A 2010 explosion and fire at the Tesoro refinery in Anacortes, which killed seven workers, “could have been prevented” if safer equipment construction materials had been used, according to a long-awaited report by the U.S. Chemical Safety Board.
The draft report, unveiled Wednesday night to victims’ families, details causes of a “catastrophic rupture of a heat exchanger” in the largest fatal incident at a U.S. petroleum refinery since the 2005 BP Texas City accident.
Nearly four years in coming, the federal report sheds light on overshadowed disaster, an “incident” that was preventible and avoidable.
The board’s investigation is certain to increase public concern about refinery operations in Anacortes and elsewhere across America.
“Despite the fact that the nation’s roughly 150 petroleum refineries represent only a small fraction of the thousands of chemical processing facilities throughout the United States, the (board) has noted a considerable frequency of significant and deadly incidents at refineries over the last decade,” said the report.
“In 2012 alone, the Chemical Safety Board tracked 125 significant incidents at U.S. petroleum refineries,” it added.
The board found parallels, namely a metallurgical failure, in the Tesoro explosion and an enormous 2012 fire at the Chevron Richmond Refinery in California. That fire caused 15,000 people to seek medical attention for respiratory problems.
“The Chemical Safety Board identified a number of similar causal findings common to both the April 2010 Tesoro Anacortes Refinery incident and the August 2012 Chevron Richmond Refinery incident,” says its report.
The “incidents” were caused by a binding of carbon-based steel with hydrogen, with a reaction that produces methane gas.
Methane cannot diffuse out of steel. It accumulates, exerting force on surrounding steel. As more methane gas is formed, the methane pressure increases. The high pressure exerted by methane creates fissures, or blisters in the steel.
“This process occurred in the E heat exchanger at the Tesoro Anacortes refinery,” the board found. Highly flammable hydrogen and naphtha at more than 500 degrees Fahrenheit were released from the ruptured heat exchanger, causing the catastrophic explosion.
Could human actions have prevented this?
U.S. Rep. Rick Larsen, D-Wash., who has bird dogged the safety board investigation, has an answer: Safety management should have listened to those who had the hazardous duty of starting up heat exchangers at the refinery.
“The biggest lesson that is that people listen to folks who actually doing the work and are familiar with the conditions they are working in,” Larsen said.
The Chemical Safety Board report details multiple lessons. Its revelations include:
–Workers exposed: The startup of heat exchangers was “hazardous nonroutine work,” the board found. “Leaks routinely developed that presented hazards to workers conducting the startup activities.”
The startup procedure specified use of one outside operator. “However, on the day of the incident, six additional personnel were requested to assist with the startup of the A/B/C exchanger bank.” All perished.
–Ineffective safeguards: For 15 years before the 2010 blast, assumptions used by PHA (Process Hazard Analysis) teams at Anacortes “contributed to ineffective safeguards, inefficient hazard identification, and ineffective control of hazards,” the board found.
Tesoro and Shell, the refinery’s former owner, “periodically” performed corrosion reviews. “These reviews were weakened by primarily relying on design operating data for these heat exchangers rather than data from actual operating conditions.”
–Warning signs: The heat exchangers “frequently leaked flammable hydrocarbons during starup,” the investigation found, “sometimes resulting in fires. Tesoro management had been complacent about these hazardous leaks and did not always investigate the cause of the leaks.
“Tesoro did take some actions to prevent the leaks, but these actions did not effectively prevent the leaks before the April 2010 incident.”
–Safety culture: “The refinery process safety culture required proof of danger rather than proof of effective safety implementation,” the board found. Design data was used to evaluate dangers to the heat exchangers.
“Data from actual operating conditions were not readily available, and these technical experts were not required to prove safety effectiveness in reaching their conclusions that the B and E heat exchangers were not susceptible to High Temperature Hydrogen Attack damage.”
–Legal requirement: The board found that Tesoro’s Process Hazardous Analysis unit “discontinued a review of its corrosion control program and a specific mechanical integrity checklist associated with the corrosion program after concluding that they were ‘not a legal requirement.’
The state of Washington Process Safety Management regulation did not require this review. Tesoro conducted the optional review ineffectively and then terminated it when the company determined that it was not strictly required.”
The Chemical Safety Board does not spare the regulators. Its revelations of neglect extend to the Washington Department of Labor and Industries (L & I).
The L & I, which oversees workplace safety in Washington, “does not have sufficient personnel resources to verify that process safety management (PSM) requirements are being implemented adequately,” its investigation found.
“The state of Washington has only four PSM specialists in its compliance section to regulate and inspect nearly 270 PSM-covered facilities, including five petroleum refineries. Of these four specialists, only one is a chemical engineer.”
In its recommendations, the Chemical Safety Board said:
–The oil company: “Implement a process safety culture program that will assess and continually improve any identified process safety culture issues at the Tesoro Anacortes Refinery.”
–The state: The Governor and Legislature must “develop and implement a step-by-step plan to supplement the existing process safety management” with a “more rigorous safety management” framework.
–The feds: The U.S. Environmental Protection Agency needs to revise its Chemical Accident Prevention Provisions, and require from refiners an “inherently safer systems analysis” and better “hierarchy of controls” for identified hazards. It has authority through the Clean Air Act’s General Duty Clause.
The Chemical Safety Board will lay out its findings at a public meeting Thursday night in Anacortes.
It is expected to produce detailed drawings on how a buildup of methane causes fissures and blisters, which is what led to the lethal Anacortes explosion.
As seen in the Chevron parallels, the findings will be of interest far beyond the Skagit County town which endured loss of seven workers.
Tesoro operates refineries in Kapolei, Hawaii; Mandan, N.D.; Salt Lake City; Martinez, Calif.; Los Angeles; and Carson, Calif.
The April 2, 2010, “incident” in Anacortes has been a curiously overshadowed disaster.
Just four days later, an explosion at the Upper Branch Mine in West Virginia killed 29 miners. The nation’s attention turned to a dramatic but unsuccessful rescue operation. President Obama flew to West Virginia and eulogized the miners.
Obama sent a letter to the memorial service in Anacortes.
It took just 13 months for an investigation to fix blame for the West Virginia mine blast. The Chemical Safety Board report is coming out nearly 46 months after the seven refinery workers were killed.