U.S. ENVIRONMENTAL PROTECTION AGENCY

OFFICE OF INSPECTOR GENERAL

U.S. Chemical Safety and 

Hazard Investigation Board 

Needs to Complete More 

Timely Investigations 

Report No. 13-P-0337 July 30, 2013 

Scan this mobile 

code to learn more 

about the EPA OIG. 
 

Report Contributors: Anthony Grear 

 Marcia Hirt-Reigeluth

 Denise Darasaw 

 Gloria Taylor-Upshaw 

 Michael Davis 

Abbreviations 

CFR Code of Federal Regulations 

CSB U.S. Chemical Safety and Hazard Investigation Board 

EPA U.S. Environmental Protection Agency 

FY Fiscal year 

GAO U.S. Government Accountability Office 

GPRA 2010 Government Performance and Results Act Modernization Act of 2010 

OIG Office of Inspector General 

OMB Office of Management and Budget 

TRIM Total Records and Information Management 

Hotline 

To report fraud, waste, or abuse, contact us through one of the following methods: 

email: OIG_Hotline@epa.gov write: EPA Inspector General Hotline 

phone: 

fax: 

1-888-546-8740 

202-566-2599 

1200 Pennsylvania Avenue, NW 

Mailcode 2431T 

online: http://www.epa.gov/oig/hotline.htm Washington, D.C. 20460 
 

 

U.S. Environmental Protection Agency 13-P-0337 

July 30, 2013 Office of Inspector General 

At a Glance
 

Why We Did This Review 

The U.S. Environmental 

Protection Agency Office of 

Inspector General initiated this 

audit to determine whether the 

U.S. Chemical Safety and 

Hazard Investigation Board has 

an effective system for 

managing its investigative 

process. CSB is an 

independent federal agency, 

authorized by the Clean Air Act 

Amendments of 1990 to 

investigate, 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. 

This report addresses the 

following CSB goal: 

 Conduct incident 

investigations and safety 

studies concerning releases 

of hazardous chemical 

substances. 

For further information, contact 

our Office of Congressional and 

Public Affairs at (202) 566-2391. 

The full report is at: 

www.epa.gov/oig/reports/2013/ 

20130730-13-P-0337.pdf 

U.S. Chemical Safety and Hazard Investigation Board 

Needs to Complete More Timely Investigations 

What We Found 

CSB does not have an effective management system to meet its established 

performance goal to “[c]onduct incident investigations and safety studies 

concerning releases of hazardous chemical substances.” CSB has not fully 

accomplished its related strategic objective to “[c]omplete timely, high quality 

investigations that examine the technical, management systems, organizational, 

and regulatory causes of chemical incidents.” We identified five reasons why CSB 

did not meet its objective to timely complete investigations: 

 A lack of defined performance indicators in CSB’s annual performance plan, 

which are necessary to assess the efficiency of its investigations process. 

 A backlog of open investigations without documented plans for resolution. 

 An average investigative staff turnover rate of 15 percent. 

 Non-collocation of files and incorrectly classified or coded investigation files. 

 A need for updated policies over current investigative procedures and a 

policy that defines final investigative products. 

By completing investigations more timely, CSB can better fulfill its mission and 

improve its ability to ensure that it provides the community and other stakeholders 

with findings and recommendations to help reduce the occurrence of similar 

incidents, which would protect human health and the environment. 

 Recommendations and CSB Planned Corrective Actions 

We made nine recommendations, including that the CSB chairperson: 

 Develop and implement performance indicators. 

 Revise and publish annual and individual action plans. 

 Review investigations open for over 3 years and develop a close-out plan. 

 Review investigation files for each ongoing investigation to ensure it contains 

all the supporting documents related to the investigation. 

 Implement and update the management policy for investigative records. 

CSB agreed with six of nine recommendations and responded in detail to each in 

appendix A. CSB plans to complete proposed corrective actions by December 31, 

2013. CSB disagreed with the remaining three recommendations and resolution 

efforts are in progress. 

 Noteworthy Achievements 

CSB has made progress in providing investigators with training and identifying 

operational tools for the investigative process. CSB also instituted the use of 

scoping documents and recommendation briefings to help improve the process. 
 

 

 

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY 

WASHINGTON, D.C. 20460 

THE INSPECTOR GENERAL 

July 30, 2013 

The Honorable Rafael Moure-Eraso, Ph.D. 

Chairperson and Chief Executive Officer 

U.S. Chemical Safety and Hazard Investigation Board 

2175 K Street, NW, Suite 400 

Washington, D.C. 20037-1809 

Dear Dr. Moure-Eraso: 

This is our report on the U.S. Chemical Safety and Hazard Investigation Board’s need to complete 

investigations more timely. This report contains findings the Office of Inspector General has identified 

and corrective actions the OIG recommends. This report represents the opinion of the OIG and does not 

necessarily represent the final CSB position on the subjects reported. CSB managers will make final 

determination on matters in this report in accordance with established audit resolution procedures. 

CSB disagreed with recommendations 2, 4 and 6 from our draft report. Resolution efforts are in progress 

on these recommendations. Please provide a written response to this final report, including proposed 

corrective actions, within 60 calendar days of the report date. The response will be posted on the OIG’s 

public website, along with our memorandum commenting on the response. 

The response should be provided as an Adobe PDF file that complies with the accessibility 

requirements of Section 508 of the Rehabilitation Act of 1973, as amended. The final response should 

not contain data that should not be released to the public; if the response contains such data, the data 

for redaction or removal should be identified. We will post this report on our website at 

http://www.epa.gov/oig. 

If you or your staff has any questions regarding this report, please contact Richard Eyermann, 

acting assistant inspector general for audit, at (202) 566-0565 or eyermann,richard@epa.gov; 

or Michael Davis, product line director, at (513) 487-2363 or davis.michaeld@epa.gov. 

Sincerely, 

Arthur A. Elkins Jr. 
 

 

 

 

 

 

 

 

U.S. Chemical Safety and Hazard Investigation Board 13-P-0337 

Needs to Complete Investigations More Timely 

Table of Contents 

Chapters 

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

 Purpose ....................................................................................................... 1 

Background ................................................................................................. 1 

 Noteworthy Achievements ........................................................................... 2 

 Scope and Methodology .............................................................................. 2 

2 CSB Needs to Improve in Meeting Its Performance Objective 

to Complete More Timely Investigations ......................................................... 4
 

CSB Not Meeting Its Goal Related to Timely Investigations ....................... 4 

Federal Laws and Policies Address How to Manage and 

 Monitor Performance Objectives .......................................................... 6 

CSB Has Guidance for Managing Processes .............................................. 7 

Reasons Why CSB Did Not Meet Its Performance Objective ..................... 8 

Conclusion................................................................................................... 14 

 Recommendations ....................................................................................... 14 

CSB Comments and OIG Evaluation .......................................................... 15 

Status of Recommendations and Potential Monetary Benefits.............................. 17 

Appendices 

A CSB Response to Draft Report ......................................................................... 19 

B CSB Board Member Response to Draft Report ............................................... 28
 

C OIG Comparison of CSB Responses to the Draft Report............................... 30 

D Distribution ......................................................................................................... 38 
 

Chapter 1

Introduction 

Purpose 

The U.S. Environmental Protection Agency Office of Inspector General 

initiated this audit to determine whether the U.S. Chemical Safety and Hazard 

Investigation Board has an effective system for managing its investigative 

process. The project contributes to CSB’s Strategic Goal 1, “[c]onduct 

incident investigations and safety studies concerning releases of hazardous 

chemical substances.” 

Background 

CSB is an independent federal agency authorized by the Clean Air Act 

Amendments of 1990. The act directs CSB to (1) investigate and report on the 

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

injury or substantial property damage; (2) make safety recommendations to 

reduce the likelihood or consequences of accidental chemical releases and 

propose corrective measures; and (3) establish by regulation requirements 

binding on persons for reporting accidental releases into the ambient air 

subject to the Board’s investigatory jurisdiction. The purpose of a CSB 

incident investigation is to determine the causes of an incident and whether 

those causes were the result of a violation of any current and enforceable 

requirement. The CSB investigative staff includes chemical and mechanical 

engineers, industrial safety experts, and other specialists with experience in 

the private and public sectors. After a CSB team reaches a chemical incident 

site, investigators conduct detailed interviews of witnesses such as plant 

employees, managers and neighbors. Chemical samples and equipment 

obtained from accident sites are sent to independent laboratories for testing. 

Company safety records, inventories and operating procedures are examined 

as investigators seek an understanding of the circumstances of the accident. 

CSB is located in Washington, D.C., with an investigation field office in 

Denver, Colorado. CSB’s authorizing statute provides for five board members, 

including a chairperson, all appointed by the President and confirmed by the 

United States Senate. As of April 2013, there were three appointed board 

members, including the chairperson, and a staff of 39 that includes 18 who are 

involved in investigations. 

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Noteworthy Achievements 

CSB has made progress in providing investigators with training and 

identifying operational tools for the investigative process. In August 2012, 

CSB began conducting semiannual investigator training conferences that 

included topics on investigation method discussions and exercises defining the 

differences between investigation products. CSB also instituted the use of 

scoping documents and recommendation briefings to help improve the 

investigation process. CSB explained that scoping documents provide staff 

with a list of personnel who are involved in an investigation and the 

percentage of time they plan to devote to an investigation, and hopes to refine 

further this process to include the total number of staff hours estimated for 

each investigation. 

Scope and Methodology 

We conducted this performance audit in accordance with generally accepted 

government auditing standards. Those standards require that we plan and 

perform the audit to obtain sufficient, appropriate evidence to provide a 

reasonable basis for our findings and conclusions and that the evidence 

obtained provides a reasonable basis for our findings and conclusions based on 

our audit objective. 

We performed our audit work from June 2012 through May 2013. Our 

objective was to determine whether CSB has an effective system for managing 

its investigative process. The scope of the audit included investigations from 

October 1, 2006, through May 31, 2012. We judgmentally selected six 

investigations based on length of time the investigation was open and were 

still open or recently closed. The cost of the investigation and the location of 

the lead investigator were also considered in our selection. Our sample 

included four investigations that remained open from 2008, 2009 or 2010 and 

two that were closed in fiscal year 2012. Three had a lead investigator from 

headquarters and remaining three had a lead investigator from CSB’s Denver 

office. We reviewed the sample investigative files for documented support. 

We interviewed CSB’s management, senior investigators and investigative 

staff to identify and discuss the investigative process. We obtained and 

reviewed CSB’s board orders (policies and procedures) that govern the 

investigative process. We reviewed the status of investigations and CSB’s 

performance goals. We performed a site visit to CSB’s Denver office. 

Prior CSB-Related Audits 

The EPA OIG assumed oversight responsibility for CSB in FY 2004. 

Previously, the Federal Emergency Management Agency and U.S. Department 

of Homeland Security OIGs had performed OIG oversight for CSB. We 

issued two prior reports to CSB relating to its implementation of prior audit 

recommendations and CSB’s safety recommendation process. 

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In EPA OIG Report No. 11-P-0115, Chemical Safety and Hazard 

Investigation Board Did Not Take Effective Corrective Actions on Prior Audit 

Recommendations, issued February 15, 2011, we sought to determine whether 

CSB had implemented audit recommendations made by those three OIGs and 

the U.S. Government Accountability Office. We found that CSB did not take 

timely corrective actions to address audit recommendations. Also, CSB had 

not established and implemented a management control program to evaluate 

and report on the effectiveness of controls related to its program operations. 

In the FY 2011 report, we recommended that CSB develop and implement a 

management control plan that documents and addresses internal control 

standards in accordance with Office of Management and Budget Circular 

A-123, Management’s Responsibility for Internal Control, and the U.S. 

Government Accountability Office’s Standards for Internal Control in the 

Federal Government. We recommended that the management control plan 

include procedures for conducting periodic internal control reviews and 

properly documenting those reviews, including verifying and ensuring that 

audit recommendations are resolved promptly. CSB noted it is in the process 

of creating a management control plan. During this audit, we identified an 

additional concern with the lack of documented internal reviews. We 

requested documented support for CSB’s FY 2011 assurance statement on the 

effectiveness of its operational program’s internal controls. CSB did not 

provide documented support as required by OMB Circular A-123, Section 6. 

CSB has certified its compliance with FY 2012 management controls based on 

internal and external evaluations and knowledge gained from daily operations. 

In EPA OIG Report No. 12-P-0724, U.S. Chemical Safety and Hazard 

Investigation Board Should Improve Its Recommendations Process to Further 

Its Goal of Chemical Accident Prevention, issued August 22, 2012, we sought 

to determine what factors impede implementation of CSB safety 

recommendations. We found that CSB did not consistently achieve its goals 

and standards, as outlined in its current strategic plan, for timely 

implementation of its safety recommendations. Although CSB does not have 

enforcement authority, and implementation of some of its recommendations 

may face lengthy regulatory processes, CSB has not established or maintained 

sufficient internal controls and processes for safety recommendations. 

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Chapter 2

CSB Needs to Improve in Meeting Its Performance 

Objective to Complete More Timely Investigations 

CSB does not have an effective management system to meet its established 

performance goal to “[c]onduct incident investigations and safety studies 

concerning releases of hazardous chemical substances.” Specifically, CSB has 

not fully accomplished its related strategic objective to “[c]omplete timely, 

high quality investigations that examine the technical, management systems, 

organizational, and regulatory causes of chemical incidents.” Various federal 

laws and policies address how federal agencies should manage and monitor 

their performance. We identified five reasons why CSB did not meet its 

objective to complete timely investigations: 

	 A lack of defined performance indicators in CSB’s annual performance 

plan, which are necessary to assess the efficiency of its investigations 

process. 

	 A backlog of open investigations without documented plans for 

resolution. 

 An average investigative staff turnover rate of 15 percent. 

 Non-collocation of files and incorrectly classified or coded 

investigation files. 

 A need for updated policies over current investigative procedures 

and a policy that defines final investigative products. 

By completing more timely investigations, CSB can better fulfill its mission and 

improve its ability to ensure that it provides the community and other 

stakeholders with findings and recommendations to help reduce the occurrence 

of similar incidents, which would protect human health and the environment. 

CSB Not Meeting Its Goal Related to Timely Investigations 

CSB’s 2012-2016 strategic plan, issued in June 2012, is a revision to its prior 

2007-2012 plan. The new strategic plan replaces the FYs 2007-2012 plan’s 

five goals with three goals. In addition, the new plan adds 13 “outcome 

oriented” strategic objectives based on the three goals, and the objectives 

measure the effectiveness or quality of their performance and the public 

benefit derived. CSB notes that the new plan places “emphasis on conducting 

investigations, securing implementation of recommendations, and 

disseminating CSB findings.” 

In the revised plan, the first goal is to “[c]onduct incident investigations and 

safety studies concerning releases of hazardous chemical substances.” CSB 

states that this goal drives the core mission to ensure that CSB selects and 

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completes incident investigations that have the potential to generate thorough 

recommendations with high preventive impact. This goal is a change from 

CSB’s prior first goal to “[s]elect and complete accident investigations and 

recommend actions with a high potential for protecting workers, the public, and 

the environment.” 

An objective for the first goal is to “[c]omplete timely, high quality investigations 

that examine the technical, management systems, organizational, and regulatory 

causes of chemical incidents.” This objective relates to its prior key result to 

“[r]educe the time to complete investigation products.” CSB’s revised plan notes 

that it “endeavors to complete its thorough investigations as quickly as possible 

and, in many cases, incident investigations are completed in less than a year.” 

CSB’s revised strategic plan identifies two performance measures for its 

objective to complete timely investigations. For FY 2012, one measure was to 

complete seven investigations and another was to establish a baseline for the 

average time to complete an investigation. 

We reviewed and compared CSB’s accomplishments reported in its FY 2007 

through 2012 performance accountability reports and the status of current and 

completed investigations. We found that over the 6-year period, CSB has 

steadily fallen behind in accomplishing its objective related to timeliness, as 

described in table 1. 

Table 1: CSB’s planned and actual accomplishments for goal 1 

FY 

Investigations 

planned to 

complete 

Investigations 

actually 

completed 

Percent 

actually 

completed 

2007 10 10 100.00% 

2008 6 6 100.00% 

2009 6 4 66.67% 

2010 8 4 50.00% 

2011 15 5 33.33% 

2012 8 2 25.00% 

Totals 53 31 (58%) 

Sources: CSB’s Performance and Accountability Reports for FYs 2007–2012. 

From comparing this information to data on the status of investigations 

provided to us during our audit and on the website, we identified an additional 

seven investigations reported as completed in FYs 2007, 2010 and 2012. 

Of the seven, only two are included on the CSB website. The remaining five 

were listed in a safety bulletin as examples for “hot works” demonstrations, 

which include burning, welding or similar operations that are capable of 

initiating fires or explosions. We could not clearly confirm whether these 

investigations were actually completed or just reported in the safety bulletin. 

CSB is not consistent in accomplishing its objective to complete timely 

investigations. Other than stating that it endeavors to complete an 

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investigation as soon as possible, CSB’s strategic plan does not clearly define 

a “timely completed investigation.” If CSB clarifies what is “timely” and uses 

that definition in its measures or indicators for setting its performance goals 

and objectives, CSB could be more consistent and efficient in completing 

investigations. 

Federal Laws and Policies Address How to Manage and Monitor 

Performance Objectives 

Several federal laws and policies address how agencies should manage and 

monitor to achieve their performance goals and objectives. 

The Government Performance and Results Act Modernization Act of 2010 

(GPRA 2010), requires that agencies annually establish agency performance 

plans to include “a balanced set of performance indicators to be used in 

measuring or assessing progress toward each performance goal.” GPRA 2010 

also stipulates that agencies are to provide in plans “a description of how the 

performance goals are to be achieved, including ... the operation processes, 

training, skills and technology, and the human, capital, information, and other 

resources and strategies required to meet those performance goals.” GPRA 

2010 states in section 3 that agency performance plans are to be made 

available annually on an agency public website. 

GAO’s Standards for Internal Control in the Federal Government addresses 

establishing internal controls for the monitoring of performance. An example 

of a control activity category common to all agencies is the establishment and 

review of performance measures and indicators because “[control] [a]ctivities 

need to be established to monitor performance measures and indicators. These 

controls could call for comparisons and assessments relating different sets of 

data to one another so that analyses of the relationships can be made and 

appropriate actions taken. Controls should also be aimed at validating the 

propriety and integrity of both organizational and individual performance 

measures and indicators.” 

OMB Circular A-123 clarifies in Section 3 that effective internal control is a 

key factor in achieving agency missions and program results through 

improved accountability. Section 4 states that agency managers should 

continuously monitor and improve the effectiveness of internal control 

associated with their programs. This continuous monitoring, and other 

periodic assessments, should provide the basis for the agency head’s annual 

assessment of and report on internal control in its annual performance plans. 

CSB’s annual performance plans and reports are sources of information CSB 

can use to assess its internal controls. 

The Code of Federal Regulations, in 36 CFR 1236.26, provides steps that 

agencies are required to take to maintain electronic information systems. 

Specifically, the regulation states, “(a)Agencies must maintain inventories of 

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electronic information systems and review the systems periodically for 

conformance to established agency procedures, standards, and policies as part 

of the periodic reviews required by 44 U.S.C. 3506. The review should 

determine if the records have been properly identified and described, and if the 

schedule descriptions and retention periods reflect the current informational 

content and use.” 

CSB Has Guidance for Managing Processes 

CSB has issued its own specific guidance for its investigative process and 

management of CSB records: Board Order 040, Investigation Protocol, 

March 2006, as amended December 2011; and Board Order 019, Records 

Management Program, March 2001, amended May 2003. These policies, if 

followed, would provide CSB with the procedures needed to ensure 

investigations and supporting investigative records are managed to achieve 

CSB’s performance objectives. 

Board Order 040 outlines several procedures for initiating, managing and 

organizing, interviewing, and gathering evidence on investigations. 

Procedure A outlines the investigator in charge responsibilities in conducting 

an incident investigation. Procedures B and C describe the planning in 

preparation for deployment and activities of the investigative team between 

the time a decision is made to deploy, their arrival at the incident scene, and 

initial field activities. Procedure D provides guidance on how to organize 

various types of investigation data. Section 2 of this procedure requires the 

investigator in charge to appoint a records liaison coordinator from the 

investigation team to label, file and track all investigation materials. The 

liaison is responsible for creating and maintaining the electronic records 

management files system for the duration of the investigation and once it is 

closed. Appendix D1 provides the codes by category that investigators should 

use for electronic evidence files. 

Board Order 019 provides the detail needed to implement and operate CSB’s 

records management program to ensure that CSB meets recordkeeping 

requirements. The order states in Appendix A, Section 2 that 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 (44 U.S.C. 3301). 

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Appendix A, Section 4 outlines CSB’s responsibilities for the records 

management program, explaining that “...each employee must [o]rganize files 

according to their functional area’s standard file plan and based on guidance 

from their Record’s Officer; [ m]ake sure that folders, disks and other filing 

media are properly labeled and have some method for identifying the full 

contents and date ranges of the records contain within.” This section also 

explains that employees must “[c]reate and maintain indexes and logs to 

facilitate the retrieval of files as needed.” The board order states that 

appropriate management of records will be a standard performance element in 

all employee performance plans. 

Reasons Why CSB Did Not Meet Its Performance Objective 

CSB did not meet its objective for timely completing investigations due to: 

 A lack of performance indicators. 

 A backlog of open investigations. 

 An investigative staff turnover rate averaging 15 percent. 

 Files not collocated and incorrectly classified or coded investigation files. 

 A need for updated policies to address current investigative procedures 

and define final investigative products. 

Lack of Defined Performance Indicators 

CSB does not have specific performance indicators to measure the efficiency 

of its investigative process. In addition, CSB does not have a current annual 

action plan describing these indicators for the key phases and periods of the 

investigative process that would help ensure it is completing timely 

investigations. 

In its FY 2012 performance accountability report, CSB noted several 

performance measures for its first goal, to conduct timely incident 

investigations and safety studies that involve accidental releases or potential 

releases of hazardous chemical substances. Those measures were: 

 Completed investigations. 

 Average time to complete an investigation. 

 Implementation of lessons learned process. 

 Complete priority sections of investigation protocol. 

 Cost per project versus historical cost per report format. 

CSB’s overall status for all the measures is “ongoing,” with the exception of 

the lessons learned measure, which CSB noted as complete for two 

investigations. As of December 2012, CSB has not defined the related 

performance indicators necessary in key phases of the investigative process to 

assess the efficiency and, ultimately, the achievement of its goals. CSB lacked 

specific performance indicators that define the amount of time necessary to 

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perform/witness interviews, prepare scoping documents, and write the report 

and/or case study. As a result, CSB did not have information to identify areas 

for improvement, plan for future investigations and allocate resources. CSB 

stated that it is very difficult to estimate the appropriate amount of time it 

takes on average to conduct witness interviews, design laboratory testing 

(where no protocols exist) and write reports. However, CSB could gain further 

efficiencies through a detailed analysis of its investigative process for 

common performance indicators. We believe that indicators could help CSB 

measure the cost effectiveness and timeliness of each phase in the 

investigation process. By not identifying performance indicators for key 

phases in the investigations cycle, CSB has less capability to hold staff 

accountable for efficient completion of chemical accident investigations. 

In addition to the performance indicators, CSB does not have a published 

FY 2011 or 2012 agency performance plan (CSB refers to it as an annual 

action plan) as required by GPRA 2010, and its individual performance plans 

(plans used to monitor staff performance) do not define timeliness 

requirements for key phases of the investigation process. According to CSB’s 

2012-2016 Strategic Plan, CSB develops an annual action plan that includes 

many additional performance measures that correspond to a specific fiscal 

year. CSB suspended the board vote on its draft 2011 action plan on 

January 17, 2011, and, as of February 2013, does not have an action plan in 

place. The strategic plan also states that it, along with the annual action plan 

and individual performance plans, constitute the foundation of the 

organization’s performance management framework. CSB stated it is in the 

process of developing an annual action plan for FY 2013. 

Backlog of Open Investigations With No Closeout Plan 

CSB needs to address its backlog of six investigations that have been open for 

over 3 years (table 2). 

Table 2: CSB’s six investigations open for more than 3 years 

Investigation Date of accident Fatalities 

Injuries to 

workers or 

contractors 

*BP America Refinery Ultracracker Explosion January 14, 2008 1 0 

*Packaging Corporation Storage Tank Explosion July 29, 2008 3 1 

Silver Eagle Refinery Flash Fire and Explosion 

and Catastrophic Pipe Explosion 

January 12, 2009 0 4 

*CITGO Refinery Hydrofluoric Acid Release and 

Fire 

July 19, 2009 0 1 

*Caribbean Petroleum Refining Tank Explosion 

and Fire 

October 23, 2009 0 0 

NDK America Inc. Explosion with Offsite Fatality December 7, 2009 1 2 

Source: CSB website www.csb.gov. 

* Investigation was in our sample. 

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Closing its backlog would allow CSB to provide to the community and other 

stakeholders its findings and recommendations, which would help reduce the 

occurrence of similar incidents and result in the protection of human health 

and the environment. Closure would also provide more time for investigative 

management to focus on recent and new incidents. 

In our sample of four investigations open for over 3 years, two involved 

fatalities. One of those open investigations is the BP America Refinery 

Ultracracker Explosion, in Texas City, Texas. On January 14, 2008, a worker 

died when the top of large steel filter housing suddenly blew off in the 

refinery’s ultracracker unit. The second open investigation involves the 

Packaging Corporation Storage Tank Explosion in Tomahawk, Wisconsin. 

On July 29, 2008, three workers died and a fourth was injured when an 

explosion occurred inside an 80-foot-tall storage tank at the corrugated 

cardboard mill; the workers were on a catwalk above the tank, performing 

hot work (welding), when the explosion occurred. 

CSB placed these investigations on hold due to their BP Deepwater Horizon 

investigation in April 2010 related to the explosion and subsequent oil spill in 

the Gulf of Mexico. However, both investigations had already identified safety 

deficiencies that CSB could have formally addressed. CSB said the two 

investigations had been left open from a prior administration and CSB has 

been faced with challenges from the company and courts in completing the 

Deepwater Horizon investigation. 

We also noted that CSB’s board orders do not identify a specific period for the 

completion of investigations even though its strategic plan notes CSB’s 

endeavors to complete thorough investigations as quickly as possible. One 

manager noted, “... there is no formal schedule for the development and 

planning of an investigation. Investigative teams often set the investigative 

plan, but that is often interrupted with new deployments that bring new 

investigations.... Investigators are often deployed to multiple incidents often 

at the request of Congress or other external stakeholders, within a 6 month 

range that often delays the progress of their investigation.” A close-out plan to 

address investigations open for more than 3 years would enable CSB to focus 

on completion. 

Turnover of Investigative Staff 

CSB’s staff average turnover rate of 15 percent for the past 5 years has an 

effect on its mission to conduct and complete timely investigations (table 3). 

According to a Board Member, the turnover includes “...senior investigative 

staff. Staff with investigative experience, particularly experience with CSB[’s] 

approach to investigations, [which] is essential in improving the timeliness and 

maintaining the quality of the CSB reports.” 

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Table 3: CSB’s turnover percentages 

FY Separations On board *Turnover percentage 

2008 3 16 19% 

2009 4 20 20% 

2010 1 21 5% 

2011 4 21 19% 

2012 3 22 14% 

5-year average 15% 

Source: OIG analysis.
 

*Turnover was calculated using separations and on-board figures for each year. 

Although senior management believes it has a much more gifted and 

committed investigative staff in place now than at any prior time, management 

stated “[t]he primary barrier [to completing investigations] is the lack of 

resources available to the agency as a whole, and the need to constantly 

reshuffle investigators among multiple new projects.” 

In response to questions regarding the investigation process, one investigator 

manager stated that “... CSB needs a retention policy. Investigators are often 

leaving due to the inconsistent travel demands of the job and lack of support.... 

There is also an overreliance on employees voluntarily working after hours to 

complete investigations. Better management can reduce this burden and 

improve the work-life balance necessary to retain competent staff.” 

We reviewed the Office of Personnel Management’s 2012 Federal Employee 

Viewpoint Survey Results to look at CSB employees’ perceptions about how 

effectively CSB is managing its workforce. Of the 35 employees asked to take 

the survey, 33 completed the survey, for a response rate of 94.3 percent. The 

results show that the staff have a positive view of their mission despite the fact 

that they believe CSB does not have sufficient resources (people, material, 

budget) to accomplish the mission. The areas identified for improvement 

primarily related to CSB’s board and senior leadership. Specifically, 

59 percent of CSB employees surveyed expressed dissatisfaction in senior 

leadership areas relating to satisfaction with policies and practices of senior 

leaders. Further, 53 percent of respondents disagreed that leaders generate 

high levels of motivation and commitment to the workforce. CSB rated below 

government averages in the senior leadership areas, but has told us the agency 

has considerably improved compared to its 2011 survey results. 

Involving staff investigators in planning process is a best practice. In A Model 

of Strategic Human Capital Management exposure draft from March 2002, 

GAO states, “[t]he involvement of employees both directly and through 

employee organizations will be crucial to success,” and notes involving 

employees can “... increase employees’ understanding and acceptance of 

organizational goals and objectives and improve motivation and morale.” 

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11 
 

 

Senior management stated that developing a formal career ladder for 

investigator development, along with expanded investigator training programs, 

will also aid in investigator retention and development of lead investigator 

candidates. As CSB’s board and senior leadership continue their commitment 

to its workforce, discussing and addressing employee concerns may result in a 

change in the turnover rate and a more efficient investigative process. 

Investigative Files Not Collocated and Incorrectly Classified or 

Coded 

Our review of CSB’s electronic investigation files showed that files were not 

in one location and the electronic records were incorrectly classified or coded. 

Staff did not properly classify or code multiple electronic investigation records 

in accordance with records management or investigation protocol policies. 

CSB does not use its electronic investigation files to store project plans, 

milestones or decision documents. CSB investigators use several in-house 

documents that support its investigation file, such as work plans, scoping 

documents and recommendation briefs. These documents provide an ongoing 

investigation status summary of what happened, how it happened, what has 

been done, and what remains to be done with the timelines and preliminary 

recommendations to correct the problems found. CSB does not maintain these 

documents in its electronic investigation file. We could not locate these 

documents to support the six sample investigations in our audit. CSB explained 

that it primarily uses its electronic system to store investigative evidence and 

not project management documents. Investigation files located together provide 

a complete review of the investigation status at any given time. 

Our review also found that CSB staffs are not classifying or coding multiple 

records in their electronic investigation files in accordance with records 

management or investigation protocol policies. Our review of six sample 

investigations found that the majority of the 21,316 documents had 

classification and document identification numbers. However, we determined 

that document identification numbers were missing from 28 percent of the 

documents in three of the investigations, and classification numbers were 

missing from 19 percent of the documents in two of these three investigations. 

Further, 13 percent of all documents had new coding inconsistent with the 

category codes listed in Board Order 040, Appendix D1, Evidence Log Filing 

System. Records should clearly identify the investigation process and support 

investigation results. We were informed that there are no routine reviews or 

assessments, but the investigation close-out process includes a certification that 

confirms the reliability of the data in the file. 

CSB noted that when an investigator separates from the agency, CSB’s most 

important task is first to make sure everything investigation-related on the 

person’s computer is uploaded to the electronic file and then, second, to 

perform manually an edit of the information. However, CSB noted it often does 

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12 
 

not have the time to perform the edits. CSB stated it “...encourages 

investigators to register evidentiary records in the system as quickly as possible 

so that record fidelity and access is controlled.” 

Ensuring investigation files are collocated and correctly classified or coded 

would enable any investigator to easily identify the status of an investigation 

and compare results from completed investigations. Investigators could more 

efficiently complete or close out investigations in a timely manner, 

particularly cases open for more than 3 years. 

Lack of Investigative Policies That Address Current Procedures 

and Define Final Products 

CSB needs updated policies that address its current investigative procedures 

and define its final products. CSB staffs follow procedures that are not listed 

in Board Order 040, CSB’s policy for its investigation process. As noted 

above, CSB did not keep investigation files collocated, and did not correctly 

classify or code investigations so that staff could efficiently identify whether 

the team followed outlined procedures in Board Order 040. From our 

interviews, we found that CSB has implemented changes to the investigation 

process but has not updated its internal policies. 

CSB teams started using scoping documents and recommendation briefings 

for its investigations in FY 2010 without a policy to define the use of the 

documents. Staff investigators designed these procedures to keep management 

and team members abreast of a recent investigation to be placed on hold due 

to the BP Deepwater Horizon investigation. Since the introduction of these 

documents, CSB has started to use these procedures on newer investigations, 

but without direction. A manager stated that the investigation scoping process 

assists the board in determining the most pertinent issues to develop in an 

investigation, the process is new, and each investigative team views the 

scoping process with varying levels of importance. Additionally, there has 

been no formal training on this new scoping process. Board Order 040 does 

not cover these documents and does not define when the investigators should 

use scoping documents. Further, CSB’s investigative process would be more 

efficient if it implemented procedure changes more consistently and updated 

policies to provide clear and complete direction. 

CSB does not determine the type of final product it will produce when it 

begins an investigation. Having some guidelines in performing the 

investigation for specific types of final products—such as case studies, safety 

studies or investigation reports—would help staff be more efficient in 

completing investigations. CSB generally makes a determination on whether 

to produce an investigation report or a case study after investigators present 

incident information to the board on a case-by-case basis. One staff 

investigator stated that it “may be months into a case before the team has been 

informed as to ... the finished product ... [e]ach type of product has a 

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13 
 

 

different degree of thoroughness for completion.” We agree with staff who 

told us that CSB should have a policy document with a product definition to 

help teams’ better scope what needs to occur earlier in the investigation so that 

the team can react accordingly. 

Conclusion 

CSB needs to ensure its investigative process supports the accomplishment of 

its goals and objectives to complete timely investigations that examine the 

causes of chemical incidents. By addressing the issues noted, CSB would 

improve the investigation process and help meet its goals and objectives to 

complete timely investigations and, ultimately, provide communities with the 

help needed to reduce the occurrence of incidents and thus protect human 

health and the environment. 

Recommendations 

We recommend that the chairperson, U.S. Chemical Safety and Hazard 

Investigation Board: 

1. Develop and implement performance indicators related to its first 

strategic performance goal and objective to complete timely 

investigations. Indicators should track and measure the efficiency of 

key phases of the investigation process and clarify the definition of a 

“timely” completed investigation. Also, address the indicators in the 

investigation protocol policy. 

2. Revise and publish an annual action plan to comply with GPRA 2010 

and update related individual performance plans to ensure that 

performance indicators are addressed and investigative staff are held 

accountable for performing key phases in the investigation process. 

3. Review investigations open for more than 3 years and develop a plan 

to close out those investigations. 

4. Develop and implement a succession or retention policy to help with 

any future effects of the turnover rate on CSB’s mission. 

5. As a best practice, involve staff in the planning process of an 

investigation. Hold meetings between senior management and staff to 

address any concerns with the investigation process. 

6. Review and collocate investigation files for each ongoing investigation 

to ensure that they contain all the supporting documents related to the 

investigation. At a minimum, ensure files have proper classifications, 

project plans, scoping documents and board decisions. 

13-P-0337
 

14 
 

7. Implement and update the records management policy to ensure that 

the classification of electronic investigation files agrees with the 

investigation protocol policy and staffs perform internal reviews of 

records as required by the policy. 

8. Update the investigation protocol policy for all current investigation 

procedures to include scoping documents and recommendation briefs. 

Provide formal training to the investigative staff on changes and 

updates to the investigative process. 

9. Provide guidelines for staff to determine the type of final product in 

the beginning of the investigation process to help staff be more 

efficient in completing investigations. 

CSB Comments and OIG Evaluation 

The OIG evaluation considers the response from the CSB chairperson as the 

official response in appendix A. We also attached a separate response to the 

report submitted by one of CSB’s other board members in appendix B. 

We compared the responses for information purposes only in appendix C. 

CSB agreed with six recommendations (1, 3, 5, 7, 8 and 9) and responded in 

detail to each. CSB plans to complete corrective actions by December 31, 2013. 

CSB did not clearly address recommendation 2 and stated, “CSB has published 

an up-to-date Strategic Plan, annual performance-based budgets, and annual 

performance reports,” which it believes meets the requirements of GPRA 2010. 

GPRA 2010 requires that agencies annually establish agency performance plans 

to include a balanced set of performance indicators to be used in measuring or 

assessing progress toward each performance goal. GPRA 2010 also stipulates 

that agencies are to provide in plans a description of how the performance goals 

are to be achieved, including the operation processes, training, skills and 

technology, and the human, capital, information, and other resources and 

strategies required to meet those performance goals. CSB’s strategic plan states 

that it, along with the annual action plan and individual performance plans, 

constitute the foundation of the organization’s performance management 

framework. CSB previously stated that it is in the process of developing an 

annual action plan for FY 2013. In response to our draft report, CSB considers 

its "action plans" as internal, evergreen documents that are developed annually 

and updated periodically through the year to track initiatives as they strive to 

accomplish the goals set in our Strategic Plan. We maintain that a published 

agency performance plan (annual action plan) with performance indicators as 

prescribed by GPRA 2010 is needed along with updated individual performance 

plans to ensure that investigative staff are held accountable for performing 

key phases in the investigation process. We request that CSB reconsider this 

recommendation and include a plan to publish an agency performance plan 

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15 
 

 

(annual action plan) with performance indicators as well as updated individual 

performance plans in its 60-day response to our final report. 

CSB did not address the need for a policy in recommendation 4 and stated it is 

a very small agency, and it is indisputable that unexpected turnover can have 

negative impacts on the completion of specific projects where individual 

investigators may have developed unique or unusual knowledge. We agree 

with CSB’s size and the impact that turnover would have on the agency. 

We calculated an average turnover rate of 15 percent for the 5-year period 

2008 through 2012, which reflects those who no longer work at CSB for 

numerous reasons. The average percent remains even though CSB lists various 

reasons for the different types of turnover in its response to our draft report. 

We have not verified those reasons and therefore cannot place the information 

in our report. Our report notes that turnover is just one of several reasons why 

CSB has not timely completed investigations. Additionally, we acknowledge 

CSB has informed us of its succession and retention initiatives and noted there 

have been zero investigative turnovers during the past 8 months. We believe 

the list of implemented initiatives should be described in an official CSB 

policy to provide transparency for current and future staff. We request that 

CSB reconsider this recommendation and include a plan to issue a policy in its 

60-day response to our final report. 

CSB disagreed with recommendation 6 and stated the OIG’s assertions 

concerning the lack of co-location of files and incorrectly classified or coded 

investigation files have nothing to do with the completion of final written 

products. During our audit, for completed investigations as well as those 

ongoing, we could not locate the investigation status summary or what remains 

to be done on an investigation for the six sample investigations in our audit. 

We were informed of the purpose of the TRIM (Total Records and Information 

Management) system, as we explained in our report that it is used to store 

investigative evidence and not project management documents. Additional 

information related to investigation files—such as work plans, scoping 

documents and recommendation briefs—provide an ongoing investigation 

status summary of what happened, how it happened, what has been done, and 

what remains to be done with the timelines and preliminary recommendations 

to correct the problems found. Having all files relating to an investigation be 

located together provides for a complete review of the investigation status at 

any given time. In addition, correctly classified and coded investigative 

documents help ensure investigations are in accordance with records 

management or investigation protocol policies. We request that CSB reconsider 

this recommendation and provide a corrective action plan to collocate 

investigative files and correctly classify/code investigative documents in its 

60-day response to our final report. 

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16 
 

 

 

 

 

 

 

 

 

 

Status of Recommendations and 

Potential Monetary Benefits 

POTENTIAL MONETARY 

RECOMMENDATIONS BENEFITS (in $000s) 

Planned 

Rec. Page Completion Claimed Agreed-To 

No. No. Subject Status1 Action Official Date Amount Amount 

1 14 Develop and implement performance indicators O 

related to its first strategic performance goal and 

objective to complete timely investigations. 

Indicators should track and measure the efficiency 

of key phases of the investigation process and 

clarify the definition of a “timely” completed 

investigation. Also, address the indicators in the 

investigation protocol policy. 

2 14 Revise and publish an annual action plan to comply U 

with GPRA 2010 and update related individual 

performance plans to ensure that performance 

indicators are addressed and investigative staff are 

held accountable for performing key phases in the 

investigation process. 

3 14 Review investigations open for more than 3 years O 

and develop a plan to close out those 

investigations. 

4 14 Develop and implement a succession or retention U 

policy to help with any future effects of the turnover 

rate on CSB’s mission. 

5 14 As a best practice, involve staff in the planning O 

process of an investigation. Hold meetings 

between senior management and staff to address 

any concerns with the investigation process. 

6 14 Review and collocate investigation files for each U 

ongoing investigation to ensure that they contain all 

the supporting documents related to the 

investigation. At a minimum, ensure files have 

proper classifications, project plans, scoping 

documents and board decisions. 

7 15 Implement and update the records management O 

policy to ensure that the classification of electronic 

investigation files agrees with the investigation 

protocol policy and staffs perform internal reviews 

of records as required by the policy. 

8 15 Update the investigation protocol policy for all O 

current investigation procedures to include scoping 

documents and recommendation briefs. Provide 

formal training to the investigative staff on changes 

and updates to the investigative process. 

Chairperson,
 

U.S. Chemical Safety 

and Hazard 

Investigation Board 

Chairperson,
 

U.S. Chemical Safety 

and Hazard 

Investigation Board 

Chairperson,
 

U.S. Chemical Safety 

and Hazard 

Investigation Board 

Chairperson,
 

U.S. Chemical Safety 

and Hazard 

Investigation Board 

Chairperson,
 

U.S. Chemical Safety 

and Hazard 

Investigation Board 

Chairperson,
 

U.S. Chemical Safety 

and Hazard 

Investigation Board 

Chairperson,
 

U.S. Chemical Safety 

and Hazard 

Investigation Board 

Chairperson,
 

U.S. Chemical Safety 

and Hazard 

Investigation Board 

December 

2013 

December 

2013 

December 

2013 

December 

2013 

December 

2013 

13-P-0337 

17 
 

 

 

 

 

RECOMMENDATIONS 

POTENTIAL MONETARY 

BENEFITS (in $000s) 

Rec. 

No. 

Page 

No. Subject Status1 Action Official 

Planned 

Completion 

Date 

Claimed 

Amount 

Agreed-To 

Amount 

9 15 Provide guidelines for staff to determine the type of 

final product in the beginning of the investigation 

process to help staff be more efficient in completing 

investigations. 

O Chairperson, 

U.S. Chemical Safety 

and Hazard 

Investigation Board 

December 

2013 

O = recommendation is open with agreed-to corrective actions pending 

C = recommendation is closed with all agreed-to actions completed 

U = recommendation is unresolved with resolution efforts in progress 

13-P-0337 

18 

1 
U.S. Chemical Safety and 	 2175 K Street, NW • Suite 650 • Washington, DC 20037-1809 

Hazard Phone : (202) 261-7600 • Fax: (202) 261-7650 Investigation Board 

www.csb.gov 

June 21,2013 

Honorable Arthur A. Elkins, Jr. 

Inspector General 

U.S. Environmental Protection Agency 

Washington, DC 20460 

Re: U.S. Chemical Safety and Hazard Investigation Board (CSB) Response to 

EPA OIG Report OA-FY12-0513 

Dear Mr. Elkins: 

Thank you for the opportunity to review and comment on the draft OIG Report OA-FY12­

0513, "U.S. Chemical Safety and Hazard Investigation Board Needs to Complete 

Investigations More Timely," dated May 8, 2013 . 

The CSB has completed its review and offers the following comments. In general terms, we 

agree with the majority of the recommendations, and note that much of what has been 

recommended here reflects work that is already in progress at the agency. 

Generally, we believe that the overwhelming factor in how quickly investigations can be 

completed is the agency's staffing level and the constraints on the agency's budget, which 

following sequestration is less than $10 .6 million and has remained largely stagnant, after 

adjusting for inflation, for more than a decade. This major issue, whi ch has weighed upon 

every CSB chair since the agency opened its doors in 1998, is barely acknowledged in the 

current draft, which focuses instead on what we regard as peripheral issues such as turnover 

rates and case file organization. Staffing and budget limitations mean that in response to 

new and unforeseen chemical disasters, our very tiny staff of about 20 investigators is 

constantly being pulled off existing projects and redeployed to new cases. Thi s unrelenting 

process of redeployment is inefficient but inevitable . Currently at least half of the agency's 

workload- including the largest cases such as Deepwater Horizon, West Fertilizer, 

Chevron, and Tesoro- has been dictated either by the statutory mandate to investigate all 

public fatalities or serious injuries, and/or by requests from Congressional members and 

committees. 

We continue to have concerns about the draft's assertions concerning investigator turnover, 

and its potential impact on timeliness of investigations. In a very small agency, it is 

indisputable that unexpected turnover can have negative impacts on the completion of 

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U.S. Chemical Safety and 

Hazard Investigation Board 

specific projects where individual investigators may have developed unique or unusual 

knowledge. 

For that reason and others , I am fully supportive of developing and retaining our highly 

talented and committed investigative staff, and am continually seeking to minimize 

voluntary turnover. I believe we have the best staff in place today of any time in the 

agency ' s history, and I want to keep these professionals. 

However, I have significant concerns about how the draft report seeks to portray the amount 

of investigative turnover as well as the reasons behind it. The draft report continues to 

allege that the CSB has "an average investigative staff turnover rate of 15 percent." 

A disturbing example- which my staff has pointed out repeatedl y to OIG personnel, 

apparently to no avail - is that the draft continues to count a CSB investigator who died 

suddenly ofnatural causes in 2009 as part of its "turnover" statistics. Yet this tragic and 

unforeseeable death remains part of the OIG's tally. 

The OIG's calculations do not follow common HR practices for determining turnover and 

its effect on an organization. There are three main types ofturnover relevant here: 

involuntary, voluntary, and unavoidable. Involuntary turnover occurs when an employee 

leaves the agency due to poor performance or fit with the agency. Voluntary turnover means 

the agency is losing an employee whose perfo rmance, skills and qualifications are valuable 

resources. Unavoidable turnover is where there is a change of life situation which the 

agency has no control over that results in a loss of an em ployee; examples include death or 

maj or life changes (e .g. pregnancy/child rearing decisions, enrollment in higher education). 

These critical distinctions are absent from the OIG report. 

Although turnover often has a negative connotation, turnover is not always a ne gative event. 

Involuntary turnover is one example. This turnover event opens a spot for a potential 

employee whose performance meets or exceeds expectations. In this case, involuntary 

turnover is desirable because poor job performance, poor teamwork, or deficient conduct are 

very costly, especially in a small organization- thus, replacing a poor performer with an 

employee who does his/her job can improve the agency's performance dramatically. 

Desirable involuntary turnover also has the added benefit ofinfusing new talent and skill s 

into the agency workforce with replacement personnel , providing opportunities for the 

introduction of new ideas and approaches. These important benefits must be weighed 

against the costs of losing any existing proj ect knowledge. 

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U.S. Chemical Sa fety and 

Hazard Investigation Board 

Therefore the industry standard way to measure the agency's turnover is represented in 

following chart: 

FY Vol InVol Unavoid On Board Vol% lnVol 0

/o Unavoid% 

2008 3 0 0 16 19% 0% 0% 

2009 1 2 1 20 5% 10% 5% 

2010 0 0 1 21 0% 0% 5% 

2011 3 0 1 21 14% 0% 5% 

2012 2 1 0 22 9% 5% 0% 

5 Year Avg 9% 3o/o 3% 

Instead of a five year average turnover rate of 15% as claimed by the OIG, the agency in 

reality experienced a 9% voluntary turnover rate for our investigators and the rate has been 

declining. Over the past eight months, there has been no investigative turnover whatsoever, 

which I believe is a tribute to agency managers' efforts at training, development, and 

retention. Comparing the CSB's turnover percentages to turnover data obtained from the 

Society for Human Resources indicates the agency's five-year average from 2008-2012 

remains below the industry average for both voluntary (1 0% vs. 9% CSB) and involuntary 

turnover (7% vs. 3% CSB). 

Based on this information the CSB requests that this section ofthe draft report be removed, 

because there is no factual basis for asserting that (a) the CSB's level ofturnover is 

unusually high, or (b) a high turnover level is a significant factor in the overall length of 

time for completing reports. At a minimum, the OIG should use the chart above, which is at 

least a factually accurate statement of how much turnover has occurred, and its type. 

The CSB offers the following responses to nine recommendations listed in the report: 

Recommendation 1 - Develop and implement performance indicators related to its 

first strategic performance goal and objective to complete timely investigation (sic) . 

Indicators should track and measure the efficiency of key phases of the investigation 

process and clarify the definition of a "timely" completed investigation. Also, 

address the indicators in the investigation protocol policy. 

The CSB agrees with this recommendation and will review the five objectives from the 

2012-2016 Strategic Plan related to Strategic Goal 1 to develop and implement 

performance indicators. In addition the CSB will also take a look at the remaining eight 

objectives relating to Goals 2 and 3 to develop performance indicators for those goals as 

well. 

The CSB continually strives to complete its open investigations in a timely manner. 

However, the CSB's definition of"timely" completed investigation is subject to change 

based on the deployment to a new incident. With our limited staff, all investigators are 

juggling multiple cases simultaneously. When new incidents occur, this results in 

shifting investigators' focus onto new cases and slowing the completion of existing ones. 

13-P-0337 21
U.S. Chemical Safety and 

Hazard Investigation Board 

In addition, the various investigations span a broad range of industries and hazards; while 

the proximate cause of one incident may become clear within days, others may require 

many months of complex study. In addition, cooperation by other parties is highly 

variable and has a dramatic effect on the speed of completion. The CSB currently 

estimates completing an investigation as follows: 

Major Investigation: 1.5-3 years 


Case Study: 1-1.5 years 


Safety Bulletin: 1 year 


The CSB will review past history and on average the length of time it takes to complete 

various phases of an investigation (i.e. , deployment, writing, and review process) and will 

further consider how best to define "timely" investigations -bearing in mind that there 

are vast differences in complexity and effort among different cases. 

The CSB is analyzing key investigation metrics such as investigator hours, costs and 

elapsed days to develop performance indicators for various investigation product types. 

These indicators will be incorporated in the Investigation Product Development and 

Review procedure of the investigation protocol, which will provide timelines for key 

milestones . Given staff resources and the investigation workload we expect to provide 

the Board with a draft Investigation Product Development and Review procedure for 

consideration and approval by December 31, 2013. 

Recommendation 2 - Revise and publish an annual action plan to comply with 

GPRA 2010 and update related individual performance plans to ensure that 

performance indicators are addressed and investigative staff are held accountable 

for performing key phases in the investigation process. 

From our review the only reports required for publishing under GPRA are Strategic 

Plans, Annual Performance Plans and Annual Performance Reports. The CSB has 

published an up-to-date Strategic Plan, annual performance-based budgets , and annual 

performance reports, which we believe meet the requirements ofGPRA. The CSB 

considers its "action plans" as internal, evergreen documents that are developed annually 

and updated periodically through the year to track initiatives as we strive to accomplish 

the goals set in our Strategic Plan. We consider action plans to be living documents that 

must be changed based on inherently unforeseeable incident deployments. The FY2014 

action plan will be developed and updated during the upcoming fiscal year. 

Recommendation 3 - Review investigations open for more than 3 years and develop 

a plan to close out those investigations. 

The CSB agrees with the recommendation and provides the following update. Of the six 

open investigations listed in the IG report, the status of each investigation is as follows: 

NDK - Final report draft in review cycle 


Caribbean Petroleum - Final report draft in review cycle 


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U.S. Chemical Safety and 

Hazard Investigation Board 

Silver Eagle- Close out plan was developed and will have to be revised in light 

ofmajor West Fertilizer and Williams Olefins explosions 

Packaging Corporation of America - Hot work safety bulletin incorporating 

findings issued in March 201 0; remaining case proposed for termination 

CITGO - Urgent recommendations issued in December 2009; remaining case 

proposed for termination 

BP America Refinery Ultracracker Explosion - Proposed for termination 

Terminating certain older cases that have been idle for several years also responds to a 

stakeholder request from January 2013 , allowing materials that were gathered by the 

Board on these cases to become more readily available for external safety use through the 

Freedom of Information Act. In addition, the CSB has prepared detailed seeping 

documents for the completion ofall currently open cases initiated after 2010 and selected 

prior cases, including the West Fertilizer, US Ink, Chevron, Deepwater 

Horizon/Macondo, and Tesoro investigations. Other cases, such as the Horsehead 

Holding Co. investigation, will likely be proposed for termination. 

The CSB will agree to update the OIG on the status and plans for closure for all 

investigations at the end of calendar 20 13. 

Recommendation 4 - Develop and implement a succession or retention policy to help 

with any future effects of the turnover rate on CSB's mission. 

As discussed above, the CSB's turnover rates, when accurately and fairly calculated, are 

equal to or less than sector averages. The agency has implemented the following 

succession/retention initiatives and they have had a positive effect with our workforce, as 

demonstrated by the fact there has been zero investigative turnover during the past eight 

months: 

1. 	 Student loan payment program - the agency has implemented OPM's program to 

assist employees paying back student loans. The employees participating in this 

program are required to commit to three years of service in exchange for the loan 

payments. 

2. 	 Supervisor development - the agency sends managers to at least one 

management/leadership development class a year in order to ensure they are up to 

date on the latest techniques for managing and developing our workforce. 

3. 	 Employee development- the agency has set up twice-a-year weeklong training 

sessions for our investigation and recommendations teams to continue the 

development of their skill sets. 

4. 	 Improved agency communication- the agency holds quarterly all hands meetings 

to ensure that the entire agenc y understands the developments of the previous 

quarter and the challenges for the next quarter. 

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U.S. Chemical Safety and 

Hazard Investigation Board 

5. 	 Workplace flexibility - the CSB has expanded opportunities for telework, work 

from home, remote duty locations, and temporary leave during parenting to 

ensure the retention of key positions 

In addition, the agency is developing or considering the following initiatives that should 

have a positive effect on both succession and retention: 

a) 	 Career ladder - the agency is creating a ladder for the development and 

advancement of investigation employees , from entry level to lead investigator (or 

other senior positions) 

b) 	 New hire orientation- the agency is developing an orientation process for new 

investigators to ensure proper integration into the agency. 

c) 	 Advance hiring - the agency will use historical vacancy and turnover data to 

project the number and location of new hires needed for each fiscal year. 

Recommendation 5 - As a best practice, involve staff in the planning process of an 

investigation. Hold meetings between senior management and staff to address any 

concerns with the investigation process. 

Investigation staff are already heavily involved and chiefly responsible for the planning 

of each investigation; this has always been the case. In the last two years this 

re sponsibility has been enhanced with the development offormal scoping documents for 

each active or new case, as well as recommendations briefs for major proposed 

recommendations. All these documents are then reviewed by the Board. In any event, 

the CSB agrees with this recommendation and has already undertaken a number of steps 

to address the issue. The protocol development team will hold three meetings with 

investigators and seni or staff to identify any concerns with the investigation process. In 

addition, investigation teams will continue to hold Lessons Learned meetings after 

returning from a deployment and upon completion of a CSB written product and/or 

investigation case closure. 

The CSB has identified key investigation mil estones as a first step in preparing the 

Investigation Product Development and Review procedure of the investigation protocol. 

Early milesto ne s include scoping documents and project work plans, which will be 

developed by the investigation team and reviewed by management and the Board; this 

has already been practiced for some time and has increased staff involvement in the 

planning process. Key investigation milestones also include report outlines, 

recommendations briefs, and interim public meetings that should provide opportunities to 

address concerns with the investigative process . We will provide the Board with a 

proposed scoping document template for consideration by August 31, 2013. This will be 

incorporated in the draft Inv estigation Product Development and Review procedure that, 

as stated above in our comments on recommendation 1, we expect to provide to the 

Board for consideration and approval by December 31, 2013. 

13-P-0337 24
U.S. Chemical Safety and 

Hazard Investigation Board 

Recommendation 6 - Review and collocate (sic) investigation files for each ongoing 

investigation to ensure that they contain all the supporting documents related to the 

investigation. At a minimum, ensure files have proper classifications, project plans, 

scoping documents and board decisions. 

The CSB disagrees with this recommendation. 

The OIG's assertions concerning the lack of co-location offiles and incorrectly classified 

or coded investigation files have nothing to do with the completion of final written 

products. As we have stated on several occasions, the purpose of the TRIM electronic 

records management system is to hold evidentiary records for investigation team 

members while they conduct their investigation; TRIM provides word-search capabilities 

that streamline and enhance investigators' abilities to review and analyze evidentiary 

materials. 

We use TRIM as a tool for searching/reviewing evidence during a case and as a system of 

archiving once the case is complete. The evergreen planning and scoping documents 

developed internally by CSB staff would not be included in such a system. Such 

evergreen documents are often not included in TRIM specifically because the team 

members do not need such records when reviewing evidence. Scoping/planning 

documents are management tools used by the team leads, supervisors, and agency 

leadership to keep abreast ofthe case; those sorts of evergreen records do not hinder or 

help the team in their review of evidence and, thus, any argument that their lack of 

placement in TRIM is unrelated to the team's ability to complete the investigations. Also, 

and very importantly, in the last few years, we have been using Optical Character 

Recognition (OCR) for most records; once documents are OCR scanned, they become 

fully word-searchable. The classification ID numbers are not needed ifthe files are OCR 

scanned and word searchable. There are many field s that can be used to find documents ­

- the ID field was an old field needed before docs could be OCR scanned. Thus, once 

OCR scanned, any categorization of the files beyond identification of the investigation 

the document pertains to become irrelevant, as the investigator can search/find the 

records needed using a variety of search data field s. We recommend corrections be made 

to page 17 of the draft report to reflect these facts. 

The OIG displays a critical misunderstanding ofthe TRIM system by the statements it 

makes in the final paragraph of the Investigation Files section: "Ensuring investigation 

files are collocated (sic) and correctly classified or coded would enable any investigator 

to easily identify the status of an investigation and compare results from completed 

investigations . Investigators could more efficiently complete or close out investigations 

in a timely manner, particularly cases open for more than 3 years." In no way would 

"correctly classified or coded records" within TRIM enable anyone to easily identify the 

status of an investigation and thus allow individuals to close out cases in a more timely 

manner; it would merely provide an additional means to locate a specific evidence record 

within the TRIM evidence database. The coding o f evidentiary materials and the need for 

project management of ongoing cases are two entirely separate i ssues. The OIG 

13-P-0337 25
U.S. Chemical Safety and 

Hazard Investigation Board 

incorrectly assumes that the coding of evidentiary materials somehow relates to the 

agency's ability to manage its investigative products. This correlation is not correct. 

Recommendation 7 -Implement and update the records management policy to 

ensure that the classification of electronic investigation files agrees with the 

investigation protocol policy and staffs (sic) perform internal reviews of records as 

required by the policy. 

The CSB agrees with this recommendation and will review its Records Management 

policy and update it by December 31, 2013, to reflect the need for a full OCR scan ofthe 

evidentiary case file for each investigation as well as completeness of the case file for 

official closeout/archiving. 

Recommendation 8- Update the investigation protocol policy for all current 

investigation procedures to include scoping documents and recommendation briefs. 

Provide formal training to the investigative staff on changes and updates to the 

investigative process. 

The CSB has been using formal scoping documents for investigations for the past two 

years and last year began developing selected recommendations briefs for major 

recommendations. All these tools have proven useful in completing cases that describe 

an agreed set of issues. The CSB agrees that a more formal policy and standard 

templates should be developed for these tools. We expect to provide the Board with a 

proposed scoping document template for consideration and approval by August 31, 2013. 

This will be incorporated in the Investigation Product Development and Review 

procedure ofthe investigation protocol along with a template for recommendations briefs. 

As previously stated, we expect to provide the Board with a draft ofthis procedure for 

consideration and approval by December 31,2013. We will then train investigative staff 

on the procedures within 90 days of Board approval. 

Recommendation 9 - Provide guidelines for staff to determine the type of final 

product in the beginning of the investigation process to help staff be more efficient 

in completing investigations . 

The Investigation Product Development and Review procedure of the investigation 

protocol will identify CSB investigation product types and their attributes. The 

procedure will also require that the scoping document include a recommended product 

type and required resources so that the investigation team, management, and the Board 

have the same expectations and goals for each investigation. Again, we expect to provide 

the Board with a proposed scoping document template by August 31, 20 13, and draft of 

the Investigation Product Development and Review procedure for consideration and 

approval by December 31, 2013. 

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U.S. Chemical Safety and 

Hazard Investigation Board 

Thank you again for your courtesy in providing the draft report. Should you have any 

questions, please contact our audit liaison, Anna Brown, at (202) 261-7639. 

Sincerely,

;2 

Rafael Moure-Eraso, Ph.D. 

Chairperson 

13-P-0337 27
 

 

 

 

U.S. Chemical Safety and 

Hazard Investigation Board 

Mark A. Griffon 

Board Member 

Honorable Arthur A. Elkins, Jr. 

Inspector General 

U.S. Environmental Protection Agency 

Washington, DC 20460 

Re: U.S. Chemical Safety and Hazard Investigation Board (CSB) EPA OIG 

Report OA-FY12-0513 

Dear Mr. Elkins: 

Thank you for the opportunity to review and comment on the OIG Report OA-FY12­

0513, “U.S. Chemical Safety and Hazard Investigation Board Needs to Complete 

Investigations More Timely,” dated May 8, 2013. 

I believe that two factors contributing to the CSBs delay in completing investigations are 

staffing levels and budget constraints. The CSB budget has remained essentially level for 

the last decade and the agency continues to have to make difficult choices on whether to 

deploy to serious incidents that clearly warrant our attention. Notwithstanding the CSBs 

budget constraints, this report points out weaknesses that I believe can and should be 

improved upon. I appreciate the insights offered regarding improving the efficiency of 

the CSBs investigative process and I believe, on the whole, the recommendations were 

appropriate and I plan to work with agency leadership to ensure implementation. 

I would offer the following specific comments on your recommendations: 

1.	 Recommendation 1: I agree with your recommendation to develop indicators 

that will track and measure the efficiency of the CSB investigations. My 

understanding from senior staff is that they plan to address this within a 

revision of the investigative protocol and I will urge that protocol be 

completed and adopted by the Board by the end of this calendar year. 

2.	 Recommendation 2: I agree with the recommendation and will encourage the 

staff to revise and publish a Board approved Annual Action Plan in 

accordance with GPRA 2010 (for 2013 and future years). 

3.	 Recommendation 3: I agree with this recommendation and I would 

recommend that agency management develop an overall agency plan for 

managing all open investigations for the Board’s consideration and approval. 

13-P-0337 28
 

 

 

 

U.S. Chemical Safety and 

Hazard Investigation Board 

This plan should be continually updated and approved by the Board at least on 

an annual basis. 

4.	 Recommendation 4: I am very concerned about the significant turnover of 

senior investigative staff. Staff with investigative experience, particularly 

experience with CSB approach to investigations, is essential in improving the 

timeliness and maintaining the quality of the CSB reports. To the extent that 

your team has further information as to the root cause of the turnover problem 

I believe it would be helpful in making improvements in this area. 

5.	 Recommendations 5-9: I believe that the revision of the investigative 

protocol, mentioned above, should address most of the issues identified in 

these recommendations. Specifically, including a formal process for scoping 

investigations, defining investigative products and incorporating the use of a 

Lessons Learned process will greatly improve the efficiency and quality of the 

CSB investigations. 

Again, thank you for the opportunity to comment on your report and please contact me if 

you have any questions. 

Sincerely, 

Mark A. Griffon 

Board Member 

13-P-0337 29
OIG Comparison of CSB Responses to the Draft Rep

OIG Recommendation CSB Chair, Moure-Eraso Response In Appendix A CSB Board Member G

In Append

Recommendation 1: Develop and implement performance indicators related to its first strategic performance goal and objective to complete timely investigation. Indicators should track and measure the efficiency of key phases of the investigation process and clarify the definition of a “timely” completed investigation. Also, address the indicators in the investigation protocol policy. 

The CSB agrees with this recommendation and will review 

the five objectives from the 2012-2016 Strategic Plan 

related to Strategic Goal 1 to develop and implement 

performance indicators. In addition the CSB will also take a 

look at the remaining eight objectives relating to Goals 2 

and 3 to de

velop performance indicators for those goals as 

well. The CSB continually strives to complete its open 

investigations in a timely manner. However, the CSB's 

definition of “timely" completed investigation is subject to change based on the deployment to a new incident. With 

our limited staff, all investigators are juggling multiple 

cases simultaneously. When new incidents occur, this results in shifting investigators' focus onto new cases and 

slowing the completion of existing ones. 

In addition, the various investigations span a broad range of 

industries and hazards; while the proximate cause of one incident may become clear within days, others may require many months of complex study. In addition, cooperation by 

other parties is highly variable and has a dramatic effect on 

the speed of completion. The CSB currently estimates 

completing an investigation as follows: 

Major Investigation: 1.5-3 years Case Study: 1-1.5 years Safety Bulletin: 1 year The CSB will review past history and on average the length of time it takes to complete various phases of an 

I agree with your recommendatindicators that will track and mthe CSB investigations. My unsenior staff is that they plan to arevision of the investigative prothat protocol be completed and by the end of the calendar year. 

13-P-0337 
investigation (i.e., deployment, writing, and review process) 

and will further consider how best to define "timely" 

investigations -bearing in mind that there are vast 

differences in complexity and effort among different cases. The CSB is analyzing key investigation metrics such as investigator hours, costs and elapsed days to develop 

performance indicators for various investigation product 

types. These indicators will be incorporated in the Investigation Product Development and Review procedure of the investigation protocol, which will provide timelines for key milestones. Given staff resources and the 

investigation workload we expect to provide the Board with a draft Investigation Product Development and Review procedure for consideration and approval by December 31, 

2013. 

Recommendation 2: Revise and publish an annual action plan to comply with GPRA 2010 and update related individual performance plans to ensure that performance indicators are addressed and investigative staff are held accountable for performing key phases in the investigation process. 

From our review the only reports required for publishing 

under GPRA are Strategic Plans, Annual Performance Plans 

and Annual Performance Reports. The CSB has published an up-to-date Strategic Plan, annual performance-based budgets, and annual performance reports, which we believe 

meet the requirements of GPRA. The CSB considers its 

"action plans" as internal, evergreen documents that are 

developed annually and updated periodically through the 

year to track initiatives as we strive to accomplish the goals 

set in our Strategic Plan. We consider action plans to be 

living documents that must be changed based on inherently unforeseeable incident deployments. The FY2014 action plan will be developed and updated during the upcoming 

fiscal year. 

 I agree with the recommendatithe staff to revise and publish a Annual Action Plan in accordan(for 2013 and future years). 

Recommendation 3: Review investigations open for more than 3 years and develop a plan to close out those investigations 

The CSB agrees with the recommendation and provides the 

following update. Of the six open investigations listed in 

the IG report, the status of each investigation is as follows: 

NDK - Final report draft in review cycle 

Caribbean Petroleum - Final report draft in review cycle

 I agree with this recommendatrecommend that agency managoverall agency plan for managiinvestigations for the Board’s capproval. This plan should be continually by the Board at least on an annu

13-P-0337 
Silver Eagle- Close out plan was developed and will have to 

be revised in light of major West Fertilizer and Williams 

Olefins explosions Packaging Corporation of America - Hot work safety bulletin incorporating findings issued in March 201 0; remaining case proposed for termination CITGO - Urgent recommendations issued in December 2009; remaining case proposed for termination BP America Refinery Ultracracker Explosion - Proposed for termination Terminating certain older cases that have been idle for several years also responds to a stakeholder request from 

January 2013, allowing materials that were gathered by the Board on these cases to become more readily available for 

external safety use through the Freedom of Information 

Act. In addition, the CSB has prepared detailed seeping documents for the completion of all currently open cases initiated after 2010 and selected prior cases, including the 

West Fertilizer, US Ink, Chevron, Deepwater 

Horizon/Macondo, and Tesoro investigations. Other cases, 

such as the Horsehead Holding Co. investigation, will likely 

be proposed for termination. The CSB will agree to update the OIG on the status and 

plans for closure for all investigations at the end of calendar 20 13. 

Recommendation 4: Develop and implement a succession or retention policy to help with any future effects of the turnover rate on CSB’s mission. 

As discussed above, [Appendix A] the CSB's turnover 

rates, when accurately and fairly calculated, are equal to or 

less than sector averages. The agency has implemented the 

following succession/retention initiatives and they have had a positive effect with our workforce, as demonstrated by the 

fact there has been zero investigative turnover during the 

past eight months: 

I am very concerned about the senior investigative staff. Staff experience, particularly experieapproach to investigations, is ethe timeliness and maintaining reports. To the extent that your information as to the root cause 

13-P-0337 
1. Student loan payment program - the agency has 

implemented OPM's program to assist employees paying back student loans. The employees participating in this 

program are required to commit to three years of service in 

exchange for the loan payments. 

2. Supervisor development - the agency sends managers to at least one management/leadership development class a year in order to ensure they are up to date on the latest techniques for managing and developing our workforce. 

3. Employee development- the agency has set up twice-ayear weeklong training sessions for our investigation and 

recommendations teams to continue the development of their skill sets. 

4. Improved agency communication- the agency holds 

quarterly all hands meetings to ensure that the entire agency 

understands the developments of the previous quarter and the challenges for the next quarter. 5. Workplace flexibility - the CSB has expanded 

opportunities for telework, work from home, remote duty locations, and temporary leave during parenting to ensure 

the retention of key positions In addition, the agency is developing or considering the following initiatives that should have a positive effect on 

both succession and retention: a) Career ladder - the agency is creating a ladder for the 

development and advancement of investigation employees, from entry level 

to lead investigator (or other senior positions) b) New hire orientation- the agency is developing an orientation process for new investigators to ensure proper 

integration into the agency. 

problem I believe it would be himprovements in this area. 

13-P-0337 
c) Advance hiring - the agency will use historical vacancy 

and turnover data to project the number and location of new 

hires needed for each fiscal year. 

Recommendation 5: As a best practice, involve staff in the planning process of an investigation. Hold meetings between senior management and staff to address any concerns with the investigation process. 

Investigation staff are already heavily involved and chiefly responsible for the planning of each investigation; this has 

always been the case. In the last two years this 

responsibility has been enhanced with the development of formal scoping documents for each active or new case, as 

well as recommendations briefs for major proposed 

recommendations. All these documents are then reviewed 

by the Board. In any event, the CSB agrees with this 

recommendation and has already undertaken a number of 

steps to address the issue. The protocol development team 

will hold three meetings with investigators and senior staff 

to identify any concerns with the investigation process. In 

addition, investigation teams will continue to hold Lessons Learned meetings after returning from a deployment and 

upon completion of a CSB written product and/or 

investigation case closure. The CSB has identified key investigation milestones as a 

first step in preparing the Investigation Product Development and Review procedure of the investigation 

protocol. Early milestones include scoping documents and 

project work plans, which will be developed by the investigation team and reviewed by management and the Board; this has already been practiced for some time and 

has increased staff involvement in the planning process. 

Key investigation milestones also include report outlines, recommendations briefs, and interim public meetings that should provide opportunities to address concerns with the investigative process. We will provide the Board with a 

proposed scoping document template for consideration by 

August 31, 2013. This will be incorporated in the draft Investigation Product Development and Review procedure 

that, as stated above in our comments on recommendation 1, we expect to provide to the Board for consideration and 

approval by December 31, 2013. 

I believe that the revision of the protocol, mentioned above, shoissues identified in these recomSpecifically, including a formal 

investigations, defining investigincorporating the use of a Lessowill greatly improve the efficieCSB investigations. 

13-P-0337 
Recommendation 6: Review and 

collocate investigation files for each ongoing investigation to ensure that they contain all the supporting documents related to the investigation. At a minimum, ensure files have proper classifications, project plans, scoping documents and board decisions. 

The CSB disagrees with this recommendation. The OIG's assertions concerning the lack of co-location of 

files and incorrectly classified or coded investigation files 

have nothing to do with the completion of final written products. As we have stated on several occasions, the 

purpose of the TRIM electronic records management 

system is to hold evidentiary records for investigation team 

members while they conduct their investigation; TRIM provides word-search capabilities that streamline and 

enhance investigators' abilities to review and analyze evidentiary materials. We use TRIM as a tool for searching/reviewing evidence during a case and as a system of archiving once the case is 

complete. The evergreen planning and scoping documents 

developed internally by CSB staff would not be included in such a system. Such evergreen documents are often not 

included in TRIM specifically because the team members 

do not need such records when reviewing evidence. Scoping/planning documents are management tools used by the team leads, supervisors, and agency leadership to keep abreast of the case; those sorts of evergreen records do not 

hinder or help the team in their review of evidence and, thus, any argument that their lack of placement in TRIM is 

unrelated to the team's ability to complete the 

investigations. Also, and very importantly, in the last few 

years, we have been using Optical Character Recognition 

(OCR) for most records; once documents are OCR scanned, they become fully word-searchable. The classification ID 

numbers are not needed if the files are OCR scanned and 

word searchable. There are many fields that can be used to 

find documents -- the ID field was an old field needed 

before docs could be OCR scanned. Thus, once OCR 

scanned, any categorization of the files beyond 

identification of the investigation the document pertains to 

become irrelevant, as the investigator can search/find the 

records needed using a variety of search data fields. We 

recommend corrections be made to page 17 of the draft 

report to reflect these facts. 

I believe that the revision of the protocol, mentioned above, shoissues identified in these recomSpecifically, including a formal investigations, defining investigincorporating the use of a Lessowill greatly improve the efficieCSB investigations. 

13-P-0337 
The OIG displays a critical misunderstanding of the TRIM 

system by the statements it makes in the final paragraph of 

the Investigation Files section: "Ensuring investigation files 

are collocated (sic) and correctly classified or coded would 

enable any investigator to easily identify the status of an 

investigation and compare results from completed 

investigations. Investigators could more efficiently 

complete or close out investigations in a timely manner, 

particularly cases open for more than 3 years." In no way 

would "correctly classified or coded records" within TRIM 

enable anyone to easily identify the status of an investigation and thus allow individuals to close out cases in a more timely manner; it would merely provide an 

additional means to locate a specific evidence record within 

the TRIM evidence database. The coding of evidentiary 

materials and the need for project management of ongoing 

cases are two entirely separate issues. The OIG incorrectly 

assumes that the coding of evidentiary materials somehow 

relates to the agency's ability to manage its investigative products. This correlation is not correct. 

Recommendation 7: Implement and update the records management policy to ensure that the classification of electronic investigation files agrees with the investigation protocol policy and staffs perform internal reviews of records as required by the policy. 

The CSB agrees with this recommendation and will review 

its Records Management policy and update it by December 

31, 2013, to reflect the need for a full OCR scan of the evidentiary case file for each investigation as well as 

completeness of the case file for official closeout/archiving. 

I believe that the revision of the protocol, mentioned above, shoissues identified in these recomSpecifically, including a formal investigations, defining investigincorporating the use of a Lessowill greatly improve the efficieCSB investigations. 

Recommendation 8: Update the 

investigation protocol policy for all current investigation procedures to include scoping documents and recommendation briefs. Provide formal training to the investigative staff on changes and updates to the investigative process. 

The CSB has been using formal scoping documents for 

investigations for the past two years and last year began 

developing selected recommendations briefs for major recommendations. All these tools have proven useful in 

completing cases that describe an agreed set of issues. The 

CSB agrees that a more formal policy and standard 

templates should be developed for these tools. We expect to 

provide the Board with a proposed scoping document template for consideration and approval by August 31, 

I believe that the revision of the protocol, mentioned above, shoissues identified in these recomSpecifically, including a formal 

investigations, defining investigincorporating the use of a Lessowill greatly improve the efficieCSB investigations. 

13-P-0337 
2013.This will be incorporated in the Investigation Product 

Development and Review procedure of the investigation 

protocol along with a template for recommendations briefs. 

As previously stated, we expect to provide the Board with a 

draft of this procedure for consideration and approval by December 31, 2013. We will then train investigative staff 

on the procedures within 90 days of Board approval. 

Recommendation 9: Provide guidelines for staff to determine the type of final product in the beginning of the investigation process to help staff be more efficient in completing investigations. 

The Investigation Product Development and Review 

procedure of the investigation protocol will identify CSB investigation product types and their attributes. The procedure will also require that the scoping document 

include a recommended product type and required resources so that the investigation team, management, and 

the Board have the same expectations and goals for each 

investigation. Again, we expect to provide the Board with a 

proposed scoping document template by August 31, 2013, 

and draft of the Investigation Product Development and 

Review procedure for consideration and approval by December 31, 2013. 

I believe that the revision of the protocol, mentioned above, shoissues identified in these recomSpecifically, including a formal investigations, defining investigincorporating the use of a Lessowill greatly improve the efficieCSB investigations. 

13-P-0337 
Appendix D 

Distribution 

Chairperson and Chief Executive Officer, U.S. Chemical Safety and Hazard Investigation Board 

Board Members, U.S. Chemical Safety and Hazard Investigation Board 

Managing Director, U.S. Chemical Safety and Hazard Investigation Board 

Deputy Managing Director, U.S. Chemical Safety and Hazard Investigation Board 

General Counsel, U.S. Chemical Safety and Hazard Investigation Board 

Senior Counselor to the Chair, U.S. Chemical Safety and Hazard Investigation Board 

Director of Administration and Audit Liaison, U.S. Chemical Safety and Hazard 

Investigation Board 

Communications Manager, U.S. Chemical Safety and Hazard Investigation Board 

13-P-0337 38