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.

 

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Recommendations

Pryor Trust Fatal Gas Well Blowout and Fire (5 Recommendations)
Patterson-UTI (5 Recommendations)
Open: 40% | Closed: 60%
View Investigation
Final Report Released On: June 12, 2019

2018-01-I-OK-7

Develop either corporate or rig-specific tripping procedure(s) that detail the required equipment configuration for tripping operations. Require that rig personnel visually verify that equipment is lined up as specified in the procedure before beginning the tripping operation. In the procedure(s), specify well-monitoring requirements for wet versus dry tripping 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.
 

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2018-01-I-OK-8

Develop an alarm philosophy and alarm rationalization for rig operations. Based on the alarm philosophy and alarm rationalization, specify necessary alarms, at a minimum, for (1) drilling, (2) tripping, (3) circulating, and (4) rig floor activities (no drill pipe in well). Additionally, develop a policy implementing the alarm philosophy and rationalization.


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

2018-01-I-OK-9

Develop a policy that incorporates recommendations in API RP 59 Recommended Practice for Well Control Operations requiring the regular testing of drillers’ influx detection and response skills through formalized drills, for example by “simulat[ing] a gain in pit drilling fluid volume by raising a float sufficiently to cause an alarm to be activated.” In this policy, require that driller response time is monitored in the spirit of continual improvement.


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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2018-01-I-OK-10

Develop and implement a policy requiring that flow checks be documented, either electronically or with a paper record. At a minimum the documentation will require the reporting of:

  1. Operation during which flow check was performed

  2. Method of performing flow check

  3. Length of time flow check was performed

  4. Result of flow check

Require that the proper authorities (e.g., driller, company man, rig manager) sign or approve the flow check documentation after performing the flow check and before resuming operations. Keep the flow check documentation as part of the well file.


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

2018-01-I-OK-11

Update the Patterson metrics program to track leading and lagging indicators to measure the effectiveness of the overall safety management system. Specifically focus on measuring the effectiveness of the following safety management system components:

(a) The effectiveness of the flow check policy, including the frequency that flow checks are performed when required by Patterson policy;

(b) The frequency that flow checks are documented and approved as recommended in 2018-01-OK-R10;

(c) The effectiveness of the management of change program, for both equipment and procedural changes, including real-time procedure changes;

(d) The frequency that alarms are set at the required set points;

(e) The frequency that drilling rig alarm horns or the entire alarm system is turned off; and

(f) The frequency that trip sheets are filled out properly.


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

Oil Site Safety (1 Recommendations)
State of Oklahoma/Oklahoma Corporation Commission (1 Recommendations)
Open: 100% | Closed: 0%
View Investigation
Final Report Released On: October 27, 2011

2011-H-1-3

Amend state oil and gas regulations to:

a) Protect storage tanks at exploration and production sites from public access by requiring sufficient security measures, such as full fencing with a locked gate, hatch locks on tank manways, and barriers securely attached to tank external ladders and stairways.

b) Require hazards signs or placards on or near tanks that identify the fire and explosion hazards using words and symbols recognizable by the general public.

c) Require the use of inherently safer tank design features such as flame arrestors, pressure vacuum vents, floating roofs, vapor recovery systems or an equivalent alternative, to prevent the ignition of a flammable atmosphere inside the tank.


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

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AL Solutions Fatal Dust Explosion (4 Recommendations)
AL Solutions, Inc. (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 16, 2014

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
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.
 

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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
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.
 

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AL Solutions, Inc. facility in Burgettstown, PA (2 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 16, 2014

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
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.
 

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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
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

Veolia Environmental Services Flammable Vapor Explosion and Fire (1 Recommendations)
Environmental Technology Council (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: July 21, 2010

2009-10-I-OH-7

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

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


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

PDF Document Recommendation Status Change Summary

Kleen Energy Natural Gas Explosion (1 Recommendations)
American Society of Mechanical Engineers (ASME) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: June 28, 2010

2010-07-I-CT-3 URGENT!

Make appropriate changes to the 2012 version of Power Piping, ASME B31.1, to require the use of inherently safer fuel gas piping cleaning methodologies rather than natural gas blows. At a minimum, for the cleaning or flushing methods discussed in B31.1 paragraph 122.10, require the use of inherently safer alternatives such as air blows and pigging with air as the motive force in lieu of flammable gas.


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

Motiva Enterprises Sulfuric Acid Tank Explosion (1 Recommendations)
American Petroleum Institute (API) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: August 28, 2002

2001-05-I-DE-12

Ensure that API recommended practices address the inerting of flammable storage tanks, such as spent H2SO4 tanks. Include the following: - Circumstances when inerting is recommended. - Design of inerting systems, such as proper sizing of inerting equipment, appropriate inerting medium, and instrumentation, including alarms.


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

Arkema Inc. Chemical Plant Fire (1 Recommendations)
Center for Chemical Process Safety (CCPS) (1 Recommendations)
Open: 0% | Closed: 100%
View Investigation
Final Report Released On: May 24, 2018

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
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