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statistics

Total # of Recommendations
788
Total # of Open Recommendations
189
Total # of Closed Recommendations
599
Total % of Open 24 vs. Closed 76

Recent Recommendation Status Updates

Each recommendation the CSB issues is monitored by CSB staff from the time it is issued to closing. CSB staff evaluate recipient responses, and the Board votes to assign status designations to recommendations based on staff evaluation. This page highlights recommendations for which the Board has recently voted to change the status of the recommendation. For more information on how the CSB defines its recommendation statuses, please visit the Recommendations Frequently Asked Questions page.


Recommendations
Williams Olefins Plant Explosion and Fire (5 Recommendations)
American Petroleum Institute (API) (2 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: October 19, 2016

2013-3-I-LA-4

To help prevent future major incidents such as a rupture of a pressure vessel in a special operating status, strengthen API Standard 521, Pressure-relieving and Depressuring Systems, by defining the various types of equipment operating statuses. Include definitions for “standby” and “out-of-service.” Specify pressure relief requirements for each type of equipment operating status.


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.
 

2013-3-I-LA-5

To help prevent future major incidents such as pressure vessel rupture from ineffective or failed administrative controls, clarify API Standard 521, Pressure-relieving and Depressuring Systems, to require a pressure relief device for overpressure scenarios where internal vessel pressure can exceed what is allowed by the design code. Although some portions of API Standard 521 already require a pressure relief device for these scenarios, other areas, such as Section 4.4.12 Hydraulic Expansion, are not as protective. Section 4.4.12 Hydraulic Expansion (the failure mode that caused the Williams overpressure incident) permits omitting a pressure relief device and allows the exclusive use of administrative controls.


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.
 

Williams Geismer Olefins Facility (3 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: October 19, 2016

2013-3-I-LA-1

Implement a continual improvement program to improve the process safety culture at the Williams Geismar Olefins Plant. Ensure oversight of this program by a committee of Williams personnel (“committee”) that, at a minimum, includes safety and health representative(s), Williams management representative(s), and operations and maintenance workforce representative(s). Ensure the continual improvement program contains the following elements:
 
a. Process Safety Culture Assessments. Engage a process safety culture subject-matter expert, who is selected by the committee and is independent of the Geismar site, to administer a periodic process safety culture assessment that includes surveys of personnel, interviews with personnel, and document analysis. Consider the process safety culture audit guidance provided in Chapter 4 of the CCPS book Guidelines for Auditing Process Safety Management Systems as a starting point. Communicate the results of the Process Safety Culture Assessment in a report; and
 
b. Workforce Involvement. Engage the committee to (1) review and comment on the expert
report developed from the Process Safety Culture Assessments, and (2) oversee the development and effective implementation of action items to address process safety culture issues identified in the Process Safety Culture Assessment report. 
 
As a component of the process safety culture continual improvement program, include a focus on the facility’s ability to comply with its internal process safety management program requirements. Make the periodic process safety culture report available to the plant workforce. Conduct the process safety culture assessments at least once every five years.

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.
 

2013-3-I-LA-2

Develop and implement a permanent process safety metrics program that tracks leading and lagging process safety indicators. Consider available industry guidance, such as the guidance presented in the Center for Chemical Process Safety (CCPS) book Guidelines for Process Safety Metrics and the example metrics provided in the book’s accompanying CD. Design this metrics program to measure the effectiveness of the Williams Geismar Olefins Facility’s process safety management programs. Include the following components in this program:
 
a. Measure the effectiveness of the Williams Geismar Management of Change (MOC)
program, including evaluating whether MOCs were performed for all applicable changes,
the quality of MOC review, and the completeness of the MOC review;
 
b. Measure the effectiveness of the Williams Geismar Pre-Startup Safety Review (PSSR)
program, including the quality of the PSSR review and the completeness of the PSSR
review;
 
c. Measure the effectiveness of the Williams Geismar methods to effectively and timely
complete action items developed as a result of Process Hazard Analyses (PHAs),
Management of Change (MOC), incident investigations, audits, and safety culture
assessments; and
 
d. Measure the effectiveness of the Williams Geismar development and implementation of
operating procedures.
 
Develop a system to drive continual process safety performance improvements based upon the data identified and analysis developed as a result of implementing the permanent process safety metrics program.

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.
 

2013-3-I-LA-3

Develop and implement a program that demands robust and comprehensive assessments of the process safety programs at the Williams Geismar facility, at a minimum including Management of Change, Pre-Startup Safety Review, Process Hazard Analyses, and Operating Procedures. Ensure that the assessments thoroughly evaluate the effectiveness of these important safety programs. To drive continual improvement of process safety programs to meet good practice guidance, ensure these assessments result in the development and implementation of robust action items that address identified weaknesses. Engage an expert independent of the Geismar site to lead these assessments at least once every three years.


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.
 

DuPont Corporation Toxic Chemical Releases (1 Recommendations)
American Chemistry Council Phosgene Panel (1 Recommendations)
Open: 0% | Closed: 100%

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

NDK Crystal Inc. Explosion with Offsite Fatality (4 Recommendations)
NDK Crystal, Inc. (4 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: November 14, 2013

2010-4-I-IL-5

For the design and operation of any new NDK Crystal facility using a hydrothermal or equivalent crystal growing process, ensure that the facility uses a process that is rigorously demonstrated to be inherently safer than the existing process (for example through using lower temperatures and pressures, and/or less corrosive conditions).


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

PDF Document Recommendations Status Change Summary

2010-4-I-IL-6

Implement a program to ensure the ongoing integrity of any coating used on the new process vessels. Employ an expert (e.g., a coatings expert certified by NACE International (National Association of Corrosion Engineers)) to design the program.


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

PDF Document Recommendations Status Change Summary

2010-4-I-IL-7

Implement an annual inspection and corrective action program to ensure vessels remain resistant to environmentally induced damage mechanisms based on the inspection guidelines set forth in the American Petroleum Institute (API) Standard 510, Pressure Vessel Inspection Code.


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

PDF Document Recommendations Status Change Summary

2010-4-I-IL-8

Commission a facility siting study of the NDK Crystal facility by an independent consultant. Identify all vessel failure scenarios prior to restarting the crystal growing process. The siting study should include the consequences, necessary preventive measures, and emergency planning and response programs relevant to each failure scenario for all surrounding points of concern. Provide a copy of this study to the City of Belvidere Building and Zoning Department and the Illinois Boiler and Pressure Vessel Safety Division.


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

Tesoro Refinery Fatal Explosion and Fire (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2014

2010-08-I-WA-11

Revise American Petroleum Institute API RP 581: Risk-Based Inspection Technology to:

a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems;

b. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure; and

c. Require verification of actual operating conditions to determine potential equipment damage mechanisms.

 


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

Chevron Refinery Fire (1 Recommendations)
Chevron USA (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: January 28, 2015

2012-03-I-CA-34

Develop an auditable process to be available for all recommended turnaround work items necessary to address mechanical integrity deficiencies or inspection recommendations that are denied or deferred.  This process shall provide the submitter of the denied or deferred recommendation with the option to seek further review by his or her manager, who can further elevate and discuss the recommendation with higher level management, such as the Area Business Unit Manager.  Maintain an auditable log of each of these potential turnaround work items, including the ultimate determination of approval, deferral, or rejection, justification determination, and the person or team responsible for that decision.


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 Recommendations Status Change Summary

Hoeganaes Corporation Fatal Flash Fires (1 Recommendations)
City of Gallatin, TN (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 05, 2012

2011-4-I-TN-11

Require all facilities covered by IFC Chapter 13 (2006 edition) to conform to NFPA standards for combustible dusts including NFPA 484.


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

Freedom Industries Chemical Release (3 Recommendations)
American Water Works Association (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 28, 2016

2014-01-I-WV-1

Communicate the findings, lessons learned and recommendations contained within this report to all American Water Works Association members. Emphasize the importance of source water protection planning, emergency planning, and coordination with local, state and federal entities, and the public, to ensure timely notification of potential water contamination events and emergencies.


Status: 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.
 

American Water Works Company, Inc. (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 28, 2016

2014-01-I-WV-2

Establish requirements for all American Water state utilities’ surface water treatment plants to undertake the following activities:

1. Conduct an inventory of all hazardous chemicals or classes of hazardous chemicals that are considered a potential source of significant contamination stored in the utility’s most vulnerable source water protection area (e.g., Zone of Critical Concern). Chemicals may be identified by accessing publicly available information, which may include Tier II reporting forms submitted to local emergency planning committees and electronically available information from federal, state or local databases.

2. For each inventoried chemical or class of chemicals, conduct a prioritized assessment to determine if existing analytical methods are available to detect the presence and/or concentration of the chemical or class of chemicals in the event of a release to the water supply and if the chemical or class of chemicals is capable of being treated or removed by the utility’s water treatment process.

3. For all chemicals or classes of chemicals that are not capable of being treated or removed by the treatment process, develop a contingency plan to respond to contamination events (e.g., as modeled by WVAW’s Kanawha Valley Water System June 2016 Source Water Protection Plan).


Status: 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.
 

Eastman Chemical Company (1 Recommendations)
Open: 100% | Closed: 0%

Final Report Released On: September 28, 2016

2014-01-I-WV-3

Update appropriate sections of the Crude MCHM Safety Data Sheet to include toxicological and ecological information based on the June 1, 2016, National Toxicology Program’s toxicity evaluation of Crude MCHM. Include information about the effects of Crude MCHM on fetal and early life growth and development. Distribute the revised Crude MCHM SDS to all customers that previously received and are currently using or storing MCHM from Eastman, and ensure all new MCHM customers receive the revised SDS with shipment.


Status: 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.
 

DuPont LaPorte Facility Toxic Chemical Release (1 Recommendations)
DuPont LaPorte, Texas Chemical Facility (1 Recommendations)
Open: 0% | Closed: 100%

Date of Accident: November 15, 2014

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

US Ink Fire (3 Recommendations)
New Jersey Department of Community Affairs (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 15, 2015

2013-01-I-NJ-4

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


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

PDF Document Status Change Summary

US Ink/Sun Chemical Corporation (2 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: January 15, 2015

2013-01-I-NJ-6

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


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

PDF Document Status Change Summary

2013-01-I-NJ-8

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

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

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

PDF Document Status Change Summary

 
 
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