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.
2004-10-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
2004-1-I-IN-12
Conduct research into the feasibility and design of improved explosion protection for aluminum dust collector applications, including explosion venting, isolation and suppression systems. Coordinate this research activity with the Fire Protection Research Foundation. Status: Closed - Unacceptable Action/No Response Received
Conduct research into the feasibility and design of improved explosion protection for aluminum dust collector applications, including explosion venting, isolation and suppression systems. Coordinate this research activity with the Fire Protection Research Foundation.
2004-1-I-IN-13
Communicate the findings and recommendations of this report to your members Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to your members
2004-1-I-IN-11
Conduct research into the feasibility and design of improved explosion protection for aluminum dust collector applications, including explosion venting, isolation and suppression systems. Coordinate this research activity with the Aluminum Association, Inc. Status: Closed - Reconsidered/Superseded
Conduct research into the feasibility and design of improved explosion protection for aluminum dust collector applications, including explosion venting, isolation and suppression systems. Coordinate this research activity with the Aluminum Association, Inc.
2004-1-I-IN-6
Conduct regular audits of all North American facilities that produce, process, or handle aluminum chips or dust, in light of the findings of this report. Emphasize engineering, hazard, and MOC reviews and compliance with NFPA-484. Ensure that: audits are documented and contain findings and recommendations, audit findings are shared with the work force at the facility, and audit recommendations are tracked and implemented. Status: Closed - No Longer Applicable
Conduct regular audits of all North American facilities that produce, process, or handle aluminum chips or dust, in light of the findings of this report. Emphasize engineering, hazard, and MOC reviews and compliance with NFPA-484. Ensure that: audits are documented and contain findings and recommendations, audit findings are shared with the work force at the facility, and audit recommendations are tracked and implemented.
2004-1-I-IN-7
Communicate the findings and recommendations of this report to the work force at Hayes and other HLI facilities with similar operations. Status: Closed - No Longer Applicable
Communicate the findings and recommendations of this report to the work force at Hayes and other HLI facilities with similar operations.
2004-1-I-IN-1
Develop and implement a means of handling and processing aluminum chips that minimizes the risk of dust explosions. Refer to: 1. The Aluminum Association Pamphlet F-1, Guidelines for Handling Aluminum Fines Generated During Various Aluminum Fabricating Operations. 2. NFPA 484, Standard for Combustible Metals, Metal Powders, and Metal Dusts. Status: Closed - No Longer Applicable
Develop and implement a means of handling and processing aluminum chips that minimizes the risk of dust explosions. Refer to: 1. The Aluminum Association Pamphlet F-1, Guidelines for Handling Aluminum Fines Generated During Various Aluminum Fabricating Operations. 2. NFPA 484, Standard for Combustible Metals, Metal Powders, and Metal Dusts.
2004-1-I-IN-2
Implement a program to provide regular training for all facility employees on the fire and explosion hazards of aluminum dust. Status: Closed - No Longer Applicable
Implement a program to provide regular training for all facility employees on the fire and explosion hazards of aluminum dust.
2004-1-I-IN-3
Develop and implement policies and procedures for conducting engineering, hazard, and management of change (MOC) reviews of plant projects and modifications to support systems such as chip processing. In particular, ensure that a hazard analysis is conducted during the design phase, as well as during the engineering and construction phases, and when changes are made to the system. Status: Closed - No Longer Applicable
Develop and implement policies and procedures for conducting engineering, hazard, and management of change (MOC) reviews of plant projects and modifications to support systems such as chip processing. In particular, ensure that a hazard analysis is conducted during the design phase, as well as during the engineering and construction phases, and when changes are made to the system.
2004-1-I-IN-4
Implement a program to conduct management reviews of incidents and near-miss incidents, including duct fires and dust flashes. Apply this program to all plant areas, including support areas such as chip processing. Address the root causes of the incidents and near-misses and implement and track corrective measures. Status: Closed - No Longer Applicable
Implement a program to conduct management reviews of incidents and near-miss incidents, including duct fires and dust flashes. Apply this program to all plant areas, including support areas such as chip processing. Address the root causes of the incidents and near-misses and implement and track corrective measures.
2004-1-I-IN-5
Develop and implement written operating procedures for chip processing and train all affected employees. Ensure that procedures address maintenance and housekeeping. Status: Closed - No Longer Applicable
Develop and implement written operating procedures for chip processing and train all affected employees. Ensure that procedures address maintenance and housekeeping.
2004-1-I-IN-10
Provide training for fire inspectors in Indiana jurisdictions on the recognition and prevention of aluminum dust explosion hazards. Status: Closed - Unacceptable Action/No Response Received
Provide training for fire inspectors in Indiana jurisdictions on the recognition and prevention of aluminum dust explosion hazards.
2004-1-I-IN-9
Develop and distribute an educational bulletin on the prevention of metal dust explosions. Status: Closed - Acceptable Action
Develop and distribute an educational bulletin on the prevention of metal dust explosions.
2004-1-I-IN-20
Communicate findings, recommendations and sections applicable to fire codes and standards to your membership. Status: Closed - Acceptable Action
Communicate findings, recommendations and sections applicable to fire codes and standards to your membership.
2004-1-I-IN-16
Communicate the findings and recommendations of this report to your membership who work in facilities with similar combustible dust hazards. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this report to your membership who work in facilities with similar combustible dust hazards.
2004-1-I-IN-18
2004-1-I-IN-19
2004-1-I-IN-15
2004-1-I-IN-8
Communicate the findings and recommendations of this investigation to owners/operators of facilities to which Premelt supplies similar aluminum chip-melting systems. Include in your communication specific information that the chip drying process liberates small particles of aluminum, and that such particles may be explosive. Status: Closed - Acceptable Action
Communicate the findings and recommendations of this investigation to owners/operators of facilities to which Premelt supplies similar aluminum chip-melting systems. Include in your communication specific information that the chip drying process liberates small particles of aluminum, and that such particles may be explosive.
2004-1-I-IN-14
2004-1-I-IN-17