U.S. Chemical Safety BoardU.S. Chemical Safety BoardCSB_37a82aa1-b7ac-4037-8471-854b58882798Workers, businesses, and communities are safe from the threat of chemical accidents._1db4fe94-7100-45cd-8451-e773211f3105To 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-a579-70bcb7e8d562Accident InvestigationsSelect and complete accident investigations and recommend actions with a high potential for protecting workers, the public, and the environment._13f9af5c-8626-43e6-ab33-ddd113cf74cf1Key Results:- Deploy to accidents that score high on selectioncriteria- Investigate selected accidents and produce writteninvestigative products that contain significant newfindings- Where appropriate, issue significant safetyrecommendations with a high potential forpreventing or reducing the impact of futureaccidents- Reduce the time to complete investigationproductsKey Strategies:Resources, Skills, and Technology Needed- Develop, revise, and periodically reviewselection criteria and other tools necessary toimprove and expedite investigations- Incorporate new components into investigativeanalysis (e.g. human factors, safety culture, andorganizational performance)- Ensure adequate emphasis in all investigationson the impact of chemical accidents on thepublic and on community preparedness andresponse issues- Improve planning to tailor the scope, detail, andresources of investigations to the importance ofthe safety issues- Develop and implement criteria for continuingor curtailing investigations- Improve capacity to conduct industry surveysto define the extent of risks- Identify potential recommendation targets andassess the magnitude of the safety issues atan early stage of the investigation- Improve the monitoring of emerging chemicalsafety issuesMetrics:- Number of significantsafety recommendations issued- Cost and average duration ofcompleted investigations- Surveys of stakeholders onimpact and significance ofinvestigative products- Adherence to incident selectioncriteria and scoping criteriaDiscussion: Chemical accidents cause fatalities andinjuries to workers and the public andproduce extensive property damageand harm the environment. The CSBinvestigates major accidents to determinetheir root causes and recommends actions toprevent future accidents.CSB has substantially increased the number ofaccident investigations it conducts each year. In FY2002, the agency issued only four accident investigationreports. Four years later, in FY 2006, theagency completed seven investigation reports.The CSB only has the resources to conductinvestigations of a small percentage of the chemicalaccidents that occur each year in the UnitedStates. In a 2006 report to Congress, the CSBnoted that over a 12-month period, the agencyscreened some 645 chemical accidents, an averageof almost two a day. The consequences of 18 ofthese accidents — including deaths, injuries, propertydamage, public impact, or environmentalharm — were serious enough to rate “medium” to“high” priority in the agency’s scoring system forchemical accidents. The CSB deployed to sevenaccident sites during the same period, and fiveinvestigations were carried forward.To make the greatest impact within resourceconstraints, CSB focuses its investigative resourceson those cases that have the potential for helpingto improve safety on a widespread basis.An example is the CSB’s investigation of the2005 refinery disaster in Texas City that killed 15workers and injured approximately 180 others.Even before this investigation was completed, itcommanded worldwide attention as the CSB publicizedits preliminary findings and early recommendationsthrough seven news conferences, amajor public meeting, and numerous speakingengagements around the country.The CSB’s three urgent safety recommendationsissued in 2005 from the Texas City investigationare already prompting major changes throughoutthe industry. For example, new policies arebeing implemented in the U.S. and overseas forplacing temporary structures such as trailers awayfrom hazardous areas of petrochemical facilities.However, the majority of accidents that occurdo not command national attention, and investigativerecommendations from those accidents havemore limited scope. Approximately 6% (24) ofCSB’s recommendations have the potential toimpact serious and widespread risks by affectingnational regulations, voluntary standards, modelcodes, or other activities of national significance.Another 32% could impact important risks in contextssuch as large cities or major corporations.The remaining 62% have focused on individualsites or smaller firms or have called on organizationsto communicate CSB findings.In smaller cases where significant national recommendationsare not warranted, the CSB willfocus on completing investigations quickly andefficiently and with a limited commitment ofresources. The Board recognizes, however, thateven smaller accidents can offer significant andimportant lessons for industry and will use the outreachprogram to publicize the findings from thosecases. Often, it is only a few fortunate circumstancesthat differentiate between a smaller accidentand a catastrophic one.The keys to achieving Goal 1 include a highlydisciplined use of the agency’s selection criteria foraccident deployments and — even more importantly — a careful scoping of resources and effortafter the initial details of an accident are revealed.CSB investigations continue to highlight thekey role that organizational behavior and humanfactors play in causing major accidents. The studyof human factors can range from examining theinterface between humans and equipment to investigatinghow organizational and staffing decisionsimpact safety performance.Almost all major U.S. chemical accidentsinvolve hazards that are known among safetyexperts and have been previously described in thetechnical literature. Accident investigations frommany sectors — including the manned space programand the nuclear energy sector — havefocused on the role of organizational safety culturein setting the stage for disasters.To better address these issues, the CSB willinclude organizational and human factors componentsin its investigative analysis, alongside theexisting rigorous technical analyses.Baseline Statistics: During FY 2006, the agency issued a total ofseven investigation reports (two full investigations,three case studies, and two safety bulletins).During the period from 1998 to 2006, the CSBissued a total of 383 safety recommendations, ofwhich approximately 36% addressed significantrisks at the national, state, or large municipal orcorporate level. The average duration of the lasteight completed investigations has been 15months, at an average total cost of $159,000.During the period from July 2004 to June2005, the agency initiated five accident investigations;all five scored at least “medium” in theagency’s selection criteria. During the same period,resource constraints prevented the agency fromdeploying investigators to eight other accidentsthat scored “medium” or above._e51eebc4-ca6e-11ed-84d7-4f402583ea00Safety StudiesSelect and complete safety studies and recommend actions with a high potential for protecting workers, the public, and the environment._476db337-35a3-4723-a4e5-65e151120fd52Key Results:- Produce safety studies that contain significantsafety recommendationsKey Strategies:Resources, Skills, and Technology Needed- Subject to availability of resources, establisha studies team to improve the quality,efficiency, and scientific rigor of the researchand studies process- Expand staff research skills related to publicpolicy, law, statistics, and accidentepidemiology- Develop and implement a written protocol forselecting and conducting safety studies- Explore appropriate partnerships with othergovernment agencies, academia, and researchorganizations for conducting studies- Organize discussions with key stakeholders toidentify significant chemical safety issuessuitable for possible CSB studies- Improve capacity for conducting researchsurveys in support of the safety studiesMetrics:- Number of significantsafety recommendationsissued- Cost and average duration ofcompleted studies- Surveys of stakeholders onimpact and significance ofsafety studies- Adherence to safetystudies protocolDiscussion:The Clean Air Act Amendments of 1990authorize the agency “to conductresearch and studies with respect to thepotential for accidental releases,whether or not an accidental releasehas occurred, where there is evidence which indicatesthe presence of a potential hazard or hazards.”Conducting safety studies is an importantaspect of the CSB’s mission to prevent accidents.Investigating the root causes of an individual accident,while obviously important, sometimes failsto reveal how prevalent a hazard is around thenation. Recommendations from an individual accidentinvestigation often focus on eliminating specificroot causes rather than addressing broadernational problems.From 1998 to 2006, the agency conductedfive safety studies that examined widespread hazardsin U.S. industry, such as reactive chemicals,combustible dust, and the dangers of nitrogenasphyxiation. Collectively, these hazards wereresponsible for numerous deaths and injuries andsubstantial property and environmental damage.The studies present recommendations for nationalactions to help save lives by preventing similaraccidents in the future.Conducting an effective safety study requiresresearch skills in fields such as public policy, law,statistics, and accident epidemiology — skills thatare represented only sparingly among current staff.The current strategic plan, therefore, includes anew goal to develop, over the next six years, a dedicatedcapacity for conducting safety studies.Essential elements of the goal include recruiting ordeveloping new skills, establishing a written protocolfor conducting safety studies, and creating amore formal process for selecting what safety issuesto study. Creating methods for conducting effectivenational surveys of safety practices is an essentialcomponent.Baseline Statistics:The agency’s most recent safety study, on combustibledust hazards, required a total of about 25months to complete, at a total cost of $300,000.Of five completed studies, only the studies of reactivehazards and combustible dust included formalsafety recommendations. Those studies contained30 recommendations, of which approximately 13were major recommendations directed to federalagencies or national trade or safety organizations._e51eed18-ca6e-11ed-84d7-4f402583ea00Implementation of RecommendationsReduce the likelihood of similar accidents in the future by securing implementation of CSB safety recommendations._b1117110-691b-4370-a4af-9faaa575a0213Key Results:- CSB safety recommendations are closed basedupon acceptable actions by recipientsKey Strategies:Resources, Skills, and Technology Needed- Maintain an efficient system for rapidlycommunicating with recommendationsrecipients, tracking the status of all opensafety recommendations, and evaluating theadequacy of recipient actions- Publicize up-to-date status information on allsafety recommendations through the CSBwebsite and other public communicationchannels, with an emphasis on most-wanted safety actions- Conduct focused advocacy programs for significant, challenging safety recommendations through ongoing dialogue with relevant government and otherstakeholders, testimony, and other public communications- Publicly recognize recommendations recipients that implement significant safety actions based on CSB safety recommendationsMetrics:- 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 citingits 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 requireextensive, time-consuming advocacy efforts to achieve successful closure. For example, in 2003 the Board determined that improvements in NewYork 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 YorkCity 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-timetracking system for the status of all of its issuedrecommendations; up-to-date status informationon hundreds of recommendations appears on theagency’s popular website, CSB.gov. The Board recognizesthat public, stakeholder, and media interestin the responses of recipients to CSB recommendationsis a key ingredient in gaining acceptance andclosure of these recommendations.Some recipients opt to go above and beyondthe actions contemplated in CSB recommendations.For example, the American Institute ofChemical Engineers’ Center for Chemical ProcessSafety — responding to a CSB recommendationfor better guidance on preventing accidents involvingreactive chemicals — developed and issued anentire book on the subject and through the fundingof government agencies made it freely availableto the entire industry. The state of Kentuckyexceeded the Board’s safety recommendation forcontrolling industrial dust explosions by establishinga comprehensive identification, inspection, andoutreach program for facilities statewide that handlecombustible powders.In such instances, the Board provides specialrecognition to recipients through public announcements,speeches, or certificates.Baseline Statistics:As of July 2006, the CSB had issued 383 safetyrecommendations, including more than 200 inthe preceding three years. To date, 145 safety recommendationshave been successfully closed basedon actions that meet or exceed the Board’s intentions.Many of the remainder are in varying stagesof implementation, and fewer than 20 recommendationshave been designated as “unacceptable” or“no longer applicable.” From a low of 10 recommendationsclosed per year in 2003 and 2004, theCSB successfully closed 54 recommendations in2005 and has closed 66 more as of July 2006._e51eedfe-ca6e-11ed-84d7-4f402583ea00Information DisseminationPromote improved safety practices by broadly disseminating the findings, lessons, and recommendations from CSB investigations and studies._a96990a4-858c-4787-b3fc-b0ed7d6b6b374Key Results:- Investigations are publicized through communityhearings, public meetings, news conferences, andwebsite dissemination- At least one public hearing or meeting for mostmajor investigations- Each investigation leads to appropriate outreachproducts that are distributed pursuant to anoutreach plan- Relevant stakeholder groups promptly receive andwidely disseminate CSB informationKey Strategies:Resources, Skills, and Technology Needed- Conduct public events (e.g. pressconferences or public meetings) for allongoing investigations- Identify industries and sectors that havesimilar risks to those investigated and targetthem for outreach efforts- Develop outreach plans and productssuch as videos and digests based on CSBinvestigations and studies- Coordinate with stakeholder organizationsto disseminate CSB information to theirmembers- Provide Board members to deployments,key conferences, and symposia- CSB website uses state-of-the-arttechnologies to provide access to essentialinvestigative information- Regularly brief Congressional committeesand offices on the status of ongoingCSB investigations and open safetyrecommendations- Surveys of web visitors,conference and meetingattendees, and recipients ofoutreach materials to measureeffectiveness of communicationand usefulness of information foractivities such as training,hazard analysis, safe facilitydesign, and improved safetypracticesMetrics:- Number of outreach productsdeveloped and distributed- Number of public meetings,events, and hearings, andspeeches to strategic audiences- Number of visits to CSB webpages, reports, and videos andaggregate distribution of newsstories describing CSB findings- Number of subscribers to CSBnews and informationDiscussion:The Board recognizes that a potent toolfor achieving its mission is more widespreadawareness of the causes ofchemical accidents and the measuresthat can prevent them. Companies andtheir employees share a strong interest in avoidingmajor chemical accidents that cost lives, damagereputations, destroy productive capacity, and oftenresult in expensive litigation. But many companies,particularly smaller businesses, are not aware of allthe high-consequence, low-probability risks theyface in operating their facilities.For example, major industrial dust explosionsare rare events but when they occur they can causemultiple fatalities and destroy or incapacitate largefacilities. The culprit is often a thin layer of combustiblepowder — such as a fine resin dust — thathas accumulated in concealed or hard-to-reachplaces. This hazard was responsible for devastatingexplosions in North Carolina and Kentucky in2003 that cost 13 lives and caused tens of millionsof dollars in property damage. In both cases, thecompanies were not fully aware of the catastrophicnature of the combustible dust hazard. If theyhad been, they would likely have taken relativelyinexpensive control and housekeeping measuresbefore the tragedies occurred.While outreach is a shared responsibilityamong many federal agencies involved in chemicalsafety, the CSB has a unique body of knowledgeand insight gained from its more than 40 detailedaccident investigations and safety studies. Theagency’s experience over the past several years isthat relatively inexpensive and achievable outreachcampaigns can greatly increase the disseminationof its reports, findings, and recommended safetypractices. Activities have included public meetings,news conferences, speeches, and the developmentof focused outreach materials such as short safetyvideos, computer recreations of accidents, andplain-language investigation summaries, known asdigests.At costs that are a fraction of those expendedon the investigations themselves, the agency caneffectively disseminate its safety information tothousands of facilities and millions of individualsin locations all over the world. The CSB’s outreachprograms have reached not only the traditionalaudiences in the oil and chemical industries butalso hospitals, national parks, nuclear powerplants, schools and universities, fire departments,and many other organizations. Perhaps mostimportantly, outreach efforts provide communitiesaround the country with essential information theyneed to promote improved safety at chemical facilitiesin their midst.In the past several years, the CSB has movedtoward virtually 100% electronic dissemination ofall its information. The CSB’s website, CSB.gov, isan internationally recognized resource for accidentprevention that receives more than one million hitsannually. The site, which was completely redesignedin 2003, is the agency’s principal interfacewith the public. The Strategic Plan envisionscontinued investment in the website to maintainits currency, including state-of-the-art technologiessuch as imbedded streaming video. As technologiesevolve we will utilize those new technologiesto extend the dissemination of CSB safety findings.The agency’s vision for outreach is that oneday, the CSB’s findings and recommendations willbe able to reach the majority of all the companies,agencies, and other organizations that can benefit.The CSB Safety Videos DVD details recommendationsissued from recent CSB investigations in aseries of short videos.Baseline Statistics: In fiscal year 2006, the CSB issued reports onseven investigations. Four of these were accompaniedby short safety videos highlighting the causesof the accidents and key findings, recommendations,and good prevention practices. In six ofseven cases, a news conference was held in thecommunity near the accident site to release thefinal reports and/or videos. In addition, videoswere issued related to two ongoing cases, and alarge public meeting was held in Texas City, Texas,related to the BP refinery disaster.During the most recent 12-month period endingin July 2006, more than 1.3 million hits wererecorded on the CSB’s public website, includingmore than 440,000 viewings of CSB’s safetyvideos. Over a seven-month period, more than10,700 video DVDs were produced and distributedto individuals and members of importantstakeholder groups, such as the American Instituteof Chemical Engineers, the American ChemistryCouncil, the Synthetic Organic ChemicalManufacturers Association, and the UnitedSteelworkers of America. More than 2,200 DVDrequests and comments were received through theCSB website over seven months; many attested tothe usefulness of CSB safety videos in workertraining, hazard analysis, and facility design.Approximately 9,000 people from around theworld have registered to receive regular CSB newsby email. Printed news stories describing CSBinvestigations and findings were distributed to atotal of 233 million people during the most recent12-month period._e51eef3e-ca6e-11ed-84d7-4f402583ea00Human Capital and InfrastructureEstablish the CSB as a recognized world leader in accident investigation and prevention by continuing to improve our human capital and infrastructure._60ecc1ea-6a50-46a7-9f92-329873e5d3c55Key Results:- The CSB staff has the necessary knowledge, skills,abilities, motivation, and diversity to accomplishthe agency’s goals- CSB has the critical infrastructure to conduct itsmission effectively, such as adequate space, ITsystems, succession plans, training programs,human capital plans, and performance management- Agency has attracted and retained high-performingcareer employees- In surveys, most employees report high overallsatisfaction with the CSB as a workplace- The CSB is recognized as a world leader inaccident investigation and preventionKey Strategies:Resources, Skills, and Technology Needed- Retain and recruit highly qualified andmotivated personnel- Ensure critical infrastructure to supportmission accomplishment by developing andimplementing the human capital plan, the ITcapital plan, succession plans, space plans,and continuity of operations plan- Develop employee development tracksand internal career paths- Ensure teamwork, communication, andcooperation among departments- Develop metrics for the effectiveness ofthe agency infrastructure and adequacyof knowledge, skills, abilities- Develop a learning culture throughout theagency through seminars, professionalexchanges, and contacts with academia,professional societies, and retired experts- Develop and implement core competencytraining programs for CSB employees- Emphasize accomplishment of action plangoals in individual performance plans andawardsMetrics:- Staff retention rate for highperformingcareer employees- Employee satisfactionsurveys- Percentage of key positionscovered by succession plansDiscussion: The CSB recognizes that high-performingemployees are essential to accomplishingits mission. Conducting high qualityaccident investigations andstudies and developing effective recommendationsand outreach activities requires anexceptional level of technical skill, motivation, anddiligence.The CSB began operation in 1998 as a newfederal agency without any transfer of staff orinfrastructure. Since that time, however, CSB hasdevoted considerable resources to hiring highlyqualified personnel and developing its organizationalstructure and procedures. From fiscal year2007 to 2012, the CSB will continue working toimprove the performance, training, productivity,and satisfaction of its workforce.In fiscal year 2005, the CSB developed its firstcomprehensive human capital plan, which calledfor the establishment of multiple investigativeteams, each with a diverse array of skills. For example,team members should have specialized expertisein evidence collection, chemical engineering,mechanical engineering, metallurgy, and humanand organizational factors. Establishment of theteams, each with its own supervisory lead investigator,will be a key to further reducing the cost andduration of investigations. In addition, the planenvisioned forming a dedicated unit for conductingsafety studies. As the plan recognized, conductingeffective studies requires distinct skills inresearch, statistics, and public policy.During the period of the current StrategicPlan, a major challenge is to recruit and developthe skills necessary to implement the human capitalvision. In fiscal year 2006, the agency reassignedone of its senior investigators to begin thetask of developing a comprehensive training programfor its investigative staff. Virtually all careeremployees participated in a variety of training programs,including specialized investigative courses,safety training, and leadership programs. Aggressiveuse of the federal career intern program hasgreatly facilitated hiring at the entry-level. By2006, nine highly talented and motivated collegegraduates had been recruited through this programfor initial two-year appointments.In 2006 the CSB completed a full overhaul ofits information technology (IT) infrastructure,with the installation of modern servers, workstations,and other equipment throughout the agency.The CSB also completed plans for the outsourcingof its public website to reduce costs and improveservice and technological currency.The CSB has benefited from excellent retentionof key employees. As of 2006, members of theCSB’s staff leadership team have an average tenureat the agency of more than six years, in an agencythat was just over eight years old. However, with alarge fraction of key employees now approachingeligibility for retirement, succession planning takeson heightened importance. Developing plans forreplacing key investigative and administrative functionswill be an important exercise during the currentperiod.Baseline Statistics: The CSB’s second biennial survey of employeesatisfaction was conducted in 2006. Although, noformalized succession plans have yet been developed,the new structure being established in theOffice of Investigations provides a successionmechanism for the agency’s largest office._e51ef04c-ca6e-11ed-84d7-4f402583ea002006-10-012012-09-302010-02-08ArthurColman (www.drybridge.com)colman@drybridge.com