CSB Updates Status of Seven Accident Investigation Recommendation – 12-19-24
Yesterday the Chemical Safety Board updated their Recent Recommendation Status Updates page to reflect actions the Board took on December 19th, 2024 on seven accident investigation recommendations. Five of those recommendations were closed, the other two were changed to ‘Open – Acceptable Response’. Last month’s actions left 133 recommendations open (out of 1,000 recommendations made to date).
The seven recommendations addressed last month were:
Pryor Trust Fatal Gas Well Blowout and Fire - 2018-01-I-OK-R11 - Patterson-UTI,
BP – Husky Oregon Chemical Release and Fire - 2022-01-I-OH-R1 - Ohio Refining Company,
BP – Husky Oregon Chemical Release and Fire - 2022-01-I-OH-R2 - Ohio Refining Company,
BP – Husky Oregon Chemical Release and Fire - 2022-01-I-OH-R4 - Ohio Refining Company,
Caribbean Petroleum Refining Tank Explosion and Fire - 2010-02-I-PR-R5 - International Code Council (ICC),
Husky Energy Superior Refinery Explosion and Fire - 2018-02-I-WI-R10 - Cenovus Energy, Inc., and
Chevron Richmond Refinery Fire - 2012-03-I-CA-R31 - American Petroleum Institute
Pryor Trust
Incident Date: January 22nd, 2018 Report Date: June 12th, 2019
2018-01-I-OK-R11 - Patterson-UTI
“Patterson-UTI updated their metrics program to track leading and lagging indicators to measure the effectiveness of the overall safety management system in accordance with the recommendation. Patterson-UTI made changes to their program which satisfied subparagraphs (a), (b), (c), and (f) and provided supporting documentation shortly after the issuance of the recommendation.
Their efforts to address subparagraphs (d) and (e) of the recommendation also began shortly after the issuance of the recommendation but were complicated by the need to work with third party service providers and difficulties associated with the COVID-19 pandemic. Patterson-UTI has now successfully addressed subparagraphs (d) and (e) of the recommendation. Upon review of the relevant procedures and information provided, the CSB concluded that Patterson-UTI’s actions satisfy all elements of the recommendation.”
Closed – Acceptable Action
BP – Husky Oregon
Incident Date: September 20th, 2022 Report Date: June 24th, 2024
2022-01-I-OH-R1 - Ohio Refining Company
“The Ohio Refining Company (ORC) notified the CSB that they have revised the safeguards used in the refinery’s Crude 1 Unit and Coker Gas Plant process hazard analyses high level and overflow scenarios. ORC has also established engineered preventative safeguards which do not rely solely on human intervention in these units. Finally, ORC has committed to aligning its operating practices with future industry guidance related to prevention of overflow scenarios when such guidance becomes available.”
Open – Acceptable Response or Alternate Response
2022-01-I-OH-R2 – Ohio Refining Company
“The Ohio Refining Company (ORC) notified the CSB that the scope of their abnormal situation management policy does not support the scope of changes sought by the recommendation. They have however, created or revised several other programs and policies to implement the recommendation. ORC has addressed all requirements of the recommendation except addressing an unplanned crude slate change as an abnormal situation. Work to update their applicable procedure is underway and expected to be completed before the end of 2024. Once ORC has updated their procedure, the CSB can evaluate this recommendation for closure.”
Open – Acceptable Response or Alternate Response
2022-01-I-OH-R4 - Ohio Refining Company
“The Ohio Refining Company (ORC) notified the CSB that they have revised and reissued the Toledo Alarm Philosophy to include the guidance from the Engineering Equipment and Manufacturers Users Association Publication 191 Chapter 6.5.1. ORC now measures key performance indicators on alarm flood analysis daily and monthly. They have also established a tracking system for board consoles exceeding a pre-determined number of alarms over a 10-minute period. Each line on the tracker is reviewed, mitigation actions identified, and closed by ORC’s Process Control Team. In addition to these actions, ORC has also undertaken an alarm rationalization effort which has significantly improved the alarm performance of the board controlling the Crude 1 unit. Upon review of the information provided, the CSB concluded that ORC’s actions satisfy all elements of the recommendation.”
Closed – Acceptable Action
Caribbean Petroleum
Date of Incident: October 23rd, 2029 Report Date: October 21st, 2015
2010-02-I-PR-R5 - International Code Council (ICC)
“The International Fire Code (IFC) 2024 Edition requires storage tanks in refineries and bulk plants or terminals to have overfill protection in accordance with API 2350, Overfill Protection for Storage Tanks in Petroleum Facilities, 5th Edition (API 2350) (IFC 5704.2.7.5.8). This requirement applies specifically to prevention of overfills during the transfer of Class I and II liquids from mainline pipelines and marine vessels (IFC 5706.4.6). The ICC has adopted the requirements of API 2350 into the IFC. These requirements are applicable to the type of facility and the specific operation involved in the CAPECO incident.”
Closed – Acceptable Alternative Action
Husky Energy
Date of Incident: April 26th, 2018 Report Date: December 29th, 2022
2018-02-I-WI-R10 - Cenovus Energy, Inc
“Cenovus Energy, Inc. notified the CSB that they have implemented the recommendation at their Superior, WI refinery. At their other facilities, where there is no overall technology licensor, they have addressed the intent of the recommendation by hiring a subject matter expert to validate their operating and training manuals as well as other process safety information. This work was completed November 15, 2024, and the final report was provided to the CSB. Upon review the relevant documentation provided, the CSB concluded that Cenovus Energy, Inc.’s actions satisfy the intent of the recommendation.”
Closed – Acceptable Alternative Action
Chevron Richmond
Date of Incident: August 6th, 2012 Report Date: January 28th, 2015
2012-03-I-CA-R31 - American Petroleum Institute
“On October 24, 2024, the API announced the publication of Addendum 1 to AP RP 2001.1 According to the API’s press release, the new addendum addresses recommendations from the CSB in two new annexes:
“Annex E: Addresses pre-planning fire response scenarios, establishing proactive measures tailored to potential incidents; and
“Annex F: Provides a detailed Leak Response Protocol, offering guidance on safely managing unignited material leaks before they escalate into fire hazards.
“While the updates made to RP 2001 do not include a requirement that users develop a process fluid leak response protocol specific to their own facility, they do provide robust guidance on planning for and responding to a process fluid leak. The guidance touches upon all aspects of this recommendation, including pre-incident command structure and meetings, establishing a hot zone, limiting site access, and isolating the leak or shutting down the unit if necessary.”
Closed – Acceptable Alternative Action