L&I Issues Record Fine In Deadly Tesoro Explosion


Department of Labor and Industries press release:

After a six-month investigation, the Department of Labor & Industries has concluded that the deadly explosion at the Tesoro petroleum refinery in Anacortes could have been prevented. At a press conference today, L&I announced it has cited Tesoro for 39 “willful” violations and five “serious” violations of state workplace safety and health regulations, fining the company $2.38 million. While no amount of money can reflect the value of a person’s life, this is the largest fine in the agency’s history. A willful violation is a category of violation where an employer knowingly violates a rule and is plainly indifferent to correcting it, while a serious violation is one involving an instance where there is a substantial probability of serious injury or death.

L&I announced it has cited Tesoro for 39 “willful” violations and five “serious” violations of state workplace safety and health regulations, fining the company $2.38 million.

A heat exchanger at the refinery ruptured around 12:30 a.m., April 2, 2010, releasing hydrocarbon vapor which almost immediately ignited. Seven workers, five men and two women, died as a result. It is the worst industrial disaster in the 37 years that L&I has been enforcing the state’s workplace safety law, the Washington Industrial Safety and Health Act.

“The loss of seven lives is a tragedy not just for their loved ones but for our entire state. What makes the loss of these lives all the more painful is that these deaths could have been prevented,” Governor Chris Gregoire said. “I believe the action L&I is announcing today and the record fine they have assessed against Tesoro sends a clear message that these tragedies are not acceptable.”

L&I inspectors found that Tesoro disregarded a host of workplace safety regulations, continued to operate failing equipment for years, postponed maintenance, inadequately tested for potentially catastrophic damage and failed to adequately protect their workers from significant risk of injury and death.

“This explosion and the deaths of these men and women would never have occurred had Tesoro tested their equipment in a manner consistent with standard industry practices, their own policies and state regulations,” said L&I Director Judy Schurke.
At today’s press conference, L&I inspectors explained that the explosion occurred in the plant’s Naphtha Hydrotreater Unit, an area that includes two banks of heat exchangers. Naphtha is a flammable, oily substance produced as part of the refining process. The naphtha flows through the heat exchangers, cylinders approximately 30 feet long, on its way for further processing. One of these heat exchangers split violently on April 2.

The blast came as workers were returning a bank of heat exchangers into service after it had been shut down for maintenance. As part of the investigation, the heat exchangers were sent to a laboratory in Ohio and dismantled for metallurgical testing. Tests revealed cracks had developed in many of the welds in the heat exchanger that exploded and in at least one other similar heat exchanger. These cracks likely developed over the years.

These heat exchangers were nearly 40 years old. In addition, they were subjected to extreme heat and pressure, wide temperature and pressure swings, extensive chemical exposure and a near doubling of production over the years. These are all stresses that can damage this equipment, including causing cracking. Despite this, Tesoro failed to test the heat exchanger that exploded in a way that would have revealed such cracks.
“If Tesoro had tested their equipment appropriately and had followed their other safety requirements, we believe that they would have found the cracks that caused this explosion and, either by replacing the equipment or repairing it, prevented this from happening,” said Dr. Michael Silverstein, assistant director, Division of Occupational Safety and Health.

Tesoro failed to test the heat exchanger that exploded in a way that would have revealed such cracks.

The equipment also leaked hot, volatile and flammable vapor and liquid from flanges and other connections for years, especially when starting up following a shutdown. Tesoro’s repair efforts, including clamps, were ineffective and when they could not correct the problem, workers had to disperse the flammable vapors with long tubes called “steam lances” in an effort to prevent ignition. Employees did this work in hard hats, gloves, goggles and basic flame-resistant coveralls, which was inadequate protection for the hazards they faced.

Tesoro’s lengthy list of willful violations include failing to inspect equipment consistent with recognized engineering practices and industry standards, failing to test for cracks and other defects in equipment prone to damage from thermal fatigue, chemical exposure, and failing to implement its own corrosion awareness and management program.

Other willful violations were cited because Tesoro also failed to repair equipment, as with the leaks on the heat exchangers; did not have start-up procedures for the heat exchangers that clearly described the hazards workers would face; and failed to ensure workers involved in starting up the heat exchangers were properly trained.
Among the serious violations, Tesoro was cited for failing to ensure fire brigade members were properly trained and failing to ensure emergency communications were coordinated by a single incident commander.

The most important thing is for Tesoro to correct the hazards identified in the investigation. “Our expectation is that in the coming weeks, we will work with Tesoro to improve their safety and health program so that work at their plant can begin again safely,” Schurke said.