TESORO REFINERY DISASTER

Marquez, Angelica
Tuazon, Gayle
Zafra, Alister Mae
TESORO REFINERY
Tesoro purchased the Anacortes refinery from
Shell Oil Company in August 1998.
Located approximately 70 miles north of Seattle,
the Tesoro Anacortes refinery has a total crude-
oil capacity of 120,000 bpd.
The refinery has been in operation since 1955.
The Anacortes refinery primarily supplies
gasoline, jet fuel, and diesel to markets in
Washington and Oregon.
It also manufactures heavy fuel oils, liquefied
petroleum gas, and asphalt.

Tesoro Anacortes Refinery,

March Point, Anacortes, 2003
Animation of Explosion at Tesoro's
Anacortes Refinery
TESORO REFINERY DISASTER
Early Friday morning, April 2, 2010, an
explosion and fire erupt in the
Naphtha Hydrotreater Unit at the
Tesoro Refinery in Anacortes, killing
seven refinery workers in the process
of returning the heat exchangers to
operation after being down for
maintenance.
The tragedy is the worst industrial
accident to date since the
Department of Labor and Industries
began enforcing the Washington
State Industrial Safety and Health
Act (WISHA), enacted in 1973. Diagram of heat exchanger units, Tesoro Refinery,
Anacortes, September 22, 2010
TIMELINE OF THE TRAGEDY
March 28, 2010 one bank of heat exchanger was taken offline and disassembled for cleaning
while the other bank remained in service. This allowed the unit to continue to operate.
By mid-afternoon on April 1st, the cleaning was complete and operators initiated the start-up of
the offline bank of heat exchanger.
By 10:30pm, the outside operator was joined by 6 workers from other units within the refinery
Shortly after midnight, the temperature of the fluid exiting the tubes of the online bank of
exchangers increased about 75 degrees over the span of 3 minutes
At 12:35am (April 2nd), employees working at a nearby process unit heard a loud hissing noise
when vapour began to leak as the heat exchanger cracked at its weakest point
Seconds later, the heat exchanger violently ruptured. Hot hydrogen and naphtha vapour rapidly
vented from the exchanger and spontaneously ignited upon contact with air resulting in a
massive fire that consumed heat exchanger structure
Three of the seven operators died at the scene. The other four operators were transported to
local burn centers with severe injuries. Two died within the hours. The other two succumbed
within days.
TWO MAJOR FACTORS IN THE EXPLOSION
lower-grade steel used in Tesoro's heat exchanger pipes
Even though it met regulations, federal investigators think
stronger steel should be used.
Tesoro was complacent and hadn't fixed flammable leaks
at the facility,
High-temperature hydrogen in the pressurized heat exchangers
used to purify crude oil at the plant had caused tiny cracks in the
steel pipes.
RECOMMENDATIONS
The U.S. Environmental Protection Agency
Revise the Chemical Accident Prevention Provisions to
require the documented use of inherently safer systems
analysis and the hierarchy of controls to the greatest extent
feasible in establishing safeguards for identified process
hazards. In addition, effectively participate in the oversight
of the process safety culture program at the Tesoro
Anacortes Refinery.
RECOMMENDATIONS
Washington State Legislature, Governor of
Washington
Augment the existing process safety management
regulatory framework with the more rigorous safety
management attributes identified in this report for
petroleum refineries in the state of Washington.
RECOMMENDATIONS
Washington State Division of Occupational
Safety and Health Labor and Industries
Perform verifications at all Washington petroleum
refineries to ensure prevention of equipment failure
because of HTHA and that effective programs are in place
to manage hazardous nonroutine work. In addition,
effectively participate in the oversight of the process safety
culture program at the Tesoro Anacortes Refinery.
RECOMMENDATIONS
Tesoro Anacortes Refinery
Implement a process safety culture program that will
assess and continually improve any identified process
safety culture issues at the Tesoro Anacortes Refinery.
RECOMMENDATIONS
United Steelworkers Local 12-591
Effectively participate in the process safety oversight
committee to continually improve any identified process
safety culture issues at the Tesoro Anacortes Refinery.
REFERENCES
http://www.kiro7.com/news/feds-blame-refinery-explosion-killed-7-
tesoro/82220694
http://www.csb.gov/final-tesoro-investigation-report-approved-at-public-meeting-
in-anacortes-wa-on-may-1-2014-/