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

Praxair Flammable Gas Cylinder Fire (2 Recommendations)
Compressed Gas Association (CGA) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 15, 2006

2005-5-I-MO-1

Communicate with your members who operate gas repackaging facilities the details of this incident and the best practices for handling and storing cylinders.


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.
 

2005-5-I-MO-2

Revise CGA standards for the CG-7 relief valves used in propylene service to require: 1) a greater margin between vapor pressure and relief valve set point (similar to propane); and 2) that valves be capable of multiple operations within the specified setpoint tolerance or be furnished with an indicator that alerts users that the valve has operated.


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.
 

Pryor Trust Fatal Gas Well Blowout and Fire (19 Recommendations)
American Petroleum Institute (API) (5 Recommendations)
Open: 40% | Closed: 60%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-2

Establish and convene a group of experts with drilling, engineering, and instrumentation expertise to discuss methods to achieve widespread implementation of automatic safety instrumented systems that could bring a well to a safe state in the event other operational barriers fail. Publish a technical bulletin discussing the strategies to implementing Blowout Preventer (BOP) safety instrumented systems.


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

2018-01-I-OK-3

For onshore drilling operations, develop and publish a recommended practice providing guidance on safely tripping drill pipe during (1) overbalanced drilling operations, (2) managed pressure drilling operations, and (3) underbalanced drilling operations. At a minimum, include information on:

(a) Required equipment for tripping operations,

(b) Techniques and procedures for controlling or preventing formation fluid influx, and

(c) Methods to monitor the well and replace the drill pipe displacement volume with drilling fluid (e.g., mud).


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

2018-01-I-OK-4

Develop a recommended practice on alarm management specifically for the drilling industry based on guidance in ANSI/ISA 18.2 Management of Alarm Systems for the Process Industries. The recommended practice will address the unique dynamic environment of the drilling industry and provide guidance on implementing a state-based alarm system for different operating modes (e.g., drilling, circulating, tripping, etc.). Include International Association of Drilling Contractors (IADC) in the development of this recommended practice.


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

2018-01-I-OK-5

Develop a new recommended practice or modify an existing recommended practice (e.g. API RP 54 Recommended Practice for Occupational Safety for Oil and Gas Well Drilling and Servicing Operations) addressing the protection of rig workers on onshore drilling rigs from fire and explosion hazards in the event of a blowout. The recommended practice will specifically address:

(a) Protecting drilling cabin occupants from blowout hazards including heat, blast overpressure, and projectiles, such as requiring an increased fire rating for the driller’s cabin that would allow enough time for occupants to evacuate during a blowout and fire;

(b) Minimum required evacuation methods from the drilling cabin, rig floor, and mast or derrick in the event of a blowout so that personnel can quickly escape in variable hazard location conditions. For example, floor exit hatches and exits on the driller’s cabin wall opposite the rig floor could provide safe evacuation routes during a blowout and fire; and

(c) Proximity of the Blow Out Preventer (BOP) activation controls with the driller.

The above options could be retrofitted on existing drilling rigs. Additionally, formally evaluate alternative locations for the drilling cabin that establishes a safe distance from fire and explosion hazards (e.g., ground level).


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

2018-01-I-OK-6

Update API Bulletin 97 Well Construction Interface Document Guidelines to specify that it applies to both onshore and offshore drilling operations.


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

PDF Document Recommendation Status Change Summary

International Association of Drilling Contractors (IADC) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-14

Participate in development of the recommended practice describe in recommendation 2018-01-OK-R4 to [American Petroleum Institute] API.


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

National Oilwell Varco (NOV) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-17

Design the M/D Totco user interface to allow drilling contractors to pre-set different alarms for different operations (e.g., different alarm configurations for drilling, tripping, circulating, and surface operations in a “state-based” alarm system).


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

2018-01-I-OK-18

Design the M/D Totco electronic drilling data system so that alarm information, including alarm set points, alarm activation log, alarm horn status (on or off), and alarm system status (on or off) is provided to customers.


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

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

Pason Systems Corp. (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-15

Design the Pason user interface to allow drilling contractors to pre-set different alarms for different operations (e.g., different alarm configurations for drilling, tripping, circulating, and surface operations in a “state-based” alarm system).


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

PDF Document Recommendation Status Change Summary

2018-01-I-OK-16

Design the Pason electronic drilling data system so that alarm information, including alarm set points, alarm activation log, alarm horn status (on or off), and alarm system status (on or off) is provided to customers.


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

Patterson-UTI (5 Recommendations)
Open: 20% | Closed: 80%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-7

Develop either corporate or rig-specific tripping procedure(s) that detail the required equipment configuration for tripping operations. Require that rig personnel visually verify that equipment is lined up as specified in the procedure before beginning the tripping operation. In the procedure(s), specify well-monitoring requirements for wet versus dry tripping operations.


Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

PDF Document Recommendation Status Change Summary

2018-01-I-OK-8

Develop an alarm philosophy and alarm rationalization for rig operations. Based on the alarm philosophy and alarm rationalization, specify necessary alarms, at a minimum, for (1) drilling, (2) tripping, (3) circulating, and (4) rig floor activities (no drill pipe in well). Additionally, develop a policy implementing the alarm philosophy and rationalization.


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

PDF Document Recommendation Status Change Summary

2018-01-I-OK-9

Develop a policy that incorporates recommendations in API RP 59 Recommended Practice for Well Control Operations requiring the regular testing of drillers’ influx detection and response skills through formalized drills, for example by “simulat[ing] a gain in pit drilling fluid volume by raising a float sufficiently to cause an alarm to be activated.” In this policy, require that driller response time is monitored in the spirit of continual improvement.


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

2018-01-I-OK-10

Develop and implement a policy requiring that flow checks be documented, either electronically or with a paper record. At a minimum the documentation will require the reporting of:

  1. Operation during which flow check was performed

  2. Method of performing flow check

  3. Length of time flow check was performed

  4. Result of flow check

Require that the proper authorities (e.g., driller, company man, rig manager) sign or approve the flow check documentation after performing the flow check and before resuming operations. Keep the flow check documentation as part of the well file.


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

2018-01-I-OK-11

Update the Patterson metrics program to track leading and lagging indicators to measure the effectiveness of the overall safety management system. Specifically focus on measuring the effectiveness of the following safety management system components:

(a) The effectiveness of the flow check policy, including the frequency that flow checks are performed when required by Patterson policy;

(b) The frequency that flow checks are documented and approved as recommended in 2018-01-OK-R10;

(c) The effectiveness of the management of change program, for both equipment and procedural changes, including real-time procedure changes;

(d) The frequency that alarms are set at the required set points;

(e) The frequency that drilling rig alarm horns or the entire alarm system is turned off; and

(f) The frequency that trip sheets are filled out properly.


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

Red Mountain Operating (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-12

Develop a new policy that a well-specific Well Construction Interface Document be in place before drilling operations begin, as specified in API Bulletin 97 Well Construction Interface Document Guidelines. Ensure the policy requires that the Well Construction Interface Document specifies the technical requirements of the rig equipment and technical qualifications of personnel (e.g., conventional drilling, managed pressure drilling, underbalanced drilling) as well as specifies which barriers must be maintained and the expected response if a barrier is lost.


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.
 

2018-01-I-OK-13

Develop a management of change policy governing real-time changes to operations and the drilling plan. As part of this policy, require hazard analysis and consideration of rig equipment, procedures, and personnel training and qualifications.


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.
 

State of Oklahoma/Oklahoma Corporation Commission (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-19

Establish and implement safety regulations requiring entities who design oil and gas well drilling plans for wells in Oklahoma (e.g., operators) and entities who perform the drilling operation (e.g., drilling contractors) to develop and implement the following prior to conducting drilling operations:

(a) Detailed written operating procedures with specified steps and equipment alignment for all operations;

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

(c) A risk assessment of hazards associated with the drilling plan;

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

(e) 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;

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

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


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Recommendation Status Change Summary

Sierra Chemical Co. High Explosives Accident (16 Recommendations)
Department of Defense (DOD) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 23, 1998

1998-001-I-NV-15

Develop a program to ensure that reclaimed, demilitarized explosives sold by the Department of Defense are free of foreign materials that can present hazards during subsequent manufacturing of explosives.


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.
 

1998-001-I-NV-16

Provide access to explosives incident reports and lessons learned information to managers and workers involved in explosives manufacturing, associations such as IME, government agencies, and safety researchers.


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.
 

Institute of Makers of Explosives (IME) (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 23, 1998

1998-001-I-NV-11

Develop and disseminate process and safety training guidelines for personnel involved in the manufacture of explosives that include methods for the demonstration and maintenance of 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.
 

1998-001-I-NV-12

Distribute the CSB report on the incident at Sierra to IME member companies.


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.
 

1998-001-I-NV-13

Develop safety guidelines for the screening of reclaimed explosive materials.


Status: Closed - Exceeds Recommended Action
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

Nevada Occupational Safety and Health Enforcement Section (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 23, 1998

1998-001-I-NV-14

Increase the frequency of safety inspections of explosives manufacturing facilities due to their potential for catastrophic incidents. (Note: Nevada Governor Bob Miller signed an Executive Order on June 10, 1998, that will require inspections at least twice a year.)


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.
 

Sierra and Explosives Manufacturers (10 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 23, 1998

1998-001-I-NV-1

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - Process hazard analyses include examination of quantity-distance requirements, building, design, human factors, incident reports, and lessons learned from explosives manufacturers.


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).
 

1998-001-I-NV-2

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - Written operating procedures are specific to the process being controlled and address all phases of the operation.


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).
 

1998-001-I-NV-3

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - Procedures, chemical hazards, and process safety information are communicated in the language(s) understood by personnel involved in manufacturing or handling of explosives.


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).
 

1998-001-I-NV-4

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: Explosives training and certification programs for workers and line managers provide and require demonstration of a basic understanding of explosives safety principles and job specific knowledge.


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).
 

1998-001-I-NV-5

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - Process changes, such as the construction or modification of buildings, or changes in explosive ingredients, equipment, or procedures are analyzed and PSM elements are updated to address these changes.


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).
 

1998-001-I-NV-6

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - Pre-startup safety reviews are performed to verify operational readiness when changes are made.


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).
 

1998-001-I-NV-7

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - All elements of OSHA's Process Safety Management Standard are verified by performing periodic assessments and audits of safety programs.


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).
 

1998-001-I-NV-8

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - The employee participation program effectively includes workers and resolves their safety issues.


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).
 

1998-001-I-NV-9

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - Explosives safety programs provide an understanding of the hazards and control of detonation sources. These include: · foreign objects in raw materials; · use of substitute raw materials; · specific handling requirements for raw materials; · impact by tools or equipment; · impingement; · friction; · sparking; and · static discharge.


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).
 

1998-001-I-NV-10

Explosives manufacturers should evaluate the effectiveness of their explosives safety programs using the following recommendations (numbered for identification) to ensure that: - The following issues are addressed in plant design or modification: · Operations in explosives manufacturing plants are separated by adequate intraplant distances to reduce the risk of propagation. · Unrelated chemical or industrial operations or facilities are separated from explosives facilities using quantity-distance guidelines. · Facilities are designed to reduce secondary fragmentation that could result in the propagation of explosions.


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).