting workers from hazardous air contaminants and from hazardous energy.


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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Evergreen Packaging Paper Mill - Fire During Hot Work (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 24, 2021

2020-07-I-NC-1

Issue a safety information product (such as a letter of interpretation) addressing the analysis and control of hazards that are not pre-existing but which result from work activities inside permit-required confined spaces. 


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-2

(Superseded by 2021-01-I-TN-R1 from the Wacker report)

Require Owner/Operators to ensure the coordination of simultaneous operations involving multiple work groups, including contractors. Include in the requirement for Owner/Operators to ensure the following activities occur:

• Identification of potential simultaneous operations

• Identification of potential hazardous interactions

• Evaluation and implementation of necessary safeguards to allow for safe simultaneous operations

• Coordination, including shared communication methods, between the simultaneous operations

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

As necessary, seek the regulatory authority to promulgate this requirement.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

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Foundation Food Group Fatal Chemical Release (5 Recommendations)
Occupational Safety and Health Administration (OSHA) (5 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 11, 2023

2021-03-I-GA-4

Update the Region 4 Poultry Processing Facilities Regional Emphasis Program to explicitly cover liquid nitrogen freezing processes. At a minimum, the update should encourage practices applicable to managing the hazards of using liquid nitrogen and other cryogenic asphyxiants, including process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.


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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2021-03-I-GA-5

Update the Region 5 Regional Emphasis Program for Food Manufacturing Industry to explicitly cover liquid nitrogen freezing processes. At a minimum, the update should encourage practices applicable to managing the hazards of using liquid nitrogen and other cryogenic asphyxiants, including process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.


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

2021-03-I-GA-6

Update the Region 6 Poultry Processing Facilities Regional Emphasis Program to explicitly cover liquid nitrogen freezing processes. At a minimum, the update should encourage practices applicable to managing the hazards of using liquid nitrogen and other cryogenic asphyxiants, including process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.


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

2021-03-I-GA-7

Promulgate a standard specific to cryogenic asphyxiants. The purpose of this standard shall be the prevention and/or mitigation of hazards arising from the storage, use, and/or handling of these substances. The new standard shall reference applicable national consensus standards such as those published by the Compressed Gas Association and others, as appropriate. At a minimum the new standard shall:

a) Address requirements for the design, construction, and installation of process equipment storing or using cryogenic asphyxiants;

b) Require atmospheric monitoring where equipment storing or using cryogenic asphyxiants is located indoors;

c) Require emergency shutdown systems such that equipment storing or using cryogenic asphyxiants may be isolated during a release without endangerment;

d) Address requirements for employee training and hazard awareness specific to cryogenic asphyxiants;

e) Require an emergency action plan in accordance with 29 CFR 1910.38; and,

f) Address requirements for the use of process safety management elements such as process hazard analysis, management of change, procedures, and others deemed necessary through the rulemaking process to prevent and/or mitigate these hazards.


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

2021-03-I-GA-8

Develop and publish a Guidance Document (similar to OSHA 3912-03 Process Safety Management for Explosives and Pyrotechnics Manufacturing) for process safety management practices applicable to processes handling compressed gases and cryogenic asphyxiants, including (at a minimum) the practices highlighted in this report.


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

Husky Energy Superior Refinery Explosion and Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

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

Acetylene Service Company Gas Explosion (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 25, 2006

2005-3-I-NJ-5

Update the OSHA 1910.102 Acetylene Standard (a. Cylinders, b. Piped Systems, and c. Generators and filling cylinders) to remove the existing references to unavailable and obsolete Compressed Gas Association Pamphlets (CGA G-1-1966, G 1.3-1959, G 1.4-1966). As an alternative, consider incorporating by reference NFPA 51A Standard for Acetylene Cylinder Charging Plants.


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.
 

Barton Solvents Explosions and Fire (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: June 26, 2008

2007-6-I-KS-1

Revise the "Guidance for Hazard Determination for compliance with the OSHA Hazard Communication Standard" to advise chemical manufacturers and importers that prepare MSDSs to: -Evaluate flammable liquids to determine their potential to accumulate static electricity and form ignitable vapor-air mixtures in storage tanks. -Test the conductivity of the flammable liquid and include the testing results in the MSDS.


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.
 

2007-6-I-KS-2

Prior to the next revision, communicate to the Sub-Committee on the Globally Harmonized System of Classification and Labeling of Chemicals (SCEGHS) the need to amend the GHS to advise chemical manufacturers and importers that prepare MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in 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

Bayer CropScience Pesticide Waste Tank Explosion (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 20, 2011

2008-08-I-WV-10

In light of the findings of this report and the serious potential hazards to workers and the public from chemicals used and stored at the Bayer Institute site (such as phosgene, MIC, and methomyl), conduct a comprehensive Process Safety Management (PSM) inspection of the complex. Coordinate with the Environmental Protection Agency, as appropriate.


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).
 

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2008-08-I-WV-11

Revise the Chemical National Emphasis Program and the targeting criteria to:
a. Expand the coverage to all OSHA regions,
b. Include in the targeting criteria from which potential inspections are selected all establishments that have submitted certifications of completions of actions in response to previous PSM citations;
c. Require NEP inspections to examine the status of compliance of all previously cited PSM program items for which the company has submitted certifications of completion to OSHA.


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.
 

Bethune Point Wastewater Plant Explosion (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 13, 2007

2006-3-I-FL-6

Revise 29 CFR 1910.106 to specifically exclude the use of thermoplastics in above ground flammable liquid service.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

BLSR Operating Ltd. Vapor Cloud Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 17, 2003

2003-06-I-TX-13

Issue a Safety and Health Information Bulletin on the potential flammability hazard associated with bulk transportation of oilfield exploration and production (E&P) waste liquids. Summarize OSHA requirements for proper hazard classification by the shipper and for the use of material safety data sheets (MSDS). Summarize U.S. Department of Transportation (DOT) requirements for proper hazard classification and manifesting of flammable liquids, approved container design, and periodic testing. Discuss safe handling to minimize the generation of flammable vapor and to control ignition sources from vehicle-mounted equipment and facility equipment. Discuss the need for the employer to provide all worker safety information in languages or formats that are clearly understood by all affected personnel. Summarize the requirements for proper labeling of storage tanks to clearly identify the hazard of the contents to all employees and contractors working at the well site.


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.
 

BP America (Texas City) Refinery Explosion (3 Recommendations)
Occupational Safety and Health Administration (OSHA) (3 Recommendations)
Open: 33% | Closed: 67%

Final Report Released On: March 20, 2007

2005-4-I-TX-5

1. Implement a national emphasis program for all oil refineries that focuses on: - The hazards of blowdown drums and stacks that release flammables to the atmosphere instead of to an inherently safer disposal system such as a flare. Particular attention should be paid to blowdown drums attached to collection piping systems servicing multiple relief valves; - The need for adequately sized disposal knockout drums to safely contain discharged flammable liquid based on accurate relief valve and disposal collection piping studies 2. Urge states that administer their own OSHA plan to implement comparable emphasis programs within their respective jurisdictions.


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

2005-4-I-TX-8

1. Strengthen the planned comprehensive enforcement of the OSHA Process Safety Management (PSM) standard. At a minimum: a. Identify those facilities at greatest risk of a catastrophic accident by using available indicators of process safety performance and information gathered by the EPA under its Risk Management Program (RMP). b. Conduct, or have conducted, comprehensive inspections, such as those under your Program Quality Verification (PQV) program at facilities identified as presenting the greatest risk. c. Establish the capacity to conduct more comprehensive PSM inspections by hiring or developing a sufficient cadre of highly trained and experienced inspectors. d. Expand the PSM training offered to inspectors at the OSHA National Training Institute.


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

PDF Document Recommendation Status Change Summary

2005-4-I-TX-9

2. Amend the OSHA PSM standard to require that a management of change (MOC) review be conducted for organizational changes that may impact process safety including: a. major organizational changes such as mergers, acquisitions, or reorganizations; b. personnel changes, including changes in staffing levels or staff experience; and c. policy changes such as budget cutting.


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.
 

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Caribbean Petroleum Refining Tank Explosion and Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 21, 2015

2010-02-I-PR-4

(Superseded by 2019-01-I-TX-R7 from the Intercontinental Terminals Company (ITC) report)
 
a) Revise the Flammable and Combustible Liquids standard (29 CFR§ 1910.106) to require installing, using, and maintaining a high-integrity automatic overfill prevention system with a means of level detection, logic/control equipment, and independent means of flow control for bulk aboveground storage tanks containing gasoline, jet fuel, other fuel mixtures or blends tocks, and other flammable liquids having an NFPA 704 flammability rating of 3 or higher, to protect against loss of containment. At a minimum, this system
shall meet the following requirements:
1. Separated physically and electronically and independent from the tank gauging system.
2. Engineered, operated, and maintained to achieve an appropriate level of safety integrity in accordance with the rrequirements of Part 1 of International Electro-technical Commission (IEC) 61511-SER ed1.0B-2004, Functional Safety - Safety Instrumented Systems for the Process Industry Sector. Such a system would employ a safety integrity level (SIL) documented in accordance with the principles in Part 3 of IEC 61511-SER ed1.0B-2004, accounting for the following factors:
i. The existence of nearby populations and sensitive environments;
ii. The nature and intensity of facility operations;
iv. The extent/ rigor of operator monitoring.
3. Proof tested in accordance with the validated arrangements and procedures with sufficient frequency to ensure the specified safety integrity level is maintained.
b) Establish hazard analysis, management of change and mechanical integrity management system elements for bulk above ground storage tanks in the revised 1910.106 standard that are similar to those in the Process Safety Management of Highly Hazardous Chemicals standard (29 CFR § 1910.119) and ensure these facilities are subject to Recognized and Generally Accepted Good Engineering Practices (RAGAGEP).

Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

Combustible Dust Hazard Investigation (5 Recommendations)
Occupational Safety and Health Administration (OSHA) (5 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 09, 2006

2006-1-H-1

(Superseded by 2017-07-I-WI-R10 from the Didion Milling Co. investigation)

Issue a standard designed to prevent combustible dust fires and explosions in general industry. Base the standard on current National Fire Protection Association (NFPA) dust explosion standards (including NFPA 654 and NFPA 484), and include at least - hazard assessment, - engineering controls, - housekeeping, - building design, - explosion protection, - operating procedures, and - worker training.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

2006-1-H-2

Revise the Hazard Communication Standard (HCS) (1910.1200) to: - Clarify that the HCS covers combustible dusts, including those materials that may reasonably be anticipated to generate combustible dusts through downstream processing or handling. - Require Material Safety Data Sheets (MSDSs) to include the hazards and physical properties of combustible dusts, as well as clear information on safe handling practices and references to relevant consensus 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 Recommendations Status Change Summary

2006-1-H-3

Communicate to the United Nations Economic Commission for Europe (UNECE) the need to amend the Globally Harmonized System (GHS) to address combustible dust hazards by: - defining combustible dusts, - specifying the hazards that must be addressed in chemical information sheets, and - addressing the physical properties that must be included on a chemical information sheet pertinent to combustible dusts.


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.
 

2006-1-H-4

Provide training through the OSHA Training Institute (OTI) on recognizing and preventing combustible dust explosions.


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.
 

2006-1-H-5

While a standard is being developed, identify manufacturing industries at risk and develop and implement a national Special Emphasis Program (SEP) on combustible dust hazards in general industry. Include in the SEP an outreach program focused on the information in the Safety and Health Information Bulletin (SHIB), Combustible Dust in Industry: Preventing and Mitigating the Effects of Fire and Explosions.


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.
 

Didion Milling Company Explosion and Fire (3 Recommendations)
Occupational Safety and Health Administration (OSHA) (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 06, 2023

2017-07-I-WI-10

Promulgate a standard for all industries that handle combustible dust, which should be based on the requirements of current NFPA combustible dust standards, including NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, NFPA 484, Standard for Combustible Metals, NFPA 652, Standard on the Fundamentals of Combustible Dust, NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids, NFPA 655, Standard for Prevention of Sulfur Fires and Explosions, NFPA 664, Standard for the Prevention of Fires and Explosions in Wood Processing and Woodworking Facilities, or a successor standard. At a minimum, the standard should include the following elements:

a. Hazard Recognition;

b. Dust Hazard Analysis;

c. Management of Change;

d. Incident Investigation;

e. Engineering Controls;

f. Building Design;

g. Fugitive Dust Management;

h. Operating Procedures;

i. Process Safety Information; 

j. External Audit Management;

k. Training;

l. Emergency Response; and

m. Personal Protective Equipment.

(Superseded the following recommendations: 2006-1-H-R1 from the Combustible Dust Hazard investigation, 2008-05-I-GA-R11 from the Imperial Sugar investigation, and 2011-04-I-TN-R1 and 2011-04-I-TN-R2 from the Hoeganaes Corporation investigation)


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

2017-07-I-WI-11

Following implementation of CSB Recommendation No. 2017-07-I-WI-R10, update the Grain Handling Facilities Standard to clarify grain handling facilities with combustible dust are covered by the new Combustible Dust Standard.


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

2017-07-I-WI-12

Develop a program to trigger follow-up inspections when hazard alert letters are issued for combustible dust hazards and there is insufficient evidence to demonstrate that those hazards have been abated.


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

DuPont Belle Toxic Chemical Releases (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: September 20, 2011

2010-06-I-WV-1

Revise OSHA 29 CFR 1910.101, General Industry Standard for Compressed Gases, to require facilities that handle toxic and highly toxic materials in compressed gas cylinders to incorporate provisions that are at least as effective as the 2010 edition of Section 7.9, Toxic and Highly Toxic Gases, in National Fire Protection Association (NFPA) 55, Compressed Gases and Cryogenic Fluids Code, including enclosures, ventilation and treatment systems, interlocked fail-safe shutdown valves, gas detection and alarm systems, piping system components, and similarly relevant layers of protection.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

2010-06-I-WV-2

Take sustained measures to minimize the exposure of hazards to workers handling highly toxic gases from cylinders and associated regulators, gages, hoses, and appliances. Ensure that OSHA managers, compliance officers, equivalent state OSHA plan personnel, and regulated parties conform, under the Process Safety Management Standard (29 CFR 1910.119) Recognized and Generally Accepted Good Engineering Practices (RAGAGEP) provisions, to industry practices at least as effective as the following:

  1. NFPA 55 - Compressed Gases and Cryogenic Fluids Code (2010)
  2. CGA P-1 Safe Handling of Compressed Gases in Containers (2008)
  3. CGA E-9 Standard for Flexible, PTFE-lined Pigtails for Compressed Gas Service (2010)
  4. ASME B31.3 Process Piping (2008)

 


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

Hoeganaes Corporation Fatal Flash Fires (3 Recommendations)
Occupational Safety and Health Administration (OSHA) (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 05, 2012

2011-4-I-TN-1

(Superseded by 2017-07-I-WI-R10 from the Didion Milling Co. investigation)

Ensure that the forthcoming OSHA Combustible Dust Standard includes coverage for combustible metal dusts including iron and steel powders.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

2011-4-I-TN-2

(Superseded by 2017-07-I-WI-R10 from the Didion Milling Co. investigation)

Develop and publish a proposed combustible dust standard for general industry within one year of the approval of this case study.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

2011-4-I-TN-3

Revise the Combustible Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities nationwide under these codes to inform them of the
hazards of combustible metal dusts and NEP coverage.


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

PDF Document Recommendation Status Change Summary

Imperial Sugar Company Dust Explosion and Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 24, 2009

2008-05-I-GA-11

(Superseded by 2017-07-I-WI-R10 from the Didion Milling Co. investigation)

Proceed expeditiously, consistent with the Chemical Safety Board’s November 2006 recommendation and OSHA’s announced intention to conduct rulemaking, to promulgate a comprehensive standard to reduce or eliminate hazards from fire and explosion from combustible powders and dust.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

Improving Reactive Hazard Management (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 08, 2002

2001-01-H-1

(Superseded by 2021-02-I-WV-R13 from the Optima Belle report)

Amend the Process Safety Management Standard (PSM), 29 CFR 1910.119, to achieve more comprehensive control of reactive hazards that could have catastrophic consequences.

  • Broaden the application to cover reactive hazards resulting from process-specific conditions and combinations of chemicals. Additionally, broaden coverage of hazards from self-reactive chemicals. In expanding PSM coverage, use objective criteria. Consider criteria such as the North American Industry Classification System (NAICS), a reactive hazard classification system (e.g., based on heat of reaction or toxic gas evolution), incident history, or catastrophic potential.
  • In the compilation of process safety information, require that multiple sources of information be sufficiently consulted to understand and control potential reactive hazards. Useful sources include:

- Literature surveys (e.g., Bretherick's Handbook of Reactive Chemical Hazards, Sax's Dangerous Properties of Industrial Materials).

- Information developed from computerized tools (e.g., ASTM's CHETAH, NOAA's The Chemical Reactivity Worksheet).

- Chemical reactivity test data produced by employers or obtained from other sources (e.g., differential scanning calorimetry, thermogravimetric analysis, accelerating rate calorimetry).

- Relevant incident reports from the plant, the corporation, industry, and government.

- Chemical Abstracts Service.

  • Augment the process hazard analysis (PHA) element to explicitly require an evaluation of reactive hazards. In revising this element, evaluate the need to consider relevant factors, such as:

- Rate and quantity of heat or gas generated.

- Maximum operating temperature to avoid decomposition.

- Thermal stability of reactants, reaction mixtures, byproducts, waste streams, and products.

- Effect of variables such as charging rates, catalyst addition, and possible contaminants.

- Understanding the consequences of runaway reactions or toxic gas evolution.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

2001-01-H-2

Implement a program to define and record information on reactive incidents that OSHA investigates or requires to be investigated under OSHA regulations. Structure the collected information so that it can be used to measure progress in the prevention of reactive incidents that give rise to catastrophic releases.


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

Intercontinental Terminals Company (ITC) Tank Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 06, 2023

2019-01-I-TX-7

Eliminate the atmospheric storage tank exemption from the PSM standard.

(Superseded 2001-05-I-DE-R1 from the Motiva report and 2010-02-I-PR-R4 from the Caribbean Petroleum (CAPECO) report)


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

Kaltech Industries Waste Mixing Explosion (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: September 30, 2003

2002-02-I-NY-8

Disseminate information on the requirements of the Hazard Communication Standard, 29 CFR 1910.1200, in the major languages spoken by workers in New York City with limited or no English speaking proficiency.


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.
 

2002-02-I-NY-9

Establish a complaint and referral system with the New York City Fire Department (FDNY) to provide for a coordinated enforcement effort that addresses the following issues: Policy and practice for referring to OSHA possible health and safety violations or unsafe conditions observed by FDNY personnel in the course of conducting inspections, but outside the scope of FDNY responsibility. Periodic training programs for FDNY personnel on how to recognize and refer serious workplace safety and health problems.


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.
 

Kleen Energy Natural Gas Explosion (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 28, 2010

2010-07-I-CT-1 URGENT!

Promulgate regulations that address fuel gas safety for both construction and general industry. At a minimum:

a. Prohibit the release of flammable gas to the atmosphere for the purpose of cleaning fuel gas piping.

b. Prohibit flammable gas venting or purging indoors. Prohibit venting or purging outdoors where fuel gas may form a flammable atmosphere in the vicinity of workers and/or ignition sources.

c. Prohibit any work activity in areas where the concentration of flammable gas exceeds a fixed low percentage of the lower explosive limit (LEL) determined by appropriate combustible gas monitoring.

d. Require that companies develop flammable gas safety procedures and training that involves contractors, workers, and their representatives in decision-making.


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendation Status Change Summary

Morton International Inc. Runaway Chemical Reaction (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 16, 2000

1998-06-I-NJ-8

Issue joint guidelines on good practices for handling reactive chemical process hazards. Ensure that these guidelines, at a minimum, address the following issues: The evaluation of reactive hazards and the consequences of reasonably foreseeable and worst-case deviations from normal operations. The importance of reporting and investigating deviations from normal operations. The determination of proper design for pressure relief capability, emergency cooling, process controls, alarms, and safety interlocks, as well as other good-practice design features for handling reactive substances. The appropriate use of chemical screening techniques such as differential scanning calorimetry.


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.
 

1998-06-I-NJ-9

Participate in a hazard investigation of reactive chemical process safety conducted by the CSB. The objectives of the special investigation will include: Determine the frequency and severity of reactive chemical incidents. Examine how industry, OSHA, and EPA are currently addressing reactive chemical hazards. Determine the differences, if any, between large/medium/small companies with regard to reactive chemical policies, practices, in-house reactivity research, testing, and process engineering. Analyze the effectiveness of industry and OSHA use of the National Fire Protection Association Reactivity Rating system for process safety management purposes. Develop recommendations for reducing the number and severity of reactive chemical incidents.


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.
 

Motiva Enterprises Sulfuric Acid Tank Explosion (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 28, 2002

2001-05-I-DE-1

(Superseded by 2019-01-I-TX-R7 from the Intercontinental Terminals Company (ITC) report)

Ensure coverage under the Process Safety Management Standard (29 CFR 1910.119) of atmospheric storage tanks that could be involved in a potential catastrophic release as a result of being interconnected to a covered process with 10,000 pounds of a flammable substance.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

Optima Belle Explosion and Fire (3 Recommendations)
Occupational Safety and Health Administration (OSHA) (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: July 06, 2023

2021-02-I-WV-11

Update the Chemical Reactivity Hazards website (https://www.osha.gov/chemical-reactivity) to include various reactivity assessment tools developed since the 2002 Index-Based Method for Assessing Exothermic Runaway Risk and the 2004 Preliminary Screening Method. Mathematical methods, thermal analysis methods (e.g., Accelerating Rate Calorimeter (ARC) testing), ASTM E1231-19 Standard Practice for Calculation of Hazard Potential Figures of Merit for Thermally Unstable Materials, Stoessel Criticality, and the O.R.E.O.S. Method (an assessment that combines Oxygen balance calculations, the Rule of 6, and the Explosive functional group list with Onset decomposition and scale) are tools that could be considered for the update. The “Additional Resources” section of the website should also be evaluated for necessary changes and updates.


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

2021-02-I-WV-12

Following the implementation of CSB recommendation 2021-02-I-WV-R11, ensure that the chemical industry is aware of the Chemical Reactivity Hazards website (https://www.osha.gov/chemical-reactivity) by developing and implementing a comprehensive outreach plan that actively targets the chemical industry and related trade associations. The outreach plan may include such means as a national news release and OSHA’s “QuickTakes” newsletter and/or Safety and Health Information Bulletins. This outreach plan should be coordinated with OSHA’s On-Site Consultation Program partners.


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

2021-02-I-WV-13

Amend the Process Safety Management (PSM) Standard, 29 CFR 1910.119, to achieve more comprehensive control of reactive hazards that could have catastrophic consequences.

  • Broaden the application to cover reactive hazards resulting from process-specific conditions and combinations of chemicals. Additionally, broaden coverage of hazards from self-reactive chemicals. In expanding PSM coverage, use objective criteria. Consider criteria such as the North American Industry Classification System (NAICS), a reactive hazard classification system (e.g., based on heat of reaction or hazardous gas evolution), incident history, or catastrophic potential.
  • In the compilation of process safety information, require that multiple sources of information be sufficiently consulted to understand and control potential reactive hazards. Useful sources include but are not limited to:

- Literature surveys (e.g., Bretherick’s Handbook of Reactive Chemical Hazards, Sax’s Dangerous Properties of Industrial Materials, CAS SciFinder).

- Information developed from computerized tools (e.g., ASTM’s CHETAH, CCPS’s Chemical Reactivity Worksheet).

- Chemical property data compiled in PubChem and the REACH (Registration, Evaluation, and Authorization of Chemicals) dossiers maintained by the European Chemicals Agency (ECHA).

- Chemical reactivity test data produced by employers or obtained from other sources following established standards such as:

- ASTM E537-20, Standard Test Method for Chemicals by Differential Scanning Calorimetry;

- ASTM E1981-22, Standard Guide for Assessing Thermal Stability of Materials by Methods of Accelerating Rate Calorimetry;

- ASTM E2550-21, Standard Test Method for Thermal Stability by Thermogravity; and

- ASTM E1231-19, Standard Practice for Calculation of Hazard Potential Figures of Merit for Thermally Unstable Materials.

- Relevant incident data from the plant, the corporation, industry, and government.

  • Augment the process hazard analysis (PHA) element to explicitly require an evaluation of reactive hazards. In revising this element, evaluate the need to consider relevant factors, such as:

- Rate and quantity of heat or gas generated.

- Maximum operating temperature to avoid a runaway reaction from decomposition.

- Time to Maximum Rate under Adiabatic Conditions (TMRad).

- Thermal stability of reactants, reaction mixtures, byproducts, waste streams, and products.

- Effect of variables such as charging rates, catalyst addition, and possible contaminants.

- Understanding the consequences of runaway reactions or hazardous gas evolution.

(Superseded 2001-01-H-XX-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

Partridge Raleigh Oilfield Explosion and Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 12, 2007

2006-7-I-MS-4

Implement a Local Emphasis Program (LEP) to inspect companies in the oil and gas production and extraction sector.


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

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Pryor Trust Fatal Gas Well Blowout and Fire (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 12, 2019

2018-01-I-OK-1

Implement one of the three following options regarding regulatory changes:

(a) OPTION 1: Apply the Process Safety Management (PSM) standard (29 CFR 1910.119) to the drilling of oil and gas wells; or

(b) OPTION 2: Apply the Process Safety Management (PSM) standard (29 CFR 1910.119) to the drilling of oil and gas wells as in OPTION 1, and make the necessary modifications to customize it to oil and gas drilling operations; or

(c) OPTION 3: Develop a new standard with a safety management system framework similar to PSM that applies only to the drilling of onshore oil and gas wells that includes but is not limited to the following:

  1. Detailed written operating procedures with specified steps and equipment alignment for all operations;

  2. Written procedures for the management of changes (except replacements in kind) in procedures, the well plan, and equipment;

  3. A risk assessment of hazards associated with the drilling plan;

  4. A requirement to follow Recognized and Generally Accepted Good Engineering Practices (RAGAGEP);

  5. Development of a Well Construction Interface Document between the operator and the drilling contractor prior to the commencement of drilling activities which at a minimum includes a bridging document and well plan specifying barriers and how to manage them;

  6. The performance and documentation of flow checks using acceptable methods at defined points during the operation for a specified duration; and

  7. A requirement for employee participation, similar to the Employee Participation requirement in the OSHA PSM standard.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

Texas Tech University Chemistry Lab Explosion (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: October 19, 2011

2011-5-CS-TX-1

Broadly and explicitly communicate to the target audience of research laboratories the findings and recommendations of the CSB Texas Tech report focusing on the message that while the intent of 29 CFR 1910.1450 (Occupational Exposure to Hazardous Chemicals in Laboratories Standard) is to comprehensively address health hazards of chemicals, organizations also need to effectively implement programs and procedures to control physical hazards of chemicals (as defined in 1910.1450(b)). At a minimum:

a.     Develop a Safety and Health Information Bulletin (SHIB) pertaining to the need to control physical hazards of chemicals; and
b.     Disseminate the SHIB (and any related products) on the OSHA Safety and Health Topics website pertaining to Laboratories (http://www.osha.gov/SLTC/laboratories/index.html)

 


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 Download

Union Carbide Corp. Nitrogen Asphyxiation Incident (1 Recommendations)
Occupational Safety and Health Administration (OSHA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: February 23, 1999

1998-05-I-LA-4

Issue a safety alert that addresses the hazards and provides safety guidelines for the use of temporary enclosures that are erected around equipment containing hazardous substances.


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.
 

Universal Form Clamp Co. Explosion and Fire (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 10, 2007

2006-8-I-IL-1

Amend 1910.106 Flammable and Combustible Liquids to require facilities that handle flammable and combustible liquids to implement the requirements of 1910.38 Emergency Action Plans.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendations Status Change Summary

2006-8-I-IL-2

Amend 1910.38 Emergency Action Plans to require employers to conduct practice evacuation drills at least annually, but more frequently if necessary to ensure employees are prepared for emergencies.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendations Status Change Summary

US Ink Fire (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 15, 2015

2013-01-I-NJ-1

Add North American Industry Classification System (NAICS) Code 325910, Printing Ink Manufacturing, to the list of industries in Appendix D-1 or Appendix D-2 of Combustible Dust National Emphasis Program (NEP), Directive CPL 03-00-008.


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

2013-01-I-NJ-2

Communicate with all OSHA Area Offices to encourage appropriate application of the following existing provisions of the Combustible Dust NEP, Directive CPL 03-00-008:

  • Paragraph IX, Section A2, indicates that area offices may add to their Combustible Dust NEP establishment lists those facilities in their jurisdictions with a Standard Industrial Classification System code, NAICS code, or both (other than those listed in Appendices D-1 and D-2 of the Combustible Dust NEP directive) if those facilities have a known pattern of combustible dust hazards.
  • Paragraph IX, Section B4, indicates that if a fatality or catastrophe investigation is performed at a facility because of a combustible dust deflagration or explosion, the inspector shall use the guidelines in Fatality/Catastrophe Investigation Procedures, Directive CPL 02-00-137, and in the Combustible Dust NEP, Directive CPL 03-00-008.

Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendation Status Change Summary

Wacker Polysilicon Chemical Release (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 15, 2023

2021-01-I-TN-1

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.

(Superseded 2020-7-I-NC-R2 from the Evergreen report)


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

2021-01-I-TN-2

Develop a safety product providing guidance on the coordination of simultaneous operations (SIMOPs) involving multiple work groups, including contractors, that is not limited to confined space or construction. Provide guidance on the following activities:

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 - 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

Wendland 1H Well Fatal Explosion (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: December 26, 2023

2020-04-I-TX-3

Remove the exemption for oil and gas drilling and well servicing from the Control of Hazardous Energy standard (29 CFR 1910.147) and expand its applicability to cover oil and gas production and workover operations.


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

2020-04-I-TX-4

Promulgate a new standard with prescriptive requirements, similar to the Control of Hazardous Energy Standard, as well as a performance-based safety management system framework, similar to the OSHA Process Safety Management (PSM) Standard, that applies to the drilling, production, and servicing/workover activities surrounding onshore oil and gas wells. At a minimum, this standard should include the following:

1. Prescriptively address requirements for primary and secondary barriers for well control;

2. Detailed written drilling, production, and servicing procedures with specified steps and equipment alignment for all operations;

3. Management of change requirements (except replacements in kind) that, at a minimum, address procedures, the well plan, and equipment;

4. A risk assessment of hazards associated with the drilling, production, and servicing/workover plans;

5. A requirement to follow Recognized and Generally Accepted Good Engineering Practices (RAGAGEP);

6. Development of a Well Construction Interface Document between the operator and the drilling contractor prior to the commencement of drilling and servicing activities and an equivalent document for production and workover contractors which, at a minimum, includes a bridging document and well plans specifying barriers and how to manage them;

7. The performance and documentation of flow checks using acceptable methods at defined points during the operation for a specified duration;

8. A requirement for employee participation, similar to the Employee Participation requirement in the OSHA PSM standard;

9. A requirement for maintaining critical well information, similar to the Process Safety Information requirement in the OSHA PSM standard, which at a minimum includes well history and documented well control methods during workovers;

10. A requirement for analyzing and assessing the hazards during all phases and steps for well servicing, similar to the Process Hazard Analysis requirement in the OSHA PSM standard;

11. A requirement for developing, executing, communicating, and maintaining procedures for drilling, production, and servicing operations on a well, similar to the Operating Procedures requirement in the OSHA PSM standard; and

12. The documentation of well control plans for drilling, production, and servicing/workover operations for a well utilizing acceptable methods for monitoring the effectiveness of well control methods.


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

West Fertilizer Explosion and Fire (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: January 28, 2016

2013-02-I-TX-4

Develop and issue a Regional Emphasis Program for Section (i) of the Explosives and Blasting Agent standard, 29 CFR 1910.109(i), in appropriate regions (such as Regions IV, VI, and VII) where fertilizer grade ammonium nitrate (FGAN) facilities similar to the West Fertilizer Company facility are prevalent.  Establish a minimum number of emphasis program inspections per region for each fiscal year.  Work with regional offices to communicate information about the emphasis program to potential inspection recipients. 


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

2013-02-I-TX-5

Implement one of the following two regulatory changes, either option (a) or (b) below, to address

FGAN hazards:
a. Add FGAN to the OSHA Process Safety Management (PSM) standard List of Highly Hazardous Chemicals, Toxics and Reactives in 29 CFR 1910.119, Appendix A, and establish an appropriate threshold quantity.  Identify National Fire Protection Association (NFPA) 400 as a source of Recognized and Generally Accepted Good Engineering Practices (RAGAGEP) for PSM-covered FGAN equipment and processes.
b. Revise the OSHA Explosives and Blasting Agents standard, 29 CFR 1910.109, to ensure that the title, scope, or both make(s) clear that the standard applies to facilities that store bulk quantities of FGAN.  Revise 1910.109(i), “Storage of Ammonium Nitrate,” to include requirements similar to those in NFPA 400, Hazardous Materials Code (2016

Edition), Chapter 11.  Ensure the following elements are considered:
i. For new construction, prohibit combustible materials of construction for FGAN facilities and FGAN bins. For existing facilities, establish a phase-in requirement for the replacement of wooden bins with bins made of noncombustible materials of construction within a reasonable time period (e.g., 3 to 5 years from the date standard revisions are enacted), based on feedback from the fertilizer industry.

ii. Require automatic fire sprinkler systems and fire detection systems for indoor FGAN storage areas.

iii. Define adequate ventilation for FGAN for indoor storage areas.

iv. Require all FGAN storage areas to be isolated from the storage of combustible, flammable, and other contaminating materials.

v. Establish separation distances between FGAN storage areas and other hazardous chemicals, processes, and facility boundaries.


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.
 

Xcel Energy Company Hydroelectric Tunnel Fire (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: August 25, 2010

2008-01-I-CO-1

Amend the OSHA Permit-Required Confined Spaces Rule for general industry (29 CFR 1910.146) to establish a maximum permissible percentage substantially below the lower explosive limit (LEL) for safe entry and occupancy in permit-required confined spaces.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendations Status Change Summary

2008-01-I-CO-2

 

Publish a “Safety and Health Information Bulletin” addressing the hazards and controls when using flammable materials in confined spaces that includes actionable guidance regarding:
 
a. The importance of implementing a hierarchy of controls to address hazards in a confined space that first seeks to eliminate hazards or substitute with a less hazardous material(s) or method(s). Examples include performing work outside of a confined space where reasonably practicable or substituting a flammable material with a non-flammable one.

b. The necessity of establishing a maximum permissible percentage substantially below the lower explosive limit (LEL) for safe entry and occupancy of permit required confined spaces.

c. The need to comprehensively control all potential ignition sources and continuously monitor the confined space at appropriate locations and elevations when work activities involve the use of flammable materials or where flammable atmospheres may be created.

d. The importance of treating confined spaces with the potential for flammable atmospheres above 10 percent of the LEL as a hazard immediately dangerous to life or health (IDLH) that requires rescuers to be stationed directly outside the permit space and available for immediate rescue with appropriate fire-extinguishing and rescue equipment.

e. The requirement that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Such spaces need to be monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working.

 


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

PDF Document Recommendation Status Change Summary