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.
2010-08-I-WA-10
Revise American Petroleum Institute API RP 941: Steels for Hydrogen Service at Elevated Temperatures and Pressures in Petroleum Refineries and Petrochemical Plants to: a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems; b. Require the use of inherently safer materials to the greatest extent feasible; c. Require verification of actual operating conditions to confirm that material of construction selection prevents HTHA equipment failure; and d. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure. Status: Closed - Unacceptable Action/No Response Received
Revise American Petroleum Institute API RP 941: Steels for Hydrogen Service at Elevated Temperatures and Pressures in Petroleum Refineries and Petrochemical Plants to:
a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems;
b. Require the use of inherently safer materials to the greatest extent feasible;
c. Require verification of actual operating conditions to confirm that material of construction selection prevents HTHA equipment failure; and
d. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure.
2010-08-I-WA-11
Revise American Petroleum Institute API RP 581: Risk-Based Inspection Technology to: a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems; b. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure; and c. Require verification of actual operating conditions to determine potential equipment damage mechanisms. Status: Closed - Unacceptable Action/No Response Received
Revise American Petroleum Institute API RP 581: Risk-Based Inspection Technology to:
b. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure; and
c. Require verification of actual operating conditions to determine potential equipment damage mechanisms.
2010-08-I-WA-1
Revise the Chemical Accident Prevention Provisions under 40 CFR Part 68 to require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible when facilities are establishing safeguards for identified process hazards. The goal shall be to reduce the risk of major accidents to the greatest extent practicable, to be interpreted as equivalent to as low as reasonably practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all management of change, incident investigation, and process hazard analysis reviews and recommendations, prior to the construction of a new process, process unit rebuilds, significant process repairs, and in the development of corrective actions. Status: Open - Awaiting Response or Evaluation/Approval of Response
Revise the Chemical Accident Prevention Provisions under 40 CFR Part 68 to require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible when facilities are establishing safeguards for identified process hazards. The goal shall be to reduce the risk of major accidents to the greatest extent practicable, to be interpreted as equivalent to as low as reasonably practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all management of change, incident investigation, and process hazard analysis reviews and recommendations, prior to the construction of a new process, process unit rebuilds, significant process repairs, and in the development of corrective actions.
2010-08-I-WA-2
Until Recommendation 2010-08-I-WA-R1 is in effect, enforce through the Clean Air Act’s General Duty Clause, section 112(r)(1), 42 U.S.C.§7412(r)(1) the use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible when facilities are establishing safeguards for identified process hazards. Status: Closed - No Longer Applicable
Until Recommendation 2010-08-I-WA-R1 is in effect, enforce through the Clean Air Act’s General Duty Clause, section 112(r)(1), 42 U.S.C.§7412(r)(1) the use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible when facilities are establishing safeguards for identified process hazards.
2010-08-I-WA-3
Develop guidance for the required use of inherently safer systems analysis and the hierarchy of controls for enforcement under 40 CFR Part 68 and the Clean Air Act’s General Duty Clause, section 112(r)(1),42 U.S.C. §7412(r)(1). Status: Open - Awaiting Response or Evaluation/Approval of Response
Develop guidance for the required use of inherently safer systems analysis and the hierarchy of controls for enforcement under 40 CFR Part 68 and the Clean Air Act’s General Duty Clause, section 112(r)(1),42 U.S.C. §7412(r)(1).
2010-08-I-WA-4
Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective actions. Status: Closed - Reconsidered/Superseded
Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective actions.
2010-08-I-WA-5
Based on the findings in this report, augment your existing process safety management regulations for petroleum refineries in the state of Washington with the following more rigorous goal-setting attributes: a. A comprehensive process hazard analysis written by the company that includes: i. Systematic analysis and documentation of all major hazards and safeguards, using the hierarchy of controls to reduce those risks to as low as reasonably practicable (ALARP); ii. Documentation of the recognized methodologies,rationale and conclusions used to claim that safeguards intended to control hazards will be effective; iii. Documented damage mechanism hazard review conducted by a diverse team of qualified personnel. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure effective safeguards are in place to control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safer design to the greatest extent feasible into this review; and iv. Documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations. b. A thorough review of the comprehensive process hazard analysis by technically competent regulatory personnel; c. Required preventative audits and preventative inspections by the regulator; d. Require that all safety codes, standards, employer internal procedures and recognized and generally accepted good engineering practices (RAGAGEP) used in the implementation of the regulations contain adequate minimum requirements; e. Require an increased role for workers in management of process safety by establishing the rights and responsibilities of workers and their representatives on health and safety-related matters, and the election of safety representatives and establishment of safety committees (with equal representation between management and labor) to serve health and safety-related functions. The elected representatives should have a legally recognized role that goes beyond consultation in activities such as the development of the comprehensive process hazard analysis, management of change, incident investigation, audits, and identification and effective control of hazards. The representatives should also have the authority to stop work that is perceived to be unsafe or that presents a serious hazard until the regulator intervenes to resolve the safety concern. Work force participation practices should be documented by the company to the regulator; and f. Requires reporting of information to the public to the greatest extent feasible such as a summary of the comprehensive process hazard analysis which includes a list of safeguards implemented and standards utilized to reduce risk, and process safety indicators that demonstrate the effectiveness of the safeguards and management systems. Status: Closed - Acceptable Alternative Action
Based on the findings in this report, augment your existing process safety management regulations for petroleum refineries in the state of Washington with the following more rigorous goal-setting attributes:
a. A comprehensive process hazard analysis written by the company that includes:
i. Systematic analysis and documentation of all major hazards and safeguards, using the hierarchy of controls to reduce those risks to as low as reasonably practicable (ALARP);
ii. Documentation of the recognized methodologies,rationale and conclusions used to claim that safeguards intended to control hazards will be effective;
iii. Documented damage mechanism hazard review conducted by a diverse team of qualified personnel. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure effective safeguards are in place to control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safer design to the greatest extent feasible into this review; and
iv. Documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.
b. A thorough review of the comprehensive process hazard analysis by technically competent regulatory personnel;
c. Required preventative audits and preventative inspections by the regulator;
d. Require that all safety codes, standards, employer internal procedures and recognized and generally accepted good engineering practices (RAGAGEP) used in the implementation of the regulations contain adequate minimum requirements;
e. Require an increased role for workers in management of process safety by establishing the rights and responsibilities of workers and their representatives on health and safety-related matters, and the election of safety representatives and establishment of safety committees (with equal representation between management and labor) to serve health and safety-related functions. The elected representatives should have a legally recognized role that goes beyond consultation in activities such as the development of the comprehensive process hazard analysis, management of change, incident investigation, audits, and identification and effective control of hazards. The representatives should also have the authority to stop work that is perceived to be unsafe or that presents a serious hazard until the regulator intervenes to resolve the safety concern. Work force participation practices should be documented by the company to the regulator; and
f. Requires reporting of information to the public to the greatest extent feasible such as a summary of the comprehensive process hazard analysis which includes a list of safeguards implemented and standards utilized to reduce risk, and process safety indicators that demonstrate the effectiveness of the safeguards and management systems.
2010-08-I-WA-6
Establish a well-funded, well-staffed, technically qualified regulator with a compensation system to ensure the Washington Department of Labor and Industries regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical qualifications. Periodically conduct a market analysis and benchmarking review to ensure the compensation system remains competitive with Washington petroleum refineries. Status: Open - Acceptable Response or Alternate Response
Establish a well-funded, well-staffed, technically qualified regulator with a compensation system to ensure the Washington Department of Labor and Industries regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical qualifications. Periodically conduct a market analysis and benchmarking review to ensure the compensation system remains competitive with Washington petroleum refineries.
2010-08-I-WA-7
Work with the regulator, the petroleum refining industry, labor, and other relevant stakeholders in the state of Washington to develop and implement a system that collects, tracks, and analyzes process safety leading and lagging indicators from operators and contractors to promote continuous process safety improvements. At a minimum, this program shall: a. Require the use of leading and lagging process safety indicators to actively monitor the effectiveness of process safety management systems and safeguards for major accident prevention. Include leading and lagging indicators that are measureable, actionable, and standardized. Include indicators that measure safety culture, such as incident reporting and action item implementation culture. Require that the reported data be used for continuous process safety improvement and accident prevention; b. Analyze data to identify trends and poor performer s and publish annual reports with the data at facility and corporate levels; c. Require companies to publicly report required indicators annually at facility and corporate levels; d. Use process safety indicators (1) to drive continuous improvement for major accident prevention by using the data to identify industry and facility safety trends and deficiencies and (2) to determine appropriate allocation of regulator resources and inspections; and e. Be periodically updated to incorporate new learning from world-wide industry improvements in order to drive continuous major accident process safety improvements in Washington. Status: Open - Awaiting Response or Evaluation/Approval of Response
Work with the regulator, the petroleum refining industry, labor, and other relevant stakeholders in the state of Washington to develop and implement a system that collects, tracks, and analyzes process safety leading and lagging indicators from operators and contractors to promote continuous process safety improvements. At a minimum, this program shall:
a. Require the use of leading and lagging process safety indicators to actively monitor the effectiveness of process safety management systems and safeguards for major accident prevention. Include leading and lagging indicators that are measureable, actionable, and standardized. Include indicators that measure safety culture, such as incident reporting and action item implementation culture. Require that the reported data be used for continuous process safety improvement and accident prevention;
b. Analyze data to identify trends and poor performer s and publish annual reports with the data at facility and corporate levels;
c. Require companies to publicly report required indicators annually at facility and corporate levels;
d. Use process safety indicators (1) to drive continuous improvement for major accident prevention by using the data to identify industry and facility safety trends and deficiencies and (2) to determine appropriate allocation of regulator resources and inspections; and
e. Be periodically updated to incorporate new learning from world-wide industry improvements in order to drive continuous major accident process safety improvements in Washington.
2010-08-I-WA-15
Implement a process safety culture continuous improvement program at the Tesoro Anacortes Refinery including a written procedure for periodic process safety culture surveys across the work force. The process safety culture program shall be overseen by a tripartite committee of Tesoro management, USW representatives, Washington State Department of Labor and Industries – Division of Occupational Safety and Health, and the U.S. Environmental Protection Agency. This oversight committee shall: a. Select an expert third party that will administer a periodic process safety culture survey; b. Review and comment on the third party expert report developed from the survey; c. Oversee the development and effective implementation of action items to address identified process safety culture issues; and d. Develop process safety culture indicators to measure major accident prevention performance. The process safety program shall include a focus on items that measure, at a minimum, willingness to report incidents, normalization of hazardous conditions, burden of proof of safety in plant process safety programs and practices, and management involvement and commitment to process safety. The periodic process safety culture report shall be made available to the plant workforce. The minimum frequency of process safety culture surveys shall be at least once every three years. Status: Closed - Acceptable Alternative Action
Implement a process safety culture continuous improvement program at the Tesoro Anacortes Refinery including a written procedure for periodic process safety culture surveys across the work force. The process safety culture program shall be overseen by a tripartite committee of Tesoro management, USW representatives, Washington State Department of Labor and Industries – Division of Occupational Safety and Health, and the U.S. Environmental Protection Agency. This oversight committee shall:
a. Select an expert third party that will administer a periodic process safety culture survey;
b. Review and comment on the third party expert report developed from the survey;
c. Oversee the development and effective implementation of action items to address identified process safety culture issues; and
d. Develop process safety culture indicators to measure major accident prevention performance.
The process safety program shall include a focus on items that measure, at a minimum, willingness to report incidents, normalization of hazardous conditions, burden of proof of safety in plant process safety programs and practices, and management involvement and commitment to process safety. The periodic process safety culture report shall be made available to the plant workforce. The minimum frequency of process safety culture surveys shall be at least once every three years.
2010-08-I-WA-12
Actively participate with API in the completion ofrecommendation 2010-08-I-WA-R10. Document this participation. Status: Closed - Acceptable Action
Actively participate with API in the completion ofrecommendation 2010-08-I-WA-R10. Document this participation.
2010-08-I-WA-13
Once recommendation 2010-08-I-WA-R12 is in effect, develop and implement a plan to meet therequirements established through the acceptable completion of recommendation 2010-08-I-WA-R10. Document the implementation of the plan and the corrective actions taken. Status: Closed - No Longer Applicable
Once recommendation 2010-08-I-WA-R12 is in effect, develop and implement a plan to meet therequirements established through the acceptable completion of recommendation 2010-08-I-WA-R10. Document the implementation of the plan and the corrective actions taken.
2010-08-I-WA-14
Revise and improve the Process Hazard Analysis (PHA), the Integrity Operating Window (IOW), and the damage mechanism hazard review (DMHR) programs and cross-linking among these three programs such that all identified hazards are effectively managed in each program. For all Tesoro refineries require: a. the IOW to review damage mechanism hazards from the most recent PHA and safeguards identified to control these hazards; b. the IOW review or revalidation to be conducted at least every five years; c. the IOW to analyze and incorporate applicable industry best practice, the hierarchy of controls, and inherently safer design to the greatest extent reasonably practicable; d. the DMHR report to be developed by the DMHR team and not just the “corrosion expert;” e.the DMHR team to review the operating data to verify an accurate understanding of how the data was obtained, what it represents, and that it appropriately addresses both routine and nonroutine operations; f. the DMHR and/or IOW review to identify and review gaps between current industry best practices and existing Tesoro practices with regard to material selection and process controls and make recommendations that reduce risks from damage mechanism hazards; g. the DMHR and IOW review to review applicable Tesoro and industry-wide damage mechanism incidents as part of the respective DMHR or IOW review; h. the DMHR to review relevant MOCs to fully evaluate the impact of the MOC on damage mechanism hazards; i. the identification of minimum qualifications for the “corrosion expert” and ensure that the DMHR team has the necessary skills to meet these requirements; j. for sites that have a corrosion/materials engineer, the corrosion/materials engineer shall be a required participant in the DMHR; k. the PHA to review the most recent DMHR and IOW reviews in order to contain a complete record of all identified damage mechanism hazards, evaluate existing safeguards, and propose new safeguards to control the identified hazards; l. the PHA to review the consequence of damage mechanism hazards identified in the risk-based inspection (RBI) program and IOW reviews to ensure effective safeguards are present to control the damage mechanism hazard; and m. the PHA to use the hierarchy of controls and implement opportunities for inherently safer design to the greatest extent reasonably practicable. Status: Closed - Acceptable Action
Revise and improve the Process Hazard Analysis (PHA), the Integrity Operating Window (IOW), and the damage mechanism hazard review (DMHR) programs and cross-linking among these three programs such that all identified hazards are effectively managed in each program. For all Tesoro refineries require:
a. the IOW to review damage mechanism hazards from the most recent PHA and safeguards identified to control these hazards;
b. the IOW review or revalidation to be conducted at least every five years;
c. the IOW to analyze and incorporate applicable industry best practice, the hierarchy of controls, and inherently safer design to the greatest extent reasonably practicable;
d. the DMHR report to be developed by the DMHR team and not just the “corrosion expert;”
e.the DMHR team to review the operating data to verify an accurate understanding of how the data was obtained, what it represents, and that it appropriately addresses both routine and nonroutine operations;
f. the DMHR and/or IOW review to identify and review gaps between current industry best practices and existing Tesoro practices with regard to material selection and process controls and make recommendations that reduce risks from damage mechanism hazards;
g. the DMHR and IOW review to review applicable Tesoro and industry-wide damage mechanism incidents as part of the respective DMHR or IOW review;
h. the DMHR to review relevant MOCs to fully evaluate the impact of the MOC on damage mechanism hazards;
i. the identification of minimum qualifications for the “corrosion expert” and ensure that the DMHR team has the necessary skills to meet these requirements;
j. for sites that have a corrosion/materials engineer, the corrosion/materials engineer shall be a required participant in the DMHR;
k. the PHA to review the most recent DMHR and IOW reviews in order to contain a complete record of all identified damage mechanism hazards, evaluate existing safeguards, and propose new safeguards to control the identified hazards;
l. the PHA to review the consequence of damage mechanism hazards identified in the risk-based inspection (RBI) program and IOW reviews to ensure effective safeguards are present to control the damage mechanism hazard; and
m. the PHA to use the hierarchy of controls and implement opportunities for inherently safer design to the greatest extent reasonably practicable.
2010-08-I-WA-16
Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15. Status: Closed - Acceptable Action
Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15.
2010-08-I-WA-8
Perform a verification audit at all Washington petroleum refineries to ensure: a. Prevention of HTHA equipment failure and safe operation of the equipment. Audit HTHA prevention and process condition monitoring techniques used at all Washington petroleum refineries. Verify that all affected equipment in use meets the requirements contained in Recommendation 2010-08-I-WA-R10; b. For nonroutine work, a written hazard evaluation is performed by a multidisciplinary team and, where feasible, conducted during the job planning process prior to the day of the job execution. Verify that each facility has an effective written decision-making protocol used to determine when it is necessary to shut a process down to safely perform work or conduct repairs. Ensure the program reflects the guidance in the CCPS Risk Based Process Safety book related to hazardous nonroutine work; and c. Effective programs are in place to control of the number of essential personnel present during all hazardous nonroutine work. Status: Open - Acceptable Response or Alternate Response
Perform a verification audit at all Washington petroleum refineries to ensure:
a. Prevention of HTHA equipment failure and safe operation of the equipment. Audit HTHA prevention and process condition monitoring techniques used at all Washington petroleum refineries. Verify that all affected equipment in use meets the requirements contained in Recommendation 2010-08-I-WA-R10;
b. For nonroutine work, a written hazard evaluation is performed by a multidisciplinary team and, where feasible, conducted during the job planning process prior to the day of the job execution. Verify that each facility has an effective written decision-making protocol used to determine when it is necessary to shut a process down to safely perform work or conduct repairs. Ensure the program reflects the guidance in the CCPS Risk Based Process Safety book related to hazardous nonroutine work; and
c. Effective programs are in place to control of the number of essential personnel present during all hazardous nonroutine work.
2010-08-I-WA-9
Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective actions. Status: Open - Awaiting Response or Evaluation/Approval of Response