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.
2004-11-I-CA-7
In collaboration with other state/regional agencies as necessary, such as California Occupational Safety and Health Administration, recommend to facilities that treat ethylene oxide backvent emissions with oxidizing emissions control devices to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices. Status: Closed - Acceptable Action
In collaboration with other state/regional agencies as necessary, such as California Occupational Safety and Health Administration, recommend to facilities that treat ethylene oxide backvent emissions with oxidizing emissions control devices to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices.
2004-11-I-CA-8
In collaboration with other state/regional agencies as necessary, such as California Environmental Protection Agency, identify the ethylene oxide sterilization facilities in California that utilize oxidizing emissions control devices and conduct inspections of those facilities (including the Sterigenics Ontario facility) in terms of the findings of this report. Ensure prompt correction of all violations identified during these inspections. Status: Closed - Acceptable Action
In collaboration with other state/regional agencies as necessary, such as California Environmental Protection Agency, identify the ethylene oxide sterilization facilities in California that utilize oxidizing emissions control devices and conduct inspections of those facilities (including the Sterigenics Ontario facility) in terms of the findings of this report. Ensure prompt correction of all violations identified during these inspections.
2004-11-I-CA-16
Communicate the findings and recommendations of this report to the states that require EO backvent emissions treatment. Emphasize the need for facilities to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to the states that require EO backvent emissions treatment. Emphasize the need for facilities to evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices.
2004-11-I-CA-14
Coordinate with NIOSH to revise and reissue Appendix C of the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically, remove the portion of paragraph D that states, "[t]he accuracy, reliability, resolution, and availability of current ethylene oxide measurement devices is questionable." Status: Closed - Acceptable Action
Coordinate with NIOSH to revise and reissue Appendix C of the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically, remove the portion of paragraph D that states, "[t]he accuracy, reliability, resolution, and availability of current ethylene oxide measurement devices is questionable."
2004-11-I-CA-15
Conduct outreach to communicate the findings and recommendations of this report, and the contents of the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities, to your membership. Status: Closed - Acceptable Action
Conduct outreach to communicate the findings and recommendations of this report, and the contents of the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities, to your membership.
2004-11-I-CA-17
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.
2004-11-I-CA-9
Review and revise NFPA 560, Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation in terms of the findings of this report. Specifically: Include references to the following: NFPA 69, Standard on Explosion Prevention Systems. NFPA 86, Ovens and Furnaces. NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions in Industrial Ethylene Oxide Sterilization Facilities.
Review and revise NFPA 560, Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation in terms of the findings of this report. Specifically:
2004-11-I-CA-10
Review and revise NFPA 560, Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation in terms of the findings of this report. Specifically: Include requirements for appropriate safeguards, such as: Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. Post-ignition deflagration detection and damage control devices.
2004-11-I-CA-11
Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Include industry guidance materials on Process Hazard Analysis (PHA), such as those published by the Center for Chemical Process Safety (CCPS). Status: Closed - Acceptable Action
Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Include industry guidance materials on Process Hazard Analysis (PHA), such as those published by the Center for Chemical Process Safety (CCPS).
2004-11-I-CA-12
Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Add references to NFPA 68 Guide for Venting of Deflagrations; NFPA 69 Standard on Explosion Prevention Systems; NFPA 86 Ovens and Furnaces; and NFPA 560 Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation. Status: Closed - Acceptable Action
Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Add references to NFPA 68 Guide for Venting of Deflagrations; NFPA 69 Standard on Explosion Prevention Systems; NFPA 86 Ovens and Furnaces; and NFPA 560 Standard for the Storage, Handling, and Use of Ethylene Oxide for Sterilization and Fumigation.
2004-11-I-CA-13
Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Coordinate with the Ethylene Oxide Sterilization Association (EOSA) to remove the portion of paragraph D of Appendix C that states, ?[t]he accuracy, reliability, resolution, and availability of current ethylene oxide measurement devices is questionable.? Status: Closed - Acceptable Action
Revise and reissue the NIOSH Alert: Preventing Worker Injuries and Deaths from Explosions at Industrial Ethylene Oxide Facilities (Publication No. 2002-119) in terms of the findings of this report. Specifically: - Coordinate with the Ethylene Oxide Sterilization Association (EOSA) to remove the portion of paragraph D of Appendix C that states, ?[t]he accuracy, reliability, resolution, and availability of current ethylene oxide measurement devices is questionable.?
2004-11-I-CA-1
Audit all Sterigenics ethylene oxide sterilization facilities using oxidizing emissions control devices. Ensure that audits assess the issues detailed below, under "Sterigenics International - Ontario Facility," and that necessary corrective measures are promptly implemented. Communicate results of these audits to your workforce. Status: Closed - Acceptable Action
Audit all Sterigenics ethylene oxide sterilization facilities using oxidizing emissions control devices. Ensure that audits assess the issues detailed below, under "Sterigenics International - Ontario Facility," and that necessary corrective measures are promptly implemented. Communicate results of these audits to your workforce.
2004-11-I-CA-2
Review and revise the Process Hazard Analysis (PHA) program to ensure that: - Hazardous scenarios are identified, evaluated, and documented. - Lessons learned from past incidents are applied, where appropriate. Status: Closed - Acceptable Action
Review and revise the Process Hazard Analysis (PHA) program to ensure that: - Hazardous scenarios are identified, evaluated, and documented. - Lessons learned from past incidents are applied, where appropriate.
2004-11-I-CA-3
Evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices. Status: Closed - Acceptable Action
Evaluate current process controls and install appropriate safeguards, such as: - Real-time chamber and/or effluent concentration monitoring connected to alarms, interlocks, and/or fast acting control devices. - Post-ignition deflagration detection and damage control devices.
2004-11-I-CA-4
Ensure that all employees with passwords capable of modifying the sterilization cycle sequence have process experience and training that enables them to make safe process decisions. Training should emphasize flammability hazards and the need for gas washes when the chamber is empty of products to be sterilized. Status: Closed - Acceptable Action
Ensure that all employees with passwords capable of modifying the sterilization cycle sequence have process experience and training that enables them to make safe process decisions. Training should emphasize flammability hazards and the need for gas washes when the chamber is empty of products to be sterilized.
2004-11-I-CA-5
Ensure that the control room, and any other room where employees congregate in dangerous proximity to the sterilization area, is located and/or designed to protect workers from an explosion. Status: Closed - Acceptable Action
Ensure that the control room, and any other room where employees congregate in dangerous proximity to the sterilization area, is located and/or designed to protect workers from an explosion.
2004-11-I-CA-6
Communicate the findings and recommendations of this report to all employees, including operators and maintenance staff. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to all employees, including operators and maintenance staff.
2006-4-I-NC-1
Establish a program to ensure that reactive hazards at Protex U.S. facilities are managed in accordance with good industry practices. At a minimum, the program should: -identify and characterize reactive hazards; -implement, document, and maintain appropriate safeguards; -manage changes to recipes; -document and maintain safety critical process equipment capabilities; -train personnel on reactive hazards, safe operating limits, and the consequences of and responses to deviations; -train personnel on emergency evacuations alarms and procedures, and conduct emergency drills; and, -conduct periodic audits of program implementation to identify and address weaknesses. Status: Closed - Acceptable Action
Establish a program to ensure that reactive hazards at Protex U.S. facilities are managed in accordance with good industry practices. At a minimum, the program should: -identify and characterize reactive hazards; -implement, document, and maintain appropriate safeguards; -manage changes to recipes; -document and maintain safety critical process equipment capabilities; -train personnel on reactive hazards, safe operating limits, and the consequences of and responses to deviations; -train personnel on emergency evacuations alarms and procedures, and conduct emergency drills; and, -conduct periodic audits of program implementation to identify and address weaknesses.
2008-03-I-FL-3
Work with the American Institute of Chemical Engineers to add reactive hazard awareness to baccalaureate chemical engineering curricula requirements. Status: Closed - Exceeds Recommended Action
Work with the American Institute of Chemical Engineers to add reactive hazard awareness to baccalaureate chemical engineering curricula requirements.
2008-03-I-FL-1
Work with the Accreditation Board for Engineering and Technology, Inc. to add reactive hazard awareness to baccalaureate chemical engineering curricula requirements. Status: Closed - Exceeds Recommended Action
Work with the Accreditation Board for Engineering and Technology, Inc. to add reactive hazard awareness to baccalaureate chemical engineering curricula requirements.
2008-03-I-FL-2
Inform all student members about the Process Safety Certificate Program and encourage program participation. Status: Closed - Acceptable Action
Inform all student members about the Process Safety Certificate Program and encourage program participation.
2003-08-I-RI-7
Update the preliminary steps in the chapter on exhaust system design in the next revision of the Industrial Ventilation Manual, emphasizing the need to evaluate potential incompatibilities between dusts, fumes, or vapors that are likely to be intermixed in main header ducts of a ventilation system to ensure that they do not result in fire or explosion hazards, or destructive corrosion. Reference appropriate methods for such evaluations, such as the ASTM E 2012-00 standard. Status: Closed - Acceptable Action
Update the preliminary steps in the chapter on exhaust system design in the next revision of the Industrial Ventilation Manual, emphasizing the need to evaluate potential incompatibilities between dusts, fumes, or vapors that are likely to be intermixed in main header ducts of a ventilation system to ensure that they do not result in fire or explosion hazards, or destructive corrosion. Reference appropriate methods for such evaluations, such as the ASTM E 2012-00 standard.
2003-08-I-RI-6
Revise the appendix of ANSI Z9.2, American National Standard Fundamentals Governing the Design and Operation of Local Exhaust Systems, emphasizing the need to evaluate potential incompatibilities when dusts, fumes, or vapors are intermixed in local exhaust ventilation systems with common headers to ensure that they do not result in fire or explosion hazards, or destructive corrosion. Reference appropriate methods for such evaluations, such as the ASTM E 2012-00 standard. Status: Closed - Acceptable Action
Revise the appendix of ANSI Z9.2, American National Standard Fundamentals Governing the Design and Operation of Local Exhaust Systems, emphasizing the need to evaluate potential incompatibilities when dusts, fumes, or vapors are intermixed in local exhaust ventilation systems with common headers to ensure that they do not result in fire or explosion hazards, or destructive corrosion. Reference appropriate methods for such evaluations, such as the ASTM E 2012-00 standard.
2003-08-I-RI-5
Revise the appendix of NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids, emphasizing the need to evaluate potential incompatibilities when dusts, fumes, or vapors are intermixed in vent collection systems to ensure that they do not result in fire or explosion hazards, or destructive corrosion. Reference appropriate methods for such evaluations, such as the ASTM E 2012-00 standard. Status: Closed - Acceptable Action
Revise the appendix of NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids, emphasizing the need to evaluate potential incompatibilities when dusts, fumes, or vapors are intermixed in vent collection systems to ensure that they do not result in fire or explosion hazards, or destructive corrosion. Reference appropriate methods for such evaluations, such as the ASTM E 2012-00 standard.
2003-08-I-RI-1
As a part of the engineering process, implement formal process safety review procedures for projects involving chemical processes- including the vent collection system. Incorporate a process hazard analysis, reactive chemical hazard evaluation, and design evaluation consistent with applicable codes and standards. Status: Closed - Unacceptable Action/No Response Received
As a part of the engineering process, implement formal process safety review procedures for projects involving chemical processes- including the vent collection system. Incorporate a process hazard analysis, reactive chemical hazard evaluation, and design evaluation consistent with applicable codes and standards.
2003-08-I-RI-2
Implement a management-of-change program and ensure that reviews are conducted for any proposed changes to the vent collection system and its connected processes. Status: Closed - Unacceptable Action/No Response Received
Implement a management-of-change program and ensure that reviews are conducted for any proposed changes to the vent collection system and its connected processes.
2003-08-I-RI-3
Implement a preventive maintenance program for the vent collection system that includes regular inspections training and troubleshooting. Status: Closed - Acceptable Action
Implement a preventive maintenance program for the vent collection system that includes regular inspections training and troubleshooting.
2003-08-I-RI-4
Work with the Cranston Fire Department to improve the facility's emergency response plan, including emergency response procedures and interface with the surrounding community. Submit the plan to the fire department for review. Status: Closed - Acceptable Action
Work with the Cranston Fire Department to improve the facility's emergency response plan, including emergency response procedures and interface with the surrounding community. Submit the plan to the fire department for review.
2010-08-I-WA-10
Revise American Petroleum Institute API RP 941: Steels for Hydrogen Service at Elevated Temperatures and Pressures in Petroleum Refineries and Petrochemical Plants to: a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems; b. Require the use of inherently safer materials to the greatest extent feasible; c. Require verification of actual operating conditions to confirm that material of construction selection prevents HTHA equipment failure; and d. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure. Status: Closed - Unacceptable Action/No Response Received
Revise American Petroleum Institute API RP 941: Steels for Hydrogen Service at Elevated Temperatures and Pressures in Petroleum Refineries and Petrochemical Plants to:
a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems;
b. Require the use of inherently safer materials to the greatest extent feasible;
c. Require verification of actual operating conditions to confirm that material of construction selection prevents HTHA equipment failure; and
d. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure.
2010-08-I-WA-11
Revise American Petroleum Institute API RP 581: Risk-Based Inspection Technology to: a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems; b. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure; and c. Require verification of actual operating conditions to determine potential equipment damage mechanisms. Status: Closed - Unacceptable Action/No Response Received
Revise American Petroleum Institute API RP 581: Risk-Based Inspection Technology to:
b. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure; and
c. Require verification of actual operating conditions to determine potential equipment damage mechanisms.
2010-08-I-WA-1
Revise the Chemical Accident Prevention Provisions under 40 CFR Part 68 to require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible when facilities are establishing safeguards for identified process hazards. The goal shall be to reduce the risk of major accidents to the greatest extent practicable, to be interpreted as equivalent to as low as reasonably practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all management of change, incident investigation, and process hazard analysis reviews and recommendations, prior to the construction of a new process, process unit rebuilds, significant process repairs, and in the development of corrective actions. Status: Open - Awaiting Response or Evaluation/Approval of Response
Revise the Chemical Accident Prevention Provisions under 40 CFR Part 68 to require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible when facilities are establishing safeguards for identified process hazards. The goal shall be to reduce the risk of major accidents to the greatest extent practicable, to be interpreted as equivalent to as low as reasonably practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all management of change, incident investigation, and process hazard analysis reviews and recommendations, prior to the construction of a new process, process unit rebuilds, significant process repairs, and in the development of corrective actions.
2010-08-I-WA-2
Until Recommendation 2010-08-I-WA-R1 is in effect, enforce through the Clean Air Act’s General Duty Clause, section 112(r)(1), 42 U.S.C.§7412(r)(1) the use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible when facilities are establishing safeguards for identified process hazards. Status: Closed - No Longer Applicable
Until Recommendation 2010-08-I-WA-R1 is in effect, enforce through the Clean Air Act’s General Duty Clause, section 112(r)(1), 42 U.S.C.§7412(r)(1) the use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible when facilities are establishing safeguards for identified process hazards.
2010-08-I-WA-3
Develop guidance for the required use of inherently safer systems analysis and the hierarchy of controls for enforcement under 40 CFR Part 68 and the Clean Air Act’s General Duty Clause, section 112(r)(1),42 U.S.C. §7412(r)(1). Status: Open - Awaiting Response or Evaluation/Approval of Response
Develop guidance for the required use of inherently safer systems analysis and the hierarchy of controls for enforcement under 40 CFR Part 68 and the Clean Air Act’s General Duty Clause, section 112(r)(1),42 U.S.C. §7412(r)(1).
2010-08-I-WA-4
Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective actions. Status: Closed - Reconsidered/Superseded
Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective actions.
2010-08-I-WA-5
Based on the findings in this report, augment your existing process safety management regulations for petroleum refineries in the state of Washington with the following more rigorous goal-setting attributes: a. A comprehensive process hazard analysis written by the company that includes: i. Systematic analysis and documentation of all major hazards and safeguards, using the hierarchy of controls to reduce those risks to as low as reasonably practicable (ALARP); ii. Documentation of the recognized methodologies,rationale and conclusions used to claim that safeguards intended to control hazards will be effective; iii. Documented damage mechanism hazard review conducted by a diverse team of qualified personnel. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure effective safeguards are in place to control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safer design to the greatest extent feasible into this review; and iv. Documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations. b. A thorough review of the comprehensive process hazard analysis by technically competent regulatory personnel; c. Required preventative audits and preventative inspections by the regulator; d. Require that all safety codes, standards, employer internal procedures and recognized and generally accepted good engineering practices (RAGAGEP) used in the implementation of the regulations contain adequate minimum requirements; e. Require an increased role for workers in management of process safety by establishing the rights and responsibilities of workers and their representatives on health and safety-related matters, and the election of safety representatives and establishment of safety committees (with equal representation between management and labor) to serve health and safety-related functions. The elected representatives should have a legally recognized role that goes beyond consultation in activities such as the development of the comprehensive process hazard analysis, management of change, incident investigation, audits, and identification and effective control of hazards. The representatives should also have the authority to stop work that is perceived to be unsafe or that presents a serious hazard until the regulator intervenes to resolve the safety concern. Work force participation practices should be documented by the company to the regulator; and f. Requires reporting of information to the public to the greatest extent feasible such as a summary of the comprehensive process hazard analysis which includes a list of safeguards implemented and standards utilized to reduce risk, and process safety indicators that demonstrate the effectiveness of the safeguards and management systems. Status: Closed - Acceptable Alternative Action
Based on the findings in this report, augment your existing process safety management regulations for petroleum refineries in the state of Washington with the following more rigorous goal-setting attributes:
a. A comprehensive process hazard analysis written by the company that includes:
i. Systematic analysis and documentation of all major hazards and safeguards, using the hierarchy of controls to reduce those risks to as low as reasonably practicable (ALARP);
ii. Documentation of the recognized methodologies,rationale and conclusions used to claim that safeguards intended to control hazards will be effective;
iii. Documented damage mechanism hazard review conducted by a diverse team of qualified personnel. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure effective safeguards are in place to control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safer design to the greatest extent feasible into this review; and
iv. Documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.
b. A thorough review of the comprehensive process hazard analysis by technically competent regulatory personnel;
c. Required preventative audits and preventative inspections by the regulator;
d. Require that all safety codes, standards, employer internal procedures and recognized and generally accepted good engineering practices (RAGAGEP) used in the implementation of the regulations contain adequate minimum requirements;
e. Require an increased role for workers in management of process safety by establishing the rights and responsibilities of workers and their representatives on health and safety-related matters, and the election of safety representatives and establishment of safety committees (with equal representation between management and labor) to serve health and safety-related functions. The elected representatives should have a legally recognized role that goes beyond consultation in activities such as the development of the comprehensive process hazard analysis, management of change, incident investigation, audits, and identification and effective control of hazards. The representatives should also have the authority to stop work that is perceived to be unsafe or that presents a serious hazard until the regulator intervenes to resolve the safety concern. Work force participation practices should be documented by the company to the regulator; and
f. Requires reporting of information to the public to the greatest extent feasible such as a summary of the comprehensive process hazard analysis which includes a list of safeguards implemented and standards utilized to reduce risk, and process safety indicators that demonstrate the effectiveness of the safeguards and management systems.
2010-08-I-WA-6
Establish a well-funded, well-staffed, technically qualified regulator with a compensation system to ensure the Washington Department of Labor and Industries regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical qualifications. Periodically conduct a market analysis and benchmarking review to ensure the compensation system remains competitive with Washington petroleum refineries. Status: Open - Acceptable Response or Alternate Response
Establish a well-funded, well-staffed, technically qualified regulator with a compensation system to ensure the Washington Department of Labor and Industries regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical qualifications. Periodically conduct a market analysis and benchmarking review to ensure the compensation system remains competitive with Washington petroleum refineries.
2010-08-I-WA-7
Work with the regulator, the petroleum refining industry, labor, and other relevant stakeholders in the state of Washington to develop and implement a system that collects, tracks, and analyzes process safety leading and lagging indicators from operators and contractors to promote continuous process safety improvements. At a minimum, this program shall: a. Require the use of leading and lagging process safety indicators to actively monitor the effectiveness of process safety management systems and safeguards for major accident prevention. Include leading and lagging indicators that are measureable, actionable, and standardized. Include indicators that measure safety culture, such as incident reporting and action item implementation culture. Require that the reported data be used for continuous process safety improvement and accident prevention; b. Analyze data to identify trends and poor performer s and publish annual reports with the data at facility and corporate levels; c. Require companies to publicly report required indicators annually at facility and corporate levels; d. Use process safety indicators (1) to drive continuous improvement for major accident prevention by using the data to identify industry and facility safety trends and deficiencies and (2) to determine appropriate allocation of regulator resources and inspections; and e. Be periodically updated to incorporate new learning from world-wide industry improvements in order to drive continuous major accident process safety improvements in Washington. Status: Open - Awaiting Response or Evaluation/Approval of Response
Work with the regulator, the petroleum refining industry, labor, and other relevant stakeholders in the state of Washington to develop and implement a system that collects, tracks, and analyzes process safety leading and lagging indicators from operators and contractors to promote continuous process safety improvements. At a minimum, this program shall:
a. Require the use of leading and lagging process safety indicators to actively monitor the effectiveness of process safety management systems and safeguards for major accident prevention. Include leading and lagging indicators that are measureable, actionable, and standardized. Include indicators that measure safety culture, such as incident reporting and action item implementation culture. Require that the reported data be used for continuous process safety improvement and accident prevention;
b. Analyze data to identify trends and poor performer s and publish annual reports with the data at facility and corporate levels;
c. Require companies to publicly report required indicators annually at facility and corporate levels;
d. Use process safety indicators (1) to drive continuous improvement for major accident prevention by using the data to identify industry and facility safety trends and deficiencies and (2) to determine appropriate allocation of regulator resources and inspections; and
e. Be periodically updated to incorporate new learning from world-wide industry improvements in order to drive continuous major accident process safety improvements in Washington.
2010-08-I-WA-15
Implement a process safety culture continuous improvement program at the Tesoro Anacortes Refinery including a written procedure for periodic process safety culture surveys across the work force. The process safety culture program shall be overseen by a tripartite committee of Tesoro management, USW representatives, Washington State Department of Labor and Industries – Division of Occupational Safety and Health, and the U.S. Environmental Protection Agency. This oversight committee shall: a. Select an expert third party that will administer a periodic process safety culture survey; b. Review and comment on the third party expert report developed from the survey; c. Oversee the development and effective implementation of action items to address identified process safety culture issues; and d. Develop process safety culture indicators to measure major accident prevention performance. The process safety program shall include a focus on items that measure, at a minimum, willingness to report incidents, normalization of hazardous conditions, burden of proof of safety in plant process safety programs and practices, and management involvement and commitment to process safety. The periodic process safety culture report shall be made available to the plant workforce. The minimum frequency of process safety culture surveys shall be at least once every three years. Status: Closed - Acceptable Alternative Action
Implement a process safety culture continuous improvement program at the Tesoro Anacortes Refinery including a written procedure for periodic process safety culture surveys across the work force. The process safety culture program shall be overseen by a tripartite committee of Tesoro management, USW representatives, Washington State Department of Labor and Industries – Division of Occupational Safety and Health, and the U.S. Environmental Protection Agency. This oversight committee shall:
a. Select an expert third party that will administer a periodic process safety culture survey;
b. Review and comment on the third party expert report developed from the survey;
c. Oversee the development and effective implementation of action items to address identified process safety culture issues; and
d. Develop process safety culture indicators to measure major accident prevention performance.
The process safety program shall include a focus on items that measure, at a minimum, willingness to report incidents, normalization of hazardous conditions, burden of proof of safety in plant process safety programs and practices, and management involvement and commitment to process safety. The periodic process safety culture report shall be made available to the plant workforce. The minimum frequency of process safety culture surveys shall be at least once every three years.
2010-08-I-WA-12
Actively participate with API in the completion ofrecommendation 2010-08-I-WA-R10. Document this participation. Status: Closed - Acceptable Action
Actively participate with API in the completion ofrecommendation 2010-08-I-WA-R10. Document this participation.
2010-08-I-WA-13
Once recommendation 2010-08-I-WA-R12 is in effect, develop and implement a plan to meet therequirements established through the acceptable completion of recommendation 2010-08-I-WA-R10. Document the implementation of the plan and the corrective actions taken. Status: Closed - No Longer Applicable
Once recommendation 2010-08-I-WA-R12 is in effect, develop and implement a plan to meet therequirements established through the acceptable completion of recommendation 2010-08-I-WA-R10. Document the implementation of the plan and the corrective actions taken.
2010-08-I-WA-14
Revise and improve the Process Hazard Analysis (PHA), the Integrity Operating Window (IOW), and the damage mechanism hazard review (DMHR) programs and cross-linking among these three programs such that all identified hazards are effectively managed in each program. For all Tesoro refineries require: a. the IOW to review damage mechanism hazards from the most recent PHA and safeguards identified to control these hazards; b. the IOW review or revalidation to be conducted at least every five years; c. the IOW to analyze and incorporate applicable industry best practice, the hierarchy of controls, and inherently safer design to the greatest extent reasonably practicable; d. the DMHR report to be developed by the DMHR team and not just the “corrosion expert;” e.the DMHR team to review the operating data to verify an accurate understanding of how the data was obtained, what it represents, and that it appropriately addresses both routine and nonroutine operations; f. the DMHR and/or IOW review to identify and review gaps between current industry best practices and existing Tesoro practices with regard to material selection and process controls and make recommendations that reduce risks from damage mechanism hazards; g. the DMHR and IOW review to review applicable Tesoro and industry-wide damage mechanism incidents as part of the respective DMHR or IOW review; h. the DMHR to review relevant MOCs to fully evaluate the impact of the MOC on damage mechanism hazards; i. the identification of minimum qualifications for the “corrosion expert” and ensure that the DMHR team has the necessary skills to meet these requirements; j. for sites that have a corrosion/materials engineer, the corrosion/materials engineer shall be a required participant in the DMHR; k. the PHA to review the most recent DMHR and IOW reviews in order to contain a complete record of all identified damage mechanism hazards, evaluate existing safeguards, and propose new safeguards to control the identified hazards; l. the PHA to review the consequence of damage mechanism hazards identified in the risk-based inspection (RBI) program and IOW reviews to ensure effective safeguards are present to control the damage mechanism hazard; and m. the PHA to use the hierarchy of controls and implement opportunities for inherently safer design to the greatest extent reasonably practicable. Status: Closed - Acceptable Action
Revise and improve the Process Hazard Analysis (PHA), the Integrity Operating Window (IOW), and the damage mechanism hazard review (DMHR) programs and cross-linking among these three programs such that all identified hazards are effectively managed in each program. For all Tesoro refineries require:
a. the IOW to review damage mechanism hazards from the most recent PHA and safeguards identified to control these hazards;
b. the IOW review or revalidation to be conducted at least every five years;
c. the IOW to analyze and incorporate applicable industry best practice, the hierarchy of controls, and inherently safer design to the greatest extent reasonably practicable;
d. the DMHR report to be developed by the DMHR team and not just the “corrosion expert;”
e.the DMHR team to review the operating data to verify an accurate understanding of how the data was obtained, what it represents, and that it appropriately addresses both routine and nonroutine operations;
f. the DMHR and/or IOW review to identify and review gaps between current industry best practices and existing Tesoro practices with regard to material selection and process controls and make recommendations that reduce risks from damage mechanism hazards;
g. the DMHR and IOW review to review applicable Tesoro and industry-wide damage mechanism incidents as part of the respective DMHR or IOW review;
h. the DMHR to review relevant MOCs to fully evaluate the impact of the MOC on damage mechanism hazards;
i. the identification of minimum qualifications for the “corrosion expert” and ensure that the DMHR team has the necessary skills to meet these requirements;
j. for sites that have a corrosion/materials engineer, the corrosion/materials engineer shall be a required participant in the DMHR;
k. the PHA to review the most recent DMHR and IOW reviews in order to contain a complete record of all identified damage mechanism hazards, evaluate existing safeguards, and propose new safeguards to control the identified hazards;
l. the PHA to review the consequence of damage mechanism hazards identified in the risk-based inspection (RBI) program and IOW reviews to ensure effective safeguards are present to control the damage mechanism hazard; and
m. the PHA to use the hierarchy of controls and implement opportunities for inherently safer design to the greatest extent reasonably practicable.
2010-08-I-WA-16
Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15. Status: Closed - Acceptable Action
Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15.
2010-08-I-WA-8
Perform a verification audit at all Washington petroleum refineries to ensure: a. Prevention of HTHA equipment failure and safe operation of the equipment. Audit HTHA prevention and process condition monitoring techniques used at all Washington petroleum refineries. Verify that all affected equipment in use meets the requirements contained in Recommendation 2010-08-I-WA-R10; b. For nonroutine work, a written hazard evaluation is performed by a multidisciplinary team and, where feasible, conducted during the job planning process prior to the day of the job execution. Verify that each facility has an effective written decision-making protocol used to determine when it is necessary to shut a process down to safely perform work or conduct repairs. Ensure the program reflects the guidance in the CCPS Risk Based Process Safety book related to hazardous nonroutine work; and c. Effective programs are in place to control of the number of essential personnel present during all hazardous nonroutine work. Status: Open - Acceptable Response or Alternate Response
Perform a verification audit at all Washington petroleum refineries to ensure:
a. Prevention of HTHA equipment failure and safe operation of the equipment. Audit HTHA prevention and process condition monitoring techniques used at all Washington petroleum refineries. Verify that all affected equipment in use meets the requirements contained in Recommendation 2010-08-I-WA-R10;
b. For nonroutine work, a written hazard evaluation is performed by a multidisciplinary team and, where feasible, conducted during the job planning process prior to the day of the job execution. Verify that each facility has an effective written decision-making protocol used to determine when it is necessary to shut a process down to safely perform work or conduct repairs. Ensure the program reflects the guidance in the CCPS Risk Based Process Safety book related to hazardous nonroutine work; and
c. Effective programs are in place to control of the number of essential personnel present during all hazardous nonroutine work.
2010-08-I-WA-9
Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective actions. Status: Open - Awaiting Response or Evaluation/Approval of Response