The Washington State Department of Labour and Industries have investigated the above incident and issued citations totaling USD 2.39 Million. I have summarized the investigation findings and citations as follows:
•On April 2nd,2010 early morning, a blast at the Tesoro refinery in Anacortes, USA, occurred killing 7 personnel. The blast occurred due to the catastrophic failure of a feed effluent exchanger in the naphtha hydrotreating unit during start up. The exchanger was about 40 years old. The original refinery was started in 1950’s by Shell. Shell sold the refinery to Tesoro in 1998. The failed heat exchanger was not tested for last 10 years. Tesoro had planned an inspection in 2008 but did not carry it out.
•6 out of 7 personnel who died were not trained in the start up procedure.
•The frequency of Tesoro Refinery's inspection of the feed effluent exchanger was not consistent with applicable manufacture's recommendations, good engineering practices, and or prior operating experience.
•The Tesoro Refinery did not correct deficiencies associated with effluent exchanger shell and tube side warm up lines before further use or in a safe and timely manner
•Tesoro Refinery did not correct deficiencies associated with effluent exchanger companion flanges and temporary clamps before further use or in a safe and timely manner when the necessary means are taken to assure safe operation. (flanges were leaking during start up and steam lances held by personnel were used to dilute the leaks)
•Tesoro Refinery did not develop and implement written procedures for startup following turnaround, or after an emergency shutdown of exchangers that provided clear instructions for safely conducting activities involved in the process consistent with the process safety information that addressed steps for each operating phase.
•Tesoro Refinery did not establish and implement written procedures to manage the change made to the warm up steps during the March 2009 start up and those conducted in February and March of 2008 on the E6600 effluent exchangers.
•Tesoro Refinery did not establish and implement written procedures to manage the changes made to the operating limit minimum hydrogen oil ratio feed to Naphtha Hydrotreater.
•Tesoro Refinery did not establish and implement written procedures to manage the change made by placing mechanical clamps on the companion flanges between effluent exchangers E-6600 A/B and D/E on or about March 2009.
•Tesoro Refinery did not establish and implement written procedures to manage the change made by placing the Anacortes Corrosion Awareness and Management Program (ACAMP) on hold indefinitely beginning the third quarter of 2004.
•Tesoro Refinery did not establish and implement written procedures to manage the change made by discontinuing the process hazard analysis revalidation system that included mechanical integrity and corrosion control review in 2006.
•Tesoro Refinery did not establish and implement written procedures to manage the changes made by temporarily or permanently suspending inspection procedure I-08.07 on or about September 2009
•The Tesoro Refinery did not ensure that the 2006 Process Hazard Analysis Revalidation was consistent with the current process.
•The Tesoro Refinery did not update process safety information following changes made to the effluent exchangers on or about December 2005.
•The Tesoro Refinery did not investigate each incident which resulted in, or could reasonably have resulted in, a catastrophic release of highly hazardous chemicals in the workplace. Failure to investigate incidents could result in their recurrence and cause serious injury or death.
•Tesoro Refinery did not ensure that appropriate checks and inspections were performed to assure that equipment, such as the warm up lines and replacement tube bundle, were installed properly and consistent with the design specifications. Lack of quality assurance inspections and checks could lead to improper installations of process equipment and result in serious injury or death.
•Tesoro Refinery did not ensure that maintenance materials, spare parts and equipment were suitable for the process application for which they will be used, such as the bellows assemblies.
•Tesoro refinery did not ensure that all emergency responders and their communications were coordinated and controlled by the Incident Commander (IC).
•Tesoro Refinery did not assure that all Fire Brigade members were fully trained prior to the incident response on the morning of April 2nd, 2010.
Read the full citation in this link.
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