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

Universal Form Clamp Co. Explosion and Fire (2 Recommendations)
Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: April 10, 2007

2006-8-I-IL-1

Amend 1910.106 Flammable and Combustible Liquids to require facilities that handle flammable and combustible liquids to implement the requirements of 1910.38 Emergency Action Plans.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs.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concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.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

2006-8-I-IL-2

Amend 1910.38 Emergency Action Plans to require employers to conduct practice evacuation drills at least annually, but more frequently if necessary to ensure employees are prepared for emergencies.


Status: Closed - Reconsidered/Superseded
Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs.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concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.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

US Ink Fire (8 Recommendations)
New Jersey Department of Community Affairs (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 15, 2015

2013-01-I-NJ-3

Revise the exemption for “manufacturing, production, and process equipment” under the New Jersey Uniform Construction Code (N.J.A.C 5:23-2.2) to require that equipment involved in processing, handling, or conveying combustible dust comply with the design and operating requirements of the current edition of the International Building Code.


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

2013-01-I-NJ-4

Develop and implement training for local code officials on the National Fire Protection Association (NFPA) standards referenced in the New Jersey adoption of the International Building Code (IBC) for occupancies with a high hazard classification (Group H); specifically, include training on equipment that handles combustible dust and the hazards involved.


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 Status Change Summary

2013-01-I-NJ-5

Promulgate a regulation that requires all occupancies handling hazardous materials to inform the local enforcement agency of any type of construction or installation of equipment at an industrial or manufacturing facility. Also require local enforcement agencies to evaluate the information to determine whether a construction permit is required.


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 Recommendation Status Change Summary

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

Final Report Released On: January 15, 2015

2013-01-I-NJ-1

Add North American Industry Classification System (NAICS) Code 325910, Printing Ink Manufacturing, to the list of industries in Appendix D-1 or Appendix D-2 of Combustible Dust National Emphasis Program (NEP), Directive CPL 03-00-008.


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

2013-01-I-NJ-2

Communicate with all OSHA Area Offices to encourage appropriate application of the following existing provisions of the Combustible Dust NEP, Directive CPL 03-00-008:

  • Paragraph IX, Section A2, indicates that area offices may add to their Combustible Dust NEP establishment lists those facilities in their jurisdictions with a Standard Industrial Classification System code, NAICS code, or both (other than those listed in Appendices D-1 and D-2 of the Combustible Dust NEP directive) if those facilities have a known pattern of combustible dust hazards.
  • Paragraph IX, Section B4, indicates that if a fatality or catastrophe investigation is performed at a facility because of a combustible dust deflagration or explosion, the inspector shall use the guidelines in Fatality/Catastrophe Investigation Procedures, Directive CPL 02-00-137, and in the Combustible Dust NEP, Directive CPL 03-00-008.

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

PDF Document Recommendation Status Change Summary

US Ink/Sun Chemical Corporation (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 15, 2015

2013-01-I-NJ-6

At the US Ink East Rutherford facility, install automatic fire alarm systems consistent with NFPA 72 (the National Fire Alarm Code) in manufacturing areas (such as mixing) where heat generation could occur.


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 Status Change Summary

2013-01-I-NJ-7

Revise the Capital Appropriations/Asset Request (CAR) form procedure for new installations and modifications to existing equipment to require at a minimum the following:

  • Process hazard analysis (PHA)
  • Management of change (MOC)
  • Review of engineering drawings for permits
  • Safety management of contractors
  • Training of plant operators based on applicable dust collection system guidelines and standards, including NFPA 91 and NFPA 654.

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

PDF Document Recommendations Status Change Summary

2013-01-I-NJ-8

Develop and implement a management of organizational change protocol to allow for the transfer of knowledge and information to new personnel, at a minimum including initial or refresher training in the following:

  • Safety and health procedures
  • Lessons learned from previous incidents
  • Technical information for equipment
  • Routine plant operations.

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

PDF Document Status Change Summary

Valero Delaware City Refinery Asphyxiation Incident (8 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-6

Revise Guidelines for Safe Work in Inert Confined Spaces in the Petroleum and Petrochemical Industries (API, 2005) to clearly address the following: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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

PDF Document Recommendations Status Change Summary

American Society of Safety Engineers (ASSE) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-7

Revise Safety Requirements for Confined Spaces, ANSI/ASSE Z117.1 to emphasize that: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


Status: Closed - Exceeds Recommended Action
Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
 

PDF Document Recommendations Status Change Summary

Compressed Gas Association (CGA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-8

Issue a safety alert to address nitrogen/inert gas hazards in confined spaces. Emphasize that: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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.
 

Matrix Service Industrial Contractors, Inc. (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-5

Conduct confined space control and inert gas purge procedure refresher training for all affected personnel. Emphasize: - The requirements to maintain posted warnings at all access points to confined space temporary openings. - The need to maintain posted warnings, barricades, and access controls as required by the client. - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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.
 

Valero Delaware City Refinery (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-1

Conduct safe work permit refresher training for all permit-preparers and approvers and affected refinery personnel and contractors. Emphasize: - All proposed work requires a jobsite visit by the requestor and a unit operator to identify special precautions, equipment status, and personal safety equipment requirements. - The conditions for marking the "nitrogen purge or inerted" (Yes/No/NA) status box. - The permit must clearly identify all hazards and special personal protective equipment requirements. - "Fresh Air" work restrictions apply to "Set up only" permits whenever an IDLH atmosphere is suspected or known to be present in the work area.


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.
 

2006-2-I-DE-2

Conduct confined space control and inert gas purge procedure refresher training for all affected refinery personnel and contractors. Emphasize: - The requirements to maintain posted warnings at all access points to confined space temporary openings. - The requirements to maintain posted warnings, barricades, and access control log at equipment during purging. - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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.
 

Valero Energy Corporation (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 02, 2006

2006-2-I-DE-3

Audit work permit procedures and nitrogen purge safety procedures at each Valero U.S. refinery. Determine if issues identified in this Case Study are occurring elsewhere. Implement corrective action, including training, where necessary.


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.
 

2006-2-I-DE-4

Require Valero U.S. refineries to revise and conduct nitrogen hazards awareness training. Emphasize: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.


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.
 

Valero McKee Refinery Propane Fire (12 Recommendations)
American Petroleum Institute (API) (4 Recommendations)
Open: 25% | Closed: 75%

Final Report Released On: July 09, 2008

2007-5-I-TX-1

Issue API-recommended practices for freeze protection in oil refinery process units that include, as a minimum: -the establishment of a written program; -periodic inspections to identify freeze hazards in dead-legs or infrequently used piping and equipment where water could collect; -specific approaches to eliminate or protect against such freeze hazards; and -identification of infrequently used piping or equipment subject to freezing as a trigger for Management Of Change (MOC) reviews.


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

PDF Document Download

2007-5-I-TX-2

Revise API 2218, Fireproofing Practices in Petroleum and Petrochemical Processing Plants, so that conformance with the standard addresses jet fire scenarios, and requires more protective fireproofing radii and other measures (e.g., emergency isolation valves, depressuring systems) for pipe rack support steel near process units containing highly pressurized flammables.


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

PDF Document Recommendation Status Change Summary

2007-5-I-TX-3

Revise API Recommended Practice 2001, Fire Protection in Refineries, and API 2030, Application of Fixed Water Spray Systems for Fire Protection in the Petroleum Industry, so that conformance with these recommended practices includes the design, installation, and use of ROSOVs and interlocked equipment controls to enable the safe and rapid emergency isolation of process equipment containing highly pressurized flammables.


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

PDF Document Recommendations Status Change Summary

2007-5-I-TX-4

Revise API Standard 2510, Design and Construction of LPG Installations, and API Publication 2510A, Fire-Protection Considerations for the Design and Operation of Liquefied Petroleum Gas (LPG) Storage Facilities, to address effective deluge system activation during emergencies originating in nearby process units.


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.
 

United Steelworkers of America (USWA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 09, 2008

2007-5-I-TX-10

Work together to benchmark effective PHA methods and practices and implement improvements to the McKee Refinery PHA program, including: -involving the workforce in PHA preparation, performance, and follow-up; -training participants; -conducting PHA quality control checks; and -following up on recommendations for timely implementation and appropriate close-out.


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

PDF Document Download

USW Local 13-487 (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 09, 2008

2007-5-I-TX-10

Work together to benchmark effective PHA methods and practices and implement improvements to the McKee Refinery PHA program, including: -involving the workforce in PHA preparation, performance, and follow-up; -training participants; -conducting PHA quality control checks; and -following up on recommendations for timely implementation and appropriate close-out.


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

PDF Document Download

Valero Energy Corporation (5 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 09, 2008

2007-5-I-TX-5

Identify all processes in this and other refineries where Valero's mandatory Emergency Isolation Valve standard is applicable, and ensure that Remotely Operable Shut-off Valves (ROSOVs) are installed to control large accidental releases of flammable materials.


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

2007-5-I-TX-6

Establish corporate requirements for written freeze protection programs at Valero refineries subject to freezing temperatures, including identification, mitigation, MOC, and audit requirements.


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

PDF Document Recommendations Status Change Summary

2007-5-I-TX-7

Revise Valero standards, including Fire Proofing Specifications, to require evaluation of jet fire scenarios and, as a minimum, ensure more protective fireproofing for pipe rack support steel near process units containing highly pressurized flammables.


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

PDF Document Status Change Summary

2007-5-I-TX-8

Audit PHA performance at its refineries to ensure adherence to company standards and good practice guidelines.


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

PDF Document Download

2007-5-I-TX-9

Implement Valero's strategic plan to replace chlorine used as a biocide in cooling water treatment with inherently safer materials, such as sodium hypochlorite, at all refineries.


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

Valero McKee Refinery (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 09, 2008

2007-5-I-TX-10

Work together to benchmark effective PHA methods and practices and implement improvements to the McKee Refinery PHA program, including: -involving the workforce in PHA preparation, performance, and follow-up; -training participants; -conducting PHA quality control checks; and -following up on recommendations for timely implementation and appropriate close-out.


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

PDF Document Download

Veolia Environmental Services Flammable Vapor Explosion and Fire (7 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 21, 2010

2009-10-I-OH-5

Revise control room siting guidelines to reflect the diversity of characteristics that Class 1B flammable liquids can exhibit (e.g., heavy vapor, and plant areas that provide congestion and confinement).


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

PDF Document Download

Environmental Technology Council (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 21, 2010

2009-10-I-OH-7

Supersedes 2007-01-I-NC-R3, issued pursuant to EQ Hazardous Waste Plant Explosions and Fire

Develop and issue standardized guidance for the processing, handling and storage of hazardous waste to reduce the likelihood of fires, explosions, and releases at hazardous waste treatment storage and disposal facilities. Include the incident findings, consequences, conclusions, and recommendations from the CSB investigations of the Environmental Quality facility and the Veolia ES Technical Solutions.


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

2009-10-I-OH-6

Supersedes 2007-01-I-NC-R2, issued pursuant to EQ Hazardous Waste Plant Explosions and Fire

Petition the National Fire Protection Association, following the guidelines of their "Codes and Standards Development Process" (www.nfpa.org), to develop an occupancy standard specific to hazardous waste treatment, storage, and disposal facilities. The purpose of the standard would be to prescribe technical requirements for the safety to life and property from fire, explosion, and release; and to minimize the resulting damage from a fire, explosion, and release.
At a minimum, but not limited to, the standard should address:
• Hazard Identification
• Chemical Fire and Release Protection and Prevention
• Facility and Systems Design
• Employee Training and Procedures
• Inspection and Maintenance


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

PDF Document Recommendation Status Change Summary

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 21, 2010

2009-10-I-OH-4

Revise NFPA 30, Chapter 17, to include a section requiring a written engineering analysis to determine the safe separation distance for occupied buildings, control rooms, and operating areas. The analysis must be acceptable to the authority having jurisdiction.


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

Veolia ES Technical Solutions (3 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: July 21, 2010

2009-10-I-OH-1

During the rebuild of the plant, revise policy to restrict occupancy of non-essential personnel in buildings in close proximity to operating plants.


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

PDF Document Download

2009-10-I-OH-2

During the rebuild, design and install a closed relief system and develop a policy for safe venting (e.g., use of a flare) for relief systems to the atmosphere.


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

PDF Document Recommendation Status Change Summary

2009-10-I-OH-3

Conduct a process hazard analysis on all OSHA Process Safety Management covered processes to ensure all buildings and structures at the West Carrollton facility are located and designed in accordance with electrical classification and spacing as defined in NFPA 70.


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

PDF Document Download

Wacker Polysilicon Chemical Release (10 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 15, 2023

2021-01-I-TN-8

Develop and publish a safety product on Safe Work Practices, including detailed and practical guidelines for evaluating simultaneous operations (SIMOPs). The guidelines, at a minimum, should:

a. Address the content found in CCPS’s website resource for implementing Safe Work Practices; and

b. Discuss guidelines for a SIMOPs life cycle, including:

1. methods to identify SIMOPs;
2. methods to conduct a SIMOPs hazard assessment;
3. safeguards and controls pertaining to SIMOPs;
4. preparation for SIMOPs; and
5. SIMOPs execution.

In developing this safety product, consider the findings presented in the CSB report titled Fire During Hot Work at Evergreen Packaging Paper Mill and this CSB report, titled Equipment Fracture and Fatal Hydrogen Chloride Release at Wacker Polysilicon North America.


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

International Code Council (ICC) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 15, 2023

2021-01-I-TN-9

Amend the International Building Code (IBC) to address conditions that may require multiple means of egress from elevated equipment platforms used for accessing equipment containing materials that pose physical and health hazards, such as the one used at Wacker in this incident. Specify the minimum number of egress points to increase the likelihood of worker escape in the event of a hazardous material release.


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

PDF Document Recommendation Status Change Summary

National Fire Protection Association (NFPA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 15, 2023

2021-01-I-TN-10

Revise NFPA 101 Life Safety Code, NFPA 55 Compressed Gases and Cryogenic Fluids Code, or NFPA 400 Hazardous Materials Code to address conditions which may require multiple means of egress from elevated industrial structures containing hazardous materials posing physical and health hazards, regardless of their combustibility, burn rate, or likelihood of explosion. The guidance should address egress situations for workers on unwalled, elevated structures in the presence of materials posing physical and health hazards. Specify the minimum number of egress points to increase the likelihood of worker escape in the event of a hazardous material release.


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

PDF Document Recommendation Status Change Summary

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

Final Report Released On: June 15, 2023

2021-01-I-TN-1

Promulgate a standard or modify existing standards to require employers to ensure the coordination of simultaneous operations (SIMOPs) involving multiple work groups, including contractors. Ensure that the requirements of this standard or standards apply to both general industry and construction activities and are not limited to activities occurring within confined spaces. Include in the standard requirements for Employers to ensure that the following activities occur:

a. Identification of potential SIMOPs;

b. Identification of potential hazardous interactions;

c. Evaluation and implementation of necessary safeguards to allow for safe SIMOPs;

d. Coordination, including shared communication methods, between the SIMOPs; and

e. Inclusion of emergency response personnel or services in the planning and coordination of the SIMOPs.

(Superseded 2020-7-I-NC-R2 from the Evergreen report)


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

PDF Document Recommendation Status Change Summary

2021-01-I-TN-2

Develop a safety product providing guidance on the coordination of simultaneous operations (SIMOPs) involving multiple work groups, including contractors, that is not limited to confined space or construction. Provide guidance on the following activities:

a. Identification of potential SIMOPs;

b. Identification of potential hazardous interactions;

c. Evaluation and implementation of necessary safeguards to allow for safe SIMOPs;

d. Coordination, including shared communication methods, between the SIMOPs; and

e. Inclusion of emergency response personnel or services in the planning and coordination of the SIMOPs.


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

PDF Document Recommendation Status Change Summary

Tennessee Division of Occupational Safety & Health (TOSHA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 15, 2023

2021-01-I-TN-7

Promulgate a standard or modify existing standards to require employers to ensure the coordination of simultaneous operations (SIMOPs) involving multiple work groups, including contractors. Ensure that the requirements of this standard or standards apply to both general industry and construction activities and are not limited to activities occurring within confined spaces. Include in the standard requirements for Employers to ensure that the following activities occur:

a. Identification of potential SIMOPs;

b. Identification of potential hazardous interactions;

c. Evaluation and implementation of necessary safeguards to allow for safe SIMOPs;

d. Coordination, including shared communication methods, between the SIMOPs; and

e. Inclusion of emergency response personnel or services in the planning and coordination of the SIMOPs.


Status: Open - Unacceptable Response/No Response Received
Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.
 

PDF Document Recommendation Status Change Summary

Wacker Polysilicon (4 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 15, 2023

2021-01-I-TN-3

Develop detailed maintenance procedures for torquing activities which:

a. Clearly communicate differing equipment torque specifications, such as those for bolts installed at PTFE-to-PTFE and PTFE-to-graphite connections through visual means such as annotated photographs, signage, physical differentiation, and other methods, as appropriate;

b. Include procedural requirements for all torquing activities conducted on equipment containing hazardous material to perform an engineering and risk analysis and implement safeguards as a result of the risk analysis, per American Society of Mechanical Engineers (ASME) PCC-1-2019 Guidelines for Pressure Boundary Bolted Flange Joint Assembly and ANSI/ASSP Z244.1-2016 The Control of Hazardous Energy Lockout, Tagout and Alternative Methods;

c. Ensure that terms such as “hot torque” are clearly defined and that employees and contractors are trained on these terms; and

d. Ensure that procedures and training conform to the mechanical integrity requirements of the Process Safety Management (PSM) standard found in 29 CFR 1910.119(j) and the Risk Management Program (RMP) rule found in 40 CFR 68.73.


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

PDF Document Recommendation Status Change Summary

2021-01-I-TN-4

Develop policy requirements to ensure torquing activities performed on equipment containing hazardous energy are performed safely, such as through de-inventorying equipment or restriction of nonessential personnel and ensuring that essential workers wear proper PPE. Document these requirements in procedures, such as Lock, Tag and Try; First Line Break – Return to Service; or other procedures as applicable. Ensure employees and contractors are trained on these procedures in accordance with the Process Safety Management (PSM) standard requirements found in 29 CFR 1910.119(f)(4) and 29 CFR 1910.119(g) and the Risk Management Program (RMP) rule found in 40 CFR 68.69(d) and 40 CFR 68.71.


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

PDF Document Recommendation Status Change Summary

2021-01-I-TN-5

Develop and implement a formalized Simultaneous Operations (SIMOPs) program addressing planned and/or permitted co-located work tasks including:

a. Identification of potential SIMOPs;

b. Identification of potential hazardous interactions;

c. Evaluation and implementation of necessary safeguards to allow for safe SIMOPs;

d. Coordination, including shared communication methods, between the SIMOPs; and

e. Inclusion of emergency response personnel or services in the planning and coordination of the SIMOPs.

Ensure relevant staff are trained on execution of the SIMOPs program.


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

PDF Document Recommendation Status Change Summary

2021-01-I-TN-6

Install additional means of egress for the T230 desorption tower platforms and other multi-floor equipment structures on-site. After completing these installations, ensure workers are made aware of exit locations from the structure platforms through training, drills, or other techniques as appropriate.


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

Watson Grinding Fatal Explosion and Fire (2 Recommendations)
Compressed Gas Association (CGA) (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: June 29, 2023

2020-03-I-TX-1

Urge member companies that handle hazardous chemicals to share information with their customers about (1) the safety issues described in this report and (2) why their customers should develop and implement effective process safety management systems as part of their own internal safety programs, including informing member companies’ customers about CGA P-86, Guideline for Process Safety Management, the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety, or an equivalent approach.


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

PDF Document Recommendation Status Change Summary

Matheson Tri-Gas Inc. (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: June 29, 2023

2020-03-I-TX-2

Provide your customers with information about (1) the safety issues described in this report and (2) why your customers should develop and implement effective process safety management systems as part of their own internal safety programs, including informing customers about CGA P-86, Guideline for Process Safety Management, the Center for Chemical Process Safety’s Guidelines for Risk Based Process Safety, or an equivalent approach.


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