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

Morton International Inc. Runaway Chemical Reaction (15 Recommendations)
American Chemistry Council (ACC) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 16, 2000

1998-06-I-NJ-10

Communicate the findings of this report to your membership.


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.
 

Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 16, 2000

1998-06-I-NJ-10

Communicate the findings of this report to your membership.


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.
 

Environmental Protection Agency (EPA) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 16, 2000

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.
 

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.
 

Morton International Inc.- Patterson, NJ Plant (6 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 16, 2000

1998-06-I-NJ-2

Revalidate Process Hazard Analyses for all reactive chemical processes in light of the findings of the U.S. Chemical Safety and Hazard Investigation Board (CSB) report and upgrade, as needed, equipment, operating procedures, and training.


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-3

Evaluate pressure relief requirements for all reaction vessels using appropriate technology, such as the Design Institute for Emergency Relief Systems (DIERS)50 method and test apparatus and upgrade equipment as needed.


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).
 

1998-06-I-NJ-4

Evaluate the need for and install, as necessary, devices, such as alarms, added safety instrumentation, and quench or reactor dump systems to safely manage reactive chemical process hazards.


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-5

Revise operating procedures and training for reactive chemical processes as needed, to include descriptions of the possible consequences of deviations from normal operational limits and steps that should be taken to correct these deviations, including emergency response actions.


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-6

Implement a program to ensure that deviations from normal operational limits for reactive chemical processes that could have resulted in significant incidents are documented and investigated and necessary safety improvements are implemented.


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-7

Revise the Yellow 96 Material Safety Data Sheet (MSDS) to show the proper boiling point and National Fire Protection Association reactivity rating. Evaluate the need for and change, as necessary, the MSDSs for other Morton dyes. Communicate the MSDS changes to current and past customers (who may retain inventories of these products).


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.
 

Morton International, Inc. (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 16, 2000

1998-06-I-NJ-1

Establish a program that ensures that reactive chemical process safety information and operating experience are collected and shared with all relevant units of the company.


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.
 

Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
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.
 

Paper, Allied-Industrial, Chemical and Energy Workers International Union (PACE) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 16, 2000

1998-06-I-NJ-10

Communicate the findings of this report to your membership.


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.
 

Synthetic Organic Chemical Manufacturers Association (SOCMA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 16, 2000

1998-06-I-NJ-10

Communicate the findings of this report to your membership.


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 (19 Recommendations)
American Petroleum Institute (API) (4 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 28, 2002

2001-05-I-DE-10

Work with NACE International (National Association of Corrosion Engineers) to develop API guidelines to inspect storage tanks containing fresh or spent H2SO4 at frequencies at least as often as those recommended in the latest edition of NACE Standard RP 0294-94, Design, Fabrication, and Inspection of Tanks for the Storage of Concentrated Sulfuric Acid and Oleum at Ambient Temperatures.


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

2001-05-I-DE-11

Revise API tank inspection standards to emphasize that storage tanks with wall or roof holes or thinning beyond minimum acceptable thickness that may contain a flammable vapor are an imminent hazard and require immediate repair or removal from service.


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.
 

2001-05-I-DE-12

Ensure that API recommended practices address the inerting of flammable storage tanks, such as spent H2SO4 tanks. Include the following: - Circumstances when inerting is recommended. - Design of inerting systems, such as proper sizing of inerting equipment, appropriate inerting medium, and instrumentation, including alarms.


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

2001-05-I-DE-13

Communicate the findings and recommendations of this report to your membership.


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.
 

Building and Construction Trades Department, AFL-CIO (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 28, 2002

2001-05-I-DE-19

Communicate the findings and recommendations of this report to your membership.


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.
 

Delaware Department of Natural Resources and Environmental Control (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 28, 2002

2001-05-I-DE-2

Ensure that regulations developed for the recently enacted Jeffrey Davis Above ground Storage Tank Act require that facility management take prompt action in response to evidence of tank corrosion that presents hazards to people or the environment.


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 LLC (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 28, 2002

2001-05-I-DE-8

In light of the findings of this report, conduct periodic audits of storage tank mechanical integrity and design, Unsafe Condition Reports, hot work, management of change, and accountability systems at Motiva oil refineries. Ensure that the audit recommendations are tracked and implemented. Share the findings with the workforce.


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 Summary Change

2001-05-I-DE-9

Communicate the findings and recommendations of this report to the workforce and contractors at all Motiva refineries.


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- Delaware City Refinery (5 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 28, 2002

2001-05-I-DE-3

Implement a system to ensure accountability for mechanical integrity decision making. Include the following specific items: - Review of inspection reports by subject area experts, such as metallurgists or equipment design engineers, to ensure adequate analysis of failure trends and suitability for intended service. - Establishment of a planning system to ensure the timely repair of equipment. The Center for Chemical Process Safety (CCPS) publication, Plant Guidelines for Technical Management of Chemical Process Safety, Chapter 3, ?Accountability Objectives and Goals,? presents a model for such a 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.
 

2001-05-I-DE-4

Review the design of existing tankage that contains or has the potential to contain flammables to ensure that, at a minimum:: - Inerting systems are installed where appropriate and are adequately sized and constructed. - Emergency venting is provided.


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.
 

2001-05-I-DE-5

Ensure that management of change reviews are conducted for changes to tank equipment and operating conditions, such as: - Tank service and contents - Tank peripherals, such as inerting and venting 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.
 

2001-05-I-DE-6

Revise the refinery hot work program to address the circumstances that require use of continuous or periodic monitoring for flammables.


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.
 

2001-05-I-DE-7

Upgrade the refinery Unsafe Condition Report system to include the following: - Designation of a specific manager with decision-making authority to resolve issues. - Establishment of a mechanism to elevate attention to higher levels of management if issues are not resolved in a timely manner. - Identification of a means to ensure communication of hazards to all potentially affected personnel. - Work with the Paper, Allied-Industrial, Chemical & Energy Workers International Union (PACE) Local 2-898 to design and implement the improved 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.
 

National Association of Corrosion Engineers (NACE) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 28, 2002

2001-05-I-DE-14

Work with the American Petroleum Institute to develop API guidelines to ensure that storage tanks containing fresh or spent H2SO4 are inspected at frequencies at least as often as those recommended in the latest edition of NACE Standard RP 0294- 94, Design, Fabrication, and Inspection of Tanks for the Storage of Concentrated Sulfuric Acid and Oleum at Ambient Temperatures.


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.
 

2001-05-I-DE-15

Communicate the findings and recommendations of this report to your membership.


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.
 

National Petrochemical and Refiners Association (NPRA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 28, 2002

2001-05-I-DE-18

Communicate the findings and recommendations of this report to your membership.


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.
 

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

Paper, Allied-Industrial, Chemical and Energy Workers International Union (PACE) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 28, 2002

2001-05-I-DE-16

Work with Motiva management on the design and implementation of an improved Unsafe Condition Report program.


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.
 

2001-05-I-DE-17

Communicate the findings and recommendations of this report to your membership.


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.
 

NDK Crystal Inc. Explosion with Offsite Fatality (8 Recommendations)
American Society of Mechanical Engineers (ASME) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: November 14, 2013

2010-04-I-IL-1

Revise the ASME Boiler and Pressure Vessel Code to include specific material thickness limitations for the design of pressure-containing components to ensure proper heat treatment and avoid environmentally induced damage mechanisms. Clarify required vessel wall thickness limitations for SA-723 steel in the following code sections:
a) ASME BPVC Section II, Part A, Material Requirements
b) ASME BPVC Section VIII, Division III, Article KM-400, Material Design Data


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

PDF Document Recommendation Status Change Summary

Illinois Office of the State Fire Marshal, Boiler & Pressure Vessel Safety Division (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: November 14, 2013

2010-4-I-IL-3

Prohibit the use of the existing pressure vessels at the NDK facility for crystal growing 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

2010-4-I-IL-4

Develop and implement state requirements and procedures to ensure the pressure vessel approval process accurately identifies vessels that may be subject to corrosion or similar deterioration mechanisms, and ensure regular inspections in accordance with these state requirements.


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

National Board of Boiler and Pressure Vessel Inspectors (NBBI) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: November 14, 2013

2010-4-I-IL-2

Communicate the findings of this Case Study to pressure vessel inspectors in all 50 states. At a minimum:

a. Send the information (such as an article summarizing the investigation) to each member who is a pressure vessel inspector; and,

b. Post a direct link to the NDK Case Study on the National Board’s webpage.


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

NDK Crystal, Inc. (4 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: November 14, 2013

2010-4-I-IL-5

For the design and operation of any new NDK Crystal facility using a hydrothermal or equivalent crystal growing process, ensure that the facility uses a process that is rigorously demonstrated to be inherently safer than the existing process (for example through using lower temperatures and pressures, and/or less corrosive conditions).


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).
 

PDF Document Recommendations Status Change Summary

2010-4-I-IL-6

Implement a program to ensure the ongoing integrity of any coating used on the new process vessels. Employ an expert (e.g., a coatings expert certified by NACE International (National Association of Corrosion Engineers)) to design the program.


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).
 

PDF Document Recommendations Status Change Summary

2010-4-I-IL-7

Implement an annual inspection and corrective action program to ensure vessels remain resistant to environmentally induced damage mechanisms based on the inspection guidelines set forth in the American Petroleum Institute (API) Standard 510, Pressure Vessel Inspection Code.


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).
 

PDF Document Recommendations Status Change Summary

2010-4-I-IL-8

Commission a facility siting study of the NDK Crystal facility by an independent consultant. Identify all vessel failure scenarios prior to restarting the crystal growing process. The siting study should include the consequences, necessary preventive measures, and emergency planning and response programs relevant to each failure scenario for all surrounding points of concern. Provide a copy of this study to the City of Belvidere Building and Zoning Department and the Illinois Boiler and Pressure Vessel Safety Division.


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).
 

PDF Document Recommendations Status Change Summary

Oil Tank Safety Study (6 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 27, 2011

2011-H-1-5

Create a new standard or amend existing standards covering exploration and production facilities to:

a) Warn that storage tanks at unmanned facilities may be subject to tampering or introduction of ignition sources by members of the public, which could result in a tank explosion or other accidental release to the environment.

b) Recommend the use inherently safer storage tank design features to reduce the likelihood of explosions, including restrictions on the use of open vents for flammable hydrocarbons, flame arrestors, pressure vacuum vent valves, floating roofs, vapor recovery systems or an equivalent alternative.

c) Require security measures at least as protective as API 2610 to prevent non-employee access to flammable storage tanks at upstream E&P sites, including such measures as a full fence surrounding the tank(s) with a locked gate, hatch locks on tank manways, and barriers securely attached to tank external ladders or stairways.

d) Require that hazard signs or placards be displayed on or near tanks to identify the fire and explosion hazards using words and symbols recognizable by the general public.

e) Recommend that new or revised mineral leasing agreements include security and signage requirements as described above.


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

Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 27, 2011

2011-H-1-1

Publish a safety alert directed to owners and operators of exploration and production facilities with flammable storage tanks, advising them of their general duty clause responsibilities for accident prevention under the Clean Air Act. At a minimum, the safety alert should:

a. Warn that storage tanks at unmanned facilities may be subject to tampering or introduction of ignition sources by members of the public, which could result in a tank explosion or other accidental release to the environment

b. Recommend the use of inherently safer storage tank design features to reduce the likelihood of explosions, including restrictions on the use of open vents for flammable hydrocarbons, flame arrestors, pressure vacuum vent valves, floating roofs, vapor recovery systems or an equivalent alternative.

c. Describe sufficient security measures to prevent non-employee access to flammable storage tanks, including such measures as a full fence surrounding the tank with locked gate, hatch locks on tank manways, and barriers securely attached to tank external ladders or stairways

d. Recommend that hazard signs or placards be displayed on or near tanks to identify the fire and
explosion hazards using words and symbols recognizable by the general public


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

Mississippi State Oil & Gas Board (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 27, 2011

2011-H-1-2

Amend state oil and gas regulations to require the use of inherently safer tank design features such as flame arrestors, pressure vacuum vents, floating roofs, vapor recovery systems or an equivalent alternative, to prevent the ignition of a flammable atmosphere inside the tank.


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.
 

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 27, 2011

2011-H-1-6

Amend NFPA 30, “Storage of Liquids in Tanks—Requirements for all Storage Tanks” as follows:
a) Remove the term “isolated” from the current wording of the standard and replace it with a more descriptive term, such as “normally unoccupied”

a) Remove the words “Where necessary” from Security for Unsupervised Storage Tanks, Chapter 21.7.2.2.

b) Add a reference to a relevant security standard that offers specifications on fencing, locks and other site security measures.

c) Add a definition of security encompassing requirements such as fencing, locked gates, hatch locks,and barriers.


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

PDF Document Recommendation Status Change Summary

State of Oklahoma/Oklahoma Corporation Commission (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 27, 2011

2011-H-1-3

Amend state oil and gas regulations to:

a) Protect storage tanks at exploration and production sites from public access by requiring sufficient security measures, such as full fencing with a locked gate, hatch locks on tank manways, and barriers securely attached to tank external ladders and stairways.

b) Require hazards signs or placards on or near tanks that identify the fire and explosion hazards using words and symbols recognizable by the general public.

c) Require the use of inherently safer tank design features such as flame arrestors, pressure vacuum vents, floating roofs, vapor recovery systems or an equivalent alternative, to prevent the ignition of a flammable atmosphere inside the tank.


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

Texas Railroad Commission (RRC) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: October 27, 2011

2011-H-1-4

Amend state oil and gas regulations to:

a) Protect storage tanks at exploration and production sites from public access by requiring sufficient security measures, such as full fencing with a locked gate, hatch locks on tank manways, and barriers securely attached to tank external ladders and stairways.

b) Require hazards signs or placards on or near tanks that identify the fire and explosion hazards using words and symbols recognizable to the general public.

c) Require the use of inherently safer tank design features such as flame arrestors, pressure vacuum vents, floating roofs, vapor recovery systems or an equivalent alternative to prevent the ignition of a flammable atmosphere inside the tank.


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

Optima Belle Explosion and Fire (15 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-15

Update Guidelines for Process Safety in Outsourced Manufacturing Operations or develop a new tolling guidance document to supplement existing guidelines. The publication should include current best practices, introduce guidance specific to tolling brokers and/or project managing companies such as Richman Chemical Inc., and cross-reference and align with the comprehensive management systems framework and terminology contained in Guidelines for Risk Based Process Safety and other contemporary industry good practice guidance.


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

Clearon Corporation (5 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-5

Develop and implement a comprehensive process knowledge management program or evaluate and revise existing process safety management procedures to ensure consistency with industry guidance publications such as the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety. The program should:

a) assign specific responsibilities for compiling content and maintaining robust process technology and safety information packages that incorporate relevant knowledge for all hazardous processes and substances operated, manufactured, and/or handled by Clearon Corporation;

b) ensure that key process personnel are aware of critical reactive chemistry information, including thermal stability and calorimetry data, chemical compatibility information, and descriptions of any past reactive incidents and safety studies involving the materials; and

c) define procedures for the transmittal of such information to toll manufacturers.


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

2021-02-I-WV-6

Update the sodium dichloroisocyanurate dihydrate (CDB-56®) safety data sheet. At a minimum, the document should:

a) provide the underlying reasoning for the storage temperature maximum and the consequences of exceeding that temperature;

b) provide the underlying reasoning for the decomposition temperature and the consequences of exceeding that temperature;

c) explain or make clear the reason(s) for and/or the circumstance(s) resulting in the differences between the decomposition temperature and the lowest temperature at which self-accelerating decomposition may occur; and

d) provide the exothermic decomposition energy in the Physical Properties section.


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

2021-02-I-WV-7

Develop and implement a written program for tolling process design and equipment selection using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety to ensure that:

a) equipment design basis is adequate for any new tolling process or product; and

b) safeguards and ancillary equipment are considered and adequately designed, installed, and function as designed and required.


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

2021-02-I-WV-8

Develop and implement a formalized program for the development of toll manufacturing agreements using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety. Ensure that the program provides for the following:

a) Identification of roles and responsibilities of all parties, including the client, toller, and any third-party technical service providers, for all phases of a proposed arrangement;

b) Evaluation of equipment requirements/specifications to ensure that they are adequate for the intended operation; and

c) Participation by all parties in tolling process development, including process hazards analysis and emergency planning, and appropriate stages of the pre-planning, pre-startup, and production phases.


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

2021-02-I-WV-9

Develop and implement a process safety management system consistent with industry guidance publications such as is contained in the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety. At a minimum, the process safety management system should address hazard identification, risk analysis, and management of risk.


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

National Center for Biotechnology Information (NCBI) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-14

Update the safety information in PubChem for sodium dichloroisocyanurate (NaDCC) dihydrate, to include publicly available reactivity and decomposition information including but not limited to the Self Accelerating Decomposition Temperature (SADT), the explosion hazard when heating metal containers containing NaDCC dihydrate, and the Differential Scanning Calorimetry (DSC) and Accelerating Rate Calorimetry (ARC) results presented in this report. When compiling this information, review sources including the Registration, Evaluation, Authorization, and Restriction of Chemicals Regulation (REACH) dossier and other publications.


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) (3 Recommendations)
Open: 100% | Closed: 0%
View Investigation
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

Optima Belle LLC (4 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-1

Develop and implement a written thermal and reactive hazards evaluation and management program. The program should adhere to industry guidance provided in publications such as the Center for Chemical Process Safety’s Essential Practices for Managing Chemical Reactivity Hazards. At a minimum, the program should identify the process that Optima Belle will use to manage chemical reactivity hazards, resources for collecting and assessing reactivity hazards, steps for determining how and when to test for chemical reactivity, documentation requirements, and training.


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

2021-02-I-WV-2

Develop and implement a written program for tolling process design and equipment selection using guidance from the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety and Guidelines for Process Safety in Outsourced Manufacturing Operations to ensure that:

a) equipment design basis is adequate for any new tolling process or product;

b) safeguards and ancillary equipment are considered and adequately designed, installed, and function as designed and required; and

c) new processes are evaluated for potential process hazards at the laboratory and/or pilot scale before production scale.

This written program should incorporate the information developed in Optima Belle’s thermal and reactive hazards evaluation program (see CSB recommendation 2021-02-I-WV-R1) to ensure that chemical hazards are fully understood and controlled.

 


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

2021-02-I-WV-3

Develop and implement a formalized program for the development of toll manufacturing agreements using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety. Ensure that the program provides for the following:

a) Identification of roles and responsibilities of all parties, including the client, toller, and any third-party technical service providers, for all phases of a proposed arrangement; 

b) Evaluation of equipment requirements/specifications to ensure that they are adequate for intended operation; and

c) Participation by all parties in the tolling process development, including process hazards analysis and emergency planning, and appropriate stages of the pre-planning, pre-startup, and production phases.


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

2021-02-I-WV-4

Develop and implement a process safety management system consistent with industry guidance publications such as is contained in the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety. At a minimum, the process safety management system should address hazard identification, risk analysis, and management of risk.


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

Richman Chemical Inc. (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 06, 2023

2021-02-I-WV-10

Develop and implement a formalized program for the development of toll manufacturing agreements using resources such as the Center for Chemical Process Safety’s Guidelines for Process Safety in Outsourced Manufacturing Operations and Guidelines for Risk Based Process Safety. Ensure that the program provides for the following:

a) Identification of roles and responsibilities of all parties, including the client, toller, and any third-party technical service providers, for all phases of a proposed arrangement; and

b) Participation by all parties in tolling process development, including process hazards analysis and emergency planning, and appropriate stages of the pre-planning, pre-startup, and production phases.


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

Packaging Corporation of America Hot Work Explosion (1 Recommendations)
Packaging Corporation of America (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: April 24, 2018

2017-03-I-LA-1

Apply the CSB safety guidance to PCA pulp and paper mills that produce NCG and operate NCG systems, which includes all foul condensate tanks. For these NCG systems:

  • Apply effective process safety management elements using good practice guidance, such as CCPS Guidelines for Risk Based Process Safety, and Guidelines for Implementing Process Safety Management;
  • Consider further expanding process safety management program boundaries beyond the minimum legal requirements to provide heightened coverage of process safety hazards;
  • Apply NFPA 69, Standard on Explosion Prevention Systems, to provide effective explosion prevention;
  • Where explosions cannot be prevented in accordance with NFPA 69, apply NFPA 68, Standard on Explosion Protection by Deflagration Venting, to provide explosion protection;
  • Ensure safety instrumented systems (safety interlocks) achieve desired risk reduction by applying the life-cycle approach provided in ISA-84, Functional Safety: Safety Instrumented Systems for the Process Industry Sector;
  • Apply TIP 0416-09, Collection and burning of concentrated noncondensible gases: regulations, design and operation, for effective NCG system design and operation;
  • Provide workers with periodic training to ensure they have an understanding of all process safety hazards applicable to areas of their responsibility and job tasks, including the safety conditions needed to permit hot work.

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