Investigation Report
Tesoro Anacortes Refinery Fatal Explosion and Fire
Tesoro Anacortes Refinery Fatal Explosion and Fire
- CSB
- Investigation Report
- ExplosionHot Work and FireProcess Safety
- Hydrogen safetyLeadership and safety cultureProcess safetyRegulation and legislationStructural and asset integrity
- Inspection and maintenance
- Pressure vesselValve
- Management of changeNon-destructive testingOperating and work proceduresRisk assessment
- Downstream and process industries
Summary
Investigation of the Tesoro Anacortes refinery heat-exchanger rupture that killed seven employees. Metallurgical analysis identified high temperature hydrogen attack in carbon steel. Process modelling, inspection limitations and Nelson curves are examined alongside hazardous startup practices, ineffective safeguards, safety culture and regulatory gaps. Recommendations emphasise inherently safer materials and verified operating conditions.
Classifications: Hydrogen safety.
Classifications: Leadership and safety culture; safety culture; safety leadership.
Classifications: Process safety; major accident hazards.
Classifications: Regulation and legislation; safety legislation; regulatory requirements.
Classifications: Structural and asset integrity; asset integrity; structural integrity.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Pressure vessel; pressure vessels.
Classifications: Valve; valves.
Classifications: Management of change; MOC; change management.
Classifications: Non-destructive testing; NDT; non-destructive examination; NDE.
Classifications: Operating and work procedures.
Classifications: Risk assessment; hazard assessment.
Classifications: Downstream and process industries; refining; petrochemicals.
Themes: explosion, hot work and fire, process safety.