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.
2022-01-I-OH-5
Develop a new publication or revise an existing publication, such as API Recommended Practice 556 Instrumentation, Control, and Protective Systems for Gas Fired Heaters, to incorporate the process hazards associated with Fuel Gas Mix Drum overflow. The publication should include the following at a minimum: a) Description of the process hazards associated with Fuel Gas Mix Drum overflow and the consequential impacts on equipment using fuel gas, b) Guidance for Fuel Gas Mix Drum design and sizing criteria which includes consideration of condensation, entrainment, overflow, and draining, c) Guidance for instrumentation to detect high level to prevent overfilling of Fuel Gas Mix Drums, and d) Recommended practices for selecting preventive safeguards to prevent overfilling of Fuel Gas Mix Drums. Status: Open - Awaiting Response or Evaluation/Approval of Response
Develop a new publication or revise an existing publication, such as API Recommended Practice 556 Instrumentation, Control, and Protective Systems for Gas Fired Heaters, to incorporate the process hazards associated with Fuel Gas Mix Drum overflow. The publication should include the following at a minimum:
a) Description of the process hazards associated with Fuel Gas Mix Drum overflow and the consequential impacts on equipment using fuel gas,
b) Guidance for Fuel Gas Mix Drum design and sizing criteria which includes consideration of condensation, entrainment, overflow, and draining,
c) Guidance for instrumentation to detect high level to prevent overfilling of Fuel Gas Mix Drums, and
d) Recommended practices for selecting preventive safeguards to prevent overfilling of Fuel Gas Mix Drums.
2022-01-I-OH-6
Develop a publication that addresses preventing the overflow of pressure vessels such as towers and drums. The publication should be applicable to both new and existing pressure vessels. Include the following at a minimum: a) Description of typical overflow events that could result during normal, upset, or transient operations (startup, shutdown, standby) including the formation of a vapor cloud, b) Recommended practices for instrumentation to monitor and detect a pressure vessel overflow, c) Process hazard analysis guidance for pressure vessel overflow scenarios, d) Recommended practices for safeguards to prevent a pressure vessel overflow, e) Recommended field and board operator process safety training topics and methods to prevent a pressure vessel overflow, f) Guidelines for process safety assessments to prevent a pressure vessel overflow, and g) Incorporate lessons learned from this CSB investigation and the CSB’s BP Texas City Refinery investigation throughout the document. Status: Open - Awaiting Response or Evaluation/Approval of Response
Develop a publication that addresses preventing the overflow of pressure vessels such as towers and drums. The publication should be applicable to both new and existing pressure vessels. Include the following at a minimum:
a) Description of typical overflow events that could result during normal, upset, or transient operations (startup, shutdown, standby) including the formation of a vapor cloud,
b) Recommended practices for instrumentation to monitor and detect a pressure vessel overflow,
c) Process hazard analysis guidance for pressure vessel overflow scenarios,
d) Recommended practices for safeguards to prevent a pressure vessel overflow,
e) Recommended field and board operator process safety training topics and methods to prevent a pressure vessel overflow,
f) Guidelines for process safety assessments to prevent a pressure vessel overflow, and
g) Incorporate lessons learned from this CSB investigation and the CSB’s BP Texas City Refinery investigation throughout the document.
2022-01-I-OH-7
Revise American National Standard ANSI/ISA 18.2-2016, Management of Alarm Systems for the Process Industries, to include performance targets for short-term alarm flood analysis so that users can evaluate alarm flood performance for a single alarm flood event. The performance targets should include: a) number of alarm floods, b) duration of each flood, c) alarm count in each flood, and d) peak alarm rate for each flood. At a minimum, a target peak alarm flood rate should be defined, such as in the guidance provided by the ASM Consortium or Engineering Equipment and Materials Users Association (EEMUA), to establish trigger points that require alarm performance improvement actions. Status: Open - Awaiting Response or Evaluation/Approval of Response
Revise American National Standard ANSI/ISA 18.2-2016, Management of Alarm Systems for the Process Industries, to include performance targets for short-term alarm flood analysis so that users can evaluate alarm flood performance for a single alarm flood event. The performance targets should include:
a) number of alarm floods, b) duration of each flood, c) alarm count in each flood, and d) peak alarm rate for each flood.
At a minimum, a target peak alarm flood rate should be defined, such as in the guidance provided by the ASM Consortium or Engineering Equipment and Materials Users Association (EEMUA), to establish trigger points that require alarm performance improvement actions.
2022-01-I-OH-1
Revise the safeguards used in the refinery’s process hazard analyses high level and overflow scenarios. At a minimum, establish effective preventive safeguards that use engineered controls to prevent liquid overfill and do not rely solely on human intervention. Status: Open - Awaiting Response or Evaluation/Approval of Response
Revise the safeguards used in the refinery’s process hazard analyses high level and overflow scenarios. At a minimum, establish effective preventive safeguards that use engineered controls to prevent liquid overfill and do not rely solely on human intervention.
2022-01-I-OH-2
Revise the Abnormal Situation Management policy to incorporate guidance provided by the ASM Consortium and the Center for Chemical Process Safety (CCPS). The revised policy should include, at a minimum: a) A broader definition of abnormal situations, such as that defined by the CCPS, b) Additional predictable abnormal situations and their associated corrective procedures. At a minimum include the following abnormal situations: 1) unplanned crude slate changes, 2) continued operation of the Crude 1 unit with the naphtha hydrotreater unit shut down, and 3) an emergency pressure-relief valve opening. c) Guidance to determine when an abnormal situation is becoming too difficult to manage and the appropriate actions to take, such as shutting down a process, putting it into a circulation mode, or implementing proper procedures for bringing it to a safe state. Status: Open - Awaiting Response or Evaluation/Approval of Response
Revise the Abnormal Situation Management policy to incorporate guidance provided by the ASM Consortium and the Center for Chemical Process Safety (CCPS). The revised policy should include, at a minimum:
a) A broader definition of abnormal situations, such as that defined by the CCPS,
b) Additional predictable abnormal situations and their associated corrective procedures. At a minimum include the following abnormal situations:
1) unplanned crude slate changes, 2) continued operation of the Crude 1 unit with the naphtha hydrotreater unit shut down, and 3) an emergency pressure-relief valve opening.
c) Guidance to determine when an abnormal situation is becoming too difficult to manage and the appropriate actions to take, such as shutting down a process, putting it into a circulation mode, or implementing proper procedures for bringing it to a safe state.
2022-01-I-OH-3
Develop and implement a policy or revise existing policy that clearly provides employees with the authority to stop work that is perceived to be unsafe until the employer can resolve the matter. This should include detailed procedures and regular training on how employees would exercise their stop work authority. Emphasis should be placed on exercising this authority during abnormal situations, including alarm floods. Status: Open - Awaiting Response or Evaluation/Approval of Response
Develop and implement a policy or revise existing policy that clearly provides employees with the authority to stop work that is perceived to be unsafe until the employer can resolve the matter. This should include detailed procedures and regular training on how employees would exercise their stop work authority. Emphasis should be placed on exercising this authority during abnormal situations, including alarm floods.
2022-01-I-OH-4
Revise the ‘Toledo Alarm Philosophy’ by incorporating the Engineering Equipment and Manufacturers Users Association (EEMUA) guidance for alarm rate following an upset and not limiting alarm performance to a single metric averaged over a month. In addition to including analyzing individual alarm flood events, the revised philosophy document should improve refinery alarm performance to reduce alarm flood duration and peak rate for events similar to the September 20, 2022, incident. Consult EEMUA Publication 191, Chapter 6.5.1, for guidance regarding abnormal condition performance levels. Apply the improved performance levels where applicable, but specifically to the Crude 1 control board alarm performance. Status: Open - Awaiting Response or Evaluation/Approval of Response
Revise the ‘Toledo Alarm Philosophy’ by incorporating the Engineering Equipment and Manufacturers Users Association (EEMUA) guidance for alarm rate following an upset and not limiting alarm performance to a single metric averaged over a month. In addition to including analyzing individual alarm flood events, the revised philosophy document should improve refinery alarm performance to reduce alarm flood duration and peak rate for events similar to the September 20, 2022, incident. Consult EEMUA Publication 191, Chapter 6.5.1, for guidance regarding abnormal condition performance levels. Apply the improved performance levels where applicable, but specifically to the Crude 1 control board alarm performance.