Accident Description
An explosion and fire led to the fatal injury of seven employees when a nearly forty-year-old heat exchanger catastrophically failed during a maintenance operation to switch a process stream between two parallel banks of exchangers at the Tesoro refinery in Anacortes, Washington
Investigation Status
The CSB’s final report was approved 3-0 at a public meeting on May 1, 2014.
RECOMMENDATIONS
American Petroleum Institute (API)
Environmental Protection Agency (EPA)
Governor and Legislature of the State of Washington
Tesoro Anacortes Refinery
Tesoro Refining & Marketing Company LLC
USW Local 12-591
Washington State Department of Labor & Industries – Division of Occupational Safety and Health