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July 6, 2020

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Report Contributors:	Eric Lewis
Andre von Hoyer
Abbreviations
C.F.R.	Code of Federal Regulations
CSB	U.S. Chemical Safety and Hazard Investigation Board
EPA	U.S. Environmental Protection Agency
FY	Fiscal Year
OIG	Office of Inspector General
U.S.C.	United States Code
Cover Image: The Clean Air Act provides for five board members for the CSB, but as of
June 2020, the board consisted of only the chairperson. (EPA OIG image)
Are you aware of fraud, waste, or abuse in an
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EPA Inspector General Hotline
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Washington, D.C. 20460
(888) 546-8740
(202) 566-2599 (fax)
OIG Hotline@epa.gov
Learn more about our OIG Hotline.
EPA Office of Inspector General
1200 Pennsylvania Avenue, NW (2410T)
Washington, D.C. 20460
(202) 566-2391
www.epa.gov/oiq
Subscribe to our Email Updates
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U.S. Environmental Protection Agency
Office of Inspector General
At a Glance
20-N-0218
July 6, 2020
What Are Management
Challenges?
According to the GPRA
Modernization Act of 2010
(GPRA stands for Government
Performance and Results Act),
major management challenges
are programs or management
functions within or across
agencies that have greater
vulnerability to waste, fraud,
abuse, and mismanagement,
and where a failure to perform
well could seriously affect the
ability of an agency or the
federal government to achieve
its mission or goals.
Per the Reports Consolidation
Act of 2000, each fiscal year the
Office of Inspector General is to
identify major management
challenges for the U.S. Chemical
Safety and Hazard Investigation
Board. In FY 2020, we examined
whether the two management
challenges we identified in
FY 2019—as detailed in Report
No. 19-N-0156, issued May 20,
2019—were addressed. We
also sought to identify any new
challenges.
This report addresses the
three CSB goals:
•	Prevent recurrence of
significant chemical incidents.
•	Advocate safety and achieve
change.
•	Create and maintain an
engaged, high-performing
workforce.
Address inquiries to our public
affairs office at (202) 566-2391 or
OIG WEBPOSTINGS@epa.gov.
List of OIG reports.
Fiscal Year 2020 U.S. Chemical Safety and Hazard
Investigation Board Management Challenges
Based on our continuous audit, evaluation, and
investigative work, we have determined that the
two management challenges we identified in
FY 2019 have not been addressed. We also
identified a new challenge for FY 2020 related to
the coronavirus pandemic—that is, the SARS-CoV-2 virus and resultant
COVID-19 disease. This new challenge affects all government agencies.
Management Challenge (Continuing): Accomplishment of CSB Mission Is
Impaired Until New Board Members Are Selected
The Clean Air Act Amendments of 1990 authorized the creation of the CSB and
established a board of five members, including a chairperson, that is responsible
for major budgeting decisions, strategic planning and direction, general Agency
oversight, and approval of investigation reports and studies. In March 2020, the
U.S. Senate confirmed a new CSB chairperson. Due to term expirations and
resignations of the other board members, the chairperson was, as of June 2020,
the only remaining board member.
Having only one member impairs the function of the CSB, as all functions rest
with that one member. CSB Order 028, Executive and Administrative Functions
of the Board, delineates executive and administrative functions of the board,
including specific authorities of the chairperson and duties of the board as a
whole. The Order does not explicitly address a situation when the only member
of the board is the chairperson. Regardless, workload limitations arising from
one board member attempting to perform the work of five affect the
accomplishment of the board's technical responsibilities, including accident
reconstruction, safety engineering, human factor identification, toxicology
reviews, and air pollution regulation assessments.
Management Challenge (Continuing): CSB Has Not Developed Policy on
Board Member Responsibilities
In FY 2018, we reported multiple instances when a board member acted
inconsistently with established practices or inappropriately provided information
to outside entities. The CSB previously agreed to develop new policy, but per the
Agency's general counsel, the board decided that a Senate-confirmed
chairperson should approve any changes to policy affecting the board.
Management Challenge (New): CSB Must Continue Operations During the
Coronavirus Pandemic
The CSB must rely on its internal controls to continue operations to the extent
practicable and to safely return employees to work at CSB facilities.
Unaddressed management
challenges will impede the
ability of the CSB to function
effectively.

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UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, D.C. 20460
THE INSPECTOR GENERAL
July 6, 2020
Katherine Lemos, Ph.D.
Chairperson
U.S. Chemical Safety and Hazard Investigation Board
1750 Pennsylvania Avenue NW, Suite 910
Washington, D.C. 20006
Dear Dr. Lemos:
Enclosed is the Office of Inspector General's fiscal year 2020 management challenges report. The Reports
Consolidation Act of 2000 requires our Office to report what we consider to be the most serious
management and performance challenges facing the U.S. Chemical Safety and Hazard Investigation
Board. We used audit, evaluation, and additional analysis of CSB operations to arrive at the issues
presented.
The two challenges that we identified in FY 2019 remain. The first challenge, Accomplishment of CSB
Mission Is Impaired Until New Board Member s Are Selected, has an elevated urgency due to the May 2020
resignation of the only remaining board member besides the chairperson. The second challenge, CSB Has
Not Developed Policy on Board Member Responsibilities, is unaddressed because the board has been
unwilling to complete the agreed-upon corrective actions without a chairperson confirmed by the
U.S. Senate. For FY 2020, we also added a new challenge, CSB Must Continue Operations During the
Coronavirus Pandemic, as the CSB must address the challenges posed by the SARS-CoV-2 virus and
resultant COVID-19 disease.
You are not required to provide a written response to this final report. Should you choose to provide a
response, we will post your response on the OIG's public website. Your 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 response should not contain data that you do not want to be released to the
public; if your response contains such data, you should identify the data for redaction or removal along
with corresponding justification. We will post this report to our website at www.epa.gov/oig.
Sincerely,
Sean W. O'Donnell
Enclosure
cc: Thomas Goonan, General Counsel, CSB
Anna Brown, Director of Administration and Audit Liaison, CSB

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Background
The U.S. Chemical Safety and Hazard Investigation Board was created under the Clean Air Act
Amendments of 1990 and is the independent federal Agency charged with investigating
chemical incidents and hazards.1 The CSB examines all aspects of chemical incidents, including
the cause (for example, equipment failure) and root cause (for example, why the equipment
failed). According to the CSB's website, the Agency's mission is to "drive chemical safety change
through independent investigation to protect people and the environment."
The CSB began operations in fiscal year 1998 and is headquartered in Washington, D.C. There is
also a CSB field office in Denver, Colorado, and employees work remotely from other locations.
The Clean Air Act Amendments of 1990 provide for an Agency board that "shall consist of
5 members, including a Chairperson." The board members are appointed by the president and
confirmed by the U.S. Senate. The board's chairperson serves as the chief executive officer and
administrator.
The board is responsible for major budgeting decisions, strategic planning and direction,
general Agency oversight, and approval of Agency investigation reports and studies. Board
members may also participate in accident investigations. Individual board members oversee the
investigation and report writing for each incident examined by the CSB. The board must
approve all report findings, determinations of root cause, and safety recommendations.
According to the CSB's website, the board's recommendations serve as the Agency's principal
tool for achieving positive change; however, compliance with CSB recommendations is
voluntary.
The CSB's 2017-2021 Strategic Plan set three goals:
1.	Prevent recurrence of significant chemical incidents through independent investigations.
2.	Advocate safety and achieve change through recommendations, outreach, and
education.
3.	Create and maintain an engaged, high-performing workforce.
CSB FY 2019 ACTIVITY
The "CSB Performance and Accountability Reports" webpage contains CSB performance
information. The CSB's "Completed Investigations" webpage contains information about
completed CSB investigations. The CSB released the following three reports in FY 2019:
1. Enterprise Pascagoula Gas Plant Explosion and Fire in Moss Point, Mississippi. A major
loss of containment resulted in the release of methane, ethane, propane, and several
other hydrocarbons, which then ignited, initiating a series of fires and explosions. The
1 42 U.S.C. § 7412(r)(6).
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probable cause was the failure of a brazed aluminum heat exchanger due to thermal
fatigue. The site was shut down for almost six months, and Enterprise incurred
$10.4 million in cost for fire response activities and $7.1 million in noncash losses.
(Report issued February 2019.)
Enterprise Pascagoula Gas Plant.
(CSB photo)
2. Pryor Trust Fatal Gas Well Blowout and Fire in Pittsburg County, Oklahoma. The CSB
found that a blowout rig fire occurred due to the failures of both the primary and
secondary barriers. The fire killed five workers. (Report issued June 2019.)
Pryor Trust Gas Well. (CSB photo)
3. DuPont La Porte Facility Toxic Chemical Release in La Porte, Texas. The CSB found that
approximately 24,000 pounds of highly toxic methyl mercaptan were released from an
insecticide production unit. The CSB identified flawed engineering and a lack of
adequate safeguards as causes for the release. The release killed three operators and a
shift supervisor. (Report issued June 2019.)
DuPont La Porte Facility. (CSB photo)
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CHALLENGE. Accomplishment of CSB Mission Is Impaired Until New
Board Members Are Selected
BACKGROUND
According to the Clean Air Act Amendments of 1990, the CSB
governing body shall have the following composition and
responsibilities:
•	Five members, including a chairperson, appointed by
the president and confirmed bythe U.S. Senate.
•	Investigate (or cause to be investigated), determine, and report to the public in writing
the facts, conditions, circumstances, and cause of any accidental release resulting in a
fatality, serious injury, or substantial property damage.
The chairperson and the other four board members govern the CSB. After a prior chairperson
resigned in June 2018, the board members internally selected an interim executive authority, as
the president did not select or install an interim chairperson. This interim executive authority
served until the Senate confirmed a chairperson on March 23, 2020.
By April 2020, due to board member term expirations, the governing body had three vacancies
and consisted only of the new chairperson and one other board member. According to the
CSB's director of Administration, the other board member resigned in May 2020, leaving the
CSB governing body with four vacancies. Until new board members are appointed and
confirmed, the board will consist of only the chairperson.
CHALLENGE
The governing body must obtain a quorum to meet its mission and goals because CSB staff do
not have the initial authority to carry out board functions, including budgeting, planning,
oversight, and approval of investigations. CSB regulatory language at 40 C.F.R. § 1600.5(a)
provides the process to establish a quorum; however, the regulatory language lacks clarity. For
example, it leaves open whether a single board member may constitute a quorum.2
CURRENT
2 If a quorum of one is permissible, then under the current circumstances the chairperson would necessarily be
exercising both the executive and administrative duties reserved for the chairperson and the authorities of the
board. However, the U.S. Government Accountability Office's Standards for Internal Control in the Federal
Government, GAO-14-704G, issued September 10, 2014, provides for the segregation of duties. It states that
management divides or segregates key duties and responsibilities among different people to reduce the risk of error,
misuse, or fraud. This segregation includes the authorization, processing, recording, and review of transactions, as
well as the handling of any related assets, so that no one individual controls all key aspects of a transaction.
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CSB Order 028, Executive and Administrative Functions of the Board, establishes functions for
the CSB chairperson separate from the other board members. The chairperson exercises the
executive and administrative functions of the board. The board as a whole, however, must
approve investigation reports; safety studies; regulations, rules, and orders; budgets and
budget submissions; operating budgets; contracts and expenditures over $50,000; strategic
plans; and statements to Congress and the president.
Having a quorum of one, even if permissible, impairs the CSB mission for reasons of both
workload management and separation of duties. The Clean Air Act provides for five technically
qualified board members who perform specified duties.3 Specifically, board members serve as
the principal spokespersons at accident sites and conduct community meetings, hearings, and
boards of inquiry during accident investigations. Following the board's approval of accident
investigation reports, board members play a significant role in advocating the adoption of the
Agency's recommendations by industry, labor, government, and others. Board members
regularly participate in conferences, in safety forums, and on committees, and they meet with
leaders of other federal agencies. A single board member is unlikely to have all the technical
qualifications or time to perform the required board duties, and CSB staff cannot assume
board-specific duties. Therefore, even if a single member is permitted to form a quorum, the
CSB's work will be impaired.
Based on the time taken to approve previous nominees, it is unlikely that even one new
member, let alone four, will be selected, nominated, and confirmed in the near term. For
example, it took nine months from the time the president nominated the new chairperson in
July 2019 until she was confirmed by the Senate in March 2020. This span does not include the
time taken by the administration to identify a nominee. The average time taken to confirm
prior board members from the time they were nominated was 10.5 months, not including the
time needed to identify qualified individuals for nomination.
Congress has documented its support for the CSB mission to the administration. In an
August 2018 letter to the White House chief of staff, the chairs of the House Committee on
Oversight and Government Reform and the Subcommittee on the Interior acknowledged the
management challenges facing the CSB and urged the administration to select new board
members to improve CSB management. In an October 2018 letter to the White House chief of
staff, the chairs of the Senate Committee on Environment and Public Works and of the
Subcommittee on Clean Air and Nuclear Safety also acknowledged the management challenges
facing the CSB and urged the administration to fill the governing body vacancies. The Senate
Committee on Environment and Public Works letter also noted that:
3The Clean Air Act requires that board members be appointed based on technical qualification; professional
standing; and demonstrated knowledge in the fields of accident reconstruction, safety engineering, human factors,
toxicology, or air pollution regulations.
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•	The CSB has investigated chemical accidents at industrial facilities since 1998.
•	The CSB has issued corrective measures to the facilities and made recommendations to
the U.S. Environmental Protection Agency, the U.S. Department of Labor's Occupational
Safety and Health Administration, and other agencies.
•	Congress has continued to fund the Agency with broad bipartisan support.
•	Until Congress decides to eliminate the Agency, it is imperative that the president and
not CSB members select the CSB leader.
•	The president should nominate someone from outside the Agency to be the
chairperson.
The nomination and March 2020 confirmation of the new chairperson addressed the last two
issues.
WHAT REMAINS TO BE DONE
The necessary actions for resolving this management challenge lie outside of the CSB's control.
For the CSB to complete its mission and goals under its current authority, the president should
nominate and the Senate should confirm new members as soon as possible.
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CHALLENGE: CSB Has Not Developed Policy on Board Member
Responsibilities
BACKGROUND
The Clean Air Act requires that board members be
appointed based on technical qualification;
professional standing; and demonstrated knowledge
in the fields of accident reconstruction, safety
engineering, human factors, toxicology, or air
pollution regulations. The statute permits removal of a
board member for inefficiency, neglect of duty, or
malfeasance in office. Unless removed, board
members serve fixed terms of five years.
CSB Order 028, Executive and Administrative Functions of the Board, establishes the
chairperson's executive and administrative functions, including the authority to preside over all
personnel matters and to supervise and authorize CSB official communications, except those
that require full board approval.4
CHALLENGE
As identified in the Office of Inspector General's FY 2018 U.S. Chemical Safety and Hazard
Investigation Board Management Challenges report, Report No. 18-N-0208. issued June 4,
2018, board members and managers said that there were multiple instances in FY 2018 when a
board member acted inconsistently with CSB Order 028. For example, a board member
publicized budget information before it was presented to Congress, attempted to share
information with one stakeholder before sharing it with all stakeholders, and made comments
on a proposed rule before a CSB position was developed.
CSB Order 028 states that the chairperson possesses the following authority over official
communications:
1.	"Authority to supervise and authorize the response to all inquiries from Congress, the
media, and the public concerning the Board and/or the CSB, except as specifically
excluded by this Order."
2.	"Authority to supervise the preparation of all official statements and other
communications concerning, or on behalf of, the Board and/or the CSB, except as
specifically excluded by this Order."
RESPONSIBILITIES
BOARD
MEMBER
BOARD
MEMBER
BOARD
MEMBER
BOARD
MEMBER
CHAIRPERSON
For access to CSB orders, see the Records Details website.
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3. "Authority to make and/or authorize all statements, written communications, and
pronouncements on behalf of the Board and/or the CSB, except as specifically excluded
by this Order."
Communication exclusions give the board as a whole, not a single board member, authority to
approve and transmit the budget and to approve but not transmit statements to Congress and
the president. Therefore, certain board-level communications, at minimum, should have full
board approval.
The CSB told the OIG that there had been no new incidents of improper communications from
board members. Several people we interviewed—including board members, the former acting
general counsel, and the senior advisor—attributed this development to better communication
among staff and the board members.
The lack of additional incidents in FYs 2019 and 2020 is a positive sign for the board; however,
policy is still needed to define the roles of the board members. The CSB's authorizing legislation
does not create a supervisory role for the chairperson with respect to the other board
members. Without the explicit authority for the chairperson to hold board members
accountable, an environment exists that enables behaviors that impede the CSB's mission and
lowers morale among CSB career staff.
Although this management challenge was originally identified in FY 2018, new policy had not
been developed as of June 2020. Per the CSB's general counsel, the board decided that a
Senate-confirmed chairperson should approve any changes to policy affecting the board.
WHAT REMAINS TO BE DONE
To follow up on this management challenge, the board agreed to take the following actions:
1.	Finalize board member roles and responsibilities in an official policy, including internal
enforcement guidelines for situations in which board member behavior deviates from
official policy.
2.	Improve onboarding materials for new members to include clear policy on expectations,
roles, and responsibilities.
These actions should be addressed by the chairperson and the governing body as a whole.
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CHALLENGE: CSB Must Continue Operations During the
Coronavirus Pandemic
BACKGROUND
During the coronavirus pandemic (that is, the SARS-CoV-2 virus and resultant COVID-19
disease), the CSB must continue to conduct root cause investigations of chemical accidents at
fixed industrial facilities. The CSB also needs to modify its practices to accommodate a scenario
in which social distancing and additional personal protective equipment are advised. Traveling
and working with others are key components of a CSB response. For example, 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. CSB investigators also examine
company safety records, inventories, and operating procedures to understand the
circumstances of an accident. In addition, the Agency is authorized to conduct investigations of
general chemical accident hazards, regardless of whether an accident has occurred.
CHALLENGE
Risks to CSB Mission Achievement: Safe and Successful Program Operations
Maintaining safe and effective operations during the coronavirus pandemic presents a key
operational challenge for the CSB. Although the CSB has not suspended deployments to
chemical incidents as a result of the coronavirus pandemic, it is planning to limit future
deployments to high-consequence incidents only and to locations that can be reached through
local travel—for example, by personal vehicle. Since March 13, 2020, no incidents have
warranted deployment.
In the event of a high-consequence incident, the CSB will need to safely deploy staff with proper
training and to identify adequately staffed independent laboratories that can perform required
tests. The CSB also needs to develop mitigating measures and methods to handle less-than-high-
consequence incidents.
Risks to CSB Operations: Maintaining a Safe and Productive Workforce
In the midst of possible deployment limitations, the CSB also faces an investigative staffing
shortage. The CSB chairperson announced an effort to hire additional investigators to assist
with ongoing investigations. As the coronavirus pandemic persists, the CSB faces the challenge
of eventually returning its workforce to federal office spaces. This goal requires successful
implementation of cleaning, social distancing, and continued protection protocols. As of June
2020, the CSB did not yet have a plan to return employees to federal office space.
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