DEPARTMENT OF HOMELAND SECURITY 

Office of Inspector General 

Washington, DC 20528 

January 7, 2004 

MEMORANDUM 

TO: Carolyn W. Merritt, Chairman/CEO 

U.S. Chemical Safety and Hazard Investigation Board 

FROM: Robert L. Ashbaugh, Assistant Inspector General for Inspections, 

Evaluations, and Special Reviews 

SUBJECT: A Report on the Continuing Development of the U.S. Chemical Safety and 

Hazard Investigation Board, OIG-04-04 

Attached for your review and action is our final inspection report, A Report on the 

Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board

(CSB). The report addresses the CSB’s efforts to carry out its mission to investigate 

accidental chemical releases at fixed facilities and to report to the public on the causes of 

those accidents. We found that the CSB fulfills some but not all of its statutory 

responsibilities, and we identified opportunities to enhance the CSB administration. Our 

report makes 11 recommendations to help strengthen the CSB. 

We incorporated both formal and informal comments from the CSB, as appropriate, within 

the body of the report. This report, including the appendix, will be posted on the Department 

of Homeland Security Office of Inspector General (DHS OIG) Internet and Intranet sites. 

Finally, while we have completed the FY 2003 reviews begun by the Federal Emergency 

Management Administration OIG prior to its transfer to the DHS OIG, this report will be our 

last review of the CSB. We are certain that whichever OIG is chosen to succeed us will 

provide the necessary continued oversight, and we are prepared to share our prior work with 

any successor OIG to ensure a smooth transition. 

If you have any questions, please call me or have your staff contact William McCarron, 

Senior Inspector, at (202) 254-4206. 

Attachment 

cc: Bea Robinson, Audit Liaison
Office of Inspector General 

DEPARTMENT OF HOMELAND SECURITY 

A Report on the 

Continuing Development of the 

U.S. Chemical Safety and 

Hazard Investigation Board 

OIG-04-04 January 2004

Office of Inspections, Evaluations, & Special Reviews 
Contents 

 Introduction.................................................................................................................................... 1 

Results in Brief .............................................................................................................................. 1 

 Background.................................................................................................................................... 3 

Purpose, Scope, and Methodology................................................................................................. 4 

The CSB Does Not Fulfill All of Its Statutory Responsibilities.................................................... 5 

Opportunities to Enhance the CSB Administration..................................................................... 31 

Appendices 

 Appendix A: Management Comments ..................................................................................46 

 Appendix B: OIG Evaluation of Management Comments....................................................51 

 Appendix C: Recommendations............................................................................................57 

Appendix D: Timeline of CSB Investigations.......................................................................59 

 Appendix E: Agency Benchmarking.....................................................................................60 

Appendix F: Major Contributors to This Report ..................................................................61 

Appendix G: Report Distribution ......................................................................................... 62 

Abbreviations 

 

ATSDR Agency for Toxic Substances and Disease Registry 

ATF Bureau of Alcohol, Tobacco, and Firearms

BTS Bureau of Transportation Statistics 

COO Chief Operating Officer 

CSB U.S. Chemical Safety and Hazard Investigation Board 

DHS Department of Homeland Security 

DISP Director, Office of Investigations and Safety Programs 

DOT Department of Transportation 

E-FOIA Electronic Freedom of Information Act Amendments of 1996 

EPA Environmental Protection Agency 

FEMA Federal Emergency Management Agency 

FOIA Freedom of Information Act 

GAO United States General Accounting Office 

GPRA Government Performance and Results Act 

MOU Memorandum of Understanding

NRC National Response Center 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page i 
Contents 

NTSB National Transportation Safety Board 

OIG Office of Inspector General 

OISP Office of Investigations and Safety Programs 

OSHA Occupational Safety and Health Administration 

PAR Performance Accountability Report 

RMP Risk Management Program

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page ii 
OIG ISP 

Report

Department of Homeland Security 

Office of Inspector General 

 

Introduction 

The Chemical Safety and Hazard Investigation Board (CSB) is an independent 

agency in its sixth year of operation. Headquartered in Washington, D.C., it 

investigates accidental chemical releases at fixed facilities and reports to the 

public on their causes. The CSB also is authorized to conduct general studies 

of chemical accident hazards. Through its reports, the CSB makes 

recommendations to prevent future accidents to federal, state, and local 

governmental entities and other parties. Although the CSB was created under 

the Clean Air Act Amendments of 1990, Pub. L. No. 101-549, the CSB did 

not receive funding or begin operations until FY 1998. In FY 2003, the CSB 

had an operating budget of $7.85 million and 37 permanent full-time 

employees. 

In FY 2001, Congress designated the Federal Emergency Management 

Agency Office of Inspector General (FEMA OIG) to serve as the Inspector 

General for the CSB.1

 The Homeland Security Act of 2002, Pub. L. No. 107-

269, transferred the FEMA OIG to the Department of Homeland Security 

(DHS) on March 1, 2003. Therefore, DHS OIG assumed responsibility for 

completing this review. We examined the role of the CSB in federal 

prevention of chemical accidents at fixed facilities and the CSB’s overall 

effectiveness in meeting its statutory responsibilities. We also reviewed the 

CSB’s systems for incident and hazard selection, investigation and reporting, 

and dissemination of findings. 

Results in Brief 

After undergoing significant management difficulties during its first four 

years, the CSB increased its productivity and stability under new management 

during the past year. The CSB is progressing toward meeting its statutory 

responsibilities and has increased the number of investigations it performs. 

However, the CSB lacks the resources to investigate all accidents within its 

purview and has no plan to address this shortfall. The CSB meets other 

responsibilities to issue recommendations, coordinate with other federal 

agencies, and perform discretionary studies of general chemical hazards. The 

CSB has intentionally refrained from meeting its responsibility to publish a 

regulation on accident reporting. 

1

 Pub. L. No. 106-377, Appendix A, H.R. 5482, Departments of Veterans Affairs and Housing and Urban Development, 

and Independent Agencies Appropriations Act, 2001. Similar provisions were contained in subsequent appropriations 

acts. 
The CSB’s statutory and legislative history suggest that the CSB has a broader 

responsibility to study whether and how chemical accidents can be prevented. 

This task involves data collection and analysis. With the Environmental 

Protection Agency, the CSB initiated a project to improve some accident data 

collection for analysis. However, the CSB’s draft strategic plan drops 

previous, more ambitious data-related goals. Resuming this responsibility can 

help the CSB progress towards a leadership role in chemical accident

prevention. 

In addition to reevaluating strategic objectives, the CSB can improve its 

administration. The CSB’s incident selection process, which the CSB uses to 

identify potential investigations, needs stricter management controls to ensure 

the accuracy, reliability, and quality of screening and screening data. Also, the 

CSB should revisit a tabled recommendation from the General Accounting 

Office on developing a policy for managing conflicts of interest. Finally, the 

CSB needs to publish additional records and policies to fulfill standards 

related to the Administrative Procedure Act, Freedom of Information Act, and 

Electronic Freedom of Information Act Amendments of 1996. 

We recommend that the CSB: 

1. Address the gap between accidents it investigates and those falling 

within its statutory jurisdiction that it does not investigate; 

2. Define a chemical accident within its purview and publish a regulation 

for receiving information on accidents;

3. Improve follow-up for the CSB’s safety recommendations;

4. Establish a plan linking the CSB’s measurement data and strategic 

improvements;

5. Develop a long-term strategy to address the shortfall in national 

chemical accident database quality;

6. Revise the incident selection process to ensure that all accidents 

meeting statutory criteria are considered for deployment;

7. Revise the incident selection process to incorporate levels of 

supervision and separation of duties;

8. Improve its recordkeeping of the selection process;

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 2 
9. Publish an agency-specific policy regarding employee conflicts of 

interest;

10. Enact required administrative regulations; and

11. Publish policies and administrative guidance on the CSB website.

Background 

An influx of key managers and staff has revitalized the CSB. In the past year, 

the CSB gained two new board members, including a chairman/chief 

executive officer, and a new chief operating officer (COO). The general 

counsel, who functioned as the acting COO for more than two years, returned 

to legal duties full time. The CSB also added seven new investigators, and 

most recently, a management analyst to manage and oversee the CSB’s human 

capital program. Ongoing improvements at the CSB include streamlining 

management, bolstering the investigations program, and intensifying efforts to 

get recommendations implemented. Furthermore, problems that FEMA OIG 

reported in March 2002—longstanding governance difficulties and internal 

conflict over the CSB’s mission and priorities—have been resolved. The CSB 

is also addressing human capital management weaknesses that the FEMA OIG 

reported in November 2002. 

The CSB has increased its investigative productivity. Since June 2002 when 

the influx of new staff began, the CSB has initiated 12 new investigations and 

two hazard studies and completed eight investigations. Generally, the CSB is 

completing investigations more quickly. Nine investigations beginning before 

January 2001 averaged 722 days, while five investigations beginning after 

January 2001 averaged 390 days. Building on this momentum, the CSB 

pledged to Congress in its FY 2004 budget request to conduct 12 

investigations next year. The COO reorganized the Office of Investigations 

and Safety Programs (OISP) to better accommodate the CSB’s investigative 

workload. Appendix C accounts for the CSB’s investigations as of October 1, 

2003, and it illustrates the increasing level of investigative activity. 

Making the recommendations program a focal point of the CSB’s prevention 

efforts, the CSB has redirected outreach activities toward promoting adoption 

of its recommendations. A CSB coordinating committee helps ensure that 

outreach activities support the safety recommendations. The CSB is also 

repackaging and communicating its reports in new ways. The CSB has started 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 3 
releasing incident digests, or non-technical investigation summaries, for all 

completed investigations dating back to 1998. 

Purpose, Scope, and Methodology 

Congress designated the FEMA OIG to serve as the Inspector General for the 

CSB in Public Law No. 106-377, the Veterans Affairs-Department of Housing 

and Urban Development and Independent Agencies Appropriations Act for 

FY 2001. The Homeland Security Act of 2002 transferred the FEMA OIG to 

the Department of Homeland Security on March 1, 2003. Therefore, the DHS 

OIG assumed responsibility for completing this review. 

We assessed: (1) the role of the CSB in federal prevention of chemical 

accidents at fixed facilities; (2) the CSB’s overall effectiveness in meeting its 

statutory responsibilities; (3) the CSB’s systems for incident and hazard 

selection, investigation and reporting, and dissemination of findings; and (4) 

whether any legislative and regulatory provisions are impeding the CSB’s 

performance. 

We reviewed the legislative history, statutes, and regulatory publications of 

the CSB. For comparison, we reviewed the statutes of the National 

Transportation Safety Board (NTSB) and regulatory publications of seven 

independent agencies including the NTSB (see Appendix D). We also 

reviewed various CSB documentation, including FY 2003 and FY 2004 

budget submissions, five-year strategic plan and draft updates, investigative 

protocols, incident selection criteria, operational data, and organizational 

strategies. 

We interviewed the CSB employees including the chairman, board members, 

chief operating officer, general counsel, deputy general counsel, the director 

of the Office of Investigations and Safety Programs, senior investigators, 

recommendation specialists, assistant to the COO, and the OISP’s program 

analyst. We also held discussions with the director of financial operations and 

the CSB’s new management analyst responsible for the human capital 

program. 

We interviewed officials from the NTSB, the Environmental Protection 

Agency (EPA), the Occupational Safety and Health Administration (OSHA), 

the Agency for Toxic Substances and Disease Registry (ATSDR), the 

National Institute for Occupational Safety and Health, and the National 

Response Center (NRC). We also interviewed representatives of various trade, 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 4 
industry, academic and union organizations, including the Massachusetts 

Institute of Technology; the Mary Kay O’Connor Process Safety Center at 

Texas A&M University; the American Chemistry Council; the American 

Institute of Chemical Engineers’ Center for Chemical Process Safety; Union 

of Needletrades, Industrial and Textile Employees; the American Petroleum 

Institute; the Paper, Allied-Industrial, Chemical and Energy Workers 

International Union; the National Association of Chemical Distributors; the 

Dow Chemical Company; BP Amoco; Rohm & Haas; and Monsanto. 

We conducted our fieldwork in Washington, D.C., from November 2002 to 

April 2003. In most cases, we included CSB productivity data during the 

remainder of FY 2003. Our inspection was conducted under the authority of 

the Inspector General Act of 1978, as amended, and according to the Quality 

Standards for Inspections issued by the President’s Council on Integrity and 

Efficiency. 

CSB Does Not Fulfill All of Its Statutory Responsibilities Including the 

Investigation of Major Chemical Accidents 

We examined the CSB’s mission as established by its enabling statute and

legislative history. The statute requires that the CSB investigate and report on 

the causes of serious chemical accidents, issue recommendations that help

prevent future chemical accidents, publish a regulation requiring reports on 

accidental releases, and establish coordination with other federal agencies 

involved in chemical accident prevention. Additionally, the statute gives the 

CSB discretionary authority to perform studies of general chemical hazards. 

The CSB is progressing toward meeting these statutory responsibilities. We 

found that the CSB partly fulfills its responsibility to investigate serious 

chemical accidents. Without the resources to investigate all the accidents 

within its purview, the CSB also is without plans to identify or address its 

investigative gap, which we approximated as several hundred accidents per 

year. We found that the CSB fulfills its responsibilities to issue 

recommendations, coordinate with other agencies, and perform discretionary 

hazard studies. The CSB has deliberately refrained from publishing a 

regulation on accident reporting. 

Finally, the CSB’s statute and legislative history suggest that the CSB has a 

broader responsibility to learn whether and how chemical accidents can be 

prevented most effectively. This responsibility will involve data collection and 

analysis, which the CSB has not indicated it is prepared to do. Although the 

CSB initiated a joint project to improve EPA data collection for certain 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 5 
chemical accidents, the CSB dropped more far-reaching, data-related goals 

from its new strategic plan. The CSB should reconsider its plan, particularly 

regarding the information it collects on the chemical accident universe, to

work toward national leadership in chemical accident prevention. 

The CSB Does Not Fully Use Its Investigative Authority

(C) The Board shall-- (i) investigate (or cause to be investigated), determine and

report to the public in writing the facts, conditions, and circumstances and the cause 

or probable cause of any accidental release resulting in a fatality, serious injury or

substantial property damages. . . . 

(E) . . . In no event shall the Board forego an investigation where an accidental

release causes a fatality or serious injury among the general public, or had the 

potential to cause substantial property damage or a number of deaths or injuries 

among the general public.

2

The CSB’s investigative output is increasing. The CSB completed six 

investigations in FY 2003, and the CSB plans to increase its output to level off 

around 12 products per year by FY 2005. Based on the CSB’s incident 

notification records, however, we counted that the number of accidents 

meeting its statutory criteria for investigation under subparagraphs (C)(i) and 

(E) is approximately 300 per year. With annual budgets under $8 million, the 

CSB has insufficient resources to investigate all the accidents within its 

statutory purview. Furthermore, the CSB has not measured or planned to 

address its investigative gap. The CSB no longer uses its “cause to be 

investigated” authority to tap other agencies’ investigative work. Thus, for the 

vast majority of accidents within its purview, the CSB collects only incident 

notifications; it does not conduct an investigation, identify an accident’s 

cause, or issue a report to inform industry and the public. 

As of June 1, 2003, the CSB completed 12 major accident investigation 

reports, issued shorter safety bulletins and case studies on three other 

accidents, and initiated eight ongoing accident investigations. All but one of 

these 23 accidents caused fatalities, serious injuries, or substantial property 

damage, which require investigation under subparagraph (C)(i). Three 

accidents (Concept Sciences, Herrig Brothers Farm, and Kaltech Industries) 

caused fatalities or serious injuries among members of the public, which 

subparagraph (E) explicitly requires the CSB to investigate, or among first 

 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 6 

2 42 U.S.C. 7412(r)(6) (Supp. 1990). 
 

responders, which subparagraph (E) may cover implicitly.3 Several of the 23 

accidents also required investigation under subparagraph (E) because they had 

the potential to harm the public. This group includes the chlorine release at 

DPC Enterprises, the only investigated accident that did not involve actual 

fatalities, serious injuries, or substantial property damage. 

In addition, the CSB began this year to produce digest versions of its 

completed reports, making them accessible to a broader audience. Also, when 

the CSB did not deploy to a phenol accident in Fall 2002, a board member

persuaded the company involved to publicize its own investigative findings on 

the Internet. This is noteworthy because one of the CSB’s greatest values to its 

industry and trade group readership involves publicizing lessons learned from

accidents, which companies themselves often do not share for liability 

reasons. 

 

In March 2003 congressional testimony, the chairman announced that the 

CSB would complete eight safety products including investigations during 

this fiscal year,4

 an increase from five in FY 2002.5 The CSB plans to 

complete 12 safety products per year for the next five years. The CSB board 

members indicated that the CSB intends to keep its output in the range of 10-

20 reports, a goal several industry and trade group representatives whom we 

interviewed also proposed. Several suggested that conducting more 

investigations would not be worthwhile because the CSB’s audiences would 

become so saturated with safety messages that further investigations would 

lose effectiveness. 

Whether or not this “saturation point” theory is valid, 12 investigations per 

year falls short of the responsibility imposed on the CSB in subparagraphs 

(C)(i) and (E). The CSB noted in its FY 2003 budget submission: “Even at its 

current funding level, the board is unable to investigate a number of serious 

chemical incidents due to a lack of resources.”6

 The gap between the number 

3

 The CSB has not officially defined which accidents it considers to meet subparagraphs (C)(i) or (E). In “Process for 

Selecting Accident Investigations,” the CSB does not distinguish whether first responder fatalities or injuries are grouped

with public consequences, requiring investigation under subparagraph (E), or with consequences subject to investigation

under subparagraph (C)(i). In “Incident Screening Guidance,” the CSB weighted first responder fatalities equally with 

public fatalities, separate from employee and contractor fatalities. Therefore, for the purposes of this report, we counted

first responder fatalities as meeting subparagraph (E). 4

 A “safety product” is how the CSB defines its output goal. The term includes accident investigation reports, hazard 

studies, and other products such as safety bulletins. 5

 In FY 2003, the CSB completed five full investigation reports, one investigation case study, and a safety bulletin, 

compared to four full investigation reports and one investigation case study in FY 2002. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 7 

6

 U.S. Chemical Safety and Hazard Investigation Board, FY 2003 Budget Justification and Annual Performance Plan, 

January 30, 2002. 
 

of possible investigations and the number the CSB undertakes is well known 

and generally accepted by the CSB and the chemical industry. However, what 

is less known is the size of the gap and what should be done to address it. The 

CSB does not have a current estimate of how many accidents it would 

investigate if it fully used its authority under subparagraphs (C)(i) and (E). In 

2000, the CSB reported that more than 100 accidents per year result in 

fatalities, injuries, evacuations/sheltering in place, or significant property 

damage.7

 The CSB no longer supports this estimate of potential investigations. 

Federal and industry representatives we interviewed had no estimate either, 

but they suggested we might search the databases of EPA, OSHA, the Agency 

for Toxic Substances and Disease Registry, and the CSB to develop one. 

We assessed the CSB’s incident screening matrix, which the CSB began using 

in March 2001 to evaluate the incident notifications it receives for possible 

investigation. The data from the screening matrix must be qualified in several 

ways.8

 First, no mechanism exists to guarantee that all chemical accidents are 

reported; the count is likely to be incomplete. Second, the CSB has yet to 

develop quality control procedures to verify that notifications are recorded

correctly in the screening matrix. Third, the CSB has not clearly defined 

which accident sites and consequences fall within its statutory jurisdiction for 

investigation, which means some accidents may be inappropriately included 

or excluded.9

 

The definition issue particularly complicates the CSB’s efforts to identify 

which accidents it must investigate under subparagraph (E) due to their 

potential to harm the public. Assessing an accident’s potential harm based on 

the limited information in an initial incident notification is imprecise. In some

cases, the CSB cannot judge the potential for public harm until the 

investigative team begins collecting evidence. For example, the CSB deployed 

to an incident at First Chemical Corporation that involved a tower’s explosion, 

which sent shrapnel into a nearby facility. Only after the investigative team

arrived did the CSB learn that the shrapnel could have landed elsewhere, and 

released hydrogen or anhydrous ammonia, flammable and toxic gases with 

potential for public harm. To estimate an accident’s potential for public harm, 

the CSB relies on whether the accident occurred at facilities in EPA’s Risk 

Management Program (RMP), which regulates 140 chemicals with the 

potential for dangerous offsite consequences. However, RMP does not cover 

7

 U.S. Chemical Safety and Hazard Investigation Board, 2001-2005 Strategic Plan to Congress, September 29, 2000. 8

 See page 31 for a more detailed discussion of limitations of the incident screening matrix. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 8 

9

 The CSB’s selection criteria define a serious accident as “one that results in one or more deaths, injuries, 

hospitalizations, evacuations/sheltering-in-place of citizens, or significant property damage.” U.S. Chemical Safety and 

Hazard Investigation Board, Process for Selecting Accident Investigations, September 15, 2000. 
every potential hazard, and the CSB is considering changes to its screening 

process to account for the bluntness of this tool.10 Given these qualifications, 

it is plausible that estimates understate the CSB’s responsibility to address 

accidents that may harm the public. 

However, since the screening matrix records contain most of the notifications 

the CSB received, they are useful because they reflect accidents to which the 

CSB might have deployed. The data suggest that the number of serious 

accidents the CSB might have investigated or caused to be investigated under 

subparagraphs (C)(i) and (E) totaled 294 in FY 2002.11

FIGURE 1.—Incident Notifications Screened by the CSB 

FY 2001 

March 13 to 

September 30, 2001 

FY 2002 

All notifications screened 313 613

(C)(i) Notifications involving any 

fatalities, serious injuries, and/or 

substantial property damage 

132 253

(E) Notifications involving actual fatalities 

and/or serious injuries among members of 

the public (includes first responders) 

3 5

(E) Notifications involving potential 

fatalities, serious injuries, and/or 

substantial property damage among 

members of the public 

25 63

Total notifications meeting (C)(i) or (E)12 146 294

 

10 RMP applies to about 15,000 facilities. In contrast, OSHA’s standard on Process Safety Management of Highly 

Hazardous Chemicals covers 137 chemicals and about 25,000 businesses, according to initial estimates when the rule 

was published in 1992. The CSB’s 2002 report Improving Reactive Hazard Management noted that both these programs

cover reactive chemicals incompletely. 11 These counts are based on 1,111 notifications that the duty officer recorded in the CSB’s Incident Selection Screening 

Matrix between March 13, 2001, and January 3, 2003. Counts reflect the date the accident was reported to the CSB. We 

established a minimum count for accidents meeting subparagraph (E) by reading notifications the CSB received and 

accident scores the duty officer assigned. We established a minimum count for accidents meeting subparagraph (C)(i) by 

reviewing accident scores. Except where stated otherwise, statistics reflect the duty officer’s uncorrected records. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 9 

12 Because some notifications met both (C)(i) and (E), the number of total notifications is not a sum of the individual 

figures for (C)(i) and (E). 
Of the 294 potential investigations in FY 2002, the CSB deployed to four (one 

percent). Even were the CSB to reach its goal of 12 reports per year, this 

production level would mean the CSB investigates less than five percent of 

the accidents within its statutory purview. For over 95 percent of the 

accidents, the CSB will not identify causes to report to the public. 

Nevertheless, the CSB members told us that the CSB today is missing no 

major deployments. Others whom we interviewed did not disagree. When we 

asked industry representatives about investigations the CSB should have 

undertaken but did not, we received three replies that cited a 2000 Phillips 66 

accident that occurred during a period when the CSB temporarily stopped all 

new deployments in order to work off a backlog of old matters. The CSB is 

now more responsive in its deployments. For example, in January and 

February 2003, the CSB deployed to four incidents within a five-week span. 

However, that deployment rate, even if the CSB had the resources to sustain 

it, would still fall short of the 294. The CSB needs to reevaluate whether 

completing four to twelve of several hundred potential investigations per year 

meets the statute’s intent.

Not only is the CSB unable to investigate all the accidents meeting 

subparagraphs (C)(i) and (E), but also the CSB is not meeting its mandatory 

requirement to investigate an important subset of the total: accidents harming 

the public, which, according to (E) “[i]n no event shall the Board forego.” 

Staff at the CSB told us that the only accident in the CSB’s history that the 

CSB was absolutely compelled to investigate was an explosion that killed an 

offsite member of the public. However, the CSB’s interpretation of which 

accidents have met (E) is an overly narrow construction. The statute does not 

target only fatalities but also serious injuries. Moreover, (E) does not specify 

that the harm must occur offsite, nor is it clear whether first responders should 

be counted as members of the public. Under a broader interpretation of (E), at 

least five accidents in FY 2002 alone had actual consequences that compelled 

deployment. For four of these, the CSB performed no investigative follow-up 

and did not even consider deployment. The CSB also did not follow up on 

dozens of accidents that met (E) due to potential public harm. The CSB needs 

to comply with subparagraph (E) or seek statutory changes. 

As part of this process, CSB should reexamine how it employs its “cause to be 

investigated” authority. The CSB’s statute allows the CSB to use 

investigations performed by agencies such as OSHA, EPA, and others in order 

to prepare its reports. However, the CSB generally prefers to investigate for 

itself any accident for which it might identify root causes or lessons learned. 

In 1999, the CSB terminated its incident review program, in which CSB staff 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 10 
analyzed others’ investigations. The CSB judged that the costs in time and 

staff produced too little benefit compared to the CSB-controlled 

investigations. 

This is not the stance taken by the National Transportation Safety Board, after 

which the CSB was patterned. The NTSB’s pipeline and hazmat division, 

whose jurisdiction somewhat resembles the CSB’s, also has limited resources 

to fulfill its responsibility to investigate certain accidents. Unlike the CSB, the 

NTSB uses its “cause to be investigated” authority to solicit others’ 

investigations when resources or other considerations prevent it from

undertaking mandatory deployments. In this manner, the NTSB builds its 

knowledge base about all the accidents within its statutory purview, despite 

resource limitations. In contrast, by not using its “cause to be investigated” 

authority, the CSB has an incomplete knowledge base for the majority of 

incident notifications within its purview.13 

The CSB’s small appropriations in its six-year history suggest that Congress 

may not expect the CSB to exercise its full statutory authority for 

investigations. In its first five years, the CSB struggled to demonstrate 

productivity. The CSB has yet to provide Congress with a clear picture of

what it is not accomplishing. For example, in its FY 2003 budget justification, 

the CSB sketched its resource limitations by listing four serious incidents 

occurring over an eight-day period (July 9-17, 2001) to which the CSB might 

have deployed if it had more resources. Actually, during this period the CSB 

received 28 incident notifications, at least 14 of which met (C)(i), and one that 

may have met (E), involving a serious injury to a first responder.14 The CSB’s 

FY 2004 budget justification does not discuss the investigative shortfall at all. 

The CSB must provide Congress with a reliable description of its investigative 

gap and how the CSB views its statutory responsibilities. 

The CSB Meets Requirement to Issue Report Recommendations But 

Should Improve Management of Issued Recommendations

(C) The Board shall – . . . (ii) issue periodic reports to the Congress, Federal, State 

and local agencies, including the Environmental Protection Agency and the 

Occupational Safety and Health Administration, concerned with the safety of

 

13 Although the CSB reexamines selected notifications to plan hazard studies and updates records in its web-based 

Chemical Incident Report Center, for the majority of chemical incidents, the CSB’s follow-up only consists of recording 

the notification and screening for deployment. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 11 

14 Although the CSB did not deploy to that accident, it deployed in succession to two of the accidents that met 

subparagraph (C)(i): ATOFINA Chemicals, on which the NTSB reported in June 2002, and Motiva Enterprises, on

which the CSB reported in August 2002. 
chemical production, processing, handling and storage, and other interested persons

recommending measures to reduce the likelihood or the consequences of accidental

releases and proposing corrective steps to make chemical production, processing, 

handling and storage as safe and free from risk of injury as is possible and may 

include in such reports proposed rules or orders which should be issued by the 

Administrator under the authority of this section or the Secretary of Labor under the

Occupational Safety and Health Act (29 U.S.C. 651 et seq.) to prevent or minimize

the consequences of any release of substances that may cause death, injury or other 

serious adverse effects on human health or substantial property damage as the result

of an accidental release. . . .

 

As of June 1, 2003, the CSB issued 13 investigation reports containing 176 

recommendations to prevent future accidents.15 Recommendations have 

targeted 72 different recipients. The CSB has directed the largest percentage 

of recommendations to industry (44%), closely followed by professional and 

trade organizations (34%). Government agencies are next (14%), then unions 

(9%). Although the CSB has directed recommendations to EPA and OSHA, 

none has contained specific proposals for rules or orders.16 The CSB began 

issuing recommendations in September 1998 with its first completed report, 

but it did not adopt a formal process to manage issued recommendations until 

December 2001. The CSB began closing completed recommendations in 

March 2002 and has closed about a quarter of its recommendations to date. 

Recommendations follow-up is an area that the CSB should continue to 

improve. 

FIGURE 2.— Recommendations Status by Recipient

Recipient Issued Closed Open 

All 176 38 (22%) 138 (78%)

Industry (corporation or facility) 77 (44%) 19 58 

Professional and trade associations 60 (34%) 14 46 

Unions 13 (9%) 2 11 

Other governmental entity 15 (9%) 1 14 

OSHA 6 (3%) 1 5 

EPA 4 (2%) 0 4 

Academic institutions 1 (1%) 1 0 

The CSB’s goal for acceptance of its safety recommendations is 80 percent. 

This goal resembles the NTSB’s, although the percentages are not strictly 

comparable. For example, the CSB issues some types of recommendations 

that the NTSB does not, such as a recommendation that the recipient 

 

15 The CSB also issued a case study and a bulletin, neither of which contained recommendations. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 12 

16 Individual board members developed a proposal in support of the reactive hazard investigation. 
communicate the report’s findings and recommendations to a target audience. 

A great number of the CSB’s recommendations issued (51, or 29 percent) and 

favorably closed (12, or 44 percent) are of this type. The next most common 

CSB recommendation type (36, or 20 percent) involved codes, standards, and 

regulations. Of the 38 recommendations the CSB has closed so far, no 

recommendation has closed with “unacceptable response,” but 11 have closed 

as no longer applicable. Overall, the CSB has closed few recommendations; 

and of those, almost two-thirds (23 out of 38) were based merely upon 

communication of the report or because the recommendation was no longer 

applicable. 

The CSB is working to bring up to date the status of its growing number of 

recommendations, but several examples suggest the CSB could do more to 

monitor its recommendations: 

• The CSB closed ten recommendations in FY 2003. 

• Although the company informed the CSB in 2000 that it no longer 

manufactures Yellow Dye 96, a recommendation from the Morton 

report for the company to revise the dye’s Material Safety Data Sheet 

remained open until August 2003. 

• Morton recommendations for EPA and OSHA to assist in the reactive 

hazard investigation remained open for 11 months after the CSB 

completed the investigation. 

• The CSB took six months to publish recommendations from the 

Georgia Pacific report on the CSB’s Internet database; the Internet 

database, which is the CSB’s primary means of publicizing 

recommendations status, was generally months out of date. 

• As of May 2003, the CSB had conducted follow-up action within the 

past six months for less than a third of its open recommendations, 

according to an internal database. Several recommendations appeared 

not to have received follow-up attention for more than 18 months. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 13 

When the CSB revised its strategic plan in July 2002, the CSB made the 

execution of its recommendations one of its three mission goals. Since then, 

the CSB increased the role of board members in promoting the adoption of the 

CSB recommendations, hired additional recommendations staff, and twice 

revised the placement of recommendations specialists within its Office of 

Investigations and Safety Programs. Also, the CSB developed an internal 
recommendations tracking database and added to its website a second, 

searchable database to inform the public about the nature and status of its 

recommendations. Recently, recommendations specialists told us that they 

were updating the CSB’s records and considering information technology 

options to streamline record keeping. By the end of FY 2003, the CSB 

reported conducting follow-up actions for approximately three quarters of its 

open recommendations within the past six months. The program is evolving. 

However, the limited number of closed recommendations signals that the CSB 

needs to increase its attention to recommendations follow-up. 

The CSB Has Not Established an Accident Reporting Regulation

(C) The Board shall - . . . (iii) establish by regulation requirements binding on

persons for reporting accidental releases into the ambient air subject to the Board's

investigatory jurisdiction. Reporting releases to the National Response Center, in

lieu of the Board directly, shall satisfy such regulations. The National Response 

Center shall promptly notify the Board of any releases which are within the Board's 

jurisdiction. 

 

The CSB has not established a regulation requiring persons to report chemical 

accidents subject to CSB investigations. Instead, the CSB relies on reporting 

requirements set by other agencies, such as EPA, and it shares their incident 

notifications through a memorandum of understanding (MOU) with the 

National Response Center. The NRC furnishes about a third of the 

notifications the CSB receives. The CSB culls almost two-thirds of its 

notifications from the media, with support from the NTSB.17 While this 

arrangement has some advantages, it does not fully satisfy the statute. 

Furthermore, it may lessen the quality and timeliness of the incident 

notification data the CSB needs for deployment decision-making and incident 

record keeping and analysis. The CSB needs to refine its mechanism for 

learning of chemical incidents, and it should publish a regulation describing 

how the CSB will receive the notifications it needs. 

The CSB chose its current reporting arrangement for several reasons. The 

CSB’s collection system mirrors the NTSB’s and supplies more than enough 

notifications to exhaust the CSB’s investigative resources. The CSB board 

members said they are satisfied that the present notification system adequately 

informs the CSB of incidents. Board members told the OIG it would not be 

cost-beneficial for the CSB to dedicate additional resources to collecting new 

 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 14 

17 Of the 1,111 incidents in the screening matrix, the NRC was listed as sole source for 318 reports (29 percent); the 

media for 718 (65 percent); the NTSB for nine (one percent); and EPA and a citizen for one each (less than one percent). 

Remaining incident reports came from a combination of NRC, media, and NTSB sources. 
 

information, because the CSB lacks the resources to respond to all the 

incidents that are reported currently. Resources will limit what the CSB might 

accomplish if it does establish a stronger chemical accident reporting 

requirement. 

However, without a regulation, the CSB has little control over the timeliness 

and completeness of the incident notifications it needs. A CSB reporting 

regulation may not guarantee that future notifications are prompt and 

thorough, but it would increase the CSB’s influence over notification quality. 

We note that Congress granted the CSB a means of enforcing its reporting 

requirement in subparagraph (O) of its statutes: 

After the effective date of any reporting requirement promulgated pursuant to

subparagraph (C)(iii) it shall be unlawful for any person to fail to report any release 

of any extremely hazardous substance as required by such subparagraph. The [EPA]

Administrator is authorized to enforce any regulation or requirements established by

the Board pursuant to subparagraph (C)(iii) using the authorities of sections 7413 

and 7414 of this title. . . . 

Since the CSB has not promulgated a reporting requirement, it has not had 

opportunity to use this enforcement mechanism. 

One reason the CSB should strive to improve chemical accident reporting is 

that the CSB receives many notifications that do not support timely 

deployment. The CSB’s incident selection criteria specify that the CSB will 

“dispatch investigation teams within the 24 to 48 hour period following the 

accident.”18 As the CSB staff commented, the CSB prefers to begin an 

investigation while evidence and witnesses’ recall are fresh and unadulterated. 

Although the CSB maintains that it could deploy to any accident no matter 

how late it learns of the event, and we agree, practice has shown that the CSB 

consistently deploys to accidents learned of within the first 48 hours after the 

event. All seven of the CSB’s full investigations during the period covered by 

the screening matrix were reported on the day of or after the incident. If an 

incident is reported after two days or more, the CSB is not likely to deploy. Of 

the 449 incidents reported after two days or more, only 17 were brought to the 

attention of the director of OISP for deployment consideration:

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 15 

18 Process for Selecting Accident Investigations. 
FIGURE 3.—Timeliness of Notifications Compared to Deployments

Timeliness of

Notification Total 

Consideration for 

deployment by

director, OISP 

Consideration for 

deployment by

management team

and/or board 

Deployment Full 

investigation

all 1,111 88 22 10 7

same day 255 33 14 7 5

next day 399 38 7 3 2

2 days later 170 5

3 days later 98 4

more than 3

days later 181 8 1

unknown date 8 

Although the CSB deployments match quickly-reported accidents, the CSB 

has set no requirement to ensure quick reports. The CSB receives more than a 

third of its notifications outside the 48-hour deployment window. In 

comparison, OSHA has set a reporting requirement that enables it to learn 

about accident fatalities and multiple hospitalizations within eight hours, 

through a regulation that requires companies to report directly to OSHA. In 

1994 OSHA lowered its reporting timeframe from 48 hours, noting one 

proposed rule comment that the “current time reporting requirement of fortyeight hours materially handicaps the capability of investigators to accurately 

establish what transpired.”19 This statement further emphasizes the importance 

of rapid deployment. But by waiting to collect reports generated by others for 

other purposes, the CSB accepts later notifications than OSHA does. For 

example, the media is the sole source for almost two-thirds of the CSB’s 

notifications, yet about half the media’s reports occur two or more days after 

the incident. 

Although the small CSB is not prepared to collect reports directly from

companies as OSHA does, the CSB has other means to improve notification 

timeliness. More than three-quarters of the NRC’s reports arrive at the CSB 

within the 48-hour window. Although the NRC can collect many different 

types of information, the CSB has not fully tapped this ability. For example, 

based on criteria in the CSB-NRC MOU and the NRC's internal standard 

 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 16 

19 59 Fed. Reg. 15595 (April 1, 1994) (amending 29 C.F.R. 1904.39.)
 

operating procedures for supporting the CSB, NRC may not forward to the 

CSB the notifications the NRC receives regarding asphyxiations or significant 

on-site property damage. Furthermore, the CSB duty officer explained that 

only a tenth of the incidents that the CSB identifies as meeting the broadest 

term of a chemical incident are legally required to be reported to the NRC. 

The CSB has yet to set its own reporting requirement regarding the chemical 

accidents that parties must report to the NRC. If the CSB were to establish a 

reporting requirement and/or broaden the criteria in its MOU with the NRC, 

the CSB could likely draw more notification information from the NRC. 

The CSB opposes developing a reporting requirement for additional reasons 

that, in our view, are less substantial. The CSB believes a new requirement to 

report accidents to the CSB would place an undue burden on companies, 

which are already obligated to report accidents to multiple government 

agencies whose reports the CSB can access during later research. While 

reducing reporting burdens on the public makes sense, (C)(iii) does not 

require the CSB to add its own notification collection system. Congress 

envisioned that the CSB might avoid duplicative requirements by using the 

NRC as its collection point.20 The CSB must distinguish between who collects 

the initial report—something the CSB is not required to do—and what 

accident data is reported—something the CSB is required to establish in 

regulation. 

The CSB’s chairman also indicated the CSB is heeding advice from Congress 

not to develop accident data, as this is beyond the CSB’s scope and not a good 

use of its resources. While Congress and OIG have encouraged the CSB to 

focus on ensuring the success of its investigative work, that advice should not 

be misconstrued as endorsing a diminution or disregard for the CSB’s 

responsibility for chemical accident reporting. As an outcome of the FY 2000 

Appropriations subcommittee hearings, Congress warned the CSB, “The 

Committee does not intend to augment the Board’s resources until it is 

confident that appropriate management practices have been implemented and 

resources are being effectively allocated to chemical accident investigations 

where the Board can make useful recommendations with broad application.”21

However, during the hearings a representative said: “I really am taken back by 

the idea that the government does not have a handle on scope with regard to 

20 Senate Report No. 101-228 states: “The regulations of the Board for accident reporting may provide that any person 

directed to make a report contact the National Response Center rather than the Board directly. This will assure 

coordination of such reports with responsibilities under the Comprehensive Environmental Response, Compensation and 

Liability Act, the Clean Water Act and the Hazardous Materials Transportation Act.” 1990 CAA Leg. Hist. 8338, 8576. 

LEXIS, Clean Air Act Amendments of 1990. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 17 

21 Senate Report 106-161 (1999), at p. 65. 
 

this problem [chemical accidents] before you ... That does seem to be a first 

step in getting a handle on this issue and trying to address it in a way that 

reduces incidents.”22 Another encouraged the CSB to follow the NTSB’s 

model and “help establish patterns, insight into overall changes that can be

made to reduce the likelihood of those accidents.”23 Both of these aims are 

difficult to achieve without accident reports that are sufficiently 

comprehensive, accurate, and timely to support analysis. 

The CSB has recognized the need for this analysis. In its reactive hazard 

investigation, the CSB searched 40 public and private databases and reported 

that its findings were limited because “existing sources of incident data are 

inadequate to identify the number, severity, frequency, and causes of reactive 

incidents.”24 The report listed several key limitations, including: 

• No single data source provides a comprehensive collection of 

chemical incidents from which to retrieve or track reactive incident 

data. . . . 

• No one comprehensive data source contains the data needed to 

adequately understand root causes and lessons learned from reactive 

incidents or other process safety incidents. . . . 

• It is difficult to identify causes and lessons learned in existing sources 

of process safety incident data because industry associations, 

government agencies, and academia generally do not collect this 

information. 

• Data sources contained incomplete and sometimes inaccurate incident 

information–for example, on numbers of injuries and community 

impacts. Descriptions of incidents and causal information were 

sometimes vague and incomplete. 

• There are limited federal or state requirements to report incidents 

unless they involve specific consequences.

While these comments target reactive incidents in particular, the lack of 

comprehensive and timely reporting on chemical accidents in general is a 

problem the CSB is both positioned and required to address. We commend the 

22 Representative Alan B. Mollohan, House Appropriations subcommittee hearing (February 24, 1999). 23 Representative Anne M. Northup, House Appropriations subcommittee hearing (February 24, 1999). 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 18 

24 U.S. Chemical Safety and Hazard Investigation Board, Improving Reactive Hazard Management, September 17, 2002.
CSB for concentrating on building its investigative program, and we 

acknowledge that the CSB’s current incident reporting system exceeds its 

current investigative resources. Nevertheless, the CSB has a responsibility to 

comply with its statute, and there are steps the CSB can take to improve 

chemical accident reporting nationwide. Doing so will help the CSB prioritize 

its investigative and hazard research and will better enable it to identify

accident patterns that might support prevention strategies. The longer it takes 

the CSB to develop a more sophisticated system for managing chemical 

accident reports, the greater the opportunity cost to the CSB; that is, the CSB 

forgoes the opportunity to build its knowledge base about ongoing incidents. 

The CSB Meets Interagency Coordination Requirement

(E) The Board shall coordinate its activities with investigations and studies 

conducted by other agencies of the United States having a responsibility to protect 

public health and safety. The Board shall enter into a memorandum of understanding

with the National Transportation Safety Board to assure coordination of functions

and to limit duplication of activities which shall designate the National 

Transportation Safety Board as the lead agency for the investigation of releases 

which are transportation related. The Board shall not be authorized to investigate 

marine oil spills, which the National Transportation Safety Board is authorized to

investigate. The Board shall enter into a memorandum of understanding with the 

Occupational Safety and Health Administration so as to limit duplication of 

activities. 

The CSB has met the specific requirements of subparagraph (E). The CSB 

developed its required memoranda of understanding with OSHA in September 

1998 and with the NTSB in December 2002. Both MOUs address how the 

agencies may reduce duplication of investigative activities, coordinate efforts 

on an investigation site, and share information and resources. 

The general requirement to coordinate its activities with other federal agencies 

will remain an ongoing responsibility for the CSB. OSHA and the NTSB are 

not the only federal agencies that conduct investigations or studies concerning 

health and safety. The United States General Accounting Office (GAO) 

reported in 2000 that more than 15 federal agencies or components work to 

protect health and safety in the workplace.25 Most commonly, incidents that 

the CSB might investigate also involve OSHA, but some have also been 

investigated by EPA; the Bureau of Alcohol, Tobacco, and Firearms (ATF); 

National Institute for Occupational Safety and Health; the U.S. Coast Guard; 

and state, local, and private entities. The CSB has developed MOUs with the 

 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 19 

25 Federal Agencies and Workplace Safety (GAO/HEHS-00-45R, January 31, 2000). GAO based its work on federal 

legislation and regulations, agency missions and strategic plans, and MOUs among the studied agencies. 
 

EPA and ATF that are similar to its agreement with OSHA. The CSB has also 

developed an MOU with the Agency for Toxic Substances and Disease 

Registry, which allows the CSB to tap technical support from ATSDR for its 

investigations and health and safety program. The CSB has incorporated 

information from ATSDR, OSHA, EPA, and the ATF in some of its reports. 

Our discussions with the CSB and representatives of OSHA, EPA, NTSB, and 

the ATSDR led us to conclude that the MOUs adequately enable cooperation 

during investigations. We also learned that EPA and OSHA no longer produce 

root-cause investigation reports on the prevention of chemical accidents, as 

the CSB does, and neither do other federal entities. 

The CSB-NTSB MOU addresses the overlap between chemical incidents that 

involve transportation and ones occurring at fixed facilities. While yielding to 

the NTSB’s lead authority, the CSB has preserved its ability to look at 

incidents occurring at fixed facilities that involve transport. In the past year, 

the CSB had undertaken two such investigations, DPC Enterprises and BLSR 

Operating Ltd., after the NTSB declined to investigate. The DPC Enterprises 

investigation produced a safety advisory regarding hoses for handling 

chlorine, and the CSB completed a full investigation report with 22 safety 

recommendations in May 2003. GAO indicated that the CSB needs to clarify 

the focus of the CSB investigations (fixed facilities versus transportation) and 

the circumstances under which the CSB might investigate transportationrelated accidents.26 We agree that this may be helpful. The CSB’s legislative 

history notes, “...whenever possible, the (chemical safety) board should rely 

on information collected by NTSB rather than conduct separate informationgathering activities."27

In addition to outlining their relationship during mutual investigations, the 

MOUs between the CSB, EPA, and OSHA support other forms of 

cooperation, such as the sharing of incident notifications and accident

information. However, OSHA, EPA, and the CSB appear rarely to share 

notifications in the manner the MOUs outline. According to the MOUs, the 

agencies will inform each other when they learn of incidents involving 

fatalities, multiple hospitalizations, property damage in excess of $500,000, or 

a significant public concern. Although more than ninety incidents in the 

CSB’s screening matrix meet the first two criteria alone, the CSB lists the 

EPA as a notification source for one incident and OSHA as a source for none. 

For one particular worker fatality that OSHA investigated, the CSB learned of 

26 Chemical Safety Board: Improved Policies and Additional Oversight Are Needed (GAO/RCED-00-192, July 11, 

2000). 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 20 

27 Senate Report No. 101-228. 1990 CAA Leg. Hist. 8338, 8572. 
the incident through the media 50 days after OSHA began its investigation. 

Another largely unused provision of the MOUs involves incidents that EPA or 

OSHA but not the CSB investigates. Both allow the CSB to collect 

information from those investigations for further analysis, which supports the 

CSB’s “cause to be investigated” authority. If the provisions of the existing 

MOUs are appropriate, then the CSB needs to work with OSHA and EPA to

build their information-sharing relationship. The CSB may benefit from

pursuing its MOU provision to take advantage of OSHA’s more rapid 

notification system. 

 

Many of the CSB’s counterparts believe greater coordination and cooperation 

will be beneficial. Several industry and trade group representatives expressed 

the wish that the agencies would consolidate their investigations and reporting 

requirements. Still, most agreed that an independent, non-enforcement agency 

like the CSB has a valid interest in investigating separately from enforcement 

agencies like OSHA, EPA, and the ATF. The CSB anticipates further 

cooperation with ATSDR, which has offered to share data and analysis from

its Hazardous Substances Emergency Events Surveillance program. ATSDR 

is also aiding the CSB in its hazard study on sodium hydrosulfide handling. 

According to the July 2002 update of its strategic plan, the CSB intends to 

revise and update its MOUs with ATSDR, NTSB, EPA, ATF, and OSHA in 

FY 2003. The CSB should ensure the revisions reflect the actual working 

relationship. 

The CSB Conducts Authorized Research Studies

(F) The Board is authorized 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. To the extent practicable, the Board shall conduct such studies in

cooperation with other Federal agencies having emergency response authorities, 

State and local governmental agencies and associations and organizations from the

industrial, commercial, and nonprofit sectors. 

 

In addition to conducting incident investigations, the CSB conducts research 

and studies. The language in subparagraph (F) shows that hazard studies are a 

discretionary mission for the CSB, not a mandatory one, but CSB officials 

told the OIG that these studies are an effective use of its limited resources. 

The CSB has begun preliminary research for seven studies, an increase from

its former strategic goal of one study per year. 

 

The CSB selects studies based on crosscutting issues identified during its 

incident investigations. Prompted by the investigation at Morton International, 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 21 
 

the CSB issued its first study, Improving Reactive Hazard Management, in 

2002. As the statute envisions, the study involved cooperation with EPA, 

OSHA, professional and trade associations, public advocacy organizations, 

and industry. More recently, based on its November 2002 Georgia Pacific 

Naheola Mill investigation, the CSB undertook two new, smaller studies 

targeting the hazards of sodium hydrosulfide handling and toxic gas emissions 

from industrial waste systems. In the past year, the CSB has increased its 

emphasis on hazard studies. Besides the two studies in progress, the CSB has 

identified five other potential topics for which it is conducting preliminary 

research before deciding whether to pursue full hazard investigations. These 

studies address themes of previous CSB investigations, but they emerged from

internal brainstorming sessions rather than specific investigations. We were 

unable to obtain formal criteria used by the CSB to select a study topic. 

Although the CSB has not defined when and how a discretionary hazard study 

might be a better use of its resources than a mandatory incident investigation, 

the CSB believes studies have a valuable impact on accident prevention. 

Several industry representatives agreed; one said that it would take far longer 

for the CSB to develop the information necessary to support regulatory 

recommendations through single incident investigations. Nonetheless, all 

pointed out that incident investigations must remain the CSB’s priority. 

The CSB board members told us that hazard studies remain subordinate to 

incident investigations. Although the CSB dedicated full-time staff to its first 

hazard study, the CSB says OISP staff now research hazards during 

investigative “downtime,” which suggests there is little trade-off between 

incident investigations and hazard studies. However, we are not convinced 

that the time given to discretionary hazard studies could not be given to 

additional mandatory incident investigations. Although there may be 

“downtime” between incidents the CSB considers major, there are no 

significant breaks between incidents with consequences meeting 

subparagraphs (C)(i) and/or (E). The average gap between such notifications 

was two days.28 Gaps over a week occurred only five times in 21 months, with 

the longest gap being 14 days. The CSB might use breaks during or between 

major investigations to develop smaller investigative products, but the CSB is 

choosing to research hazards instead. 

In its 2001-2005 strategic plan, the CSB committed to one hazard study per 

year. In its FY 2004 appropriations request and new draft strategic plan, the 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 22 

28 Based on incident screening matrix data. The CSB often receives more than one report meeting (C)(i) or (E) in a day,

which this calculation takes into account. 
CSB pledged to increase its production to 12 safety products per year. The 

CSB has not defined what proportion of the 12 will be hazard studies. By 

applying a single label to both tasks, the CSB invites confusion over the 

number of investigations it actually undertakes. The CSB should clarify the 

cost-benefits of pursuing discretionary hazard studies when the CSB has 

insufficient resources to undertake mandatory mission components. 

The CSB Can Pursue a Broader Strategy

With recent accomplishments including increased productivity, the CSB has 

improved the fulfillment of its basic legislative responsibilities. As the CSB 

matures, it could expand its strategy to prevent chemical accidents for several 

reasons. First, the CSB statutes and legislative history describe broader 

responsibilities than the CSB currently meets. Second, the CSB needs datadriven measurement criteria to assess the impact of its prevention efforts. 

Third, the CSB can help address gaps in national chemical accident data. The 

CSB should pursue a broader strategy if it is to learn whether and how 

chemical accidents might be prevented more effectively. 

The CSB’s 2001-2005 strategic plan states that the CSB’s core purpose is to 

protect workers, the public, and the environment by investigating and 

preventing chemical accidents. Previously, management issues hindered the 

conduct of investigations, its primary mission. However, based on 

congressional and OIG guidance, leadership changes, and a summer 2002 

strategic plan revision, the CSB refocused on increasing investigative 

productivity and promoting its recommendations. Investigative productivity 

and capacity are increasing, and CSB management issues and mission 

disagreements have abated. Ongoing operations suggest that the CSB intends 

to limit an expansion of its role. New goals contained in July 2002 strategic 

plan revision and draft 2003-2008 strategic plan reflect a narrowed focus: the 

CSB has redirected former goals related to outreach and cut most goals related 

to data collection and analysis. While we support the idea that the CSB may 

need time to internalize recent positive changes, we also believe that the CSB 

has broader responsibilities for chemical accident prevention that the CSB 

should fulfill. 

Statutes Indicate a Broader Role for the CSB 

A review of the CSB’s statutory authority and legislative history led us to 

conclude that the CSB has responsibilities beyond its current productivity 

goals and strategic plans. According to subparagraphs (C)(i), (E), and (C)(iii), 

the CSB needs to plan to address its investigative gap and meet its statutory 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 23 
 

requirement to issue a reporting regulation, two tasks that will likely require 

the CSB to refine its relationship with EPA, OSHA, the NTSB, and other 

parties. Furthermore, subparagraph (S) of the CSB’s statute also supports the 

CSB’s expansion of its chemical accident prevention efforts: 

(S) The Board shall submit an annual report to the President and to the Congress 

which shall include, but not be limited to, information on accidental releases which 

have been investigated by or reported to the Board during the previous year, 

recommendations for legislative or administrative action which the Board has made,

the actions which have been taken by the Administrator or the Secretary of Labor or 

the heads of other agencies to implement such recommendations, an identification of

priorities for study and investigation in the succeeding year, progress in the 

development of risk-reduction technologies and the response to and implementation 

of significant research findings on chemical safety in the public and private sector.

Although the Federal Reports Elimination and Sunset Act of 1995, Pub. L. 

No. 104-66, exempted the CSB from submitting an annual report, we question 

whether the CSB’s responsibilities under (S) are fully relieved by the change. 

The responsibilities described in this subparagraph are substantive as well as 

administrative. Some of these responsibilities the CSB already meets; for 

example, it publishes information on the accidental releases the CSB 

investigates each year on the CSB website. However, the CSB does not 

routinely assemble other related information, including analysis of the 

accidental releases reported to the CSB each year, identification of priorities 

for investigation in the succeeding year, status of the development of riskreduction technologies, and status of implementation of significant research 

findings on chemical safety. The CSB has not yet fully defined which 

chemical accidents it considers to be within its statutory purview for 

investigation, and it has not yet adopted objective means for identifying and 

prioritizing its hazard studies and investigations. Whether or not the CSB 

reports to Congress on the items in (S), the OIG concluded that the CSB 

would benefit by developing the information for internal and public use. 

Ultimately, the elements of subparagraph (S) demonstrate that Congress 

intended the CSB to develop and act on a broader perspective of chemical 

accident prevention than the current CSB operations and plans involve. 

Excerpts from its legislative history support the proposition that the CSB 

should have a national leadership role in chemical accident prevention: 29

• The board is . . . to function as a source of expertise at the center of 

the chemical accident prevention and response programs of the 

Federal Government. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 24 

29 Senate Report No. 101-228. 1990 CAA Leg. Hist. 8338, 8547-8548. 
 

• The board, through its investigations and reports, is to drive the 

regulatory agenda in this field [accident prevention at facilities 

handling extremely hazardous substances].

• The board may also serve as a point of communication among the 

various Federal agencies to improve the effectiveness of accident 

prevention programs and reduce the burden of duplicative 

requirements on regulated entities. 

These statements suggest the CSB should do more than produce 12 safety 

products per year. 

Current Measurement Criteria Do Not Ensure the CSB Can Demonstrate 

Its Effectiveness 

The CSB should obtain and define measurement criteria to assess its impact. 

The CSB noted, “Investigative and research efforts need to be focused where 

they can provide the greatest benefit in preventing accidents.”

30 However, the 

CSB does not have the data to confirm that its efforts prevent accidents. The 

CSB does not have access to statistically valid data on the characteristics and 

frequency of all chemical accidents within its purview. Without benchmark 

data on the chemical accident universe, the CSB will be challenged to justify 

how it prioritizes its workload and to show it is helping to prevent chemical 

accidents. 

The CSB’s current data indicators have limits, and measuring its effectiveness 

will be an increasing concern for the CSB.31 To comply with the Government 

Performance and Results Act (GPRA), the CSB is working to demonstrate its 

effectiveness, such as by defining measurable goals in its strategic plan. One 

CSB performance goal is to “achieve industry wide implementation of the 

CSB recommendations and related accident prevention measures.”32 This goal 

meets GPRA requirements that it be quantitative or directly measurable. The 

CSB can account for whether the recipient implements a recommendation; the 

measurable outcome is an implemented recommendation. However, what the 

30 FY 2003 Budget Justification and Annual Performance Plan. 31 Beginning in FY 2002, OMB required that agencies begin submitting Performance and Accountability Reports (PAR). 

Consequently, the CSB prepared its first PAR as part of its FY 2002 consolidated financial statement audit. The report 

contains financial and performance information that enables Congress, the President, and the public to assess the 

performance of an organization relative to its mission. The PAR satisfies several reporting requirements for agencies, 

including the Government Performance and Results Act.

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 25 

32 U.S. Chemical Safety and Hazard Investigation Board, Strategic Plan, July 2002. 
 

CSB strategic plan does not measure is the impact of this outcome: whether 

implementing the recommendation made a difference in preventing chemical 

accidents. For the CSB, using recommendation outcomes to demonstrate that 

the CSB achieves its impact goal of “preventing chemical accidents” is 

difficult, even if the CSB validates what resulted from the recommendation. 

GPRA allows an agency to define a performance goal in a descriptive 

manner that is not self-measuring, such that one cannot determine whether 

the goal was met by comparing actual performance to a quantified target 

level. If a performance goal is not self-measuring, the agency must include in 

its plan one or more performance indicators for the goal. The performance 

indicators set out specific, measurable values or characteristics related to the 

performance goal, which aid in assessing goal achievement. Examples of 

performance indicators include common forms of measurement: incidence 

rates, lengths, weights, percentages affected, and frequency measurements. In 

fact, the CSB’s goal for recommendations adoption (80 percent) could be 

considered a performance indicator. The CSB can more easily assess its 

efforts by applying these indirect types of measurement. However, were the 

CSB to shift its emphasis from counting implemented recommendations to 

analyzing the effect of the implementation, the CSB would be nearer to 

measuring its impact on preventing chemical accidents.33 The NTSB 

published a requirement to analyze its proposed recommendations in order to 

assess their predicted safety effect, and the CSB should emulate this practice. 

Furthermore, the CSB will need benchmark data about the chemical accident 

universe if it is to demonstrate that accidents are being prevented. To help 

generate measurable chemical accident data, the CSB is working with EPA to 

increase the frequency of company-submitted RMP accident reports, from 

every five years to each year. While this is a positive improvement, even the 

CSB members agree that it is a small step. In a paper analyzing RMP data, an 

EPA staff member noted as an unanswered question: “Does the [RMP] 

database constitute a large enough sample of chemical facilities to determine 

risk distributions with significant confidence to make decisions about lowfrequency, high-consequence events?”34 We already have noted that RMP 

covers a limited number of chemicals and facilities. The scope of the CSB’s 

investigative work extends well beyond RMP’s scope. Of the ten 

investigations the CSB initiated during the 21-month period in the screening 

33 For further discussion, see Ludwig Benner Jr., Ranking Safety Recommendation Effectiveness, International Society of

Air Safety Investigators, Proceedings of 1992 conference, Dallas, Texas. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 26 

34 James C. Belke, Chemical accident risks in U.S. industry - A preliminary analysis of accident risk data from U.S.

hazardous chemical facilities, September 25, 2002. 
 

matrix, only five (50 percent) occurred at RMP-covered facilities. If the CSB 

pursues measurements of the chemical accident universe, it must look beyond 

RMP.

The CSB Can Address the National Chemical Accident Data Shortfall 

Last year, the CSB informed Congress: 35 

The United States presently lacks any comprehensive national data system 

simply to track the occurrence of accidental chemical releases. Individual 

government agencies have separate reporting requirements and maintain 

separate databases. Efforts at uniting these databases (by the CSB and 

others) have not been fruitful. The lack of reliable accident data hampers 

the CSB and other agencies from measuring national progress in accident 

reduction and identifying emerging hazards. 

The lack of reliable and comprehensive chemical accident data is a national 

issue, and not one that the small CSB can resolve unilaterally. However, the 

CSB is in a position to help improve shortfalls in chemical accident data 

collection. 

Many of our interviewees concurred that data-gathering and the lack of sound 

trend analysis on chemical accidents is a problem needing resolution. Multiple 

databases are already in place.36 Although the National Response Center has 

the capability to serve as a consolidated collection point for incident reports, 

in reality, other agencies, including OSHA, ATSDR, and state and local 

entities, collect different information through separate reports. For several 

government agencies to collect reports creates duplicative work for companies 

and first responders. Industry and trade group representatives told the OIG

they support a system to collect comprehensive and measurable data if the 

system relieves the burden of multiple report requirements. However, there is 

little consensus on how to define which data to include, a crucial step. 

The CSB has its own interests in developing comprehensive chemical accident 

data. The ability to survey and analyze a defined chemical accident universe 

would permit the CSB not only to develop better measurements of the impact 

of accident prevention efforts, but also to develop more objective means to 

prioritize its work and stronger support for its safety recommendations. The 

35 FY 2003 Budget Justification and Annual Performance Plan. The CSB did not reiterate this challenge in FY 2004. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 27 

36 See Feasibility of Using Federal Incident Databases to Measure and Improve Chemical Safety, Mary Kay O’Connor 

Process Safety Center, (MKOPSC Report 2002-02, April 2002). 
 

CSB has shifted strategically in how it pursues these interests. In February 

1999, the CSB attempted to produce a composite database of nationwide 

chemical accidents, but in December 2000, the CSB withdrew the report,37

citing serious flaws in the data upon which the report was based. The CSB 

signaled in its 2001-2005 Strategic Plan that it would continue to pursue 

developing a “system for chemical accident data collection and analysis” to 

remedy the lack of an “accepted measure of the frequency of chemical 

accidents that are within the purview of the CSB.” However, more recently 

the CSB withdrew its goal of developing an accident data system. The CSB 

has removed other efforts from its recent strategic plans, including: (1) a 

national discussion of key metrics, methodologies, and requirements for 

chemical accident data collection and analysis; and (2) initiation of a design 

for performance metrics. 

The CSB board members remain interested in addressing issues affecting the 

quality of incident data, but their interest now falls below a strategic level. In 

November 2002, the CSB convened a roundtable discussion with EPA and 

OSHA for the purpose of identifying measures to improve EPA’s data 

collection program. EPA is now considering whether to require companies 

who submit RMP reports every five years to add accident data to their reports 

quarterly. The measures are supposed to benefit the CSB and other 

government agencies that look at accident rates. However, because RMP 

covers a limited number of facilities and chemicals, the rates revealed may say 

little about the broader chemical accident universe within the CSB’s purview. 

When we asked whether the CSB was pursuing any data initiatives beyond the 

RMP project, the chairman referred to the CSB’s recommendation to OSHA 

in Improving Reactive Hazard Management, which calls for OSHA to 

(1) implement a program to define and record information on reactive 

incidents that OSHA investigates or requires to be investigated under OSHA 

regulations and (2) structure the collected information so that it can be used to 

measure progress in the prevention of reactive incidents that give rise to 

catastrophic releases. Again, the changes the CSB supports do not address the 

issue of assessing the chemical accident universe as a whole. 

Regardless of whether the CSB sees a larger role for itself in resolving the 

accident data collection problem, the CSB has already represented that the 

problem affects its work. In its FY 2003 strategic plan, the CSB cited “data 

inadequacies” as one of its four challenges. The challenge arguably meets 

OMB’s criteria for “key factors, external to the agency that could significantly 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 28 

37 The 600K Report: Commercial Chemical Incidents in the United States 1987-1996. 
 

affect the achievement of general goals.”38 OMB notes that, in a strategic 

plan, “An agency may describe significant risks that threaten achievement of 

general goals.”39 The CSB’s current strategic revisions do not include this 

information. 

The CSB is uniquely positioned to coordinate federal efforts to improve 

chemical accident data collection. The CSB’s statutes and legislative history 

clearly state that the CSB should work to guide the chemical accident 

prevention efforts of the federal government, particularly EPA and OSHA, 

two of the most prominent data collectors. The legislative history charges the 

CSB to work to reduce duplicative reporting requirements. Existing federal 

databases contain useful data on chemical accidents.40 However, their 

individualization has complicated previous attempts to create a commonly 

useful system. As a first step in improving chemical accident data, the CSB 

might coordinate an assessment of what it would take to unify existing data 

productively. It would be a challenge for the CSB to build consensus about 

how to define a reportable accident and to demonstrate the cost-effectiveness 

of altering data collection efforts. Nevertheless, at least according to statute 

and legislative history, the challenge is a CSB responsibility. 

A 2002 study conducted by the NTSB is instructive. The NTSB relies on 

many external databases when performing accident investigations, safety 

studies, and special investigations. Most of these databases are sponsored and 

operated by the modal administrations of the U.S. Department of 

Transportation (DOT). The NTSB studied transportation safety databases to 

evaluate data quality issues and to encourage improvements in this area. The 

effort had four specific objectives: (1) highlight the value and potential uses of 

transportation safety data; (2) describe some accident and incident databases 

commonly used by the NTSB; (3) summarize past recommendations 

involving transportation data; and (4) evaluate Bureau of Transportation 

Statistics (BTS)41 efforts to establish data quality standards, identify 

information gaps, and ensure compatibility among the safety data systems 

maintained by DOT. Finding that inadequate data reduces the ability of the 

federal government to understand safety problems and target safety resources, 

38 OMB Circular No. A-11, Section 210.1(b). 39 OMB Circular No. A-11, Section 210.2. 40 Mary Kay O’Connor Process Safety Center, Defining Indicators and Metrics for Measuring Improvements in 

Chemical Safety, (MKOPSC Report 2002-03, April 2002).

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 29 

41 In 1991, Congress created the Bureau of Transportation Statistics (BTS) within DOT to be a central statistical agency 

responsible for compiling and analyzing transportation statistics, issuing data collection guidelines, making statistics 

accessible, identifying information needs, implementing a comprehensive long-term data collection program, and 

coordinating the collection of statistical information.
the NTSB issued a recommendation to the BTS to develop a long-term

program to improve the collection of data describing exposure to 

transportation risk in the United States. There is no equivalent to the BTS or 

its data collection efforts for the chemical field, and the CSB lacks the 

resources to create one. However, the interplay between the BTS and NTSB 

helps to illustrate the magnitude and importance of efforts to improve safety 

data collection. 

The CSB does not plan to develop independent chemical accident data, as the 

NTSB, which has a reporting regulation, does with air carrier accident data. 

CSB officials generally agree that collecting information on more accidents 

would enable the CSB to build a data set that would make the CSB’s 

recommendations more persuasive, but they do not agree this is an efficient 

use of the CSB’s finite resources. The CSB chairman suggested that interested 

parties should work to unify, update, and streamline existing chemical 

accident databases. The CSB would like to see EPA and OSHA create a 

common database that all agencies could use to understand the accident 

universe and target improvements. However, the CSB has not planned to seek 

this change. The CSB plans instead to cull disjointed accident data from

multiple sources when needed in support of CSB investigations, even though 

the CSB already reported on the limitations of this process in Improving 

Reactive Hazard Management. The CSB has also discussed exploring other 

federal incident data systems such as the ATSDR’s. 

The CSB’s current vision speaks little to the role the CSB may play in 

resolving the chemical accident data collection problem. In five years, the 

CSB hopes to be “a nationally recognized chemical safety investigative 

agency, respected for our timely, high quality investigations and 

recommendations, our technical expertise, our products, effective 

management, and model work environment.” While the CSB’s desire to focus 

on investigative work and promote its recommendations is a reasonable shortterm goal, other entities are keenly interested in seeing the CSB commit to 

enhancing the quality of chemical accident data. The OIG encourages the CSB 

to expand its strategic role in resolving the accident data collection problem so 

that the CSB may measure its impact, target its resources at the most 

significant accident trends, and develop stronger support for its safety 

recommendations. 

We recommend that the Chairman: 

Recommendation 1: Develop a plan to describe and address the gap between 

the number of accidents the CSB investigates and the number falling within its 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 30 
statutory investigative jurisdiction. Include this information in future budget 

submissions to Congress and the Office of Management and Budget. 

Recommendation 2: Define what constitutes a chemical accident within the 

CSB’s purview and publish a regulation that outlines how the CSB will 

receive information on these accidents. 

Recommendation 3: Evaluate the CSB’s performance on recommendations 

follow-up and consider policies and practices to improve the CSB’s timeliness 

for closing recommendations.

Recommendation 4: Establish a plan linking measurement data and strategic 

improvements that enables the CSB to assess and enhance its impact on 

chemical accident prevention. 

Recommendation 5: Develop a long-term strategy to address the shortfall in 

national chemical accident database quality. 

Opportunities to Enhance the CSB Administration 

The CSB has done much to build its structure and policies to support its work 

as an independent federal agency since FY 1998. We identified opportunities 

to improve the CSB’s administration. The CSB’s incident selection process, 

which is used to identify accidents to which the CSB will deploy, needs 

stricter management controls to ensure the accuracy, reliability, and quality of 

screening and screening data. In particular, the CSB must revise the process to 

ensure that the CSB managers consider accidents meeting statutory criteria for 

deployment. In addition, the CSB should revisit a tabled 2000 

recommendation from the GAO on developing a policy for managing conflicts 

of interest. Finally, the CSB needs to publish additional records and policies to 

comply with the Administrative Procedure Act, Freedom of Information Act, 

and Electronic Freedom of Information Act amendments. 

Incident Selection Process Requires Improved Management Controls

The CSB is confident that its incident selection protocol enables the CSB to 

select deployments that yield meaningful investigative reports. At the same

time, staff has expressed interest in refining the protocol, and the CSB began 

considering revisions in summer 2002. We found several weaknesses that the 

CSB should include in reconsidering the protocol. Currently, the first phase of 

the selection process does not ensure that CSB managers consider for 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 31 
 

deployment all accidents that meet the statutory criteria for investigation. 

Additionally, there are inadequate management controls on the CSB duty 

officer’s decisions to elevate or eliminate incidents for deployment 

consideration. Finally, there are inadequate quality controls on the incident 

notification and screening data, which serve as important historical records. 

The CSB’s Process Does Not Ensure Statutorily-Mandated Investigations 

Are Considered for Deployment 

In November 1999, the CSB followed a Senate Appropriations directive to 

develop a protocol for sifting through incident notifications to select and 

prioritize investigations. Including input from two national roundtables, the 

CSB developed a two-part selection process. In the first phase, a duty officer 

from the OISP staff receives the notifications from the media, National 

Response Center, NTSB, and a few other sources. Notifications are received 

at any time, with the NTSB’s 24-hour staff contracted to provide support 

when the CSB employees are off-duty.42 The duty officer screens the 

notification by deciding whether to record or discard it. If the incident is not 

discarded, the duty officer enters it into a spreadsheet matrix that captures 

qualitative background information and assigns a numerical score based on 

the accident’s actual and potential consequences. For example, an incident 

receives 16 points for each public or first responder fatality. To evaluate an 

accident’s potential consequences, the duty officer multiplies the actual 

consequence score by a factor of six if the facility falls under EPA’s Risk 

Management Program, an indicator of potentially serious offsite 

consequences. The duty officer flags all accidents scoring above a threshold of 

50 points and forwards them to the director of the Office of Investigations and 

Safety Programs (DISP) to consider deployment.43 The objective scoring 

process is designed to filter out notifications that do not meet deployment 

criteria. As written, first-phase screening criteria leave little room for the duty 

officer’s discretion, for the duty officer has not been delegated authority to 

make deployment decisions. 

The DISP, a staff team including the COO, and the board members, in that 

order, apply managerial discretion in choosing deployments.44 They evaluate 

the accident according to five subjective criteria: how feasible it is for the 

CSB to undertake the investigation at the time, the accident’s community 

42 While the staff member screens all notifications during duty hours, during non-duty hours the NTSB holds the 

notifications to submit on the next duty day, paging the CSB only when the accident involves multiple fatalities. 43 When the OISP reorganized, the CSB replaced the DISP with three team leaders who report to the COO. For 

simplicity, this discussion refers to the DISP, which should be understood as a designated manager within the OISP. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 32 

44 The COO has authority to deploy a team before board member review. 
 

impact, what public recognition the accident has, history of similar accidents 

and number of similar facilities, and how much might be learned from that 

particular investigation. Few notifications undergo this managerial review. 

About eight percent of incidents recorded in the screening matrix between 

March 13, 2001, and January 3, 2002, were considered by the DISP, and only 

one percent of the notifications rose to be considered by the board members 

for deployment.45 

In reviewing the CSB’s incident selection process, we concentrated on the 

first phase because in that phase over 90 percent of notifications (1,023 of

1,111) were eliminated. The CSB commented that some eliminated accidents 

were simply outside the CSB’s jurisdiction. However, the CSB has not yet 

defined which accidents it considers within its jurisdiction, such as through its 

incident screening guidance or required reporting regulation. Therefore, for 

the purposes of this review, we considered accidents that the CSB logged in 

the incident screening matrix to be within the CSB’s jurisdiction. The primary 

weakness of the first selection phase is that the CSB structured the scoring in a 

way that does not flag the accidents to which the CSB is required to deploy by 

subparagraphs (C)(i) and (E) of its statute. According to subparagraph (C)(i) 

of its statute, the CSB is responsible for investigating any incident resulting in 

a fatality, serious injury, or substantial property damages. Additionally, 

according to subparagraph (E), the CSB must not forgo investigating any 

incident in which such consequences actually or potentially affect the public. 

Nevertheless, the duty officer’s first-phase screening eliminated the majority 

of notifications that the OIG review of notification data found to meet these 

deployment criteria. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 33 

45 These percentages reflect 88 and 11 of 1,111 notifications that the duty officer recorded. 
FIGURE 4.—Incident Notifications Considered for Deployment 

Considered for 

Deployment 

Eliminated During 

First-Phase Screening 

Met 

Threshold 

Score 

Did Not 

Meet 

Threshold 

Score 

Met 

Threshold 

Score 

Did Not 

Meet 

Threshold 

Score 

All notifications 33 55 1 1022 

Notifications

meeting (C)(i) 20 47 0 397

Notifications

meeting (E) due to 

actual consequences 

1 0 0 7

Notifications

meeting (E) due to 

potential or unclear 

consequences 

24 3 0 67

A little less than half the accidents in the screening matrix met the 

investigation criteria in subparagraph (C)(i)—any fatality, serious injury, or 

substantial property damage—but they were inconsistently flagged. Most did 

not meet the threshold, and the duty officer eliminated them before the CSB 

managers considered deployment. Of the accidents that met (C)(i) during the 

21-month period, the duty officer eliminated 397 of 464 notifications. Thus, 

such accidents received deployment consideration from the DISP less than 15 

percent of the time. Even accidents that involved all three consequences—

fatality, serious injury, and substantial property damage—were forwarded for 

second-phase review less than half the time (eight of 17). 

Accidents that meet the investigation criteria in subparagraph (E) were 

frequently eliminated as well, even though they are an even greater priority 

for the CSB to investigate. The CSB’s September 2000 report on the incident 

selection process abbreviates: “Thus, if adequate resources are available, the 

CSB must investigate any accident where a member of the public is killed or 

seriously injured, but in many other cases the board needs to exercise 

discretion in deciding whether to initiate an investigation.” [emphasis added] 

However, we found that most accidents with public fatalities or injuries are 

eliminated from consideration by the duty officer during first-phase screening. 

Using the CSB’s records, we identified five accidents in which a member of 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 34 
 

the public and three in which a first responder was killed or seriously injured. 

The duty officer eliminated seven of these from deployment consideration 

during the first phase. The one accident that scored above the threshold, 

Kaltech Industries, was elevated to second-phase screening and approved for a 

full investigation. 

More than these eight accidents might have met (E). Over a 21-month period, 

at least seven additional incidents that might compel deployment also did not 

receive second-phase consideration. For example, we found three accidents 

involving substantial public property damage.46 One became the Third Coast 

Industries investigation, and the two others were never forwarded for 

consideration. We found six more notifications that also may have met (E), 

but the CSB did not verify the seriousness of the consequences or whether 

they affected the public. The duty officer eliminated five of those accidents, 

all of which scored under the threshold, from deployment consideration. 

Furthermore, the above count of accidents meeting (E) is based on actual 

public consequences, and it does not include potential public fatalities, serious 

injuries, and significant property damage, which also fall under (E). The 

screening matrix’s RMP multiplier identifies many facilities with the potential 

for public harm; at least 86 accidents during the 21-month period had this 

potential. However, even though the CSB marked these accidents as having 

the potential to cause public harm, the duty officer eliminated 61 of them

without second-phase consideration. Of those 61, 17 also caused actual 

serious injury or significant property damage (not among the general public) 

and yet still were eliminated. Moreover, more than 86 incidents showed 

potential for public harm. As noted earlier, the RMP factor flags only a 

portion of the accidents with potential for public harm; others, such as the 

accident at First Chemical Corporation, were not flagged. Accidents without 

the RMP factor are even more likely to be eliminated from consideration by 

the duty officer. The duty officer eliminated 94 percent of accidents without 

the RMP multiplier, compared to 71 percent of incidents with it. 

In conclusion, the CSB’s scoring procedure does not directly relate an 

incident’s consequences to the statutory criteria that mandate deployment. 

Because the total accident score and threshold are the main factors used to

flag accidents for deployment consideration, specific consequences meriting 

deployment can go unnoticed. For example, when an exploding oil storage 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 35 

46 Curiously, subparagraph (E) requires the CSB to investigate potential public property damage but makes no specific 

mention of actual public property damage. For this reason, we counted significant, actual public property damage as 

possibly meeting (E). 
tank caused second and third-degree burns to a teenager walking in a nearby 

field, the notification scored only eight points and received no follow-up from

the CSB. This serious public injury should have risen for deployment 

consideration under subparagraph (E). According to the CSB’s statement, 

only second-phase resource considerations should have prevented the CSB 

from deploying to this accident.47 However, because first-phase screening did 

not flag the low-scoring accident, second-phase screening did not occur. As 

shown in the chart below, the vast majority of notifications that met (C)(i) and 

(E) criteria scored well below the 50-point threshold for second-phase 

consideration. Median scores for accidents with these consequences were at 

26 or below. Therefore, it is not surprising that the CSB did not consider many 

accidents meeting (C)(i) and (E) for deployment. Moreover, the threshold

caused the CSB to consider for deployment some accidents that met neither 

(C)(i) nor (E); eight of the 88 accidents receiving second-phase review (nine 

percent) were of this type. 

FIGURE 5.— Distribution of Notification Scores with Actual Consequences 

That Met Investigation Criteria in Subparagraphs (C)(i) and (E) 

0 10 20 30 40 50 60 70 80 90 100

Scores

Public fatality

Public serious injury

Any fatality

Any serious injury

Any substantial 

Property damage

median: 26

median: 20

median: 12

median: 10

median: 16

>

 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 36 

47 Process for Selecting Accident Investigations. 
It would be possible for the CSB to recalibrate its existing scoring system to 

raise the score of accidents with fatalities, serious injuries, and substantial 

property damage. However, the existing system is set up in a manner that does 

not fully distinguish which of those consequences affects the public. Instead, 

the scoring system divides consequences primarily by whether they occur 

onsite or offsite. While this may be a useful distinction, it results in records 

that blur the difference between accidents that invoke (E) and (C)(i). For 

example, there is no mechanism in the matrix to distinguish offsite public 

fatalities. Also, for onsite consequences, the scoring criteria mix together 

serious injuries that affect visitors and first responders with those that affect 

workers and contractors. Thus, the scoring system does not highlight public 

injuries that compel deployment under (E). We had to re-read incident 

notifications to extrapolate that data. The screening matrix requires substantial 

revision if it is to flag all accidents which meet the investigation criteria in

subparagraphs (C)(i) and (E). 

Inadequate Management Controls 

The first phase of incident selection requires revision because there is 

inadequate management control over the duty officer’s work. In practice, the 

duty officer has sole authority to record or discard all notifications that the 

CSB receives. For example, when we asked why a high-scoring accident

involving worker inhalation injuries was not forwarded for second-phase 

review, the duty officer explained that the accident simply should not have 

been recorded in the first place. It is not clear why that is so. The written 

screening criteria do not clearly define which notifications the duty officer 

should record or discard. 

In the screening matrix there are notifications that arguably might not have 

been recorded with the others: transportation and pipeline accidents, a foreign 

accident, and more than 100 zero-scoring accidents with no injuries, property 

damage, or offsite consequences. On the other hand, missing from the matrix 

are 279 of the 495 notifications that the National Response Center sent the 

CSB in FY 2002. Since the CSB’s MOU requires the NRC to send 

notifications involving fatalities and serious injuries at fixed facilities, one 

would expect all NRC notifications to be recorded, but less than half are. A

duty officer explained that many of the NRC notifications do not meet the 

MOU criteria, and our review of recorded NRC notifications supported that 

possibility. However, since no records of the discarded NRC reports are kept, 

there is no mechanism to verify that the duty officer’s discards are 

appropriate. Moreover, the duty officer records accidents outside fixed 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 37 
facilities and zero-scorers in some cases, which is inconsistent with the 

explanation professed for not recording the NRC notifications. 

The CSB needs to define which types of accidents, including what types of

facilities and consequences, must be scored in the screening matrix. The CSB 

should allow itself the flexibility to record accidents for historical, nondeployment purposes, but these records should be clearly differentiated. In 

addition, the CSB needs to emplace stricter record keeping and supervisory 

review to ensure that duty officers do not discard notifications through error or 

malfeasance. Under the existing system, because first-phase screening duties 

are not segregated, it is possible for the duty officer to discard relevant 

incident notifications. 

The CSB also needs to emplace management controls on the amount of 

discretion exercised by the duty officer. As designed, the officer is to submit 

accidents that meet the threshold, without exercising decision-making 

authority. In practice, however, the officer decides also to elevate many 

accidents that do not meet the threshold. The CSB relies on the duty officer to 

select low-scoring accidents for deployment consideration; five of the ten 

deployments in the screening matrix were to accidents that did not meet the 

threshold. Almost two-thirds of the notifications the duty officer elevated to 

second-phase review (55 of 88) were below the threshold. However, there are 

no standards to distinguish which low-scoring accidents the duty officer 

should elevate. For example, of the 15 sub-threshold accidents that involved a 

fatality, serious injury, and significant property damage, the duty officer 

elevated six but eliminated nine. Since the duty officer is not a CSB manager 

and does not have delegated authority to make deployment decisions, the CSB 

needs to revise the first-phase selection process. 

The CSB may wish to delegate authority to the duty officer and hold him or 

her accountable for these judgments, but a more complete system of 

management controls will involve segregation of duties, supervisory review, 

and stricter record keeping. In the past, the DISP did not formally review any 

notifications but the ones that the duty officer forwarded for deployment 

consideration. For example, the duty officer has been the only CSB staff 

member to see the vast majority of NRC notifications. Of 464 accidents 

meeting (C)(i) and (E), 86 came solely from NRC notifications, and the duty 

officer alone judged them unsuitable for deployment consideration. This is 

inappropriate because a CSB staff member without decision-making authority 

should not make judgments involving statutory compliance. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 38 
 

Having a manager within the OISP provide secondary review of notifications 

meeting (C)(i) and (E) would be more appropriate and would not impose an 

undue burden on the CSB. Such notifications appear on average about one per 

day, although the CSB does not receive them at a consistent rate. While the 

CSB once recorded seven statutory notifications in one day, 86 percent of 

such notifications occurred no more frequently than twice a day, and days 

with none were most common. All accidents that meet statutory investigation 

criteria should receive second-phase deployment consideration in addition to 

the duty officer’s first-phase review.

Inadequate Quality Controls 

Finally, the CSB has inadequate control over the quality of the incident 

notification and screening data. One duty officer developed the screening 

matrix informally to support first-phase screening, but the matrix has grown 

into an agency record.48 In addition to supporting the decisions during incident 

selection, the screening matrix has been used to support the CSB hazard 

investigations, and the CSB relies on the matrix to answer historical inquiries. 

Thus, the CSB needs to manage the quality of this data for completeness, 

accuracy, timeliness, and usefulness. Specifically, the CSB needs to develop a 

mechanism to control which notifications the duty officer scores, so that the 

matrix more completely reflects the accidents reported to the CSB. Also, the 

CSB needs to verify the accuracy of matrix scores. We found several 

accidents in the matrix with mis-scored consequences and invalid RMP 

multipliers. In fact, one of the zero-scoring notifications involved serious 

offsite property damage and potentially met (E); this accident should have 

scored between 8 and 24 points. Some of these errors could be prevented by 

incorporating self-correcting and error checking mechanisms into the 

screening matrix. Adding data quality checks on the completeness and 

accuracy of the recorded notifications will result in a more reliable 

deployment selection process. 

Better management of the notification data will help the CSB derive 

secondary benefits as well. The CSB is missing an opportunity to measure the 

effectiveness of its screening and selection process by not standardizing and 

augmenting the screening data for analysis. The CSB should be able to judge 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 39 

48 Per 44 U.S.C. 3301, records include all books, papers, maps, photographs, machine-readable materials, or other 

documentary materials, regardless of physical form or characteristics, made or received by an agency of the United 

States Government under Federal law or in connection with the transaction of public business and preserved or

appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, 

policies, decisions, procedures, operations, or other activities of the Government or because of the informational value of 

the data in them. 
 

and maximize the matrix’s timeliness and usefulness. For example, the CSB 

could be using the data in the screening matrix to evaluate how effectively its 

current notification system supports its objective of deploying to an accident 

site within 24-48 hours. Several of the CSB staff informed us that they rely on 

the media because it provides the timeliest notifications. However, we 

determined that only 13 percent of the media’s notifications arrive on the 

same day as the accident, whereas 45 percent of the NRC’s notifications do. 

Objective analysis of the notification data can be more reliable than the staff’s 

subjective evaluation. 

Regular analyses of the screening data could supplement other subjective 

evaluations the staff and board members make, including second-phase 

deployment consideration and selection of hazard studies. Currently, the 

informal “clips” help support these choices, but the CSB could do more. 

While the screening matrix will never be a complete record of all chemical 

accidents, it is a record of chemical accidents to which the CSB might have 

deployed. It sets a floor for types of accidents occurring. The current data 

enables the CSB to count how many accidents to which it might have 

deployed in a year were it fully funded, something the CSB has not calculated. 

The data would also allow the CSB to identify facilities with repeated 

accidents and roughly to count notifications per industry sector. Some of these 

assessments can be made with the CSB website’s Chemical Incident Report 

Center database, which has overlapping data and forms for standardized 

reports. However, the website database is also an incomplete record without 

data quality controls, and the CSB updates it less frequently than the screening 

matrix.49 The CSB should upgrade the screening matrix to a database to 

extend its potential for analysis. 

The CSB needs immediate improvements for the first phase of the selection 

protocol, but the CSB also needs to look at long-term improvements for the 

second phase as well. Basing first-phase incident selection on statutory criteria 

is defensible and will help the CSB filter out more than half of its notifications 

for possible investigations. However, because of its limited resources, the 

CSB is unable to investigate 100 percent or even ten percent of the remaining 

accidents that do meet the statutory criteria. How will the CSB best choose 

among these accidents? Currently, deployment choices are based on the 

subjective judgment of the CSB management and board members. This 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 40 

49 According to a comparison of 2002 records. The screening matrix has not been updated since the CSB’s primary duty 

officer departed in early 2003. The CSB is hiring a new duty officer and plans to reactivate the matrix and record 

backlogged notifications then.
process, too, is defensible; it resembles the NTSB’s process and allows the 

CSB the flexibility to weigh hard-to-measure factors such as past and ongoing 

CSB work and the frequency of particular accidents. However, the second

phase may be more subjective than necessary. In time, the CSB should 

consider prioritizing investigations based on criteria that target risks identified 

through objective analysis of incident and industry trends. Because of the 

CSB’s small size and newness, its incident selection has not often been 

questioned, but as the CSB’s reputation grows, so will scrutiny of its choices. 

Incident selection is a critical process that the CSB must continue to refine. 

The CSB Needs To Finish Policy on Conflicts of Interest

In July 2000, the General Accounting Office responded to a congressional 

request to review the effectiveness of the CSB in carrying out its mission.50

We assessed the CSB’s actions in response to five recommendations made by 

the GAO to develop and implement clear policies and procedures in the 

investigation protocol. The CSB implemented four of the recommendations, 

but it tabled the suggestion that it publish a policy to manage staff conflicts of 

interest. The CSB should sharpen its policy concerning conflicts. 

In its January 2001 response to GAO, the CSB agreed with GAO’s 

recommendation and stated it was developing a regulation on staff conflicts of 

interest that it expected to publish in the Federal Register by March 2001. The 

CSB indicated several months would elapse because of the rulemaking 

process. However, it has not published the regulation. The CSB took some

action in April 2001 by approving Board Order 21, the CSB Ethics Program. 

The order appointed the general counsel to administer the CFR-outlined basics 

of an ethics program, including annual training and financial disclosure 

statements. However, the CSB does not have a policy to govern employees’ 

retaining memberships in societies or organizations to which the CSB issues 

recommendations. Furthermore, the CSB does not have a regulation on 

contractors, and the CSB’s website has no contractor ethics standards. 

We followed up with CSB attorneys concerning the CSB’s conflict of interest 

policy. The attorneys responded, “Care continues to be taken to insure that 

board members and employees avoid a situation that could create a potential 

conflict. To date, there have been few concerns. To further address this area, 

the CSB may issue a supplemental ethics regulation for its employees, a 

regulation on organizational conflicts of interest to address contractor matters, 

and/or may add provisions to its protocol on conflicts issues.” The CSB 

 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 41 

50 Chemical Safety Board: Improved Policies and Additional Oversight Needed. 
employees, particularly investigative personnel recruited heavily from the 

private sector, must always be aware of potential conflicts of interest. In 

keeping with its continued efforts to strengthen its administrative 

infrastructure, we encourage the CSB to extend its ethics policy to address 

memberships. 

The CSB Needs To Publish Additional Records and Policies

The CSB has published in the Federal Register and on its website regulations 

covering the Freedom of Information Act (FOIA), the Privacy Act, the 

availability of unpublished information, CSB testimony, and the Sunshine 

Act. However, the CSB has not fully complied with federal standards for 

publishing certain information in the Federal Register, making information 

available electronically, and furnishing other information upon request. 

Although noncompliance may not have hampered the CSB operations 

significantly, the degree to which the CSB may or may not be affected does 

not excuse it from its statutory requirements to make information available to 

the public. There are primarily three categories of information that the CSB 

must prepare and either publish immediately or make available upon request. 

First, 5 U.S.C. § 552(a)(1) states that an agency must publish in the Federal 

Register its organization structure, rules of procedures, scope and content of 

agency records and reports, and substantive rules and statements of general 

agency policy. The CSB has not published regulations for its organizational 

structure, nor has it published a required accident reporting regulation. The 

CSB has published partial regulations regarding its investigative work, which 

address availability of information and materials, requests to withhold 

information, right to representation, and records of legal proceedings. Some 

CSB discretion will be involved in defining the CSB’s substantive rules and 

statements of general policy. The CSB could benefit by reviewing what 

information other independent agencies publish according to the standards of 

section 552(a)(1). We compared the CSB’s significant regulatory publications 

with those of the seven agencies with which we benchmarked the CSB in an 

earlier report (see Appendix D). Several of these also have investigative 

functions. The majority has published regulations on agency organizational 

structure, reporting requirements, and inspection or investigation procedures. 

Second, 5 U.S.C. § 552 (a)(2) states that an agency must prepare and make 

available in its public reading room final opinions, statements of policy and 

interpretations which have been adopted by the agency and are not published 

in the Federal Register, administrative staff manuals and instructions, 

“frequently requested records” in FOIA-processed form, and an index to 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 42 
 

facilitate public access to such information. The Electronic Freedom of 

Information Act Amendments of 1996 (E-FOIA), which amended 5 U.S.C. § 

552, require that all agencies make certain types of records created by the 

agency available electronically to improve and ensure public access to agency 

records and information. Because the CSB began operations after November 

1, 1996, all of its records related to section 552(a)(2) must be in its electronic 

reading room. However, the CSB’s FOIA program, and E-FOIA program in 

particular, do not fully comply with the statute. 

We compared NTSB and CSB publications to identify areas in which the CSB 

may need or wish to issue policy-related regulations in accordance with 

section 552(a)(1) or to publish policy and information on its website in 

accordance with section 552(a)(2). For example, the NTSB published 

regulations governing its investigative protocol, addressing issues such as the 

conduct of investigations and availability of public dockets on information 

collected during investigations. In addition, the NTSB provides on its website 

a link to those regulations, along with a summary of the investigative process, 

the composition of its deployment team, and so forth. The NTSB published 

delegations of authority, including authority for employees to take depositions 

during investigations and to disclose investigative facts. The NTSB published 

dockets and its internal staff manual for aviation investigations on the 

Internet.51 

In contrast, the CSB has neither regulation nor web-published policy for 

routine investigative items such as authority, scope of investigation, 

delegation, investigator-in-charge, authority of board representatives, the flow 

and dissemination of accident information, and proposed findings. Some of 

these items are in the CSB’s statutes; and some have been discussed in 

assorted narrative on the CSB’s website. Some are addressed in the CSB’s 

unpublished investigative protocol, an administrative staff manual, which 

section 552(a)(2) may require to be published. Some investigative issues, such 

as external comments on draft reports, are addressed in published CSB 

regulations or guidelines. There are no public dockets of these investigations 

on the CSB website; the CSB maintains all investigative information on 

completed accident investigations in the investigative file. In other words,

except for the investigation reports themselves, the CSB investigative policies 

and information have been developed and published in a fragmented and 

incomplete manner. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 43 

51 National Transportation Safety Board, Aviation Investigation Manual Major Team Investigations,

(http://www.ntsb.gov/Aviation/Manuals/MajorInvestigationsManual.pdf). 
 

We discussed the CSB’s compliance with sections 552(a)(1) and (2) with the 

general counsel, who explained that the CSB delayed developing and 

publishing items due to the CSB’s newness, limited resources, and past 

organizational and management issues. While the CSB has published some

regulations and policies, gaps are the result of a deliberate strategy to 

prioritize items that resolve issues most critical to investigators in the field. 

For example, issues raised during investigations spurred the CSB to publish a 

regulation on the role of attorneys representing accident witnesses. The CSB 

has relied on its statutes to address other issues up to this point. While it is 

true that the CSB has the authority to clarify its role and behavior during an 

investigation, waiting for problems to occur that highlight regulatory and 

policy needs is a questionable strategy. For example, in the absence of 

published policies, a company may take greater liberty to impede the CSB’s 

access to its plant and staff and to affect how the CSB operates once inside the 

plant. Industry representatives and the CSB staff noted two investigations 

where this may have occurred. The conduct of the CSB is less likely to suffer 

interference when the CSB can point toward published regulation and policy. 

Third, 5 U.S.C § 552(g) states that an agency must prepare and make available 

upon request reference material or a guide for requesting records or 

information from the agency, including: (1) an index and description of the 

agency's “major information systems”; (2) a description of the agency's

“record locator systems”; and (3) a handbook for obtaining various types and 

categories of public information from the agency. The CSB has not published 

a system of records pertaining to investigative activity or made available 

descriptions of what information is kept regarding investigations. The general 

counsel stated that the CSB waits to provide such information upon request, 

because infrequent requests show insufficient interest to justify publication. 

However, we note that in the absence of published record descriptions, it is 

more difficult for the public to identify records to request. In the supporting 

analysis for “Management of Federal Information Resources,” OMB noted: 

“Every agency has a responsibility to inform the public within the context of 

its mission. This responsibility requires that agencies distribute information at 

the agency's initiative, rather than merely responding when the public requests 

information.”52 Furthermore, as the CSB’s body of work and reputation grow, 

the CSB should prepare for public information requests to grow as well. 

In 1999, the CSB won an award for the quality and content of its website, and 

its Chemical Incident Report Center database continues to receive praise. But 

the CSB is still working toward greater transparency and compliance with

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 44 

52 Management of Federal Information Resources, (OMB Circular No. A-130 Revised, Appendix IV, February 8, 1996). 
FOIA and E-FOIA. Recently, the CSB issued “Interim Final Guidelines for 

Ensuring and Maximizing the Quality, Objectivity, Utility, and Integrity of

Disseminated Information,” which address how the CSB will handle external 

feedback on its investigative reports. Since the CSB recently resolved key

organizational and management issues, the CSB planned to publish 

regulations on its organizational structure and delegations of authority in FY 

2003. However, the CSB did not do so. The CSB also planned in FY 2003 to 

update its investigative protocols; these also should be published. We

encourage the CSB to adopt a proactive stance toward complying with FOIA 

and E-FOIA and developing public transparency. 

We recommend that the Chairman: 

Recommendation 6: Revise the incident selection process to ensure that all 

accidents meeting statutory investigation criteria are considered for 

deployment by a manager with delegated authority for such decisions. 

Recommendation 7: Revise the incident selection process to incorporate 

appropriate levels of supervision and separation of duties associated with 

receiving, evaluating, and recording or discarding notifications. 

Recommendation 8: Improve its recordkeeping of the selection process, 

including a definition of which types of notifications the CSB will record or 

discard, to manage the quality of incident selection data and enable the CSB to 

analyze it in the future. 

Recommendation 9: Publish a policy regarding employee conflicts of interest 

related to investigations.

Recommendation 10: Enact required administrative regulations, including 

the CSB organization. 

Recommendation 11: Publish policies and administrative guidance on the 

CSB website, particularly regarding the conduct of investigations, but also 

including other relevant materials such as board voting records and orders. 

 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 45 
Appendix A 

Management Comments 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 46 
Appendix A 

Management Comments 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 47 
Appendix A 

Management Comments 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 48 
Appendix A 

Management Comments 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 49 
Appendix A 

Management Comments 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 50 
Appendix B

OIG Evaluation of Management Comments

Recommendation 1: Develop a plan to describe and address the gap between 

the number of accidents the CSB investigates and the number falling within its 

statutory investigative jurisdiction. Include this information in future budget 

submissions to Congress and the Office of Management and Budget. 

Management Comments and OIG Analysis: The CSB concurred with the 

intent of the recommendation and agreed that it would be beneficial to 

investigate more chemical accidents and determine their root causes. The CSB 

cited its lack of resources to investigate more than a small percentage of the 

accidents that fall within its legal jurisdiction. The CSB believes it has 

responded to its understanding of current Congressional intent and conducting 

a larger number of superficial investigations would neither conform to the 

legislative intent of the Clean Air Act Amendments nor serve the ultimate 

goal of reducing accident rates. The CSB agreed that Congress and the 

Executive branch are likely to be unaware of the extent of injuries, damage, 

and dislocation caused by chemical accidents. Beginning in fiscal year 2004, 

the CSB will submit to Congress and OMB an account of the total number of 

incident reports received and a listing of the serious chemical accidents 

evaluated by the agency for possible deployment. The CSB will also seek 

guidance from Congress for investigating a prioritized set of significant 

accidents that it has identified. 

We concur with the CSB’s response. However, the extent that the CSB is 

going to address the gap between the number of accidents it investigates and 

the number falling within its statutory investigative jurisdiction is not clear 

and must be stated forthrightly in its report to Congress. The CSB will satisfy 

this recommendation once it submits its first report to Congress. 

Recommendation 2: Define what constitutes a chemical accident within the 

CSB’s purview and publish a regulation that outlines how the CSB will 

receive information on these accidents. 

Management Comments and OIG Analysis: The CSB acknowledged that it 

has not yet developed a regulation requiring the reporting of chemical 

incidents falling within its jurisdiction, but it has developed non-regulatory 

alternatives. It has postponed undertaking a formal regulation for a number of 

reasons, including the significant financial and staffing implications for the 

Board and possible burden on affected parties. Given the questions concerning 

the benefits of and potential impacts of such a regulation, the CSB must seek 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 51 
Appendix B

OIG Evaluation of Management Comments

additional guidance from OMB and Congress before it commits to a long-term

regulatory plan of action. In light of the statutory language and the OIG’s 

recommendation, the CSB will seek this guidance and define a further course 

of action by June 30, 2004. 

We concur with part of the CSB’s response. In response to recommendation 

six, the CSB stated that it will more clearly define incidents under the CSB’s 

purview and this will benefit the incident selection process. The CSB will 

satisfy this recommendation by defining these accidents and obtaining 

guidance from OMB and Congress regarding its reporting regulation. 

Recommendation 3: Evaluate the CSB’s performance on recommendations 

follow-up and consider policies and practices to improve the CSB’s timeliness 

for closing recommendations. 

Management Comments and OIG Analysis: The CSB accepted the 

recommendation. In response to the increasing number of recommendations, 

the CSB is tracking and closing them more expeditiously. The CSB has 

recently reorganized to establish a separate recommendations supervisor with 

three staff, has developed a recommendations tracking database, and has 

initiated contact with recipients of all previous recommendations. With 

adequate funding, the CSB will make a major effort to close old 

recommendations and keep current on new ones during the first half of FY 

2004. 

We concur with the CSB’s response and consider the recommendation closed.

Recommendation 4: Establish a plan linking measurement data and strategic 

improvements that enables the CSB to assess and enhance its impact on 

chemical accident prevention. 

Management Comments and OIG Analysis: The CSB responded that in its 

five-year strategic plan, it has set measurable goals for its investigation 

activity and its recommendation implementation activity. The CSB believes 

these goals will clearly demonstrate the CSB’s effectiveness. The CSB, 

working in concert with other federal agencies and private organizations, 

expects to help reduce the incidence of chemical accidents over time. It cited 

EPA’s RMP database as the best available metric for measuring this reduction 

and asserted that no one agency or private organization will be able to take

credit for any decline in the incidents reported to this database, but the activity 

of each can be expected to have an effect. The CSB does not envision 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 52 
Appendix B

OIG Evaluation of Management Comments

establishing any additional measurement devices that measure the impact of 

CSB activity alone, but does expect to continue working with others to 

continue to improve the best available measure for chemical incidents. The 

CSB implied in its response that circumstances beyond its control will hinder 

its ability to carry out the recommendation. 

We acknowledge the CSB’s willingness to continue to work with other 

agencies to improve the quality of chemical accident databases. Our aim is to 

cause the CSB to determine how it might better evaluate its impact. The 

CSB’s primary metrics--counting the number of safety products issued and the 

overall percentage of recommendations implemented—are at most a weak 

reflection of whether the CSB contributes to reducing chemical accident rates. 

We encourage the CSB to seek measurement devices that tell more about the 

impact of CSB work and that enable the agency to target its resources more 

strategically. Improved national data that capture chemical accident rates

might help the CSB demonstrate that general chemical accident prevention 

efforts are having a positive impact. However, this is not the only means by 

which the CSB might pursue improved metrics. Another means would be for 

the CSB to develop more detailed data about the results of its 

recommendations. Moving beyond the overall percentage of 

implementations, the CSB might rate the relative importance of its 

recommendations and analyze what changes they spur. For example, the 

NTSB develops and monitors a list of “Most Wanted” recommendations, 

reflecting an ongoing effort to monitor or bring about change in the 

transportation industry. As the CSB’s recommendations program grows, the 

CSB may find illustrative performance data there. 

The CSB could satisfy this recommendation by modifying its strategic plan or 

expanding work within the recommendations program, to include analytical 

assessments of outcomes generated by its recommendations. We would like 

the CSB to reconsider these actions before this recommendation is closed. 

Recommendation 5: Develop a long-term strategy to address the shortfall in 

national chemical accident database quality. 

Management Comments and OIG Analysis: The CSB acknowledged the 

shortfall in national chemical accident database quality recognized by the OIG 

and the difficulties it presents for the CSB. The CSB repeated that Congress 

has directed the CSB to focus on investigation activity, not data gathering. 

The CSB stated that there is no organization in the US that focuses on data 

quality for chemical safety such as the Bureau of Transportation Statistics 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 53 
Appendix B

OIG Evaluation of Management Comments

does for transportation safety. The CSB will continue to work with other 

agencies to improve the quality of chemical accident databases. 

 

The CSB’s response that it will continue to work with other agencies is not a 

long-term strategy. Gathering quality chemical accident data is a complex 

issue, but we maintain that the CSB has the authority to expand its role and 

has a strong interest in improved accident data. This recommendation should 

remain open until the CSB either reports to Congress on specific 

improvements it has made or informs Congress explicitly that it will not do so. 

Recommendation 6: Revise the incident selection process to ensure that all 

accidents meeting statutory investigation criteria are considered for 

deployment by a manager with delegated authority for such decisions. 

Management Comments and OIG Analysis: The CSB suggested that we 

combine recommendations 6-8 into one recommendation. While these 

particular recommendations all address aspects of the incident selection 

process, they have three different focal points, and we elected not to combine 

them. The CSB referred to its response to recommendation six for its 

responses to recommendations seven and eight, so we took this to mean CSB 

agreed with all three recommendations. The CSB may satisfy all three 

recommendations through its proposed action plan. 

The CSB agreed with the recommendation. It intends to revise the 

investigation selection process in its FY 2004 action plan. To ensure that all 

accidents meeting statutory investigation criteria are considered, the CSB will 

more clearly define incidents within the CSB’s purview under (C)(i) and (E). 

CSB will review the terms of its agreements with the NTSB and the NRC to 

ensure that they report these incidents to the CSB. 

We concur with the CSB’s response. We will consider recommendation six 

closed when the CSB publishes newly defined statutory investigative criteria 

that require a staff member with appropriately delegated authority to make the 

decision to deploy or not to deploy to a reported incident. 

Recommendation 7: Revise the incident selection process to incorporate 

appropriate levels of supervision and separation of duties associated with 

receiving, evaluating, and recording or discarding notifications. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 54 
Appendix B

OIG Evaluation of Management Comments

Management Comments and OIG Analysis: The CSB agreed with the 

recommendation. Its action plan will contain clearly defined lines of authority 

and control between the incident screeners (duty officers) and the Board to 

ensure that decision regarding incident selection and investigation deployment 

are made with proper management control and oversight. 

We concur with the CSB’s response. CSB will satisfy this recommendation by 

addressing the necessary separation of duties in incident selection and 

deployment, in its action plan. We modified our recommendation to be more 

explicit regarding the need to separate duties between CSB members. 

Recommendation 8: Improve its recordkeeping of the selection process, 

including a definition of which types of notifications the CSB will record or 

discard, to manage the quality of incident selection data and enable the CSB to 

analyze it in the future. 

Management Comments and OIG Analysis: The CSB agreed with the 

recommendation. In its FY 2004 action plan, it will revise the selection 

process by improving recordkeeping of incident notifications and follow-up 

activities. The CSB will upgrade the screening matrix to a database. 

We concur with the CSB’s response. We would consider this recommendation 

closed upon receiving the action plan that will reflect these changes. We

modified our recommendation to clarify the need for better controls over 

recordkeeping. 

Recommendation 9: Publish a policy regarding employee conflicts of interest 

related to investigations.

Management Comments and OIG Analysis: The CSB agreed with the 

recommendation. It agreed that the policy should address employee 

participation in professional associations. The CSB will also publish guidance 

on contractor issues. 

We concur with the CSB’s response. The CSB did not offer a timetable for 

this action. This recommendation will remain open until the CSB publishes 

these policies.

Recommendation 10: Enact required administrative regulations, including 

the CSB organization. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 55 
Appendix B

OIG Evaluation of Management Comments

Management Comments and OIG Analysis: The CSB generally agreed 

with this recommendation. The CSB recently published a regulation on its 

organization, functions, quorum, and voting procedures and it plans to pursue 

further action on a reporting regulation. The CSB will also consider 

benchmarking information provided by the OIG and decide what additional 

regulations on investigative functions it should publish. 

We concur with the CSB’s response. We reviewed the CSB’s new regulation, 

which it published shortly after we issue our draft report. The regulation does 

not include delegations of authority. The CSB will satisfy this 

recommendation by publishing regulations on reporting incidents and its 

delegations of authority. 

Recommendation 11: Publish policies and administrative guidance on the 

CSB website, particularly regarding the conduct of investigations, but also 

including other relevant materials such as board voting records and orders. 

Management Comments and OIG Analysis: The CSB agreed that it could 

take additional steps to improve the public’s understanding of its functions. 

The CSB will ensure that materials required under 5 U.S.C. § 552(a)(2) are 

published on the agency’s website. The CSB will determine what additional 

information on investigative functions it should publish. 

We generally concur with the CSB’s response. However, absent a proposed 

deadline to make information available electronically and because what 

investigative information should be published remains unresolved, we are 

leaving the recommendation open. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 56 
Appendix C

Recommendations 

We recommend that the Chairman: 

Recommendation 1: Develop a plan to describe and address the gap between 

the number of accidents the CSB investigates and the number falling within its 

statutory investigative jurisdiction. Include this information in future budget 

submissions to Congress and the Office of Management and Budget. 

Recommendation 2: Define what constitutes a chemical accident within the 

CSB’s purview and publish a regulation that outlines how the CSB will 

receive information on these accidents. 

Recommendation 3: Evaluate the CSB’s performance on recommendations 

follow-up and consider policies and practices to improve the CSB’s timeliness 

for closing recommendations. 

Recommendation 4: Establish a plan linking measurement data and strategic 

improvements that enables the CSB to assess and enhance its impact on 

chemical accident prevention. 

Recommendation 5: Develop a long-term strategy to address the shortfall in 

national chemical accident database quality. 

Recommendation 6: Revise the incident selection process to ensure that all 

accidents meeting statutory investigation criteria are considered for 

deployment by a manager with delegated authority for such decisions. 

Recommendation 7: Revise the incident selection process to incorporate 

appropriate levels of supervision and separation associated with receiving, 

evaluating, and recording or discarding notifications. 

Recommendation 8: Improve its recordkeeping of the selection process, 

including a definition of which types of notifications the CSB will record or 

discard, to manage the quality of incident selection data and enable the CSB to 

analyze it in the future. 

Recommendation 9: Publish a policy regarding employee conflicts of interest 

related to investigations.

Recommendation 10: Enact required administrative regulations, including 

the CSB organization. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 57 
Appendix C

Recommendations 

Recommendation 11: Publish policies and administrative guidance on the 

CSB website, particularly regarding the conduct of investigations, but also 

including other relevant materials such as board voting records and orders. 

 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 58 
Appendix D 

Timeline of CSB Investigations (as of October 1, 2003) 

10

71

156

170

220

234

242

244

269

276

311

311

348

257

305

515

304

401

430

308

751

748

1048

938

980

434

848

326

917

256

Jan-98 Jul-98 Jan-99 Jul-99 Jan-00 Jul-00 Jan-01 Jul-01 Jan-02 Jul-02 Jan-03 Jul-03 Jan-04

Isotec

Honeywell International, Inc.

Avery Dennison Corp.

D.D. Williamson & Co

CTA Acoustics

Technic Inc.

West Pharmaceuticals

BLSR Operating Ltd.

Catalyst Systems

Environmental Enterprises

Toxic Gas Emission Hazards

Sodium Hydrosulfide Hazards

First Chemical Corp.

Festus Enterprises

Third Coast Industries

Kaltech Industries

Georgia-Pacific Naheola Mill

Motiva Enterprises LLC

BP Amoco Polymers, Inc.

Bethlehem Steel Corporation

Reactive Chemical Hazards

Tosco Avon Refinery

Concept Sciences Inc.

Equilon Enterprises*

CONDEA Vista Company*

Herrig Brothers Farm

Morton International, Inc.

Union Carbide

Sonat Exploration Company

Sierra Chemical Company

*These investigations were issued together in one study, the Management of Change bulletin.

10

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 59 
Appendix E 

Agency Benchmarking 

This chart reflects selected published regulations of the CSB and the seven 

federal boards and commissions with which we benchmarked in our March 

2002 report, Issues Regarding Management Accountability, Control, and 

Direction Have Not Been Resolved. Chemical Safety and Hazard Investigation Board National Transportation Safety Board 

N

uclear

Regulatory Commission 

Defense N

uclear Facilities 

Safety Board 

Consumer Products 

Safety Commissio

n

Federal E

nergy

Regulatory Commission 

Occupational Safety and Health

Revie

w Co

m

mission 

Federal Housing

Finance Board 

Title (CFR) 40 49 10 10 16 18 29 12 

Agency

Organizational

Structure 

NP 800 1 NP 1000 375.39 NP 905 

Reporting 

Requirements 

NP 830,

840 21 NP 1115, 1116 330.2 NP NP 

Availability of

Unpublished

Information 

1602 801 9.15 1703.103 1100 388.106 2201.5 911

Inspection or

Investigation

Procedures

NP 831 19.14 O225.1A53 1118 1b.1

Agency 

Testimony

1611 835 9.200 1707 1016 388.111 NP NP 

Freedom of 

Information Act 1601 801 9.11 1703.105 1015 388.108 2201 910

Privacy Act 

Of 1974 1602 802 9.5 1705 1014 NP 2400 913

Sunshine Act 1603 804 9.100 1704 1013 375.203 2203 912

NP=Not published.

 

53 The DNFSB investigates only the Department of Energy's defense nuclear facilities. One of the DOE Orders of 

Interest to the Board, O225.1A Accident Investigation, provides an official investigative procedure. 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 60 
Appendix F 

Major Contributors to This Report 

William J. McCarron, Senior Inspector 

E. Wynne Krause, Inspector 

Lumumba Yancey, Program Analyst 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 61 
Appendix G 

Report Distribution 

U.S. Chemical Safety and Hazard Investigation Board

Chairman/CEO 

OIG Audit Liaison 

Office of Management and Budget

DHS OIG Budget Examiner 

CSB Budget Examiner 

Congress

Congressional Oversight and Appropriations Committees 

U.S. Environmental Protection Agency

Inspector General 

A Report on the Continuing Development of the U.S. Chemical Safety and Hazard Investigation Board - Final Page 62