The CSB today released a new computer animation recreating the explosion and fire that killed seven workers at the Tesoro Refinery in Anacortes, Washington on April 2, 2010. The five-minute animation illustrates the process of “high temperature hydrogen attack,” which over the years damaged and weakened a nearly forty-year-old carbon steel heat exchanger, leading to a catastrophic rupture on the night of the accident. The CSB investigation concluded that the accident at Tesoro could have been prevented had the company replaced the vulnerable carbon steel heat exchangers with inherently safer alloys that were already well known within the industry, but not required.
The animation also explains that seven workers were present on the night of the accident assisting with startup of the heat exchangers – mitigating recurring leaks never adequately addressed by Tesoro, and manually opening a series of long-winded valves. All seven lost their lives as a result of the blast.
The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.
The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov.
