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

Didion Milling Company Explosion and Fire (13 Recommendations)
Didion Milling, Inc. (9 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 06, 2023

2017-07-I-WI-1

Contract a competent third party to develop a comprehensive combustible dust process safety management system, such as OSHA’s Process Safety Management standard or the requirements in the 2019 edition of NFPA 652, Standard on the Fundamentals of Combustible Dust, Chapter 8, which includes, at a minimum, the following elements:

a. Management of Change for combustible dust;

b. Process Safety Information Management;

c. Management of Audits and Inspections;

d. Fugitive Dust Management;

e. Incident Investigation;

f. Dust Hazard Analyses;

g. Management of Engineering Controls for combustible dust

h. Personal Protective Equipment; and

i. Emergency Preparedness.


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

2017-07-I-WI-2

Contract a competent third party to develop and implement modifications to the pneumatic conveying and dust collector ductwork systems in accordance with guidance such as NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, NFPA 652, Standard on the Fundamentals of Combustible Dust, and NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids, to include, at a minimum:

a. Ensure minimum required transport velocity is maintained throughout the system.

b. Implement a periodic inspection and testing program for pneumatic conveying and dust collector ductwork systems, following industry guidance such as NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Particulate Solids, and FM Global guidance. The program should include cleaning on a set frequency and measuring transport velocities on a routine basis to ensure proper system function.


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

2017-07-I-WI-3

Contract a competent third party to perform dust hazard analyses (DHAs) on all buildings and units that process combustible dust. Ensure that the DHAs are revalidated at least every five years. Implement pre-deflagration detection, deflagration venting, deflagration suppression, deflagration isolation, and deflagration pressure containment engineering controls identified in the initial and revalidation DHA in accordance with NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, NFPA 68, Standard on Explosion Protection by Deflagration Venting, NFPA 69, Standard on Explosion Prevention Systems, and NFPA 652, Standard on the Fundamentals of Combustible Dust.


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

2017-07-I-WI-4

Contract a competent third party to assess and implement engineering controls for the structural design and venting requirements of the reconstructed facility to ensure they meet the requirements and guidance in NFPA 68, Standard on Explosion Protection by Deflagration Venting, for adequacy of venting capacity.


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

2017-07-I-WI-5

Incorporate recording any paper-based process safety information into Didion’s existing electronic records management system so that the information can be reliably retained, retrieved, and analyzed in the event of a catastrophic incident.


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

2017-07-I-WI-6

Contract a competent third party to perform personal protective equipment hazard analyses, such as those prescribed by NFPA 2113, Standard on Selection, Care, Use, and Maintenance of Flame-Resistant Garments for Protection of Industrial Personnel Against Short-Duration Thermal Exposures from Fire, and require appropriate flame-resistant garments for all operations that handle combustible dusts during normal and upset conditions.


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

2017-07-I-WI-7

Contract a competent third party to update the facility emergency response plan and train all employees on updated emergency response plan. The update should include the guidance in NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, and NFPA 652, Standard on the Fundamentals of Combustible Dust, Chapter 8 and Section A.8.10.1, which includes, at a minimum, the following elements:

a. A signal or alarm system;

b. Emergency shutdown procedures; 

c. Provide instructions for when and how to trigger emergency evacuations;

d. Provide instructions for when to notify emergency responders for need of assistance;

e. Response to potential fire scenarios, such as smoldering fires inside equipment; and

f. Prevent firefighting of process fires inside equipment.


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

2017-07-I-WI-8

Contract a competent third party to assess and update the pre-deflagration detection and suppression engineering controls, such as those discussed in Chapter 9 of the 2019 edition of NFPA 69, Standard on Explosion Prevention Systems, for adequacy to detect and alarm employees of an emergency situation, such as a smoldering fire, and trigger an evacuation.


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

2017-07-I-WI-9

Contract a competent third party to develop and implement a process safety leadership and culture program, based on the guidance of the CCPS’s Guidelines for Auditing Process Safety Management Systems and Process Safety: Leadership from the Boardroom to the Frontline. The program should include, at a minimum, the following elements:

a. A process safety policy;

b. A process safety leadership and culture committee;

c. Appropriate goals for process safety;

d. A commitment to process safety culture;

e. Leading and lagging process safety metrics;

f. Process Safety Culture Assessments; and,

g. Engagement with external process safety leadership and culture experts.


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%
View Investigation
Final Report Released On: December 06, 2023

2017-07-I-WI-13

Update NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, or a successor standard, to incorporate, at a minimum, the following elements:

1. Unify the requirements for performing dust hazard analyses to remove equipment exemptions and require the assessment of all processes, such as cyclones, as required in:

a. The 2019 edition of NFPA 652, Standard on the Fundamentals of Combustible Dust

b. Chapters 3, 5, and 6 of the CCPS’s Guidelines for Combustible Dust Hazard Analysis.

2. Incorporate the additional guidance for Management of Change to include but not limited to:

a. Harmonize the 2019 edition of NFPA 652, Standard on the Fundamentals of Combustible Dust, requirements for section 8.12.2.4, modifications to operating and maintenance procedures, and section 8.12.2.4, employee training requirements.

b. Chapter 3 and Appendix B of the CCPS’s Guidelines for the Management of Change for Process Safety, such as addressing temporary changes, operating and maintenance procedures, employee training, and dust testing results, to standardize MOC requirements across all industries that handle combustible dust.

3. Update the requirements for incident investigation management systems, to include but not limited to:

a. Incorporate the optional guidance of the 2019 edition of NFPA 652, Standard on the Fundamentals of Combustible Dust, as a mandatory requirement.

b. Chapters 4 and 10 of CCPS’s Guidelines for Investigating Process Safety Incidents (3rd Edition).  


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

Occupational Safety and Health Administration (OSHA) (3 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: December 06, 2023

2017-07-I-WI-10

Promulgate a standard for all industries that handle combustible dust, which should be based on the requirements of current NFPA combustible dust standards, including NFPA 61, Standard for the Prevention of Fires and Dust Explosions in Agricultural and Food Processing Facilities, NFPA 484, Standard for Combustible Metals, NFPA 652, Standard on the Fundamentals of Combustible Dust, NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids, NFPA 655, Standard for Prevention of Sulfur Fires and Explosions, NFPA 664, Standard for the Prevention of Fires and Explosions in Wood Processing and Woodworking Facilities, or a successor standard. At a minimum, the standard should include the following elements:

a. Hazard Recognition;

b. Dust Hazard Analysis;

c. Management of Change;

d. Incident Investigation;

e. Engineering Controls;

f. Building Design;

g. Fugitive Dust Management;

h. Operating Procedures;

i. Process Safety Information; 

j. External Audit Management;

k. Training;

l. Emergency Response; and

m. Personal Protective Equipment.

(Superseded the following recommendations: 2006-1-H-R1 from the Combustible Dust Hazard investigation, 2008-05-I-GA-R11 from the Imperial Sugar investigation, and 2011-04-I-TN-R1 and 2011-04-I-TN-R2 from the Hoeganaes Corporation investigation)


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

2017-07-I-WI-11

Following implementation of CSB Recommendation No. 2017-07-I-WI-R10, update the Grain Handling Facilities Standard to clarify grain handling facilities with combustible dust are covered by the new Combustible Dust Standard.


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

2017-07-I-WI-12

Develop a program to trigger follow-up inspections when hazard alert letters are issued for combustible dust hazards and there is insufficient evidence to demonstrate that those hazards have been abated.


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

Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire (12 Recommendations)
Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: January 17, 2013

2011-06-I-HI-12

Effectively participate in the National Fire Protection Association’s standard development process to develop guidance on the safe disposal of fireworks, as recommended under recommendation 2011-06-I-HI-R7.


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendation Status Change Summary

Department of the Treasury - Office of the Procurement Executive (OPE) (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: January 17, 2013

2011-06-I-HI-2

Establish formal policy requiring that: • Solicitations for contracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, incorporate rigorous safety-related contractor selection provisions such as those provided in the DoD’s Contractor’s Safety Manual for Ammunition and Explosives, Section C1.5, “Pre-Award Safety Survey”; and • Contracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, include a provision requiring that any subcontract (regardless of tier) for the storage, handling, and disposal of explosives (including fireworks) be selected based on rigorous safety-related contractor selection provisions such as those provided in the DOD's Contractor Safety Manual for Ammunition and Explosives, Section C1.5, "Pre-Award Safety Survey."


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.
 

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2011-06-I-HI-3

Establish a formal policy requiring that contracts and subcontracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, incorporate rigorous safety-related contractor oversight provisions such as those provided in the DoD’s Contractor’s Safety Manual for Ammunition and Explosives, Section C1.6, “Pre-Operational Safety Survey” and C1.7, “Post-Award Contractor Responsibilities” to provide effective oversight of subcontractors handling and disposing of explosives and hazardous 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 Download

2011-06-I-HI-4

When the NFPA guidance developed by the National Fire Protection Association for the safe disposal of fireworks as recommended under recommendation 2011-06-I-HI-R7 is completed, incorporate this document by reference into the formal policies established by 2011-06-I-HI-R2 and 2011-06-I-HI-R3.


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

Environmental Protection Agency (EPA) (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: January 17, 2013

2011-06-I-HI-9

Revise the Resource Conservation and Recovery Act (RCRA) Subtitle C regulations to require a permitting process with rigorous safety reviews to replace the use of emergency permits under 40 CFR §270.61 for the disposal of explosive hazardous materials, including fireworks. At a minimum, the new process should require the use of best available technology, safe disposal methodologies, as well as safety management practices, such as those required by OSHA’s Process Safety Management Standard (PSM), 29 CFR §1910.119 (e.g., hazard analysis and control, management of change).


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendations Status Change Summary

2011-06-I-HI-10

Until recommendation 2011-06-I-HI-R9 can be implemented, develop and issue a policy guidance document to provide a regulatory process with rigorous safety reviews to replace the use of emergency permits under 40 CFR §270.61 for the disposal of explosive hazardous materials, including fireworks. At a minimum, the new process should require the use of best available technology, safe disposal methodologies, as well as safety management practices, such as those required by OSHA’s Process Safety Management Standard (PSM), 29 CFR §1910.119 (e.g., hazard analysis and control, management of change). Ensure its effective communication to all EPA regional administrators, state environmental agencies, and organizations within the fireworks industry


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

2011-06-I-HI-11

Effectively participate in the National Fire Protection Association’s standard development process to develop guidance on the safe and environmentally sound disposal of fireworks, as recommended under recommendation 2011-06-I-HI-R7. Status


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

Federal Acquisition Regulatory (FAR) Council (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: January 17, 2013

2011-06-I-HI-1

Establish an additional contractor responsibility determination requirement under Subpart 9.104-1 of the Federal Acquisition Regulation (FAR) addressing contractor safety performance. The analysis under this requirement should focus on incident prevention, and environmental and system safety. At a minimum, the language should specifically require the review of a prospective contractor’s: • Environmental and safety programs; • Safety record and incident history; • Ability to use safe methods for any work involving hazardous materials (including explosives); and • Suitable training and qualifications for the personnel involved in the work including prior relevant safety experience.


Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

PDF Document Recommendations Status Change Summary

National Fire Protection Association (NFPA) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: January 17, 2013

2011-06-I-HI-7

Develop a new standard, or incorporate within an existing standard, best practices for the safe disposal of waste fireworks that are consistent with environmental requirements. At a minimum this guidance or standard should: • Discourage the disassembly of waste fireworks as a step in the disposal process; • Minimize the accumulation of waste explosive materials, and encourage practices that reduce, recycle, reuse,or repurpose fireworks; and • Incorporate input from ATF, EPA, and other agencies, experts, and available resources on fireworks disposal methodologies.


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

2011-06-I-HI-8

Once fireworks disposal best practices under recommendation 2011-06-I-HI-R7 is completed, develop and implement an outreach plan to promptly communicate the new NFPA practices to relevant government agencies and private entities that dispose of waste fireworks


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

Treasury Executive Office for Asset Forfeiture (TEOF) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: January 17, 2013

2011-06-I-HI-5

Require additional provisions within the TEOAF seized property management contract, such as a contract line item number (CLIN), that provide for the prime contractor to use expert(s) to assist the prime contractor’s personnel in the selection and oversight of subcontractors who handle, store, or dispose of explosive hazardous materials, including fireworks, pursuant to the main contract.


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

VSE Corporation (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: January 17, 2013

2011-06-I-HI-6

Use experts to: • Assist VSE procurement in selecting vendors to properly handle, store, and dispose of explosive hazardous materials, including fireworks, pursuant to prime contract requirements; and, • Assist VSE personnel in overseeing the work to ensure it is being conducted safely. Status:


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

DPC Enterprises Festus Chlorine Release (24 Recommendations)
Agency for Toxic Substances and Disease Registry (ATSDR) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 01, 2003

2002-04-I-MO-17

Work with State and local agencies to address concerns about the long-term health effects of the chlorine release in Festus, Missouri, and communicate your findings to the community.


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).
 

Branham Corporation (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 01, 2003

2002-04-I-MO-11

Implement a materials verification procedure to improve quality assurance during chlorine transfer hose fabrication and shipment, such that hoses shipped to customers are readily identifiable and meet required specifications.


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.
 

Chlorine Institute (4 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 01, 2003

2002-04-I-MO-18

Work with the Association of Hose and Accessories Distributors (NAHAD) and chlorine hose manufacturers, such as Crane-Resistoflex, to develop and implement a recommended practice requiring continuous positive identification (e.g., coding, stenciling, stamping) throughout the supply chain, from manufacturing to the end user of the product.


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.
 

2002-04-I-MO-19

Develop recommended practices to address moisture in dry chlorine piping systems. Include information on suggested material specifications, prevention and corrective measures, and adverse consequences (particularly for emergency shutdown [ESD] systems).


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.
 

2002-04-I-MO-20

Develop recommended practices for testing, inspection, and preventative maintenance of ESD systems for bulk transfer of chlorine.


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.
 

2002-04-I-MO-21

Communicate the findings and recommendations of this report to your membership.


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.
 

DPC Enterprises, Festus Site (7 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 01, 2003

2002-04-I-MO-1

Revise the mechanical integrity program: Develop and implement a quality assurance management system, such as positive materials identification, to confirm that chlorine transfer hoses (CTH) are of the appropriate materials of construction.


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.
 

2002-04-I-MO-2

Revise the mechanical integrity program: Implement procedures and practices to ensure the emergency shutdown (ESD) system operates properly. Include procedures to verify that the ESD valves will close to shut down the flow of chlorine.


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.
 

2002-04-I-MO-3

Revise the mechanical integrity program: Revise the preventive maintenance and inspection program for the chlorine transfer system to address moisture-related corrosion. Evaluate and correct any problems associated with corrosion that could potentially lead to chlorine transfer and safety system failure.


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.
 

2004-04-I-MO-4

Revise the mechanical integrity program: Require periodic inspection of the above critical safety systems by the operations or facility manager.


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.
 

2002-04-I-MO-5

Revise the Emergency Response Plan: Develop procedures to clearly designate the roles and responsibilities of facility emergency response personnel, including post-incident remediation.


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.
 

2002-04-I-MO-6

Revise the Emergency Response Plan: Develop and implement a timetable for drills to test emergency response personnel on various levels of response, including a large uncontrolled release that could affect the public. Coordinate these drills with local emergency response authorities. Provide a copy of the revised Emergency Response Plan to the local emergency planning committee, and review the plan with the committee and the local fire department. Work with these authorities to implement an improved community emergency notification system.


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.
 

2002-04-I-MO-7

Revise the Emergency Response Plan: Improve accessibility of equipment required for emergency response, considering likely response scenarios.


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.
 

DX Group (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 01, 2003

2002-04-I-MO-8

In light of the findings of this report, conduct periodic audits of the safety management systems involved in this incident, such as mechanical integrity, emergency response, and material quality assurance. Ensure that the audit recommendations are tracked and implemented. Share findings and recommendations with the work force at your repackaging facilities.


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.
 

2002-04-I-MO-9

To improve supervision of day-to-day operations, revise your corporate safety management training program on chlorine repackaging operations. Emphasize safety critical systems, including verification of safety system performance.


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.
 

2002-04-I-MO-10

Communicate the findings and recommendations of this report to all DPC facilities.


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.
 

Jefferson County Emergency Management Agency (EMA) (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 01, 2003

2002-04-I-MO-12

Work with DPC to implement a community notification system that will immediately alert neighboring residents and businesses of a chemical release.


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.
 

2002-04-I-MO-13

Work with DPC, local emergency planning and response authorities in Jefferson and adjacent counties, the City of Festus, and Crystal City to improve overall response and mitigation time.


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.
 

2002-04-I-MO-14

Communicate the findings and recommendations of this report to your membership.


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.
 

Missouri Department of Natural Resources (DNR) and other Appropriate Agencies (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 01, 2003

2002-04-I-MO-16

In collaboration with appropriate agencies, hold a community meeting in Festus, Missouri, to hear concerns raised by local citizens affected by the DPC incident and to respond to issues raised by the community.


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).
 

Missouri State Emergency Response Commission (MERC) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 01, 2003

2009-04-I-MO-15

Communicate the findings and recommendations of this report to local emergency planning committees (LEPC), emergency management agencies (EMA), and local fire departments.


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.
 

National Association of Chemical Distributors (NACD) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 01, 2003

2009-04-I-MO-24

Communicate the findings and recommendations of this report to your membership.


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.
 

National Association of Hose and Accessories Distributors (NAHAD) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 01, 2003

2002-04-I-MO-22

Work with The Chlorine Institute and chlorine hose manufacturers, such as Crane-Resistoflex, to develop and implement a recommended practice requiring continuous positive identification (e.g.,coding, stenciling, stamping) throughout the supply chain, from manufacturing to the end user of the product.


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.
 

2009-04-I-MO-23

Communicate the findings and recommendations of this report to your membership.


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.
 

DPC Enterprises Glendale Chlorine Release (14 Recommendations)
Chlorine Institute (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 28, 2007

2004-2-I-AZ-14

Clarify the chemistry involved in over-chlorination incidents so that "Chlorine Scrubbing Systems, Pamphlet 89," and other pertinent publications: -Ensure that the recommended practices and safeguards prevent, mitigate, and control hazardous releases due to bleach decomposition. -Provide sufficient detail on the safety and environmental consequences of over-chlorination to enable companies to provide emergency responders with information on the potential characteristics of over-chlorination events, and on the best means of mitigating the bleach decomposition reaction following a release.


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.
 

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DPC Enterprises, L.P. (6 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 28, 2007

2004-2-I-AZ-1

Establish and implement DPC corporate engineering standards that include adequate layers of protection on chlorine scrubbers at DPC facilities, including: -additional interlocks and shutdowns, such as automatically stopping chlorine flow to the scrubber upon oxidation-reduction potential alarm; -mitigation measures, such as systems to automatically add caustic to over-chlorinated scrubbers, or back-up scrubbing capability to treat emissions from over-chlorinated scrubbers; -increases in the final caustic concentration in the scrubbers to eight percent or higher to provide a substantial safety margin against over-chlorination; and -use of the site's continuous bleach manufacturing system to convert scrubber solution to saleable bleach.


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.
 

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2004-2-I-AZ-2

Revise scrubber SOPs to include: -clearly described operating limits and warnings about the consequences of exceeding those limits, and -the safety and environmental hazards associated with scrubber over-chlorination.


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

2004-2-I-AZ-3

Train employees on the revised SOPs and include a test to verify understanding. Periodically review operator understanding of and conformance to the scrubber SOPs.


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.
 

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2004-2-I-AZ-4

Include scrubber operation in facility PHAs. Ensure that they: -include lessons learned from this incident and other DPC scrubber incidents, as well as industry experience with over-chlorination, and -consider off-site consequences when evaluating the adequacy of existing safeguards.


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.
 

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2004-2-I-AZ-5

Use a qualified, independent auditor to evaluate DPC's PSM and RMP programs against best practices. Implement audit recommendations in a timely manner at all DPC chlorine repackaging sites.


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.
 

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2004-2-I-AZ-6

Implement a recognized safety management system, including third party verification and certification, to achieve documented continuous improvement in safety performance at Glendale and the other DPC chlorine repackaging sites.


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.
 

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Glendale, AZ Fire Department (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 28, 2007

2004-2-I-AZ-7

Work with the Glendale Police Department to integrate them into the incident command structure during hazardous material incidents, and address communications issues, such as radio interoperability, to ensure the timely transmission of critical safety information to responding officers.


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.
 

2004-2-I-AZ-8

Conduct hazardous materials exercises with the Glendale Police Department to identify and resolve police/fire integration issues. Coordinate exercise planning with the Arizona Division of Emergency Management Exercise Officer and with the Maricopa County LEPC. Schedule periodic hazardous materials incident drills to ensure safe and effective responses to future hazardous materials incidents.


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.
 

Glendale, AZ Police Department (4 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 28, 2007

2004-2-I-AZ-9

Work with the Glendale Fire Department to integrate the Glendale Police Department into the command structure during hazardous material incidents, and address communications issues, such as radio interoperability, to ensure the timely transmission of critical safety information to responding officers.


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.
 

2004-2-I-AZ-10

Ensure that police officers responding to hazardous material incidents are briefed on specific incident conditions, and are equipped with and trained on the proper use, capabilities, and limitations of appropriate protective equipment.


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.
 

2004-2-I-AZ-11

Ensure that police officers receive hazardous materials - operations level training, and annual hazardous materials and air purifying respirator (APR) refresher training.


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.
 

2004-2-I-AZ-12

Conduct exercises with the Glendale Fire Department to identify and resolve police/fire integration issues. Coordinate exercise planning with the Arizona Division of Emergency Management Exercise Officer and with the Maricopa County LEPC. Schedule periodic hazardous materials incident drills to ensure safe and effective responses to future hazardous materials incidents.


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.
 

Maricopa County Department of Air Quality (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: February 28, 2007

2004-2-I-AZ-13

Revise DPC's permitted operating conditions to specify a minimum scrubber caustic concentration of 8 percent or more, as determined by laboratory measurement, with measurements taken daily and upon completion of each scrubber batch.


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.
 

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DuPont Belle Toxic Chemical Releases (14 Recommendations)
American Chemistry Council Phosgene Panel (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 20, 2011

2010-06-I-WV-11

Revise the Phosgene Safe Practice Guidelines Manual  to

  • Advise against the use of hoses for phosgene transfer that are constructed of permeable cores and materials subject to chlorides corrosion.
  • Include guidance for the immediate reporting and prompt investigation of all potential (near-miss) phosgene releases.

 


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

Compressed Gas Association (CGA) (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 20, 2011

2010-06-I-WV-9

Revise CGA P-1, Safe Handling of Compressed Gases in Containers, to include specific requirements for storing and handling highly toxic compressed gas, including enclosure ventilation and alarm requirements at least as protective as Section 7.9, Toxic and Highly Toxic Gases and NFPA 55, Compressed Gases and Cryogenics Fluids 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.
 

2010-06-I-WV-10

Revise CGA P-1, Safe Handling of Compressed Gases in Containers, to incorporate by reference CGA E-9, Standard for Flexible, PTFE-lined Pigtails for Compressed Gas Service.


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.
 

DuPont Belle Plant (3 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 20, 2011

2010-06-I-WV-3

Improve the existing maintenance management by

  • Supplementing the computerized system with sufficient redundancy to ensure tracking and timely scheduling of preventive maintenance for all PSM-critical equipment.
  • Conducting Management-of-Change (MOC) reviews for all changes to preventive maintenance orders for all PSM-critical equipment in the computerized maintenance management system.

 


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 Summary Change

2010-06-I-WV-4

Revise the facility emergency response protocol to require that a responsible and accountable DuPont employee always be available (all shifts, all days) to provide timely and accurate information to the Kanawha County Emergency Ambulance Authority (KCEAA) and Metro 9-1-1 dispatchers.


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.
 

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2010-06-I-WV-5

Revise the near-miss reporting and investigation policy and implement a program that includes the following at a minimum:

  • Ensures employee participation in reporting, investigating, analyzing, and recommending corrective actions as appropriate for all near-misses and disruptions of normal operations.
  • Develops and encourages use of an anonymous electronic and/or hard copy near-miss reporting process for all DuPont Belle site employees.
  • Establishes roles and responsibilities for ownership, management, execution, and resolution of recommendations from incident or near-miss investigations at the DuPont Belle facility.
  • Ensures that the near-miss investigation program requires prompt investigations, as appropriate, and that results are promptly circulated to well-suited recipients throughout the DuPont Corp.
  • Ensures that this program is operational at all times (e.g. nights, weekends, and holiday shifts).

 


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.
 

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E. I. duPont de Nemours and Company (6 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: September 20, 2011

2010-06-I-WV-6

Revise safeguards for phosgene handling at all DuPont facilities by

  • Requiring that all indoor phosgene production and storage areas, as defined in NFPA 55, have secondary enclosures, mechanical ventilation systems, emergency phosgene scrubbers, and automated audible alarms, which are, at a minimum, consistent with the standards of NFPA 55 for highly toxic gases.
  • Prohibiting the use of hoses with permeable cores and materials susceptible to chlorides corrosion for phosgene transfer.
  • Conducting annual phosgene hazard awareness training for all employees who handle phosgene, including the hazards associated with thermal expansion of entrapped liquid phosgene in piping and equipment.

 


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

2010-06-I-WV-7

Review all DuPont units that produce and handle phosgene that, at a minimum, observe and document site-specific practices for engineering controls, construction materials, PPE, procedures, maintenance, emergency response, and release detection and alarms, and use information from external sources to develop and implement consistent company-wide policies for the safe production and handling of phosgene.


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 Summary Change

2010-06-I-WV-8

For each DuPont facility that uses, but does not manufacture, phosgene onsite:

  • Conduct a risk assessment of manufacturing phosgene onsite against the current configuration.
  • Communicate the findings of each assessment to compile recommendations applicable to all DuPont phosgene delivery systems.
  • Implement these recommendations.

 


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

2010-06-I-WV-12

Commission an audit in consultation with operations personnel to establish and identify the conditions that cause nuisance alarms at all DuPont facilities. Establish and implement a corporate alarm management program as part of the DuPont PSM Program, including measures to prevent nuisance alarms and other malfunctions in those systems. Include initial and refresher training as an integral part of this effort.


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.
 

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2010-06-I-WV-13

Revise the DuPont PSM standard to require confirmation that all safety alarms/interlocks are in proper working order (e.g., not in an active alarm state) prior to the start-up of all Higher-Hazard Process facilities.


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

2010-06-I-WV-14

Reevaluate and clarify the DuPont corporate MOC policies to ensure that staff can properly identify and use the distinctions between subtle and full changes and train appropriate personnel how to properly apply the distinctions on any changes in the policy.


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

Occupational Safety and Health Administration (OSHA) (2 Recommendations)
Open: 50% | Closed: 50%
View Investigation
Final Report Released On: September 20, 2011

2010-06-I-WV-1

Revise OSHA 29 CFR 1910.101, General Industry Standard for Compressed Gases, to require facilities that handle toxic and highly toxic materials in compressed gas cylinders to incorporate provisions that are at least as effective as the 2010 edition of Section 7.9, Toxic and Highly Toxic Gases, in National Fire Protection Association (NFPA) 55, Compressed Gases and Cryogenic Fluids Code, including enclosures, ventilation and treatment systems, interlocked fail-safe shutdown valves, gas detection and alarm systems, piping system components, and similarly relevant layers of protection.


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

2010-06-I-WV-2

Take sustained measures to minimize the exposure of hazards to workers handling highly toxic gases from cylinders and associated regulators, gages, hoses, and appliances. Ensure that OSHA managers, compliance officers, equivalent state OSHA plan personnel, and regulated parties conform, under the Process Safety Management Standard (29 CFR 1910.119) Recognized and Generally Accepted Good Engineering Practices (RAGAGEP) provisions, to industry practices at least as effective as the following:

  1. NFPA 55 - Compressed Gases and Cryogenic Fluids Code (2010)
  2. CGA P-1 Safe Handling of Compressed Gases in Containers (2008)
  3. CGA E-9 Standard for Flexible, PTFE-lined Pigtails for Compressed Gas Service (2010)
  4. ASME B31.3 Process Piping (2008)

 


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

DuPont La Porte Facility Toxic Chemical Release (9 Recommendations)
DuPont LaPorte, Texas Chemical Facility (7 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 25, 2019

2015-01-I-TX-1

Prior to resuming Insecticide Business Unit (IBU) manufacturing operations, conduct a comprehensive
engineering analysis of the manufacturing building and the discharge of pressure relief systems with toxic
chemical scenarios to assess potential inherently safer design options. At a minimum, evaluate the use of
an open building structure, and the direction of toxic chemical leaks and the discharge of pressure relief
systems with toxic chemical scenarios to a destruction system. Implement inherently safer design
principles to the greatest extent feasible and effectively apply the hierarchy of controls such that neither
workers nor the public are harmed from potential highly toxic chemical releases. Detail the analysis,
findings, and corrective actions in a written report and make this report available to DuPont La Porte
employees, their representatives, and the CSB.

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

2015-01-I-TX-2

Prior to resuming Insecticide Business Unit (IBU) manufacturing operations, conduct a robust
engineering evaluation of the manufacturing building and the dilution air ventilation system that includes
the implementation of corrective action(s) to the greatest extent feasible in order to ensure a safe
environment for all workers. Develop a documented design basis for the manufacturing building and the
air dilution ventilation system that identifies effective controls for highly toxic, asphyxiation, and
flammability hazards and implement these controls to the greatest extent feasible. Address nonroutine
operations and emergency response activities in the design basis. The design basis for the manufacturing
building and the dilution air ventilation system must use the hierarchy of controls and inherently safer
design principles to the greatest extent feasible.

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

2015-01-I-TX-3

Prior to resuming manufacturing operations, ensure all Insecticides Business Unit (IBU) pressure relief
systems are routed to a safe location and effectively apply the hierarchy of controls to protect workers and
the public. Commission a pressure relief device analysis, consistent with API Standard 521 and the
ASME Code, including a field review. Include an evaluation of relief system discharge location to ensure
that relief systems are discharged to a safe location that will prevent toxic exposure, flammability, or
asphyxiation hazards in order to ensure public and worker health and safety to the greatest extent feasible.
Include an evaluation of relief scenarios consistent with API Standard 521.

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

2015-01-I-TX-4

Develop and implement an expedited schedule to perform more robust process hazard analyses (PHAs)
consistent with R1, R2, and R3 for all units within the Insecticides Business Unit (IBU). At a minimum,
the PHAs must effectively identify and control the hazards referenced in this document utilizing the
hierarchy of controls. The PHA schedule must be prioritized based on anticipated risks to the public and
workers in order to ensure that the highest risk areas receive priority consideration. At a minimum, the
more robust PHAs must be consistent with the approach applied to post-incident reviews described above
in paragraph 10.

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

2015-01-I-TX-5

Work together with the International Chemical Workers Union Council of the United Food and
Commercial Workers (ICWUC/UFCW) Local 900C and the ICWUC/UFCW staff (at the request of the
local) to develop and implement a plan to ensure active participation of the workforce and their
representatives in the implementation of Recommendations R1 through R4. In addition, provide a copy
of DuPont’s integrated plan for restart to La Porte workers and their local union representatives.

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

2015-01-I-TX-6

Make publicly available (on a website) a summary of the DuPont November 15, 2014 incident
investigation report, the integrated plan for restart, and actions to be taken for the implementation of
Recommendations R1 through R5. This website must be periodically updated to accurately reflect the
integrated plan for restart and implementation of Recommendations R1 through R5.

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

2015-01-I-TX-8

Work together with emergency response team (ERT) member companies (DuPont, Chemours, Kuraray, and Invista), the International Chemical Workers Union Council of the United Food and Commercial Workers (ICWUC/UFCW) Local 900C, and the ICWUC/UFCW staff (if requested by the Local 900C) to update the DuPont La Porte emergency response plan. The emergency response program should ensure that periodic exercises or drills are performed on new procedures developed to address key lessons to strengthen ERT capabilities. The emergency response program should address the following:

  • Preidentifying unit experts as technical support personnel and ensuring that backup capability is available in the event the primary technical support personnel become unavailable. (Section 4.2: Process Coordinator Was Missing)
  • Clearly detailing in plant emergency procedures the alerting and notification protocols for different types of plant emergencies. Provide initial training to new plant personnel and periodic training to all plant personnel on these emergency communication procedures. These procedures should also include guidance for emergency responders when there is insufficient initial information to effectively assess the nature of the problem and the level of ERT resources required. (Section 4.3.1: Call for ERT Response)
  • Developing and applying regular maintenance schedules for emergency response vehicles consistent with the National Fire Protection Association’s Standard for the Inspection, Maintenance, Testing, and Retirement of In-Service Emergency Vehicles (NFPA 1911), which requires weekly visual and operational checks of emergency vehicles and has example checklists to use when performing preventive maintenance on emergency vehicles. (Section 4.3.2: ERT Mini-Pumper Truck Not Operational)
  • Ensuring that ERTs have reliable means to characterize hazardous atmospheres, for example equipment that monitors toxicity, explosivity, and oxygen levels. Additionally, ensure that ERT members know where the equipment is stored, can access it, and are trained on its proper use. (Section 4.4.1: Entry into Potentially Explosive Atmosphere)
  • Evaluating high-hazard areas, including PSM covered processes, to determine whether detectors and alarms are necessary to identify chemical releases (or other types of emergencies). Additionally, consider equipping high-hazard areas with surveillance technology to identify personnel in the field. (Section 4.4.2: No Technology to Locate Missing Workers)
  • Developing and implementing written policy and procedures to update emergency response plan documents when hazards are identified. For example, personnel can identify these types of hazards in process hazard analyses, facility siting studies, management of change reviews, and incident investigations. Changes to emergency planning documents should be effectively communicated to the site ERT as soon as possible after identifying the hazard. (Section 4.4.3: Unrecognized Manufacturing Building Collapse Hazard)
  • Ensuring that emergency response planning accounts for difficulties in conducting response efforts, including (1) maps included in emergency response plans to show the layout of buildings containing hazardous chemicals, for use by emergency responders and to aid evacuation and rescue efforts; (2) coordination of periodic (at least annual) site tours for plant and external emergency responders; (3) training emergency responders to help ensure familiarity with facility access points, hazards, emergency response issues, and site or facility layout; and (4) building teamwork by having members (from the different companies) of the ERT field train (by conducting drills) together when practicable. (Section 4.5: Difficulties Navigating Manufacturing Building)
  • Assigning knowledgeable personnel the responsibility to analyze process data to assess the source, scope, and magnitude of any incident. (Section 4.6: No Analysis of Process Data to Identify Source of Leak)
  • Training emergency response team members to (1) physically designate the hot zone; (2) communicate the location of the hot zone and entry control points to all personnel assisting with the emergency response, including operations personnel; and (3) control entry and exit points of the hot zone. (Section 4.7: Inadequate Control of Hot Zone)
  • Addressing in the emergency response plan how to characterize (including size, concentration, location, and direction of release) hazardous chemical releases and providing guidance on how and where people should take protective action (e.g., sheltering-in-place) in the event of a chemical release. (Section 4.8.1: Release Modeling)
  • Developing a procedure in the emergency response plan to effectively monitor for hazardous gases along the fence line at chemical facilities during the release to help workers understand and clearly communicate the extent of a release. (Section 4.8.4: Air Monitoring)

In addition, provide a copy of the emergency response plan to the Emergency Response Team and their local union representatives.


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

International Chemical Workers Union Council (ICWUC) of the United Food and Commercial Workers (UFCW) and Local 900C (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 25, 2019

2015-01-I-TX-7

Work together with DuPont to develop and implement a plan to ensure active participation of the
workforce and their representatives in the implementation of Recommendations R1 through R4.

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

2015-01-I-TX-9

Work together with DuPont to develop and implement the emergency response plan described in Recommendation R8 (2015-01-I-TX-R8).


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