Yesterday, the Chemical Safety Board updated their web site to reflect changes to the status of seven accident investigation recommendations. Six of the recommendations were closed and one was changed to Open - Acceptable Response or Alternate Response. Changes were approved by the Board on February 2nd, 2024.
The closed recommendations included:
Kuraray Pasadena Release and Fire – 2018-03-I-TX-R10,
Kuraray Pasadena Release and Fire – 2018-03-I-TX-R8,
Kuraray Pasadena Release and Fire – 2018-03-I-TX-R7,
Evergreen Packaging Paper Mill Fire During Hot Work – 2020-07-I-NC-R1,
Xcel Energy Company Hydroelectric Tunnel Fire - 2008-01-I-CO-R2,
TPC Port Neches Explosions and Fire - 2020-02-I-TX-R1
Kuraray Updates
Recommendation 2018-03-I-TX-R10 required Kuraray to improve their safety management system to address six specific problems. According to the update:
“Kuraray notified the CSB and provided supporting documentation demonstrating that the company has made improvements to the EVAL site’s safety management system through the completion of enhancements to site operations and written standard operating procedures (SOPs) that address Items 1 through 6 of this recommendation.”
Recommendation 2018-03-I-TX-R8 required Kurary to improve the EVAL Plant’s operator training program in four specific ways. According to the update:
“Kuraray notified the CSB and provided supporting documentation that the company has updated its training manuals to strengthen the four items identified in this recommendation.”
Recommendation 2018-03-I-TX-R7 required Kurray to develop and implement a program to ensure that the company’s EVAL Plant nightly operating instructions do not conflict with its written operating procedures. According to the update:
“Kuraray notified the CSB that the company has developed a standard operating procedure (SOP) instructing technicians to elevate differences between SOPs and operating instructions to supervisors immediately for clarification. In addition, Kuraray requires all changes to SOPs to be approved through the site’s Management of Change (MOC) system, which is used to communicate and manage a variety of changes. Finally, Kuraray developed and implemented a written procedure and conducted training on how to perform the EVAL Reactor methanol flush operation. Upon review of the relevant procedures provided, the CSB concluded that Kuraray’s actions satisfy all elements of the recommendation.”
As a result of Friday’s vote, the status of all three recommendations were changed to “Closed – Acceptable Action”.
Evergreen Packaging Update
Recommendation 2020-07-I-NC-R1 required OSHA to issue a safety information product addressing the analysis and control of hazards that are not pre-existing, but which result from work activities inside permit-required confined spaces. According to the update:
“OSHA published a fatal facts document titled “Confined Space Fire” in the summer of 2023. This document provides a brief description of the Evergreen incident and its likely causes. The document also contains recommended actions for incident prevention cross referenced with the requirements of OSHA’s standard on Permit-Required Confined Spaces (29 CFR 1910.146). The incident prevention section recommends following the hierarchy of controls and advocates for removal of the hazard or at least substitution. Identifying hazards that are created by the work being performed within the space are called out specifically in the incident prevention section.”
As a result of Friday’s vote, the status of the recommendation was changed to “Closed – Acceptable Action”.
XCEL Energy Update
Recommendation 2008-01-I-CO-R2 required OSHA to Publish a “Safety and Health Information Bulletin” addressing the hazards and controls when using flammable materials in confined spaces. According to the update:
“OSHA published a Fatal Facts guidance document titled “Confined Space Fire” in the summer of 2023. This document provides a brief description of the Evergreen incident and its likely causes. It also contains recommended actions for incident prevention cross referenced with the requirements of OSHA’s standard on Permit-Required Confined Spaces (29 CFR 1910.146).”
As a result of Friday’s vote, the status of the recommendation was changed to “Closed - Acceptable Alternative Action”.
TPC Port Neches Update
Recommendation 2020-02-I-TX-R1 requires all TPC PNO terminal operations in high-purity butadiene service (e.g., greater than 80 percent butadiene concentration), develop and implement a program to identify and control, or eliminate, dead legs. According to the update:
“TPC Group notified the CSB that they have developed and implemented a program to identify and control, or eliminate, dead legs, for all the Port Neches Operations facility operations in high-purity butadiene service as required by the recommendation. TPC Group provided all the necessary policy documents and records of past program activities to demonstrate implementation of the recommendation.”
As a result of Friday’s vote, the status of the recommendation was changed to “Closed – Acceptable Action”.
Kuraray Recommendation Still Open Update
Recommendation 2018-03-I-TX-R11 requires Kuraray to modify the EVAL Plant’s safe operating limits program to prevent operating under conditions that rely upon equipment design safety factors, such as the American Society of Mechanical Engineers (ASME) code material safety factors. According to the update:
“Kuraray notified the CSB that the company has revised its Safe Operating Limits and plans to revise its Safe Operating Limits Plant Process Equipment procedure. Once revisions are finalized and a copy of the updated procedure is sent to the CSB, the recommendation can be evaluated for closure.”
As a result of Friday’s vote, the status of the recommendation was changed to “Open – Acceptable Response or Alternate Response.”