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Recording of the CSB’s July 29, 2021, public meeting. The Board reviewed the CSB’s progress in meeting its mission and highlighted safety products newly released through investigations and safety recommendations.
All audio is courtesy: U.S. Chemical Safety Board. The audio was cleaned up and meeting breaks removed.
If you want to see the visuals, you can watch the YouTube video CSB July 29, 2021, Quarterly Board Meeting posted on the CSB Public Events channel
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Disclaimer: This transcript is auto generated and is not manually checked for errors. It more than likely contains very significant errors.
SIP CSB Quarterly Board Meeting, July 29, 2021
Good morning, you have joined the us chemical safety and hazard investigation boards, or the CSBs public meeting. We will now begin this meeting with Dr. Katherine limos, the chairperson and CEO of the city. Welcome, and thank you to everyone that has joined our quarterly public meeting. These meetings are a great opportunity to provide an update on CSB activities and progress.
[00:00:27] Since our previous meeting in April, this is our first virtual public meeting that we did have a successful virtual board meeting in may to close out the ag horn investigation. I look forward to continuing in this medium and also look forward to this time when we can safely meet in person. It’s important for us to personalize incredible staff behind the voices.
[00:00:55] Some of what you’ll hear. Allow me to first summarize the mission activities of the CSP. We are an independent non-regulatory federal agency with a mandate to investigate accidental chemical releases at fixed facilities, with significant impact to the safety of onsite workers, members of the community and our environment, the investigations examine and evaluate a wide range of aspects to include equipment and system design regulations, industry standards, and guidance, training operations, and procedures and human and organizational factors.
[00:01:43] And with these facts, we conduct analysis to determine the probable cause and contributing factors of the event so that we can better understand not just what happened. But why we issue safety recommendations for the purpose of preventing the likelihood and consequence of similar incidents in the future.
[00:02:08] So today I’m joined virtually by Bruce Walker, our senior advisor, David lesser, our executive council, senior advisor, and acting managing director, Stephen Kleist, our executive director of investigations and recommendations and talk Barbie, our director of recommendations. Now executive director clients is calling in from Laport, Texas, supporting our deployment team.
[00:02:38] And we thank him for his dedication to our mission and to our public meetings. Now allow me to walk through today’s agenda. After my opening, we will hear from acting managing director will assert who will provide some administrative updates on the agency, as well as our anticipated schedule of product delivery over the coming several months.
[00:03:03] I know this is important to everybody. Executive director Kleist will introduce a new safety product being released today, which I’m very enthusiastic about. And then director Barbie will highlight a sample of key recommendations. We have recently closed as with previous meetings. I will have questions to highlight the impact of the safety action and why I supported the staff’s recommendation for there, for my vote.
[00:03:40] So an opening, I have several topics to cover. I’d like to start by reviewing the purpose of today’s public meeting, which is to provide stakeholders and the general public with the insight and transparency into the business of the CSB in meeting our mission. These quarterly public meetings have not traditionally involved board member deliberation and voting recent administrative actions and open investigations are already listed on our website.
[00:04:14] So we have chosen to review substantive business items and updates with a greater focus on our mission performance in our movement towards greater transparency. We are holding public board meetings for the close of investigations. So you have insight to staff investigation, process, the facts and analysis and findings and recommendations.
[00:04:42] And further the board’s deliberation is public and occurs in real time. Poor our requests. Some of you have submitted comments to firstname.lastname@example.org and consistent with previous meetings. We will address some of those comments during today’s meeting. If you have comments during the meeting, please continue to send them to the same email address.
[00:05:12] On that note, we receive a significant number of comments and input throughout the year. It would be impossible to address all of these topics in a public meeting. And in most cases, we’ve responded by scheduling virtual meetings with the individual stakeholder or groups that race adjustments concerns.
[00:05:34] And in many cases, requests for further support of the CSPs mission. How can we help. We will continue with this practice as a productive medium for dialogue on the range of really quite complex issues. I want you to know that I am listening. We, as the leadership team are listening, we appreciate your comments and input and trust that you will continue to provide it for the good of the CSB and the safety of our nation.
[00:06:13] I’ll now address the topic of recommendations. Many of you are already aware of the significant progress and improvement we have made in fiscal year 2021 and advancing recommendations from previous investigations or safety studies. In fact, much of our effort over the past quarter has been dedicated to key recommendations that remain.
[00:06:39] Their resolution is just as important as the investigation itself, without stakeholder support in adopting and implementing these recommendations, the process would be left incomplete and any effective and driving needed safety changes for the Cape chemical community. And for this reason, we have been highlighting recommendation status changes over the past year in our public meetings, many recommendations require a significant amount of work and investment on the part of CSB staff, the recipients and the stakeholder community.
[00:07:22] And we appreciate all of your efforts due date and fiscal year 2021. We have issued nine new recommendations. And advanced 47 recommendations of which 28 have been closed with successful outcomes. This is an increase up from fiscal year 2020, which yielded no new recommendations, 15 advanced of which four were closed with successful outcomes.
[00:08:00] These advancements occurred late in fiscal year, 2020 during my tenure. So I want you to know how diligently we’re working on our mission performance. All recommendations, status changes are voted on the board and a critical role for board members is to advocate for our top Prayerview recommendations, likely to yield the most impact in safety chain.
[00:08:31] So before I turn the meeting over to acting managing director was cert, I’d like to point out a video we’ve posted on the CSB website Tuesday. It’s a message for me as the CSPs, chairperson and CEO, that outlines our priorities to meet the mission of our agency, commitment and advances in enhanced transparency and our commitment to remain independent and objective throughout the investigative process.
[00:09:05] These priorities and commitments have remained consistent for the past year and have been communicated in every possible medium. With that. I would like to turn the meeting over to acting managing director of assert Vistaril assert. Please proceed.
[00:09:28] As the chairman of stated, my name is David and I serve as senior advisor and executive council. And I’m also continuing to fill in as acting managing director. I’d like to first start off with staffing, we recognize the importance of a career acting managing director for which we plan to begin the recruiting process shortly after completing our current wave of filling for investigator positions, we have received a large number of applications for this round of investigative hiring.
[00:09:56] We hope to narrow the field shortly after bring and bring a number of investigators on board from this applicant pool. We do plan on another applicant pool after another round of hiring at a more junior grade. Although the CSB has attempted to maintain a team of generalists who can respond to any incident, the agency is making further efforts to diversify experience and background during the subject matter expert review.
[00:10:26] This is an effort undertaken with feedback from stakeholders before a more diverse skillset among investigative teams or the increasingly complex missions before the agency and approach, which has been very successful at the CSB. In previous years, additionally, we will be posting and hiring a significant number of support positions in the fields of procurement, human resources, legal and other key areas, which we will address following our highest priority of hiring.
[00:10:57] That is the mission staff vacancies, admission staff includes both investigators and recommendation specialists working together as a team to affect safety chain. Of course, we also have several prospective board members, which may maybe onboarding in the coming months. We are grateful for the attention from president Biden and recognizing our need for additional board members.
[00:11:21] And we are also thankful to the United States Senate in fulfilling their duties throughout the confirmation process. This morning, in the meantime, the CSB continues to meet our mission of driving chemical safety change. The challenges of continuing to move forward in the face of COVID-19 pandemic were noted by the inspector general.
[00:11:40] In last year’s management challenges report, we are pleased to highlight that the CSB has deployed staff who seven incidents in the previous calendar year, a sharp rise after making four deployments in each of 2018 and 2019. Additionally, the CSB has deployed to another three incidents in the current calendar year, and there’s a sharp contrast to some of our federal colleagues.
[00:12:04] For example, for one regulator inspection figures in fiscal year 2020 dropped 34% from a relatively steady average over the prior five years. The lean and agile nature of our agency has enabled us to be better equipped to navigate through the challenges of this all investigative staff and many support and management positions are now fully remote recruitment of the bulk of our workforce.
[00:12:33] May now be done on a nationwide basis with strengthens our applicant pools as geographic diversity, and allows us to better reach our goals and equity and inclusion. The design of our pandemic workforce is still in progress. As we consult with the recently issued and still evolving guidance from OPM, we are mindful of our priority on safety.
[00:12:57] We also seek advantage, seek to take advantage of the options and this new worldwide environment become even more efficient and effective in meeting our mission. The credit in our success stories in the face of this pandemic launched efforts over the investigative staff and support personnel work behind the scenes to keep them in the.
[00:13:16] I commend the staff at this as this is hard work in tough environments and away from their families. Thank you. There’s also plenty of room for improvement. Our agency. We need to do a better job of timely finalizing investigative files and accompanying recommendations. A primary driver of this has been turnover of investigator position and the learning curve of a new investigator inheriting an older file.
[00:13:43] I’m happy to report that all files have an assigned investigator in charge and that we are diligently working toward closing all activities. Moving on to our anticipated schedule of product delivery. Two board meetings to close investigations in the August and September timeframe. The 2019 trial tragic explosion and fire at AB specialty Silicon in Illinois playing the lives of forwards and seriously injured.
[00:14:10] The fatal fire in 2020 at the evergreen packing mill packaging mill and Canton, North Carolina tragically resulted in the deaths of two contractors. Additional information on these incidents can be email@example.com. And we look forward to bringing the investigations before the board for a full public board meeting or public board meeting in may was the first CSB meeting and several years to present investigations for vote for the board in an open and transparent public meeting.
[00:14:40] As the chairman mentioned, this new level of transparency can be expected moving forward as we can now close investigations in full view of the public. One topic we’ve been asked about frequently is how we intend to use and share the incident data we’ve received directly. We have the national response center.
[00:14:58] This initiative is a constant work in progress, but we are continuously analyzing. How did that, um, will inform our deployments are critical drivers. Safety product options and advocacy priorities to address the many events that meet our reporting criteria. We are revisiting a range of products to maximize our assignment of resources, as well as the safety outcomes from those events and all or nothing approach for investigation and deeper review leaves, a gap for more analysis and a wider broadcast of lessons learned and incidents, which did not meet both criteria, adopting an approach to include additional products such as what is seen at the NTSB.
[00:15:39] An incident brief model would provide an opportunity for additional influence and gains to our mission without impacting our full deployments and investigative reports as voted on at our open board meetings, I’m working diligently with executive director Kleist on how to best capture the right level of information, prioritize our efforts.
[00:16:00] Oh, to phase in and resource these new activities, which will yield additional safety, understanding safety products and safety recommendations. As I have mentioned, the CSB has launched deployments for full investigations at a rate of 150 of the historical average over calendar years, 2020 and 2021. Even in the face of the pandemic, the CSB anticipates continuing this aggressive approach to accomplishing our mission.
[00:16:29] In the meantime, our top priority is to complete our backlog of open investigations while attending to new investigations. I’d like to make a note regarding an operational update in the external company review of pre-decision investigation products in the past, the agency would provide a copy of the draft investigative report to key stakeholders to include the company involved and the accident as well as the EPA and OSHA for their review and comment prior to presentation of the.
[00:17:00] Policy moving forward will be a default position to only provide the factual portion of the report to these external stakeholders. Prior to board review, there will be situations which warrant a more detailed review by the owner operator or other stakeholders, especially if there is a specialized information use of technology or resources, which will enhance the understanding of the investigative team.
[00:17:27] In fact, we currently already seek input from independent subject matter experts in a variety of fields and disciplines. In some reports. This position is a change from CSB operations in recent years, but it better reinforces the independence of our investigative team from the stakeholders in which we engage.
[00:17:47] This approach also allows the agency, the flexibility to incorporate valuable information from them on a case by case basis, as mentioned by the chairman. We encourage all stakeholders to include citizens, corporations, and associations. You submit your full input throughout the investigative process, based on your knowledge and perspectives.
[00:18:09] As you can see, we have a considerable amount of movement here at the agency. And with our mission, we know this impact stakeholders across government industry, the workforce, and with a number of non-governmental organizations, many organizations have reached out and I’m very happy that we share common goals and the agency looks forward to continuing our dialogue and how to achieve our mutually beneficial outcomes.
[00:18:34] As always, we look forward to providing the public with these updates and comments are firstname.lastname@example.org, which we will attempt to address each public meeting. I can also be reached personally at David at csb.gov. If anyone would like to discuss a particular. I think the chairman for the opportunity to serve.
[00:18:56] And I think all of our CSB staff, again, for the hard work and dedication or agency and mission thank you. As, um, acting administrator acting managing director of David listserv mentioned, we’re looking to close two investigations over the coming two months, executive director Kleist and his team have been diligently working to refine the internal review process, which will allow us to close and investigations at a more efficient pace moving forward.
[00:19:32] I sincerely appreciate these critical efforts. Thank you, director. Kleist I’ll now hand the meeting over to executive director of investigations and recommendations, Mr. Kleist. Thank you, chairman linens. Thank you, Mr. . The recommendations team has been working aggressively to review and assess responses from recommendation recipients.
[00:19:58] I would like to take this opportunity to thank the recommendations after their hard work, to advance safety in the chemical and petrochemical industry. Today, we are going to highlight five recommendations. Status changes recently adopted by the board director. Bobby will present this information to you.
[00:20:15] Dr. Barbie, please proceed. Thank you very much. Executive dreads collide. As previously stated we will be highlighting the five recommendations that were issued from the CSP of safety or a hazard study and three CSB investigations. They are from the oil sites safety hazard study. We will highlight the EPA is implementation of our work.
[00:20:37] From the Arkema plant, a chemical plant fire investigation, we will highlight Arkema incorporated implementation of our three from the prior test, fatal gas, well explosion and fire investigation. We will highlight the American petroleum institutes or API implementation of our six as well as pays on systems, corporations implementation of our 16.
[00:21:00] And lastly, from the California refinery fire investigation, we will highlight the state of California implementation of our 21. So without further hesitation, let’s begin with the oil site safety hazard study sometimes referred to as the teens in tanks study for an incident summary on October 31st, 2009, two teenagers they’d 16 and 18 were fatally injured when a petroleum storage tank.
[00:21:29] In a Royal oral field in Carnes, Mississippi, six months later, a group of young adults and teenagers were exploring a similar tank site. And Weleetka Oklahoma when an explosion and fire fatally injured one individual two weeks later, a 25 year old man and a 24 year old woman were on top of an oil tank in rural new London, Texas.
[00:21:55] When the tank exploded finally entering the woman and seriously injuring the man in April, 2010, the CSB initiated a hazard study into the cause of these tragic things. All three incidents involve rural unmanned oil and gas stored sites and lacked fencing and signs warning of the hazards, which might’ve otherwise deterred members of the public from using them as places to gather the CSB identified 26 similar incidents between 1983 and 2010, which resulted in a total of 44 fatalities and twenty-five injuries.
[00:22:31] As a part of this hazard study, all of the victims were 25 years of age or less as a part of a hazard study. The CSB also reviewed a number of environmental statutes, relevant to oil and gas production, including the clean air act, the clean water act, the comprehensive environmental response, compensation and liability act.
[00:22:51] The resource conservation and recovery act and the toxic substances control act four provisions related to protection of human health. The CSB found that many of these statutes contained various exemptions, applicable oil and gas Wells. But that’s a general duty clause and reduced in 1990 by the clean air act amendments applies to extremely hazardous substances has a high rate of carbon stored at these oil exploration and production facilities.
[00:23:21] Meet the definition of extremely hazardous substances based on his flammable properties. The CSB concluded that they would be subject to the clean air act general duty clause, which holds owners and operators responsible for preventing chemical accidents involving these substances. Consequently, the board voted to issue a recommendation to the EPA, to publicist safety alert directly to owners and operators of exploration and production facilities with flammable storage tanks, advising them of the general duty clause responsibilities for accident prevention under the clean air act.
[00:23:54] So the number of recommendations. That were issued during this hazard study, we’re six and only three of those, including this one, um, remain open. And number of recommendations that were issued to the EPA was one. And so this is going to close them out. So the highlighted recommendation here is recommendation number 2 0 1 1 2011 dash H X X dash one dash one.
[00:24:20] And it reads, published the safety alert, directed to owners and operators of exploration and production facilities with flammable storage, gas storage tanks, advising them of the general duty clause responsibilities for accident prevention under the clean air act at a minimum, the safety alert should a Warren that storage tanks that unmanned facilities may be subject to tampering or introduction of ignition sources by members of the public, which could result in the tank explosion or other accidental release to the environment.
[00:24:54] Recommend the use of inherently safer storage tank design features to reduce the likelihood of explosions, including restriction on the use of open vans for flammable heart hydrocarbon, flame arresters pressure vacuum event valves, floating roofs, vapor recovery systems, or an equivalent alternative C describe sufficient security measures to prevent non-employees access to flannel the storage tanks, including sets, measures as full fence surrounding the tank with locked gate hatch locks on tank man ways and barrier securely attached to the tank, external ladders or stairways, and the recommend that hazard signs or placards be placed on or near tanks to identify the fire and explosion hazards, using words and symbols recognizable by the general.
[00:25:48] Okay, so now here’s what the EPA did. The closest recommendation in March of 2021. The CSB received notification from the EPA that his office of land and emergency management had published a new safety alert, entitled public safety at oil and gas upstream facilities, which is EPA 5 4 0 B 2 0 0 0 1, dated March of 2021 in response to the CSP recommendation.
[00:26:18] And it also made it available on his website. The EPA also advise the CSB that this new safety alert was being sent to state and territorial emergency response commission and to the Indian tribal governing bodies. The safety alert was very detailed and addressed all aspects of the recommendation. As a result on July 28th, 2021, the board voted to change the status to close acceptable action.
[00:26:50] I know, I know there are follow-up questions. I’m trying to follow the script here. Um,
[00:26:59] sorry. Um, so Chuck, I have a few questions for you, director Barbie, since the publication of CSPs 2011 hazard study, which I think was really important and critical. Have there been additional incidents affecting the public that have occurred at oil and gas storage sites?
[00:27:31] Unfortunately, yes. The CSB is aware of at least 10 incidents that have occurred at oil and gas storage sites. Since the publication of our hazard setting, the most recent occurred in April of this year. And we as Deanna, that resulted in one fatality, which was a 14 year old, who was trespassing when the tank exploded.
[00:27:51] The other nine incidents are described in appendix B of the EPA safety alert. Three occurred in Texas two in both Oak, uh, an Ohio and Oklahoma one each in New York and Pennsylvania that have resulted either in fatalities or serious injuries, community evacuations, or releases of hazardous material, new residence.
[00:28:17] So thank you, Dr. Uh, director of Barbie question next. And that was, uh, it was great information. Why is the publication. Of this recent safety alert by the EPA, so significant that we chose to highlight it them. Okay. Well, prior to the issuance of the EPA safety alert, voluntary guidance, most notably published by the American petroleum Institute has been the primary method used to communicate the hazards and safeguards needed to protect the public from the hazards posed by these sites.
[00:28:53] The EPA is safety alert, reminder oil and gas facility owners, and operators of their existing obligations under the general duty clause of the clean air act to identify hazard design and maintain safe facilities and minimize consequences of offsite releases. Okay. Um, the next recommendation comes from the Arkema incident, chemical plant fire investigation, and here’s the incident.
[00:29:21] On August 24th, 2017, hurricane Harvey, a category four camp hurricane made landfall in the Southeast Texas extensively caused by heavy rain fall from the hurricane, exceeded the equipment design elevations and caused the Arkema Houston it’s implant to lose power, backup, power, and critical organic peroxide refrigeration systems.
[00:29:46] Consequently are going to use standby refrigerated trailers to keep the organic peroxide products. Cool on August 31st, 2017 organic peroxide products stored inside the refrigerated trailer decompose causing the peroxide and the trailer to burn. When people sought medical attention from the exposure of fumes rated by the decomposing products.
[00:30:10] When the vapor traveled across the public highway, adjacent to the bus. Emergency response officials initially decided to keep it just highway open because this road served as an important route for hurricane recovery efforts. During the next several days, a second fire and a controlled burn conducted by a unified command consumed eight more trailers, holding Archimedes remaining organic peroxide products that required low temperature storage over the course of the free fires.
[00:30:39] The three fires, an excess of 350,000 pounds of organic peroxide combusted as a result, more than 200 relative is living within a 1.5 mile radius of the facility who had evacuated the area could not return home for. As a part of this investigation, the CSB examined our corporate policies pertaining to the evaluation of process safety, risks, risks due to extreme weather events and determined that while the existing corporate policy address flooding, it did not address other extreme weather events that are coming facilities, may experience consequences.
[00:31:16] Consequently, the board issued a recommendation to Arkema to ensure that critical safeguards are available and function as intended during extreme weather events. Now, the number of recommendations issued in this investigation were five and only three of those, which include this one, um, remained open a number of recommendations issued to our committee, Inc was to, and this was their, their final remaining open recommendation.
[00:31:45] And the highlighted recommendation is CFE recommendation. Number 2017 dash eight dash oh. Dash PX dash R three, which reads established corporate requirements for his facility is that manufacturer organic peroxide or that processes, which involve more than the threshold, quantity of highly hazardous chemicals to ensure that critical safeguards such as backup power functions as an tended during extreme weather events, including hurricanes or floods.
[00:32:23] And here’s what the recommend, uh, dation recipient did the closest recommendation between October, 2020 and January, 2021. Arkema supplied the CSB with copies of the natural disaster preparedness assessment and their natural hazards, assessment procedures, and other tools that are developed for plant sites to ensure that critical safeguards function as intended during extreme weather prevent, uh, events.
[00:32:49] In addition, Arkema supplied examples for the CSB review of individual plant site gap analyses and corrective action plans among the 22 plants that conducted these assessments, the procedures and supplemental documentation provided by Arkema meet the intent of the safety objectives as envisioned by the board.
[00:33:10] And therefore, as a result on July 28th, 2021, the board voted to change the status to closed acceptable. Thank you, director Barbie. So I have a few questions. So always to know me well enough. Um, how did Arkema conduct its natural hazard assessment? Um, argument evaluated his current facilities conditions against a variety of natural hazards, such as maximum potential height, wind loads, and seismic activity.
[00:33:41] Using a checklist to ensure consistency across all 22 facilities. Natural hazard potentials for all facilities were then scored and ranked then appropriate mitigation measures were developed and tracked to completion. Wait, I was needing my, uh, voice because we have some construction going on there. Um, but I’ll unmute.
[00:34:06] Let’s see here. Am I in reading? Um, were any special techniques used for these assessments, besides the checklist for a lower scoring facilities, publicly available data from the federal emergency management agency or FEMA and the national oceanographic and atmospheric administration or NOAA were utilized for higher scoring facilities, advanced modeling tools and techniques were used such as 3d drone flyovers for detailed evaluation measurements and or other commercial third party tools and software.
[00:34:48] So the next two recommendations come from the prior trust, fatal gas, well explosion and fire investigation, which, uh, you know, I’ve said previously, this is, this is my favorite investigation for dates. I love talking about it. So the, um, the incident summary is. On January 22nd, 2018, a blowout and rig fire occurred at prior trust 0 7 1 8 gas.
[00:35:10] Well number H R 180 9, located in Pittsburg county, Oklahoma. The fire resulted in the fatalities of five workers who were inside the drillers cabin on the rig floor. They died from a thermal burn injuries and smoke and foot inhalation. The blowout occurred approximately three and a half hours after removing drill pipe or tripping out of the well, the cause of the blowout in the rig fire was the failure of both the primary barrier.
[00:35:39] The hydrostatic pressure produced by drilling mud and the secondary barrier humid detection of influx and ax and activation of the blowout preventer, which were both intended to be in place to prevent a blowout as a part of this investigation. And specific to the two recommendations we are addressing today.
[00:35:59] The CSB determined that the lack of a well construction interface document or WCID between the drilling contractor and lease operator likely contributed to the lack of hazard analysis and management of change by both companies. When there were signs that the operations were veering from the original plan, however, the American petroleum Institute bullets in 97, well construction interface document guidelines applies solely to the offshore drilling industry had API bullets in 97, also applied to onshore operations.
[00:36:35] It could have potentially prevented this. Additionally, the CSB determined that pays on systems corporation supplied the electronic drilling data system for the prior trust drilling rig, but no alarm data was included as a part of the data package supply to the driller. This data could, could provide valuable insight into alarm performance, providing the basis for improving alarm management for drilling contractors.
[00:37:05] Now, from this investigation, there were 19 recommendations that were issued 13 of which including the two we’re talking about today, remain open. The number of recommendations issued to API where five of which this is the first of the recommendations that is to be implemented. And that recommendation number is 2018 dash one dash I dash.
[00:37:30] Okay. Dash R six, which reads. Update API bullets in 97. Well construction interface, document guidelines to specify that it applies to both onshore and offshore drilling operations. And here’s what API did in January of 2021 API communicated to CSB that rather than update bullets and 97 to apply to onshore drilling operations in December, 2020 API published recommended practice 97 L onshore.
[00:38:03] Well construction interface document to address WCID issues for onshore drilling operations, due to the differences between offshore and onshore operations and the response API outlined, how recommended practice 97 now addresses the provisions contained in the CSB recommendation. The CSB purchased and reviewed a copy of the December, 2020 edition of API recommended practice 97 out to evaluate that information.
[00:38:33] Although API did not extend the scope of 90 and 97 to include onshore drilling operations as envisioned by the CSB recommendation API met the intent of the recommendation by issuing a new recommended practice 97. Now that applies to WC IDs to onshore drilling as a result on July 28th, 2021, the board voted to change the status to closed acceptable alternative actions.
[00:39:05] Well, in, in past, uh, in anticipation of chairman limo’s questions, um, I’m going to answer what I would think would be a good question. Um, so you may ask, why did API, why did API issue recommended practice rather than just extending offshore documents to apply to the onshore drilling operations? Um, that would be because API and they, and they, they explained this when they responded to us, uh, they thought it was more appropriate to develop a separate document, given the, the significant difference between onshore and offshore operation.
[00:39:49] And I mean, when you start looking at that includes terminology, environment, conditions, and, and all kinds of things like that.
[00:40:04] I had not intended to not engage in that discussion director, Bobby, that I really appreciate it because my next question is why does API issue or new with emendation practice rather than just extending its off shore? Thank you for taking up the slack for this technical challenge, um, to apply it to onshore drilling operations.
[00:40:28] Oh, and it was, as I said, they’re just so radically different. They, they involve different groups, different terminology and environmental conditions. So, um, it just seemed that that was a better way to address the recommendation. I, and I appreciate that direct your poppy. So I thank you for taking the technical so cure.
[00:40:49] Can you provide additional details on what is to be addressed in the new onshore well construction interface? Document. Yes, ma’am the well construction interface document serves as a bridging document between lease operators and drilling contractors safety and a banner environmental management systems to address five provisions, one, it outlines responsibilities for lease operators and drilling contractor personnel.
[00:41:23] Two. It acknowledges that management of change and risk assessment processes should be used during well construction activities. And to address personnel, organizational changes to ensure personnel skill level is sufficient for the applicable position three, it provides a means for the drilling contractor to be involved when operational changes or conditions are identified that could require a well activity risk assessing.
[00:41:53] An example of that is a change from overbalanced to under balanced drilling or change. That affects a well barrier for it provides a method to align all parties regarding drilling health, safety, and environmental standards and applicable regulatory requirements. And five, it provides a method of communicating stop, work authority,
[00:42:19] and you know what, uh, director Bobby, I want to appreciate the fact that your background is, um, well suited to this topic. Um, having come from, you know, working with Bessie at Bessie, you understand what the regulator challenges are, the regular, they you’re responsive, sorry. Responsibilities are. And I, I appreciate that.
[00:42:47] Um, okay. Continue on. Thanks chairman. Um, the second, um, recommendation that we’re going to highlight from the prior trust investigation, um, was issued to pays on system corporation. And the number of recommendations that we issued to them was to, and this was the remaining open recommendation and it’s a CSP recommendation number is 20 18 1 dash R dash I dash.
[00:43:19] Okay. which reads design the pays on electronic drilling data systems. So that alarm information, including alarm set points, alarm activation, log, alarm horn status, which is on or off and alarm status on or off is provided to customers. And here’s what pays on did to close it in March of 2021, based on informed the CSB that they released the software enhancement to their electronic drilling recorder or EDR software, uh, last April that addressed all elements of the CSB recommendation.
[00:43:56] And they provided the CSB with a copy of the software release notes, which explain the changes that were made. Um, and based on our review, the changes that were made by a pilot pays on to its EDR software meets the intent of the recommendation. And as a result on July 28th, 2021, the board voted to change the status to closed exceptable action.
[00:44:21] I’ve got gardening people outside. So, you know, it’s, it’s just the fact of, uh,
[00:44:30] the fact of working tele-working. Um, so we are now on. Highlighting Chevron refinery or so the questions from the chairman regarding the software changing and pacing, why is it acceptable closure of this recommendation? Significant, there are two primary reasons that the acceptable closure of this recommendation is significant.
[00:45:01] First pays on systems. Corporation is one of two companies providing driven software to the onshore oil and gas industry. So this recommendation has a far reaching impact within this industry. Second second, now that this recommendation will be accepted, we closed Patterson UTI, which is one of the other recommendation recipients can use the updated software to provide information needed, to assist them in closing out their remaining open recommendation.
[00:45:32] So you said, so. Got it. That makes sense. And what specific enhancements at Payson Payson systems corporation make to their software to satisfy the CSP recommendations? Ah, well, the upgraded software now has a new event history feature that stores and displays a list of past events that can be used to determine the alarm systems state.
[00:46:03] And it can be used to reconstruct past events as well as to audit the system use. Okay. So finally, the last recommendation we are highlighting, so arguably the most significant specific deposit that we driving process safety change comes from the Chevron refinery fire investigation. And here’s the incident summary on August six.
[00:46:27] 2012, the Chevron refinery in Richmond, California experienced a catastrophic site failure in a crude unit causing the release of flammable hydrogen prosper or hydrocarbon processed fluid was partially vaporized into a large cloud. 19 Chevron employees engulfed by the vapor cloud escaped narrowly avoiding serious injury.
[00:46:52] The ignition and subsequent continued burning of the hydrocarbon process. Fluid resulted in a large plume of unknown particular vapor, approximately 15,000 people from the surrounding area sought medical treatment in the weeks. Following the end. If California is division of occupational safety and health administers, the California occupational safety and health program and enforces California’s process safety management standard established under title eight, section 5, 1 8 9 of the California code of regulations, U S chemical safety and hazard investigation board examine the effectiveness of the Cal OSHA program.
[00:47:35] The CSPs investigation concluded the following. The California PSM regulation did not effectively establish goals to prevent accidents or reduce risks. Only two of the 14 elements, process, hazard analysis and mechanical integrity of the PSM standard contains some goal setting. CalOSHA did not receive sufficient funding to employ a well-staffed multidisciplinary team capable of conducting thorough inspections of PSM covered facilities in California and Cal OSHA did not effectively collect or promote industry use of major accident performance indicators to drive industry, to reduce risks, to as low as reasonably practicable for eight alarm.
[00:48:24] So the number of recommendations that came out of this investigation were 37 11 of which remain open a number of recommendations issued to the governor and legislature in the state of California were nine and only three of those remain open. And that included this one, the CSB recommendation number is 2012 three I C a R 21.
[00:48:52] Which reads, and it’s a level one based on the findings in this report, enhance and restructure California’s process, safety management, or PS regulations for petroleum refineries by including the following goal-setting attributes. Hey require a comprehensive process hazard analysis or PHA written by the county company.
[00:49:18] That includes I, or one systematic analysis and documentation of all major hazards and safeguards using the hierarchy of controls to identify hazards and significantly reduce risks to a goal of as low as reasonably practical or similar to. Documentation of the recognized methodologies, rationale and conclusions used to claim that inherently safer systems have been implemented to as low as reasonably practical or similar.
[00:49:53] And that additional safeguards intended to control remaining hazards will be effective. Three documented damage mechanism has a review conducted by a diverse team of qualified personnel. This review shall be an integral part of the process hazard analysis cycle and shall be conducted on all covered processes, piping circuits, and.
[00:50:18] The damage mechanism, hazard review shall identify potential process, damage mechanisms and consequences of failure and challenges. Sure. Effective safeguards are in place to prevent or control hazards presented by those damage mechanisms require the analysis and incorporation of applicable industry, best practices and inherently safer design to the greatest extent, feasible into this review and for documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent, feasible and establishing safeguards for identified process.
[00:51:00] The goal shall be to drive the risk of major accidents to as low as reasonably practicable or similar include requirements for inherently safer systems analysis, to be automatically triggered for all management of change and process hazard analysis reviews, as well as prior to the construction of new processes, process, unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations B require a thorough review of the comprehensive process hazard analysis by technically competent regulatory personnel C require preventative audits and preventative inspections by the regulator to ensure the effective implementation of the comprehensive process hazard analysis.
[00:51:52] The require that all safety codes, standards, employer, internal procedures, and recognize, and generally accepted good engineering practices or rag again, using the implementation of the regulations contain adequate minimum requirements E require mechanisms for the regulator, the refinery and workers, and the representatives to play an equally and essential role in the direction of preventing major incidents require an expanded role for workers and management of process safety by establishing the rights and responsibilities of workers and the representative.
[00:52:31] On a health and safety related matters and the election of safety representatives and the establishment of safety committees with equal representation between management and labor to serve health and safety related functions. The elected representatives should have a legally recognized role that goes beyond consultation and activities, such as the development of the comprehensive process hazard analysis, implementation of corrective actions generated from hierarchy control analysis, management of change, incident investigation audits, and the identification prevention and control of all process hazards.
[00:53:10] The regulation should provide workers and their representatives with the authority to stop work that is perceived to be unsafe until the employer resolves the matter or the renovator intervene. Workforce participation practices should be documented by the refinery to the regulator. Require reporting of information to the public, to the greatest extent feasible.
[00:53:34] So it, as a summary of the comprehensive process, hazard analysis would, should include a list of inherently safer systems, implemented safeguards and implemented for remaining hazards standards utilized to reduce risks, to as low as reasonably practical or similar and process safety indicators that demonstrate the effectiveness of the safeguards and management system.
[00:54:00] G implement an approach or system that demonstrates when new or improved industry standards and practices are needed and initiate programs and other activities such as an advisory committee or forum to prompt the timely development and implementation of set standards and practices, and H ensure that it means of sustained funding as established to support an independent well-funded well-staffed technically competent regulators.
[00:54:32] Then here’s what the state of California did. The closer California’s newly adopted process safety management regulation for petroleum refineries. Under section 500 809 became effective on October 1st, 2017. The new regulation applies only to petroleum refinery. Within California. And it has the goal of reducing a risk of major incidents and eliminating or minimizing process safety hazards to its employees may be exposed according to the press release from California department of industrial relations or DIR the elements outlined in the regulation require the refinery employers to one conduct, damage mechanism reviews for processes that result in equipment or material degradation to conduct a hierarchy of hazard controls analysis to encourage refinery management, to implement the most effective safety measures when considering competing demands and costs when correcting hazards three, implementing human factors program, which requires analyses of human factors, such as staffing levels, training and competency, fatigue, and other effects of ship work and the human machine interface.
[00:55:49] For develop, implement and maintain written procedures for the men and management of organizational change to ensure that plant safety remains consistent during personnel changes five, utilize root cause analysis when investigating any incident that results in or could have reasonably resulted in a major incident, six perform and document a process hazard analysis of the effectiveness of safeguards that apply to processes and identify, evaluate, and control hazards associated with each process.
[00:56:26] And lastly, understand the attitudes, beliefs, perceptions, and values that employees share in relation to safety and evaluate responses to reports and hazards by implementing and maintaining an effective, effective process safety culture assessment program. The new regulation is intend to make California petroleum refineries safer for both workers and surrounding communities.
[00:56:52] And although California has newly adopted DSM regulations for petroleum refinery is not accomplish everything requested by the recommendation is the much more robust regulation that goes a long way toward improving process safety management. At these refineries, California CSM regulation introduces several new management system elements previous to the identified by the CSB as being necessary for improved refinery safety, including the use of hierarchy of hazard controls, performing damage mechanism reviews, and conducting safeguard protection analysis.
[00:57:30] The parts of the recommendation or the, excuse me, the parts of the regulation that were determined to be missing are further addressed in this parish. The recommendation requires proactively providing PHA information to the regulator and requires that the information to be reviewed by the regular, that the information would be reviewed by the regulator.
[00:57:51] So the regulation does not include this requirement. It does require a triennial compliance audit from the employer, as well as provides the authority for the regulator to receive that PHA information upon request. The regulations does not specifically require audits and inspections to be conducted by the regulator, but the regulator already has that authority to implement these programs on their own.
[00:58:17] Should they desire to do so? The regulation does not require the public reporting of PSM related information. However, The public already does have the ability to access this information. And lastly, the requirement to implement an approach that determines when new or improved industry standards and practices are needed and initiate programs and other activities to prompt the timely development of implementation is neither practical, enormous, measurable, any new standard or practice initiated and implemented is assumed to be based upon a need.
[00:58:54] And therefore can meet this requirement. Typically the need is based on some negative consequence and the timeliness requirement is relative to the parameters that already exist that allow for the development and implementation of set standards and practices though. Not specifically address in this regulation, the requirement all as written already generally exists in practice.
[00:59:18] So in summation, Of the totality of the requirements of the recommendation that are not addressed by the California’s PSM recommendation. It appears that there are alternatives that currently exist that allow that the objectives to be generally met California’s new PSM regulation, adopted many improvements, and it making refinery safer for workers and citizens, though, a more robust process safety management approach aimed at identifying hazards, implementing inherently safer solutions and reducing risks to the greatest extent feasible.
[00:59:58] So as a result of all of that information, um, on July 28th, 2021, the board voted to change the status to close, acceptable alternative actions
[01:00:15] as a big one.
[01:00:20] Um, I have just a few questions for you. Um, can you please provide some insights of the process of the state of California went through, uh, to create the PSM regulation for refineries? Yes ma’am. Um, as you can imagine, the state of California implied or employed a very thorough and rigorous rulemaking process to arrive upon the final adopted DSM regulation for refinery, they created a task force to conduct a significant amount of information gathering as well as interviews to better understand all the issues that needed to be addressed with the new rule.
[01:01:01] The state of California, occupational safety and health standards board issued a notice of proposed rulemaking in July, 2016, which provided the public, including the CSB, the opportunity. Public comments on the proposed rule. In September, 2016, they held a public hearing to consider revisions to the proposal.
[01:01:23] They held another public hearing in spring of 2017. And then finally in October of 2017, the new rule was adopted. Thank you, director Barbie. And I know we’re going a little bit long, but I, I, this is important information. Are you aware of any other states who may be looking to adopt this type of rule, um, for, for finery fees?
[01:01:50] Uh, I’m really glad you asked that question from the CSB is to thorough refinery fail explosion and fire investigation. Uh, the CSB in 2014 issued similar recommendations. To the governor and legislator, legislature of the state of Washington, as a result, they’ve been working diligently on drafting, a similar rule for their refinery.
[01:02:14] Over the last two years, the state of Washington has held a number of listening sessions and stakeholder meetings to discuss the specifics of the California rule and the desired topics to be covered in a new PS room rule or PSM rule for the state of Washington. The CSB is very hopeful that the state of Washington will be issuing a proposed rulemaking for comment sometime this year.
[01:02:40] So unless you have additional questions, I thank you for the opportunity to highlight these extremely impactful safety recommendations and pass it back to you. I thank you so much, director Barbie. I think we should move to something that I’m very excited about. Um, which director, uh, executive director Kleist will introduce, which is a new safety product that relates to our ag one, uh, closed investigation last month.
[01:03:13] Oh, we wait for Steve to pull up his screen. Uh, just wanna re rate, uh, the chairman’s earlier comments. Um, uh, I want to thank the, the investor, the recommendation staff. I think it’s incredibly important that the, the, uh, the general public is aware that the recommendations and the clearance of the rest of those recommendations is every bit as important as the investigation itself.
[01:03:35] Um, so with that, I think Steve, so Steve, take it away. Yes. Thank you. Uh, Mr. and thank you chairman for your very insightful comment about the staff’s work. We very much appreciate the recognition. This is the CSB we’ll be releasing today. The safety video that was produced to supplement the ag horn investigation report that was previously adopted by the board.
[01:04:01] Before we show the animation in the video, I will begin with an overview of the incident on October 26th, 2019 and ag horn employee pumper hae responded to the pump oil level alarm at ag horns foster D waterflood station in Odessa, Texas. The pump was located in a building whole they pump house in response to the alarm pumper, a work to isolate the pump from the process by closing the pumps, discharge and suction valve.
[01:04:31] Number eight did not first perform lockout tagout to isolate number one from the energy source before performing work on the pump while closing the pumps, discharge and suction vows war produced water containing hydrogen sulfide released from the pump. The CSB found post-incident that the pump had a broken plunger from which the water and hydrogen sulfide released bumper a was fatally injured from his exposure to the release of my consultant.
[01:05:05] Subsequently the spouse of pumper, a gained access to the waterflood station and search for pumper a during her search efforts, she was also exposed to the V released hydrogen sulfide and was fatally injured. The investigation team identified seven safety issues and its investigation of the issue.
[01:05:27] Non-use of pumper A’s personal hydrogen sulfide detector, nonperformance of lockout-tagout confinement of hydrogen sulfide in the pump house ag horns, lack of a safety management program, safety management oversight, ag horns, non-functioning hydrogen sulfide detection and alarm system. And according to deficient site security, we will now show the animation.
[01:05:54] That is part of video. Again, that will be released today.
[01:06:07] The acorn waterflood station is used as part of a process to extract oil from underground reservoirs in west Texas oil extraction starts at an oil well where pump jacks are used to lift oil from underground reservoirs. Reservoirs in west Texas also contain hydrogen sulfide, a toxic gas, which comes to the surface with the oil that is extracted.
[01:06:32] The oil comes out of the ground with some water in it to remove the water. The mixture is fed to a tank battery. As the oil and water mixture sits in the tanks. The water separates from the oil. The oil is then transported for further processing. The water is pumped through pipelines to the waterflood station.
[01:06:54] It is now called produced water because it can contain residual oil and other contaminants such as toxic hydrogen sulfide gas at the waterflood station, the produced water flows into a large storage tank called a suction tank. The water then enters a building called the pump house. Their pumps are used to pressurize the produced water and inject it back into the oil field through injection Wells.
[01:07:23] The injected water increases, reservoir pressure and displaces, the oil, allowing a larger quantity of oil to be extracted at the time of the incident. There were two pumps in the pump house. The pump house also contains a control room from which employees run the station. Typically the station is not continuously occupied.
[01:07:43] Instead. An ag horn employee called a pumper visits twice per day to record meter readings and inspect equipment. If there is an equipment problem and a pumper is not at the station and alarm system triggers an automated phone call to the pumper. It is then the pumpers responsibility to acknowledge the alarm and go to the station to determine what is causing it.
[01:08:07] The station was also equipped with a hydrogen sulfide detection and alarm system that would trigger a separate automated phone call to the pumper on duty. If it detected dangerous levels of the toxic gas, the system would also, aluminate a rotating red beacon light on top of the pump house, but the CSB found that this critical detection and alert system was not functional on the night of the incident.
[01:08:32] At 6:38 PM. On October 26th, the waterfloods stations controlled system activated an oil level alarm on a pump. Five minutes later, the phone system called an egg horn pumper alerting him of a pump malfunction of some kind. The pumper drove to the waterflood station. The hydrogen sulfide beacon light was not illuminated when the pumper arrived at the waterflood station or at any time for the rest of the night.
[01:09:00] The pumper parked near the waterflood station, leaving his personal hydrogen sulfide monitor inside his truck. The pumper went into the control room where the control system indicated the alarm was for pump. Number one, the pumper prepared for work on pump. Number one, the pump, which could automatically start when enough water was available to pump to the injection.
[01:09:23] Wells was still connected to its power source. The pumper did not. De-energize the pump. The pumper then walked to the pumps. He closed pump number one, discharge valve, and partially closed the pumps intake valve. While the pumper was near the pump, he was overcome and fatally injured by toxic hydrogen sulfide gas.
[01:09:46] After the incident, the CSB, I found that a plunger on the pump had shattered, which had allowed water containing hydrogen sulfide to escape from the pump into the pump house where the pumper was working. Due to limitations of available evidence. The CSB was unable to determine whether the pump failure and water release occurred before the pumper arrived at the facility, or if the pump automatically turned on while the pumper was closing bounds.
[01:10:13] After several hours, when the pumper did not return home, his spouse drove with their two children to the station to check on him. She entered the waterflood station facility and searched for him. She soon found him on the floor in the pump house. She then was also overcome and fatally injured by the toxic hydrogen sulfide gas.
[01:10:35] A short time later, emergency responders approached the pump house. They detected a very strong smell of hydrogen sulfide. This required them to set up the command post outside the front gate of the facility. And where’s, self-contained breathing apparatus. They found the pumper and his wife deceased inside the pump house and water spilling from pump.
[01:10:59] Number one, the responders rescued the two children who were inside the spouse’s car, working with ag horn employees. They were able to stop the water release the following morning.
[01:11:18] Thank you, Mr. Kleist. Uh, I’d like to spotlight the staff, uh, in who assisted in developing this, this short form video in long form can be found on all CSB outlets, specifically Hilary Cohen, John Sharma Longhorn and supervisory investigator of the ag court investigation. Lauren grim, uh, Dr. Lamaze, this concludes the public meeting and I invite you to issue any closure of your March remarks, which you may have, like Dr.
[01:11:47] Lewis might have a mic issue currently. Okay, there we go. Okay. Are we good now? All right. I want to thank everyone for their attendance of its public meeting and for your attention and support. I also want to thank my senior advisors and our dedicated agency staff for their contributions. All of them share a strong interest in preventing chemical accidents like this one in the future.
[01:12:26] And once again, the, we must remain true to our mission in conducting an issuing independent and objective. And now LASUS and recommendations is important to consider the expertise, knowledge, and priorities of our stakeholder community. Please look out for our upcoming announcements. In the very near term, uh, board meetings to close out the investigations that were mentioned in today’s meeting and our next quarterly public meeting with this, the meeting is adjourned.