The CSB issues safety recommendations to prevent the recurrence or reduce the likelihood or consequences of similar incidents or hazards in the future. Recommendations are issued to a variety of parties, including government entities, safety organizations, trade unions, trade associations, corporations, emergency response organizations, educational institutions, and public interest groups. Recommendations are published in CSB reports and are closed only by vote of the Board. The CSB tracks all recommendations and communicates regularly with recommendations recipients to ensure that the recommended corrective actions are implemented.

For more information, see Frequently Asked Questions about CSB recommendations.


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Recommendations

Sterigenics Ethylene Oxide Explosion (1 Recommendations)
Environmental Protection Agency (EPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: March 30, 2006

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
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Tesoro Anacortes Refinery Fatal Explosion and Fire (4 Recommendations)
Environmental Protection Agency (EPA) (4 Recommendations)
Open: 50% | Closed: 50%

Final Report Released On: May 01, 2014

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
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

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
Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).
 

PDF Document Recommendations Status Change Summary

2010-08-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
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

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
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
 

PDF Document Recommendations Status Change Summary

West Fertilizer Explosion and Fire (3 Recommendations)
Environmental Protection Agency (EPA) (3 Recommendations)
Open: 33% | Closed: 67%

Final Report Released On: January 28, 2016

2013-02-I-TX-1

Develop a guidance document on Emergency Planning and Community Right-to-Know Act (EPCRA) requirements that is issued annually to State Emergency Response Commissions(SERCs) and Local Emergency Planning Committees (LEPCs) and ensure that the guidance focuses on the following:

a. Explains which chemicals are exempt and which must be reported.

b. Describes how emergency responders should use Tier I and Tier II inventory reports and Safety Data Sheets, such as in safety training, practice drills, and for emergency planning.

c. Includes comprehensive LEPC planning requirements, with an emphasis on annual training exercises and drills for local emergency response agencies.


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

PDF Document Recommendation Status Change Summary

2013-02-I-TX-2

Develop a general guidance document on the agricultural exemption under EPCRA Section311(e)(5) and its associated regulation, 40 CFR 370.13(c)(3), to clarify that fertilizer facilities that store or blend fertilizer are covered under EPCRA.  Communicate to the fertilizer industry publication of this guidance document as well as the intention of Section 311(e)(5).


Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

PDF Document Recommendation Status Change Summary

2013-02-I-TX-3

Revise the Risk Management Program rule to include fertilizer grade ammonium nitrate (FGAN) at an appropriate threshold quantity on the List of Regulated Substances.

a. Ensure that the calculation for the offsite consequence analysis considers the unique explosive characteristics of FGAN explosions to determine the endpoint for explosive effects and overpressure levels.  Examples of such analyses include that adopted by the 2014 Fire Protection Research Foundation report, “Separation Distances in NFPA Codes and Standards,” Great Britain’s Health and Safety Executive, and other technical guidance.

b. Develop Risk Management Program rule guidance document(s) for regulated FGAN facilities.


Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

PDF Document Recommendation Status Change Summary