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.
2003-01-I-MS-10
Amend the Technical Specifications guidelines in the Responsible Care Management System to explicitly require facilities to identify findings and lessons learned from process hazard analyses and incident investigations in one unit and apply them to other equipment that processes similar material. Status: Closed - Acceptable Action
Amend the Technical Specifications guidelines in the Responsible Care Management System to explicitly require facilities to identify findings and lessons learned from process hazard analyses and incident investigations in one unit and apply them to other equipment that processes similar material.
2003-01-I-MS-11
Ensure that ACC members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility process safety programs. Status: Closed - Acceptable Action
Ensure that ACC members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility process safety programs.
2003-01-I-MS-12
Communicate the findings of this report to your membership. Status: Closed - Acceptable Action
Communicate the findings of this report to your membership.
2003-01-I-MS-2
Establish a program for conducting process hazard analyses of processes involving reactive materials. Status: Closed - Acceptable Action
Establish a program for conducting process hazard analyses of processes involving reactive materials.
2003-01-I-MS-3
Evaluate the need for layers of protection and install appropriate safeguards, such as alarms and interlocks, to reduce the likelihood of a runaway reaction and catastrophic release of material. Status: Closed - Acceptable Action
Evaluate the need for layers of protection and install appropriate safeguards, such as alarms and interlocks, to reduce the likelihood of a runaway reaction and catastrophic release of material.
2003-01-I-MS-4
Review and revise as necessary procedures for units that process highly energetic material, effectively communicate the updated procedures, and train workers appropriately. Revised procedures should include: Specific steps for isolation of energy sources. Warnings and cautions concerning process chemicals and consequences of deviations from operating limits. Critical operating limits and guidance when the limits are exceeded. Instruction on how to perform a shutdown for all foreseeable causes, to ensure proper isolation, and to continue monitoring critical parameters (such as temperature) while the column is shut down; in addition, review conditions under which material must be deinventoried (such as during extended shutdowns). Status: Closed - Acceptable Action
Review and revise as necessary procedures for units that process highly energetic material, effectively communicate the updated procedures, and train workers appropriately. Revised procedures should include: Specific steps for isolation of energy sources. Warnings and cautions concerning process chemicals and consequences of deviations from operating limits. Critical operating limits and guidance when the limits are exceeded. Instruction on how to perform a shutdown for all foreseeable causes, to ensure proper isolation, and to continue monitoring critical parameters (such as temperature) while the column is shut down; in addition, review conditions under which material must be deinventoried (such as during extended shutdowns).
2003-01-I-MS-5
Conduct a facility-wide survey of pressure vessels to ensure that all equipment that processes reactive materials has appropriate overpressure protection. Status: Closed - Acceptable Action
Conduct a facility-wide survey of pressure vessels to ensure that all equipment that processes reactive materials has appropriate overpressure protection.
2003-01-I-MS-6
Identify equipment critical to safe operation of processes containing reactive materials. Upgrade the maintenance program and establish inspection schedules to ensure the integrity of such equipment. Status: Closed - Acceptable Action
Identify equipment critical to safe operation of processes containing reactive materials. Upgrade the maintenance program and establish inspection schedules to ensure the integrity of such equipment.
2003-01-I-MS-7
Survey and take appropriate action to ensure that buildings occupied by plant personnel are of adequate construction and are located so as to protect people inside in the event of an explosion in equipment processing reactive materials. Status: Closed - Acceptable Action
Survey and take appropriate action to ensure that buildings occupied by plant personnel are of adequate construction and are located so as to protect people inside in the event of an explosion in equipment processing reactive materials.
2003-01-I-MS-1
Conduct audits to ensure that the First Chemical Pascagoula facility addresses the issues detailed below. Communicate results of these audits to the workforce. Status: Closed - Acceptable Action
Conduct audits to ensure that the First Chemical Pascagoula facility addresses the issues detailed below. Communicate results of these audits to the workforce.
2003-01-I-MS-8
Update the community notification system to: Immediately alert residents in the Moss Point community when an incident occurs that could affect their health and safety. Determine when a community response should be initiated. Communicate the nature of the incident and the appropriate response by residents. Alert residents when the incident is over (i.e., the all-clear has sounded). Status: Closed - Acceptable Action
Update the community notification system to: Immediately alert residents in the Moss Point community when an incident occurs that could affect their health and safety. Determine when a community response should be initiated. Communicate the nature of the incident and the appropriate response by residents. Alert residents when the incident is over (i.e., the all-clear has sounded).
2003-01-I-MS-9
Conduct an awareness campaign to educate residents on the proper steps for a shelter-in-place and orderly evacuation. Status: Closed - Acceptable Action
Conduct an awareness campaign to educate residents on the proper steps for a shelter-in-place and orderly evacuation.
2003-01-I-MS-13
Amend the Technical Specifications in the Responsible Care Management System to explicitly require facilities to identify findings and lessons learned from process hazard analyses and incident investigations in one unit and apply them to other equipment that processes similar material. Status: Closed - No Longer Applicable
Amend the Technical Specifications in the Responsible Care Management System to explicitly require facilities to identify findings and lessons learned from process hazard analyses and incident investigations in one unit and apply them to other equipment that processes similar material.
2003-01-I-MS-14
Ensure that SOCMA members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility process safety programs. Status: Closed - No Longer Applicable
Ensure that SOCMA members understand the audit requirements of Responsible Care and accurately identify and address gaps in facility process safety programs.
2003-01-I-MS-15
2006-1-I-TX-6
Incorporate guidance for vehicular traffic protection and remote equipment isolation into the next revision of the Center for Chemical Process Safety?s Guidelines for Hazard Evaluation Procedures. Status: Closed - Acceptable Action
Incorporate guidance for vehicular traffic protection and remote equipment isolation into the next revision of the Center for Chemical Process Safety?s Guidelines for Hazard Evaluation Procedures.
2006-1-I-TX-1
Revise policies and procedures for process hazard analysis and pre-startup safety review to more fully evaluate vehicle impact hazards, passive fire protection, and catastrophic releases. Status: Closed - Acceptable Action
Revise policies and procedures for process hazard analysis and pre-startup safety review to more fully evaluate vehicle impact hazards, passive fire protection, and catastrophic releases.
2006-1-I-TX-2
Require flame resistant clothing for workers in units at the Point Comfort complex where there is a risk of flash fires. Status: Closed - Acceptable Action
Require flame resistant clothing for workers in units at the Point Comfort complex where there is a risk of flash fires.
2006-1-I-TX-3
Communicate the findings and recommendations of this report to all companies that contracted with either M. W. Kellogg or Kellogg, Brown, and Root (KBR) for plant designs similar to the Formosa Olefins II unit. Status: Closed - Exceeds Recommended Action
Communicate the findings and recommendations of this report to all companies that contracted with either M. W. Kellogg or Kellogg, Brown, and Root (KBR) for plant designs similar to the Formosa Olefins II unit.
2006-1-I-TX-4
Communicate the findings and recommendations of this report to your petrochemical process plant design engineers. Emphasize the importance of using current consensus safety standards when designing and constructing petrochemical process plants, including the earlier designs reused for new facilities. Status: Closed - Exceeds Recommended Action
Communicate the findings and recommendations of this report to your petrochemical process plant design engineers. Emphasize the importance of using current consensus safety standards when designing and constructing petrochemical process plants, including the earlier designs reused for new facilities.
2006-1-I-TX-5
Revise KBR petrochemical process plant design procedures to ensure they address the use of current safety standards for new designs and earlier designs reused for new facilities. Status: Closed - Acceptable Action
Revise KBR petrochemical process plant design procedures to ensure they address the use of current safety standards for new designs and earlier designs reused for new facilities.
2004-10-I-IL-8
Develop guidelines for auditing chemical process safety at newly acquired facilities. Emphasize the identification of major hazards, a review of the acquired facility's previous incident history and hazard analyses, the adequacy of management safety systems, and harmonization of the acquired facility's standards and practices with those of the acquiring company. Status: Closed - Acceptable Action
Develop guidelines for auditing chemical process safety at newly acquired facilities. Emphasize the identification of major hazards, a review of the acquired facility's previous incident history and hazard analyses, the adequacy of management safety systems, and harmonization of the acquired facility's standards and practices with those of the acquiring company.
2004-10-I-IL-7
Ensure that the EPA's Enforcement Alert concerning PVC facilities includes the causes and lessons learned from this investigation. Emphasize the importance of analyzing human factors and the need to implement adequate safeguards to minimize the likelihood and consequences of human error that could result in catastrophic incidents. Status: Closed - Acceptable Action
Ensure that the EPA's Enforcement Alert concerning PVC facilities includes the causes and lessons learned from this investigation. Emphasize the importance of analyzing human factors and the need to implement adequate safeguards to minimize the likelihood and consequences of human error that could result in catastrophic incidents.
2004-10-I-IL-1
Review the design and operation of FPC USA manufacturing facilities and implement policies and procedures to ensure that: -Site-wide policies are implemented to address necessary steps and approval levels required to bypass safety interlocks and other critical safety systems. -Chemical processes are designed to minimize the likelihood and consequences of human error that could result in a catastrophic release. -Safety impacts of staffing changes are evaluated. -Risks identified during hazard analyses and near-miss and incident investigations are characterized, prioritized, and that corrective actions are taken promptly. -High-risk hazards are evaluated using layers of protection analysis (LOPA) techniques and that appropriate safeguards are installed to reduce the likelihood of a catastrophic release of material. -All credible consequences are considered in near-miss investigations. -Emergency procedures clearly characterize emergency scenarios, address responsibilities and duties of responders, describe evacuation procedures, and ensure adequate training. Ensure that periodic drills are conducted. -The siting of offices for administrative and support personnel is evaluated to ensure the safety of personnel should an explosion or catastrophic release occur. Status: Closed - Acceptable Action
Review the design and operation of FPC USA manufacturing facilities and implement policies and procedures to ensure that: -Site-wide policies are implemented to address necessary steps and approval levels required to bypass safety interlocks and other critical safety systems. -Chemical processes are designed to minimize the likelihood and consequences of human error that could result in a catastrophic release. -Safety impacts of staffing changes are evaluated. -Risks identified during hazard analyses and near-miss and incident investigations are characterized, prioritized, and that corrective actions are taken promptly. -High-risk hazards are evaluated using layers of protection analysis (LOPA) techniques and that appropriate safeguards are installed to reduce the likelihood of a catastrophic release of material. -All credible consequences are considered in near-miss investigations. -Emergency procedures clearly characterize emergency scenarios, address responsibilities and duties of responders, describe evacuation procedures, and ensure adequate training. Ensure that periodic drills are conducted. -The siting of offices for administrative and support personnel is evaluated to ensure the safety of personnel should an explosion or catastrophic release occur.
2004-10-I-IL-2
Conduct periodic audits of each FPC USA PVC manufacturing facility for implementation of the items in Recommendation R1. Develop written findings and recommendations. Track and promptly implement corrective actions arising from the audit. Share audit findings with the workforce at the facilities and the FPC USA Board of Directors. Status: Closed - Acceptable Action
Conduct periodic audits of each FPC USA PVC manufacturing facility for implementation of the items in Recommendation R1. Develop written findings and recommendations. Track and promptly implement corrective actions arising from the audit. Share audit findings with the workforce at the facilities and the FPC USA Board of Directors.
2004-10-I-IL-3
Design and implement a program requiring audits of newly acquired facilities that address the issues highlighted in this report. Document, track, and promptly address recommended actions arising from the audits. Status: Closed - Acceptable Action
Design and implement a program requiring audits of newly acquired facilities that address the issues highlighted in this report. Document, track, and promptly address recommended actions arising from the audits.
2004-10-I-IL-4
Communicate the contents of this report to all employees of FPC USA PVC facilities. Status: Closed - Acceptable Action
Communicate the contents of this report to all employees of FPC USA PVC facilities.
2004-10-I-IL-5
Revise NFPA 15, Standard for Water Spray Fixed Systems for Fire Protection, to provide additional design guidance for deluge systems designed to prevent or mitigate fires and explosions. Include information concerning the limitations of using deluge systems for this purpose. Status: Closed - Acceptable Action
Revise NFPA 15, Standard for Water Spray Fixed Systems for Fire Protection, to provide additional design guidance for deluge systems designed to prevent or mitigate fires and explosions. Include information concerning the limitations of using deluge systems for this purpose.
2004-10-I-IL-6
Issue a safety alert to your membership highlighting the need to identify design features that may render processes vulnerable to human error and to implement sufficient layers of protection to minimize the likelihood human error causing catastrophic releases of hazardous material. Include lessons from PVC industry industrial accidents (including those described in this report and others highlighted in The Encyclopedia of PVC and elsewhere) that involved human error. Status: Closed - Acceptable Action
Issue a safety alert to your membership highlighting the need to identify design features that may render processes vulnerable to human error and to implement sufficient layers of protection to minimize the likelihood human error causing catastrophic releases of hazardous material. Include lessons from PVC industry industrial accidents (including those described in this report and others highlighted in The Encyclopedia of PVC and elsewhere) that involved human error.
2014-01-I-WV-1
Communicate the findings, lessons learned and recommendations contained within this report to all American Water Works Association members. Emphasize the importance of source water protection planning, emergency planning, and coordination with local, state and federal entities, and the public, to ensure timely notification of potential water contamination events and emergencies. Status: Closed - Acceptable Action
Communicate the findings, lessons learned and recommendations contained within this report to all American Water Works Association members. Emphasize the importance of source water protection planning, emergency planning, and coordination with local, state and federal entities, and the public, to ensure timely notification of potential water contamination events and emergencies.
2014-01-I-WV-2
Establish requirements for all American Water state utilities’ surface water treatment plants to undertake the following activities: 1. Conduct an inventory of all hazardous chemicals or classes of hazardous chemicals that are considered a potential source of significant contamination stored in the utility’s most vulnerable source water protection area (e.g., Zone of Critical Concern). Chemicals may be identified by accessing publicly available information, which may include Tier II reporting forms submitted to local emergency planning committees and electronically available information from federal, state or local databases. 2. For each inventoried chemical or class of chemicals, conduct a prioritized assessment to determine if existing analytical methods are available to detect the presence and/or concentration of the chemical or class of chemicals in the event of a release to the water supply and if the chemical or class of chemicals is capable of being treated or removed by the utility’s water treatment process. 3. For all chemicals or classes of chemicals that are not capable of being treated or removed by the treatment process, develop a contingency plan to respond to contamination events (e.g., as modeled by WVAW’s Kanawha Valley Water System June 2016 Source Water Protection Plan). Status: Closed - Acceptable Action
Establish requirements for all American Water state utilities’ surface water treatment plants to undertake the following activities:
1. Conduct an inventory of all hazardous chemicals or classes of hazardous chemicals that are considered a potential source of significant contamination stored in the utility’s most vulnerable source water protection area (e.g., Zone of Critical Concern). Chemicals may be identified by accessing publicly available information, which may include Tier II reporting forms submitted to local emergency planning committees and electronically available information from federal, state or local databases.
2. For each inventoried chemical or class of chemicals, conduct a prioritized assessment to determine if existing analytical methods are available to detect the presence and/or concentration of the chemical or class of chemicals in the event of a release to the water supply and if the chemical or class of chemicals is capable of being treated or removed by the utility’s water treatment process.
3. For all chemicals or classes of chemicals that are not capable of being treated or removed by the treatment process, develop a contingency plan to respond to contamination events (e.g., as modeled by WVAW’s Kanawha Valley Water System June 2016 Source Water Protection Plan).
2014-01-I-WV-3
Update appropriate sections of the Crude MCHM Safety Data Sheet to include toxicological and ecological information based on the June 1, 2016, National Toxicology Program’s toxicity evaluation of Crude MCHM. Include information about the effects of Crude MCHM on fetal and early life growth and development. Distribute the revised Crude MCHM SDS to all customers that previously received and are currently using or storing MCHM from Eastman, and ensure all new MCHM customers receive the revised SDS with shipment. Status: Closed - Acceptable Action
Update appropriate sections of the Crude MCHM Safety Data Sheet to include toxicological and ecological information based on the June 1, 2016, National Toxicology Program’s toxicity evaluation of Crude MCHM. Include information about the effects of Crude MCHM on fetal and early life growth and development. Distribute the revised Crude MCHM SDS to all customers that previously received and are currently using or storing MCHM from Eastman, and ensure all new MCHM customers receive the revised SDS with shipment.
2002-01-I-AL-10
Evaluate and amend as necessary the ATSDR Medical Management Guidelines to consider the risk to responders posed by exposure to victims of high levels of hydrogen sulfide (H2S) gas. Specify procedures for adequate decontamination. Communicate the results of this activity to relevant organizations, such as the American Association of Occupational Health Nurses. Status: Closed - Acceptable Action
Evaluate and amend as necessary the ATSDR Medical Management Guidelines to consider the risk to responders posed by exposure to victims of high levels of hydrogen sulfide (H2S) gas. Specify procedures for adequate decontamination. Communicate the results of this activity to relevant organizations, such as the American Association of Occupational Health Nurses.
2002-01-I-AL-13
Communicate the findings and recommendations of this report to your membership. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to your membership.
2002-01-I-AL-11
Train your employees on the specific hazards of hydrogen sulfide (H2S), including appropriate emergency response practices, in areas where Georgia-Pacific has identified this material as a hazard. Status: Closed - Acceptable Action
Train your employees on the specific hazards of hydrogen sulfide (H2S), including appropriate emergency response practices, in areas where Georgia-Pacific has identified this material as a hazard.
2002-01-I-AL-2
Communicate the findings and recommendations of this report to those employees who haul or handle sodium hydrosulfide Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to those employees who haul or handle sodium hydrosulfide
2002-01-I-AL-1
Conduct periodic safety audits of Georgia-Pacific pulp and paper mills in light of the findings of this report. At a minimum, ensure that management systems are in place at the mills to: Evaluate process sewers where chemicals may collect and interact, and identify potential hazardous reaction scenarios to determine if safeguards are in place to decrease the likelihood or consequences of such interactions. Take into account sewer system connections and the ability to prevent inadvertent mixing of materials that could react to create a hazardous condition. Status: Closed - Exceeds Recommended Action
Conduct periodic safety audits of Georgia-Pacific pulp and paper mills in light of the findings of this report. At a minimum, ensure that management systems are in place at the mills to: Evaluate process sewers where chemicals may collect and interact, and identify potential hazardous reaction scenarios to determine if safeguards are in place to decrease the likelihood or consequences of such interactions. Take into account sewer system connections and the ability to prevent inadvertent mixing of materials that could react to create a hazardous condition.
Conduct periodic safety audits of Georgia-Pacific pulp and paper mills in light of the findings of this report. At a minimum, ensure that management systems are in place at the mills to: Identify areas of the mill where hydrogen sulfide (H2S) could be present or generated, and institute safeguards (including warning devices) to limit personnel exposure. Require that personnel working in the area are trained to recognize the presence of H2S and respond appropriately. Update emergency response plans for such areas to include procedures for decontaminating personnel exposed to toxic gas. Status: Closed - Acceptable Action
Conduct periodic safety audits of Georgia-Pacific pulp and paper mills in light of the findings of this report. At a minimum, ensure that management systems are in place at the mills to: Identify areas of the mill where hydrogen sulfide (H2S) could be present or generated, and institute safeguards (including warning devices) to limit personnel exposure. Require that personnel working in the area are trained to recognize the presence of H2S and respond appropriately. Update emergency response plans for such areas to include procedures for decontaminating personnel exposed to toxic gas.
2002-01-I-AL-3
Conduct periodic safety audits of Georgia-Pacific pulp and paper mills in light of the findings of this report. At a minimum, ensure that management systems are in place at the mills to: Apply good engineering and process safety principles to process sewer systems. For instance, ensure that hazard reviews and management of change (MOC) analyses are completed when additions or changes are made where chemicals could collect and react in process sewers. (Such principles may be found in publications from the Center for Chemical Process Safety [CCPS].) Status: Closed - Acceptable Action
Conduct periodic safety audits of Georgia-Pacific pulp and paper mills in light of the findings of this report. At a minimum, ensure that management systems are in place at the mills to: Apply good engineering and process safety principles to process sewer systems. For instance, ensure that hazard reviews and management of change (MOC) analyses are completed when additions or changes are made where chemicals could collect and react in process sewers. (Such principles may be found in publications from the Center for Chemical Process Safety [CCPS].)
2002-01-I-AL-4
Communicate the findings and recommendations of this report to the workforce and contractors at all Georgia-Pacific pulp and paper mills. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to the workforce and contractors at all Georgia-Pacific pulp and paper mills.
2002-01-I-AL-5
Evaluate mill process sewer systems where chemicals may collect and react to identify potential hazardous reaction scenarios to determine if safeguards are in place to decrease the likelihood or consequences of such interactions. Evaluate sewer connections and ensure that materials that could react to create a hazardous condition are not inadvertently mixed, and that adequate mitigation measures are in place if such mixing does occur. Status: Closed - Acceptable Action
Evaluate mill process sewer systems where chemicals may collect and react to identify potential hazardous reaction scenarios to determine if safeguards are in place to decrease the likelihood or consequences of such interactions. Evaluate sewer connections and ensure that materials that could react to create a hazardous condition are not inadvertently mixed, and that adequate mitigation measures are in place if such mixing does occur.
2002-01-I-AL-6
Establish programs to comply with recommendations from manufacturers of sodium hydrosulfide (NaSH) regarding its handling, such as preventing it from entering sewers because of the potential for acidic conditions. Status: Closed - Acceptable Action
Establish programs to comply with recommendations from manufacturers of sodium hydrosulfide (NaSH) regarding its handling, such as preventing it from entering sewers because of the potential for acidic conditions.
2002-01-I-AL-7
Establish programs to require the proper design and maintenance of manway seals on closed sewers where hazardous materials are present. Status: Closed - Acceptable Action
Establish programs to require the proper design and maintenance of manway seals on closed sewers where hazardous materials are present.
2002-01-I-AL-8
Identify areas of the plant where hydrogen sulfide (H2S) could be present or generated, and institute safeguards (including warning devices) to limit personnel exposure. Institute a plan and procedures for dealing with potential H2S releases in these areas, and require that anyone who may be present is adequately trained on appropriate emergency response practices, including attempting rescue. Require contractors working in these areas to train their employees on the specific hazards of H2S, including appropriate emergency response practices. Status: Closed - Acceptable Action
Identify areas of the plant where hydrogen sulfide (H2S) could be present or generated, and institute safeguards (including warning devices) to limit personnel exposure. Institute a plan and procedures for dealing with potential H2S releases in these areas, and require that anyone who may be present is adequately trained on appropriate emergency response practices, including attempting rescue. Require contractors working in these areas to train their employees on the specific hazards of H2S, including appropriate emergency response practices.
2009-01-I-AL-9
Update the Naheola mill emergency response plan to include procedures for decontaminating personnel who are brought to the first-aid station. Include specific instructions for decontaminating personnel exposed to H2S so that they do not pose a secondary exposure threat to medical personnel. Status: Closed - Acceptable Action
Update the Naheola mill emergency response plan to include procedures for decontaminating personnel who are brought to the first-aid station. Include specific instructions for decontaminating personnel exposed to H2S so that they do not pose a secondary exposure threat to medical personnel.
2002-01-I-AL-14
2009-01-I-AL-15
2009-01-I-AL-16
Communicate the findings and recommendations of this report to your membership. Status: Closed - No Longer Applicable