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.
2016-02-I-MS-1
Develop a new informational product or incorporate into the next revision of Brazed Aluminum Plate-Fin Heat Exchangers for General Refinery Services 1st ed.; ANSI/API Standard 668 (formerly Standard 662, Part 2), guidance focused on the safe operation, maintenance, and repair of brazed aluminum heat exchangers (BAHX) to advance understanding of thermal fatigue hazards and how to mitigate them. At a minimum the informational product/incorporated material must include: a. Information on the potential for both minor leaks and catastrophic failure as a result of accumulated thermal fatigue (beyond a single cyclic thermal shock event); b. Clarification on the optimal placement of BAHX temperature and pressure sensors to effectively monitor the operating conditions for the potential impact of accumulated thermal fatigue on BAHX, including temperature rates of change; and c. Clarification on the need to safely vent layers that have been blocked off as part of the repair process for interpass leaks in all BAHX configurations, as well as information describing the consequences when safe venting does not occur. d. Should applicable data from CSB Recommendation No. 2016-02-I-MS-R4 (R4) be available prior to finalizing the requirements of this recommendation, then the data from R4 will be considered for inclusion and/or incorporation by reference in the product required by this recommendation. If the decision is made not to include/incorporate by reference the data from R4, then a detailed explanation for the exclusion will be provided. Status: Closed - Acceptable Action
Develop a new informational product or incorporate into the next revision of Brazed Aluminum Plate-Fin Heat Exchangers for General Refinery Services 1st ed.; ANSI/API Standard 668 (formerly Standard 662, Part 2), guidance focused on the safe operation, maintenance, and repair of brazed aluminum heat exchangers (BAHX) to advance understanding of thermal fatigue hazards and how to mitigate them. At a minimum the informational product/incorporated material must include:
a. Information on the potential for both minor leaks and catastrophic failure as a result of accumulated thermal fatigue (beyond a single cyclic thermal shock event);
b. Clarification on the optimal placement of BAHX temperature and pressure sensors to effectively monitor the operating conditions for the potential impact of accumulated thermal fatigue on BAHX, including temperature rates of change; and
c. Clarification on the need to safely vent layers that have been blocked off as part of the repair process for interpass leaks in all BAHX configurations, as well as information describing the consequences when safe venting does not occur.
d. Should applicable data from CSB Recommendation No. 2016-02-I-MS-R4 (R4) be available prior to finalizing the requirements of this recommendation, then the data from R4 will be considered for inclusion and/or incorporation by reference in the product required by this recommendation. If the decision is made not to include/incorporate by reference the data from R4, then a detailed explanation for the exclusion will be provided.
2016-02-I-MS-2
Revise GPA Technical Bulletin: Brazed Aluminum Heat Exchangers, or develop a new bulletin, to incorporate the significant lessons learned from this incident, including but not limited to: a. information on the potential of both minor leaks and catastrophic failure as a result of thermal fatigue; b. clarification on the optimal placement of BAHX temperature and pressure sensors to better monitor operating conditions, including temperature rates of change; and c. clarification on the need to safely vent layers that have been blocked off after interpass leak repairs, in all BAHX configurations. Status: Closed - Acceptable Action
Revise GPA Technical Bulletin: Brazed Aluminum Heat Exchangers, or develop a new bulletin, to incorporate the significant lessons learned from this incident, including but not limited to:
a. information on the potential of both minor leaks and catastrophic failure as a result of thermal fatigue;
b. clarification on the optimal placement of BAHX temperature and pressure sensors to better monitor operating conditions, including temperature rates of change; and
c. clarification on the need to safely vent layers that have been blocked off after interpass leak repairs, in all BAHX configurations.
2016-02-I-MS-3
Develop a database for operators to submit BAHX operational data for collaborative industry learning and analysis. Encourage your members to submit pressure and temperature data associated with the entire service life of brazed aluminum heat exchangers as well as the date(s) of leak(s) or failure(s) for each exchanger on which data is being submitted. At a minimum this system should: a. provide a way to anonymously input data into the database; b. specify the time interval between measurements such that data can be normalized across different exchangers; and c. capture the type of service in which the exchanger was operating. Status: Closed - Reconsidered/Superseded
Develop a database for operators to submit BAHX operational data for collaborative industry learning and analysis. Encourage your members to submit pressure and temperature data associated with the entire service life of brazed aluminum heat exchangers as well as the date(s) of leak(s) or failure(s) for each exchanger on which data is being submitted. At a minimum this system should:
a. provide a way to anonymously input data into the database;
b. specify the time interval between measurements such that data can be normalized across different exchangers; and
c. capture the type of service in which the exchanger was operating.
2016-02-I-MS-4
Using available operational process data of BAHXs in midstream gas plant operation collected in fulfillment of 2016-02-I-MS-R3, continue data analysis efforts to determine what, if any, correlation exists between operational process data and the frequency or timing of thermal fatigue-generated cracking to more accurately predict the service life of a BAHX. Should predictors be identified, develop and offer to your members industry tools, techniques, or criteria for estimating when thermal fatigue warrants preemptive replacement of a BAHX (e.g., risk assessment tools or damage rate calculations). Status: Closed - No Longer Applicable
Using available operational process data of BAHXs in midstream gas plant operation collected in fulfillment of 2016-02-I-MS-R3, continue data analysis efforts to determine what, if any, correlation exists between operational process data and the frequency or timing of thermal fatigue-generated cracking to more accurately predict the service life of a BAHX.
Should predictors be identified, develop and offer to your members industry tools, techniques, or criteria for estimating when thermal fatigue warrants preemptive replacement of a BAHX (e.g., risk assessment tools or damage rate calculations).
2016-02-I-MS-5
Work with members (industry, emergency response, community) to explicitly define the communication methods for community notification and incident updates (e.g., social media, local news outlets, passive phone system), and the expectations for their use, so that members of the public can efficiently and effectively obtain current safety information. Publish these defined community notification methods and expectations for use on the most appropriate mediums available, such as the Jackson County Emergency Management website, the Jackson County LEPC website, and the social media outlets Jackson County utilizes to disseminate safety information to the community. Status: Closed - Acceptable Action
Work with members (industry, emergency response, community) to explicitly define the communication methods for community notification and incident updates (e.g., social media, local news outlets, passive phone system), and the expectations for their use, so that members of the public can efficiently and effectively obtain current safety information. Publish these defined community notification methods and expectations for use on the most appropriate mediums available, such as the Jackson County Emergency Management website, the Jackson County LEPC website, and the social media outlets Jackson County utilizes to disseminate safety information to the community.