U.S. Chemical Safety Board U.S. Chemical Safety Board CSB _37a82aa1-b7ac-4037-8471-854b58882798 Workers, businesses, and communities are safe from the threat of chemical accidents. _1db4fe94-7100-45cd-8451-e773211f3105 To investigate chemical accidents and hazards at fixed industrial facilities, to issue safety recommendations, and to provide information on preventing accidents to Congress, government, industry, labor, and the American public. _6bbf91f0-1463-4729-a579-70bcb7e8d562 Accident Investigations Select and complete accident investigations and recommend actions with a high potential for protecting workers, the public, and the environment. _13f9af5c-8626-43e6-ab33-ddd113cf74cf 1 Key Results: - Deploy to accidents that score high on selection criteria - Investigate selected accidents and produce written investigative products that contain significant new findings - Where appropriate, issue significant safety recommendations with a high potential for preventing or reducing the impact of future accidents - Reduce the time to complete investigation products Key Strategies: Resources, Skills, and Technology Needed - Develop, revise, and periodically review selection criteria and other tools necessary to improve and expedite investigations - Incorporate new components into investigative analysis (e.g. human factors, safety culture, and organizational performance) - Ensure adequate emphasis in all investigations on the impact of chemical accidents on the public and on community preparedness and response issues - Improve planning to tailor the scope, detail, and resources of investigations to the importance of the safety issues - Develop and implement criteria for continuing or curtailing investigations - Improve capacity to conduct industry surveys to define the extent of risks - Identify potential recommendation targets and assess the magnitude of the safety issues at an early stage of the investigation - Improve the monitoring of emerging chemical safety issues Metrics: - Number of significant safety recommendations issued - Cost and average duration of completed investigations - Surveys of stakeholders on impact and significance of investigative products - Adherence to incident selection criteria and scoping criteria Discussion: Chemical accidents cause fatalities and injuries to workers and the public and produce extensive property damage and harm the environment. The CSB investigates major accidents to determine their root causes and recommends actions to prevent future accidents. CSB has substantially increased the number of accident investigations it conducts each year. In FY 2002, the agency issued only four accident investigation reports. Four years later, in FY 2006, the agency completed seven investigation reports. The CSB only has the resources to conduct investigations of a small percentage of the chemical accidents that occur each year in the United States. In a 2006 report to Congress, the CSB noted that over a 12-month period, the agency screened some 645 chemical accidents, an average of almost two a day. The consequences of 18 of these accidents — including deaths, injuries, property damage, public impact, or environmental harm — were serious enough to rate “medium” to “high” priority in the agency’s scoring system for chemical accidents. The CSB deployed to seven accident sites during the same period, and five investigations were carried forward. To make the greatest impact within resource constraints, CSB focuses its investigative resources on those cases that have the potential for helping to improve safety on a widespread basis. An example is the CSB’s investigation of the 2005 refinery disaster in Texas City that killed 15 workers and injured approximately 180 others. Even before this investigation was completed, it commanded worldwide attention as the CSB publicized its preliminary findings and early recommendations through seven news conferences, a major public meeting, and numerous speaking engagements around the country. The CSB’s three urgent safety recommendations issued in 2005 from the Texas City investigation are already prompting major changes throughout the industry. For example, new policies are being implemented in the U.S. and overseas for placing temporary structures such as trailers away from hazardous areas of petrochemical facilities. However, the majority of accidents that occur do not command national attention, and investigative recommendations from those accidents have more limited scope. Approximately 6% (24) of CSB’s recommendations have the potential to impact serious and widespread risks by affecting national regulations, voluntary standards, model codes, or other activities of national significance. Another 32% could impact important risks in contexts such as large cities or major corporations. The remaining 62% have focused on individual sites or smaller firms or have called on organizations to communicate CSB findings. In smaller cases where significant national recommendations are not warranted, the CSB will focus on completing investigations quickly and efficiently and with a limited commitment of resources. The Board recognizes, however, that even smaller accidents can offer significant and important lessons for industry and will use the outreach program to publicize the findings from those cases. Often, it is only a few fortunate circumstances that differentiate between a smaller accident and a catastrophic one. The keys to achieving Goal 1 include a highly disciplined use of the agency’s selection criteria for accident deployments and — even more importantly — a careful scoping of resources and effort after the initial details of an accident are revealed. CSB investigations continue to highlight the key role that organizational behavior and human factors play in causing major accidents. The study of human factors can range from examining the interface between humans and equipment to investigating how organizational and staffing decisions impact safety performance. Almost all major U.S. chemical accidents involve hazards that are known among safety experts and have been previously described in the technical literature. Accident investigations from many sectors — including the manned space program and the nuclear energy sector — have focused on the role of organizational safety culture in setting the stage for disasters. To better address these issues, the CSB will include organizational and human factors components in its investigative analysis, alongside the existing rigorous technical analyses. Baseline Statistics: During FY 2006, the agency issued a total of seven investigation reports (two full investigations, three case studies, and two safety bulletins). During the period from 1998 to 2006, the CSB issued a total of 383 safety recommendations, of which approximately 36% addressed significant risks at the national, state, or large municipal or corporate level. The average duration of the last eight completed investigations has been 15 months, at an average total cost of $159,000. During the period from July 2004 to June 2005, the agency initiated five accident investigations; all five scored at least “medium” in the agency’s selection criteria. During the same period, resource constraints prevented the agency from deploying investigators to eight other accidents that scored “medium” or above. a2dba3e3-afc9-416d-b6b0-6bfb2cb3986b 2e1fbf74-501b-4d15-b6b1-25ff21b10db7 adb9c2f5-2a7a-46a3-824a-941414faf891 Safety Studies Select and complete safety studies and recommend actions with a high potential for protecting workers, the public, and the environment. _476db337-35a3-4723-a4e5-65e151120fd5 2 Key Results: - Produce safety studies that contain significant safety recommendations Key Strategies: Resources, Skills, and Technology Needed - Subject to availability of resources, establish a studies team to improve the quality, efficiency, and scientific rigor of the research and studies process - Expand staff research skills related to public policy, law, statistics, and accident epidemiology - Develop and implement a written protocol for selecting and conducting safety studies - Explore appropriate partnerships with other government agencies, academia, and research organizations for conducting studies - Organize discussions with key stakeholders to identify significant chemical safety issues suitable for possible CSB studies - Improve capacity for conducting research surveys in support of the safety studies Metrics: - Number of significant safety recommendations issued - Cost and average duration of completed studies - Surveys of stakeholders on impact and significance of safety studies - Adherence to safety studies protocol Discussion: The Clean Air Act Amendments of 1990 authorize the agency “to conduct research and studies with respect to the potential for accidental releases, whether or not an accidental release has occurred, where there is evidence which indicates the presence of a potential hazard or hazards.” Conducting safety studies is an important aspect of the CSB’s mission to prevent accidents. Investigating the root causes of an individual accident, while obviously important, sometimes fails to reveal how prevalent a hazard is around the nation. Recommendations from an individual accident investigation often focus on eliminating specific root causes rather than addressing broader national problems. From 1998 to 2006, the agency conducted five safety studies that examined widespread hazards in U.S. industry, such as reactive chemicals, combustible dust, and the dangers of nitrogen asphyxiation. Collectively, these hazards were responsible for numerous deaths and injuries and substantial property and environmental damage. The studies present recommendations for national actions to help save lives by preventing similar accidents in the future. Conducting an effective safety study requires research skills in fields such as public policy, law, statistics, and accident epidemiology — skills that are represented only sparingly among current staff. The current strategic plan, therefore, includes a new goal to develop, over the next six years, a dedicated capacity for conducting safety studies. Essential elements of the goal include recruiting or developing new skills, establishing a written protocol for conducting safety studies, and creating a more formal process for selecting what safety issues to study. Creating methods for conducting effective national surveys of safety practices is an essential component. Baseline Statistics: The agency’s most recent safety study, on combustible dust hazards, required a total of about 25 months to complete, at a total cost of $300,000. Of five completed studies, only the studies of reactive hazards and combustible dust included formal safety recommendations. Those studies contained 30 recommendations, of which approximately 13 were major recommendations directed to federal agencies or national trade or safety organizations. e3cdac06-9f4e-4bfd-b7fb-ce4f245a63ba 205f6d64-7c0a-4ffb-a0c9-6006a2090f65 1f8aec1e-5485-4caf-9aad-d98bf306940a Implementation of Recommendations Reduce the likelihood of similar accidents in the future by securing implementation of CSB safety recommendations. _b1117110-691b-4370-a4af-9faaa575a021 3 Key Results: - CSB safety recommendations are closed based upon acceptable actions by recipients Key Strategies: Resources, Skills, and Technology Needed - Maintain an efficient system for rapidly communicating with recommendations recipients, tracking the status of all open safety recommendations, and evaluating the adequacy of recipient actions - Publicize up-to-date status information on all safety recommendations through the CSB website and other public communication channels, with an emphasis on most-wanted safety actions - Conduct focused advocacy programs for significant, challenging safety recommendations through ongoing dialogue with relevant government and other stakeholders, testimony, and other public communications - Publicly recognize recommendations recipients that implement significant safety actions based on CSB safety recommendations Metrics: - Number and percentage of safety recommendations closed successfully Discussion: Specific, measurable recommendations are a primary tool of the Board for encouraging safety improvements that help protect workers, the public, and the environment. Most CSB reports, bulletins, case studies, and hazard investigations include a number of safety recommendations directed to specific named organizations. Recommendations recipients include government agencies at all levels, standard-setting organizations, trade associations, labor unions, and private corporations such as oil and chemical firms, engineering companies, and insurers. By statute, the EPA and OSHA must respond to any CSB safety recommendation within 180 days. The CSB’s recommendations staff works with recipients and other interested parties to help ensure the successful acceptance of recommendations. As soon as a recommendation is issued, the Board communicates with the recipient in writing, providing the text of the recommendation and citing its rationale in a specific CSB investigation. Recipients are requested to provide extensive documentation of the actions they take in response to the CSB’s recommendations. In some cases, CSB staff and board members may visit sites to assess the safety changes made in response to a recommendation. If a recipient’s actions meet or exceed the intent of the CSB’s recommendation, the staff develops a formal, written evaluation urging closure of the recommendation by a vote of the full board. Significant recommendations may require extensive, time-consuming advocacy efforts to achieve successful closure. For example, in 2003 the Board determined that improvements in New York City’s 85-year-old fire code were required to help prevent future accidents similar to a 2002 building explosion in downtown Manhattan that injured 36 people. The recommendation to modernize the fire code at first encountered skepticism and resistance. Board members conducted two public meetings in New York City, testified twice before the New York City Council, met with key stakeholders, and made a number of media appearances to discuss the importance of the requested safety changes. Within one year, the New York City government changed course and began working on a complete overhaul of the code. In 2005, the Board developed a real-time tracking system for the status of all of its issued recommendations; up-to-date status information on hundreds of recommendations appears on the agency’s popular website, CSB.gov. The Board recognizes that public, stakeholder, and media interest in the responses of recipients to CSB recommendations is a key ingredient in gaining acceptance and closure of these recommendations. Some recipients opt to go above and beyond the actions contemplated in CSB recommendations. For example, the American Institute of Chemical Engineers’ Center for Chemical Process Safety — responding to a CSB recommendation for better guidance on preventing accidents involving reactive chemicals — developed and issued an entire book on the subject and through the funding of government agencies made it freely available to the entire industry. The state of Kentucky exceeded the Board’s safety recommendation for controlling industrial dust explosions by establishing a comprehensive identification, inspection, and outreach program for facilities statewide that handle combustible powders. In such instances, the Board provides special recognition to recipients through public announcements, speeches, or certificates. Baseline Statistics: As of July 2006, the CSB had issued 383 safety recommendations, including more than 200 in the preceding three years. To date, 145 safety recommendations have been successfully closed based on actions that meet or exceed the Board’s intentions. Many of the remainder are in varying stages of implementation, and fewer than 20 recommendations have been designated as “unacceptable” or “no longer applicable.” From a low of 10 recommendations closed per year in 2003 and 2004, the CSB successfully closed 54 recommendations in 2005 and has closed 66 more as of July 2006. 28867827-d335-4842-8b77-2f9a5d7433cc 4f7d7ef7-b264-4fa1-a787-a712ed9e9293 6c587c85-5330-4e59-abc8-3a647f5675e8 Information Dissemination Promote improved safety practices by broadly disseminating the findings, lessons, and recommendations from CSB investigations and studies. _a96990a4-858c-4787-b3fc-b0ed7d6b6b37 4 Key Results: - Investigations are publicized through community hearings, public meetings, news conferences, and website dissemination - At least one public hearing or meeting for most major investigations - Each investigation leads to appropriate outreach products that are distributed pursuant to an outreach plan - Relevant stakeholder groups promptly receive and widely disseminate CSB information Key Strategies: Resources, Skills, and Technology Needed - Conduct public events (e.g. press conferences or public meetings) for all ongoing investigations - Identify industries and sectors that have similar risks to those investigated and target them for outreach efforts - Develop outreach plans and products such as videos and digests based on CSB investigations and studies - Coordinate with stakeholder organizations to disseminate CSB information to their members - Provide Board members to deployments, key conferences, and symposia - CSB website uses state-of-the-art technologies to provide access to essential investigative information - Regularly brief Congressional committees and offices on the status of ongoing CSB investigations and open safety recommendations - Surveys of web visitors, conference and meeting attendees, and recipients of outreach materials to measure effectiveness of communication and usefulness of information for activities such as training, hazard analysis, safe facility design, and improved safety practices Metrics: - Number of outreach products developed and distributed - Number of public meetings, events, and hearings, and speeches to strategic audiences - Number of visits to CSB web pages, reports, and videos and aggregate distribution of news stories describing CSB findings - Number of subscribers to CSB news and information Discussion: The Board recognizes that a potent tool for achieving its mission is more widespread awareness of the causes of chemical accidents and the measures that can prevent them. Companies and their employees share a strong interest in avoiding major chemical accidents that cost lives, damage reputations, destroy productive capacity, and often result in expensive litigation. But many companies, particularly smaller businesses, are not aware of all the high-consequence, low-probability risks they face in operating their facilities. For example, major industrial dust explosions are rare events but when they occur they can cause multiple fatalities and destroy or incapacitate large facilities. The culprit is often a thin layer of combustible powder — such as a fine resin dust — that has accumulated in concealed or hard-to-reach places. This hazard was responsible for devastating explosions in North Carolina and Kentucky in 2003 that cost 13 lives and caused tens of millions of dollars in property damage. In both cases, the companies were not fully aware of the catastrophic nature of the combustible dust hazard. If they had been, they would likely have taken relatively inexpensive control and housekeeping measures before the tragedies occurred. While outreach is a shared responsibility among many federal agencies involved in chemical safety, the CSB has a unique body of knowledge and insight gained from its more than 40 detailed accident investigations and safety studies. The agency’s experience over the past several years is that relatively inexpensive and achievable outreach campaigns can greatly increase the dissemination of its reports, findings, and recommended safety practices. Activities have included public meetings, news conferences, speeches, and the development of focused outreach materials such as short safety videos, computer recreations of accidents, and plain-language investigation summaries, known as digests. At costs that are a fraction of those expended on the investigations themselves, the agency can effectively disseminate its safety information to thousands of facilities and millions of individuals in locations all over the world. The CSB’s outreach programs have reached not only the traditional audiences in the oil and chemical industries but also hospitals, national parks, nuclear power plants, schools and universities, fire departments, and many other organizations. Perhaps most importantly, outreach efforts provide communities around the country with essential information they need to promote improved safety at chemical facilities in their midst. In the past several years, the CSB has moved toward virtually 100% electronic dissemination of all its information. The CSB’s website, CSB.gov, is an internationally recognized resource for accident prevention that receives more than one million hits annually. The site, which was completely redesigned in 2003, is the agency’s principal interface with the public. The Strategic Plan envisions continued investment in the website to maintain its currency, including state-of-the-art technologies such as imbedded streaming video. As technologies evolve we will utilize those new technologies to extend the dissemination of CSB safety findings. The agency’s vision for outreach is that one day, the CSB’s findings and recommendations will be able to reach the majority of all the companies, agencies, and other organizations that can benefit. The CSB Safety Videos DVD details recommendations issued from recent CSB investigations in a series of short videos. Baseline Statistics: In fiscal year 2006, the CSB issued reports on seven investigations. Four of these were accompanied by short safety videos highlighting the causes of the accidents and key findings, recommendations, and good prevention practices. In six of seven cases, a news conference was held in the community near the accident site to release the final reports and/or videos. In addition, videos were issued related to two ongoing cases, and a large public meeting was held in Texas City, Texas, related to the BP refinery disaster. During the most recent 12-month period ending in July 2006, more than 1.3 million hits were recorded on the CSB’s public website, including more than 440,000 viewings of CSB’s safety videos. Over a seven-month period, more than 10,700 video DVDs were produced and distributed to individuals and members of important stakeholder groups, such as the American Institute of Chemical Engineers, the American Chemistry Council, the Synthetic Organic Chemical Manufacturers Association, and the United Steelworkers of America. More than 2,200 DVD requests and comments were received through the CSB website over seven months; many attested to the usefulness of CSB safety videos in worker training, hazard analysis, and facility design. Approximately 9,000 people from around the world have registered to receive regular CSB news by email. Printed news stories describing CSB investigations and findings were distributed to a total of 233 million people during the most recent 12-month period. 154c76b6-81f1-4199-9c90-1bf09d9fd0a7 2910a11a-5fac-489b-9b4f-d50a79eb4044 1b333d62-af98-4e0b-b07c-2bca5c561d8f Human Capital and Infrastructure Establish the CSB as a recognized world leader in accident investigation and prevention by continuing to improve our human capital and infrastructure. _60ecc1ea-6a50-46a7-9f92-329873e5d3c5 5 Key Results: - The CSB staff has the necessary knowledge, skills, abilities, motivation, and diversity to accomplish the agency’s goals - CSB has the critical infrastructure to conduct its mission effectively, such as adequate space, IT systems, succession plans, training programs, human capital plans, and performance management - Agency has attracted and retained high-performing career employees - In surveys, most employees report high overall satisfaction with the CSB as a workplace - The CSB is recognized as a world leader in accident investigation and prevention Key Strategies: Resources, Skills, and Technology Needed - Retain and recruit highly qualified and motivated personnel - Ensure critical infrastructure to support mission accomplishment by developing and implementing the human capital plan, the IT capital plan, succession plans, space plans, and continuity of operations plan - Develop employee development tracks and internal career paths - Ensure teamwork, communication, and cooperation among departments - Develop metrics for the effectiveness of the agency infrastructure and adequacy of knowledge, skills, abilities - Develop a learning culture throughout the agency through seminars, professional exchanges, and contacts with academia, professional societies, and retired experts - Develop and implement core competency training programs for CSB employees - Emphasize accomplishment of action plan goals in individual performance plans and awards Metrics: - Staff retention rate for highperforming career employees - Employee satisfaction surveys - Percentage of key positions covered by succession plans Discussion: The CSB recognizes that high-performing employees are essential to accomplishing its mission. Conducting high quality accident investigations and studies and developing effective recommendations and outreach activities requires an exceptional level of technical skill, motivation, and diligence. The CSB began operation in 1998 as a new federal agency without any transfer of staff or infrastructure. Since that time, however, CSB has devoted considerable resources to hiring highly qualified personnel and developing its organizational structure and procedures. From fiscal year 2007 to 2012, the CSB will continue working to improve the performance, training, productivity, and satisfaction of its workforce. In fiscal year 2005, the CSB developed its first comprehensive human capital plan, which called for the establishment of multiple investigative teams, each with a diverse array of skills. For example, team members should have specialized expertise in evidence collection, chemical engineering, mechanical engineering, metallurgy, and human and organizational factors. Establishment of the teams, each with its own supervisory lead investigator, will be a key to further reducing the cost and duration of investigations. In addition, the plan envisioned forming a dedicated unit for conducting safety studies. As the plan recognized, conducting effective studies requires distinct skills in research, statistics, and public policy. During the period of the current Strategic Plan, a major challenge is to recruit and develop the skills necessary to implement the human capital vision. In fiscal year 2006, the agency reassigned one of its senior investigators to begin the task of developing a comprehensive training program for its investigative staff. Virtually all career employees participated in a variety of training programs, including specialized investigative courses, safety training, and leadership programs. Aggressive use of the federal career intern program has greatly facilitated hiring at the entry-level. By 2006, nine highly talented and motivated college graduates had been recruited through this program for initial two-year appointments. In 2006 the CSB completed a full overhaul of its information technology (IT) infrastructure, with the installation of modern servers, workstations, and other equipment throughout the agency. The CSB also completed plans for the outsourcing of its public website to reduce costs and improve service and technological currency. The CSB has benefited from excellent retention of key employees. As of 2006, members of the CSB’s staff leadership team have an average tenure at the agency of more than six years, in an agency that was just over eight years old. However, with a large fraction of key employees now approaching eligibility for retirement, succession planning takes on heightened importance. Developing plans for replacing key investigative and administrative functions will be an important exercise during the current period. Baseline Statistics: The CSB’s second biennial survey of employee satisfaction was conducted in 2006. Although, no formalized succession plans have yet been developed, the new structure being established in the Office of Investigations provides a succession mechanism for the agency’s largest office. 9723f5f0-cd06-4934-8323-cc69710102a7 20dff345-4eb5-483d-b230-07a5096350d5 3d78f8b8-6008-43b9-a066-f7939f5d394a 2006-10-01 2012-09-30 2010-02-08 http://www.csb.gov/news_releases/docs/CSBStrategicPlan2007-2012.pdf Arthur Colman (www.drybridge.com) colman@drybridge.com Submit error.