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.
2016-04-I-FL-5
Provide effective warning about nitrous oxide decomposition hazards Modify nitrous oxide pump product literature to include warnings about nitrous oxide decomposition hazards, illustrated by examples from historical incidents, and refer users to this CSB investigation report for additional information. Status: Closed - Acceptable Action
Provide effective warning about nitrous oxide decomposition hazards
Modify nitrous oxide pump product literature to include warnings about nitrous oxide decomposition hazards, illustrated by examples from historical incidents, and refer users to this CSB investigation report for additional information.
2016-04-I-FL-1
The goal of 2016-04-I-FL-R1 is to prevent all nitrous oxide explosions at its facilities, while preventing harm to workers and the public. Following the August 28, 2016, incident, the company began a comprehensive initiative to review its nitrous oxide production facilities, trucking fleet, and cylinder-filling operations. The scope of the ongoing Air Liquide initiative is shown in Table 1. Complete the development and implementation of the company’s nitrous oxide business process safety initiative as shown in Table 1, consistent with the findings, conclusions, and recommendations contained in this report. Status: Closed - Exceeds Recommended Action
The goal of 2016-04-I-FL-R1 is to prevent all nitrous oxide explosions at its facilities, while preventing harm to workers and the public.
Following the August 28, 2016, incident, the company began a comprehensive initiative to review its nitrous oxide production facilities, trucking fleet, and cylinder-filling operations. The scope of the ongoing Air Liquide initiative is shown in Table 1.
Complete the development and implementation of the company’s nitrous oxide business process safety initiative as shown in Table 1, consistent with the findings, conclusions, and recommendations contained in this report.
2016-04-I-FL-2
Safety Management System for Nitrous Oxide Manufacturing Develop and implement a safety management system standard for nitrous oxide manufacturing, to manage known process safety hazards, including nitrous oxide decomposition, which includes appropriate elements based on chemical industry good practice guidance, such as CCPS Guidelines for Risk Based Process Safety, Essential Practices for Managing Chemical Reactivity Hazards, and Guidelines for Implementing Process Safety Management. Status: Closed - Exceeds Recommended Action
Safety Management System for Nitrous Oxide Manufacturing
Develop and implement a safety management system standard for nitrous oxide manufacturing, to manage known process safety hazards, including nitrous oxide decomposition, which includes appropriate elements based on chemical industry good practice guidance, such as CCPS Guidelines for Risk Based Process Safety, Essential Practices for Managing Chemical Reactivity Hazards, and Guidelines for Implementing Process Safety Management.
2016-04-I-FL-3
Ensure Effective Flame Arrestor Design Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to require testing of safety devices, such as strainers used as flame arrestors, for applications where a safety device is used to quench a nitrous oxide decomposition reaction. To ensure that these safety devices meet the intended purpose, the user should test the safety device by simulating conditions of use. In addition, require users to document the required performance standard or test protocol followed. Status: Closed - Acceptable Alternative Action
Ensure Effective Flame Arrestor Design
Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to require testing of safety devices, such as strainers used as flame arrestors, for applications where a safety device is used to quench a nitrous oxide decomposition reaction. To ensure that these safety devices meet the intended purpose, the user should test the safety device by simulating conditions of use. In addition, require users to document the required performance standard or test protocol followed.
2016-04-I-FL-4
Require Pump Run-Dry Safety Interlocks Apply ISA-84 Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to reference and require applying International Society of Automation (ISA) standard ISA-84, Functional Safety: Safety Instrumented Systems for the Process Industry Sector to safety interlocks such as the nitrous oxide pump “run-dry” shutdown. Status: Closed - Acceptable Action
Require Pump Run-Dry Safety Interlocks Apply ISA-84
Modify Compressed Gas Association (CGA) standard CGA G-8.3, Safe Practices for Storage and Handling of Nitrous Oxide to reference and require applying International Society of Automation (ISA) standard ISA-84, Functional Safety: Safety Instrumented Systems for the Process Industry Sector to safety interlocks such as the nitrous oxide pump “run-dry” shutdown.
2016-04-I-FL-6
2011-3-I-WV-1
For all new and existing equipment and operations at AL Solutions facilities that process combustible dusts or powders, apply the following chapters of NFPA 484-2012, Standard for Combustible Metals: Chapter 12, Titanium Chapter 13, Zirconium Chapter 15, Fire Prevention, Fire Protection, and Emergency Response Chapter 16, Combustible Metal Recycling Facilities Status: Closed - Unacceptable Action/No Response Received
For all new and existing equipment and operations at AL Solutions facilities that process combustible dusts or powders, apply the following chapters of NFPA 484-2012, Standard for Combustible Metals:
2011-3-I-WV-2
Develop training materials that address combustible dust hazards and plant-specific metal dust hazards and then train all employees and contractors. Require periodic (e.g., annual) refresher training for all employees and contractors. Status: Closed - Unacceptable Action/No Response Received
Develop training materials that address combustible dust hazards and plant-specific metal dust hazards and then train all employees and contractors. Require periodic (e.g., annual) refresher training for all employees and contractors.
2011-3-I-WV-3
Prohibit the use of sprinkler systems and water deluge systems in all buildings that process or store combustible metals. Status: Closed - Unacceptable Action/No Response Received
Prohibit the use of sprinkler systems and water deluge systems in all buildings that process or store combustible metals.
2011-3-I-WV-4
Conduct a process hazard analysis as defined in NFPA 484-2012, Section 12.2.5, and submit a copy to the local fire department or the enforcing authority for the fire code. Status: Closed - Unacceptable Action/No Response Received
Conduct a process hazard analysis as defined in NFPA 484-2012, Section 12.2.5, and submit a copy to the local fire department or the enforcing authority for the fire code.
2009-3-I-VA-1 URGENT!
Take immediate action to reduce the risk of a catastrophic failure of Tanks 202, 205, and 209 at the Allied Terminals Hill Street facility including but not limited to significantly reducing the maximum liquid levels ("safe fill height") based on sound engineering principles. Report the actions taken to the City of Chesapeake. Status: Closed - No Longer Applicable
Take immediate action to reduce the risk of a catastrophic failure of Tanks 202, 205, and 209 at the Allied Terminals Hill Street facility including but not limited to significantly reducing the maximum liquid levels ("safe fill height") based on sound engineering principles. Report the actions taken to the City of Chesapeake.
2009-3-I-VA-2 URGENT!
Select and retain a qualified, independent tank engineering firm to evaluate Tanks 202, 205, and 209 and determine their fitness for continued service. The evaluation should be based on recognized and generally accepted good engineering practices, such as API 653 - Tank Inspection, Repair Alteration, and Reconstruction and API 579 - Fitness for Service. Status: Closed - No Longer Applicable
Select and retain a qualified, independent tank engineering firm to evaluate Tanks 202, 205, and 209 and determine their fitness for continued service. The evaluation should be based on recognized and generally accepted good engineering practices, such as API 653 - Tank Inspection, Repair Alteration, and Reconstruction and API 579 - Fitness for Service.
2009-3-I-VA-3 URGENT!
Within 30 days, provide the report prepared by the independent tank engineering firm to the City of Chesapeake, together with a comprehensive action plan and schedule to address any identified deficiencies. Status: Closed - No Longer Applicable
Within 30 days, provide the report prepared by the independent tank engineering firm to the City of Chesapeake, together with a comprehensive action plan and schedule to address any identified deficiencies.
2009-3-I-VA-6
Hire a qualified independent reviewer to verify that maximum liquid levels for all tanks at Allied’s Norfolk and Chesapeake terminals meet the requirements of American Petroleum Institute Standard 653, Tank Inspection, Repair, Alteration, and Reconstruction. At a minimum, the review should verify that all requirements for welding, inspection of welds, and In-Service and Out-of-Service tank inspections are met. Make the complete review report for both terminals available to the Cities of Norfolk, Chesapeake, and Portsmouth, Virginia, as well as the Virginia Department of Environmental Quality. Status: Closed - Acceptable Action
Hire a qualified independent reviewer to verify that maximum liquid levels for all tanks at Allied’s Norfolk and Chesapeake terminals meet the requirements of American Petroleum Institute Standard 653, Tank Inspection, Repair, Alteration, and Reconstruction. At a minimum, the review should verify that all requirements for welding, inspection of welds, and In-Service and Out-of-Service tank inspections are met. Make the complete review report for both terminals available to the Cities of Norfolk, Chesapeake, and Portsmouth, Virginia, as well as the Virginia Department of Environmental Quality.
2009-3-I-VA-7
Develop and implement worker safety procedures for initial filling of tanks following major modification or change-in-service. At a minimum, require the exclusion of all personnel from secondary containment during the initial filling. Status: Closed - Acceptable Action
Develop and implement worker safety procedures for initial filling of tanks following major modification or change-in-service. At a minimum, require the exclusion of all personnel from secondary containment during the initial filling.
2009-3-I-VA-4
Revise and reissue the Chemical Emergency Preparedness and Prevention Office Rupture Hazard from Liquid Storage Tanks Chemical Safety Alert. At a minimum, revise the alert to: 1) Include the Allied Terminals tank failure, 2) Discuss the increased rupture hazard during first fill or hydrostatic testing, and 3) List The Fertilizer Institute fertilizer tank inspection guidelines in the reference section. Status: Closed - Acceptable Action
Revise and reissue the Chemical Emergency Preparedness and Prevention Office Rupture Hazard from Liquid Storage Tanks Chemical Safety Alert. At a minimum, revise the alert to: 1) Include the Allied Terminals tank failure, 2) Discuss the increased rupture hazard during first fill or hydrostatic testing, and 3) List The Fertilizer Institute fertilizer tank inspection guidelines in the reference section.
2009-3-I-VA-10
Formally recommend to all member companies the incorporation of The Fertilizer Institute tank inspection guidelines into contracts for the storage of liquid fertilizer at terminals. Status: Closed - Acceptable Action
Formally recommend to all member companies the incorporation of The Fertilizer Institute tank inspection guidelines into contracts for the storage of liquid fertilizer at terminals.
2009-3-I-VA-5
Require state regulation of 100,000-gallon and larger fertilizer storage tanks (which presently are located solely along and in the area of the Elizabeth River) or authorize local jurisdictions to regulate these tanks. The regulations should: 1) Address design, construction, maintenance, and inspection of 100,000-gallon and larger liquid fertilizer storage tanks, and 2) Incorporate generally recognized and accepted good engineering practice. Status: Closed - Acceptable Action
Require state regulation of 100,000-gallon and larger fertilizer storage tanks (which presently are located solely along and in the area of the Elizabeth River) or authorize local jurisdictions to regulate these tanks. The regulations should: 1) Address design, construction, maintenance, and inspection of 100,000-gallon and larger liquid fertilizer storage tanks, and 2) Incorporate generally recognized and accepted good engineering practice.
2009-3-I-VA-8
Implement The Fertilizer Institute’s inspection guidelines as part of tank inspector training and inspection procedures for fertilizer tank inspection. Status: Closed - Acceptable Action
Implement The Fertilizer Institute’s inspection guidelines as part of tank inspector training and inspection procedures for fertilizer tank inspection.
2009-3-I-VA-9
Revise company procedures to require tank inspectors to verify that radiography required as part of the calculation for a maximum liquid level has been performed. Status: Closed - Acceptable Action
Revise company procedures to require tank inspectors to verify that radiography required as part of the calculation for a maximum liquid level has been performed.
2017-08-I-TX-1
Reduce flood risk to as low as reasonably practicable (ALARP). Ensure that any safeguards for flooding meet independent layer of protection requirements. Status: Closed - Acceptable Action
Reduce flood risk to as low as reasonably practicable (ALARP). Ensure that any safeguards for flooding meet independent layer of protection requirements.
2017-08-I-TX-2
Within 18 months, develop a policy requiring that Arkema and its subsidiaries that manufacture organic peroxides or that have processes which involve more than the threshold quantities of highly hazardous chemicals (HHC) periodically (corresponding with PHA cycle), analyze such facilities to determine whether they are at risk for extreme weather events such as hurricanes or floods. Status: Closed - Acceptable Action
Within 18 months, develop a policy requiring that Arkema and its subsidiaries that manufacture organic peroxides or that have processes which involve more than the threshold quantities of highly hazardous chemicals (HHC) periodically (corresponding with PHA cycle), analyze such facilities to determine whether they are at risk for extreme weather events such as hurricanes or floods.
2017-08-I-TX-3
Establish corporate requirements for its facilities that manufacture organic peroxides or that have processes which involve more than the threshold quantities of highly hazardous chemicals (HHC) to ensure that critical safeguards, such as backup power, function as intended during extreme weather events, including hurricanes or floods. Status: Closed - Acceptable Action
Establish corporate requirements for its facilities that manufacture organic peroxides or that have processes which involve more than the threshold quantities of highly hazardous chemicals (HHC) to ensure that critical safeguards, such as backup power, function as intended during extreme weather events, including hurricanes or floods.
2017-08-I-TX-4
Develop broad and comprehensive guidance to help companies assess their U.S. facility risk from all types of potential extreme weather events. Guidance should address the issues identified in this report and cover actions required to prepare for extreme weather, resiliency and protection of physical infrastructure and personnel during extreme weather, as well as recovery operations following an extreme weather event, where appropriate. Include guidance for each of the following: • Addressing common mode failures of critical safeguards or equipment that could be caused by extreme weather events, including but not limited to flooding. For flooding scenarios, sufficient independent layers of protection should be available if floodwater heights reach the facility. • Evaluating facility susceptibility to potential extreme weather events. Relevant safety information such as flood maps should be incorporated as process safety information. • Involving relevant professional disciplines, including engineering disciplines, to help ensure risk assessments and process hazard analyses are as robust as practicable for any given facility. Status: Closed - Acceptable Action
Develop broad and comprehensive guidance to help companies assess their U.S. facility risk from all types of potential extreme weather events. Guidance should address the issues identified in this report and cover actions required to prepare for extreme weather, resiliency and protection of physical infrastructure and personnel during extreme weather, as well as recovery operations following an extreme weather event, where appropriate. Include guidance for each of the following:
• Addressing common mode failures of critical safeguards or equipment that could be caused by extreme weather events, including but not limited to flooding. For flooding scenarios, sufficient independent layers of protection should be available if floodwater heights reach the facility.
• Evaluating facility susceptibility to potential extreme weather events. Relevant safety information such as flood maps should be incorporated as process safety information.
• Involving relevant professional disciplines, including engineering disciplines, to help ensure risk assessments and process hazard analyses are as robust as practicable for any given facility.
2017-08-I-TX-5
Update your emergency operations training using lessons learned from the Arkema incident to help ensure that personnel enforcing evacuation perimeters are not harmed by exposure to hazardous chemical releases. Update existing protocols and revise training curricula to include the use of analytical tools, air monitoring, and personal protective equipment, to provide appropriate protection when emergency equipment or personnel need to be moved through an evacuation zone during a hazardous materials release. Include a process for periodic refresher training. Status: Closed - Acceptable Action
Update your emergency operations training using lessons learned from the Arkema incident to help ensure that personnel enforcing evacuation perimeters are not harmed by exposure to hazardous chemical releases. Update existing protocols and revise training curricula to include the use of analytical tools, air monitoring, and personal protective equipment, to provide appropriate protection when emergency equipment or personnel need to be moved through an evacuation zone during a hazardous materials release. Include a process for periodic refresher training.
2007-6-I-KS-4
Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. Status: Closed - Acceptable Action
Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.
2007-6-I-KS-3
Revise ANSI Z400.1 to advise chemical manufacturers and importers that prepare MSDSs to: -Identify and include a warning for materials that are static-accumulators and that may form ignitable vapor-air mixtures in storage tanks; -Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)); and -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. Status: Closed - Acceptable Action
Revise ANSI Z400.1 to advise chemical manufacturers and importers that prepare MSDSs to: -Identify and include a warning for materials that are static-accumulators and that may form ignitable vapor-air mixtures in storage tanks; -Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)); and -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.
2007-6-I-KS-5
2007-6-I-KS-6
2007-6-I-KS-7
2007-6-I-KS-8
2007-6-I-KS-1
Revise the "Guidance for Hazard Determination for compliance with the OSHA Hazard Communication Standard" to advise chemical manufacturers and importers that prepare MSDSs to: -Evaluate flammable liquids to determine their potential to accumulate static electricity and form ignitable vapor-air mixtures in storage tanks. -Test the conductivity of the flammable liquid and include the testing results in the MSDS. Status: Open - Acceptable Response or Alternate Response
Revise the "Guidance for Hazard Determination for compliance with the OSHA Hazard Communication Standard" to advise chemical manufacturers and importers that prepare MSDSs to: -Evaluate flammable liquids to determine their potential to accumulate static electricity and form ignitable vapor-air mixtures in storage tanks. -Test the conductivity of the flammable liquid and include the testing results in the MSDS.
2007-6-I-KS-2
Prior to the next revision, communicate to the Sub-Committee on the Globally Harmonized System of Classification and Labeling of Chemicals (SCEGHS) the need to amend the GHS to advise chemical manufacturers and importers that prepare MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. Status: Closed - Acceptable Action
Prior to the next revision, communicate to the Sub-Committee on the Globally Harmonized System of Classification and Labeling of Chemicals (SCEGHS) the need to amend the GHS to advise chemical manufacturers and importers that prepare MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.
2007-6-I-KS-9