WISHA Issues Record Fine for Tesoro Explosion

After a six-month investigation, the Washington State Department of Labor & Industries (L&I) has concluded that the deadly explosion at the Tesoro petroleum refinery in Anacortes, Wa., could have been prevented.

At a press conference recently, 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 $2.39 million. 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.

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,” said Gov. Chris Gregoire. “What makes the loss of these lives all the more painful is that these deaths could have been prevented. 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.

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.

“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’s 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.

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