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statistics

Total # of Recommendations
16
Total # of Open Recommendations
10
Total # of Closed Recommendations
6
Total % of Open 62 vs. Closed 38

Documents

   
Feb 27, 2017 PDF Document Response to Public Comments - CSB Responses to Public Comments
Aug 11, 2016 PDF Document CSB Safety Alert: Preventing High Temperature Hydrogen Attack (HTHA) - Related Safety Bulletin
The CSB’s investigation into the catastrophic failure of a forty-year-old heat exchanger at the Tesoro Refinery determined that the fatal explosion and fire was caused by a damage mechanism known as high temperature hydrogen attack, or HTHA, which severely cracked and weakened the carbon steel heat exchanger over time, leading to a rupture. The CSB’s report released in May 2014 concluded that the standard industry uses for determining vulnerability of equipment to HTHA is inadequate. To address its findings, the CSB made recommendations intended to prevent HTHA to the industry group that issues guidance on HTHA, the American Petroleum Institute (API). Because of these noted deficiencies, the Board voted on July 13, 2016, to designate the Recommendation 2010-08-I-WA-R10 with the status of Closed – Unacceptable Action. In the absence of industry guidance that incorporates findings from the Tesoro Anacortes failure, the CSB is issuing a safety alert to provide additional direction for industry.
May 02, 2014 PDF Document Final Investigation Report - Final Report
Mar 06, 2014 PDF Document Rafael Moure-Eraso Written Senate Testimony 3.6.14 - Congressional Testimony
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198,_TESORO_6600E_HEAT_EXCHANGER_E_SUMMARY_OF_THE_RESULTS__PART_6600-E_HEAT_EXCHANGER_E,_ALL_PARTS,_DAMAGE_DEPTH_AND_PART_17_MOUNTS_RE_(1)
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198,_TESORO_LS2_AND_LS2CS2_TEE_FINDINGS_PART_6600E_HEAT_EXCHANGER,_LS2_22_IN,_LS2_T2L_SEM_FRACTOGRAPHY_AND_PART_22_LS2-CS2_TEE
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_LS3_TOP_PART_6600-E_HEAT_EXCHANGER_LS_3_TOP_PART_15_Part 5
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_LS3_TOP_PART_6600-E_HEAT_EXCHANGER_LS_3_TOP_PART_15_Part 4
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_LS3_TOP_PART_6600-E_HEAT_EXCHANGER_LS_3_TOP_PART_15_Part 3
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
ETA_LAB_NO.M10198-_LS3_TOP_PART_6600-E_HEAT_EXCHANGER_LS_3_TOP_PART_15_Part 2
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_LS3_TOP_PART_6600-E_HEAT_EXCHANGER_LS_3_TOP_PART_15_Part 1
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10329,_TESORO_EXCHANGER_E6600B_EXAMINATION_DATA_PARTS_6600B_HEAT_EXCHANGER,_PARTS_1B,_2B,_AND_3B
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10329-B,_TESORO_EXCHANGER_E6600-B_EXAMINATION_DATA_PARTS_E6600B_HEAT_EXCHANGER,_PARTS_1B,_4B,_AND_5B
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-02_PART_6600-E_HEAT_EXCHANGER_CS4_PART_19___20_Part 4
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO_M10198-_LS2-CS3_TEE_INDICATIONS_PART_6600-E_HEAT_EXCHANGER_LS2-CS3_TEE_INDICATIONS_PART_16-1_Part 5 of 5
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
ETA_LAB_NO_M10198-_LS2-CS3_TEE_INDICATIONS_PART_6600-E_HEAT_EXCHANGER_LS2-CS3_TEE_INDICATIONS_PART_16-1_Part 4 of 5
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
ETA_LAB_NO_M10198-_LS2-CS3_TEE_INDICATIONS_PART_6600-E_HEAT_EXCHANGER_LS2-CS3_TEE_INDICATIONS_PART_16-1_Part 3 OF 5
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO_M10198-_LS2-CS3_TEE_INDICATIONS_PART_6600-E_HEAT_EXCHANGER_LS2-CS3_TEE_INDICATIONS_PART_16-1_Part 2 OF 5
Feb 18, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
Uploading BETA LAB NO M10198- LS2-CS3 TEE INDICATIONS PART 6600-E HEAT EXCHANGER LS2-CS3 TEE INDICATIONS PART 1 of 5
Feb 13, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA Lab No-M10198 6600-E Heat Exchanger E, Summary of Results and Part 17 Mounts Evaluation (6600-E)
Feb 13, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198,_TESORO_LS2_AND_LS2CS2_TEE_FINDINGS_PART_6600E_HEAT_EXCHANGER,_LS2_22_IN,_LS2_T2L_SEM_FRACTOGRAPHY_AND_PART_22_LS2-CS2_TEE_
Feb 13, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
ETA_LAB_NO_M10198-_LS3_TOP_PART_6600-E_HEAT_EXCHANGER_LS_3_TOP_PART
Feb 13, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO_M10198_TESORO_6600E_HEAT_EXCHANGER_E_SUMMARY_OF_THE_RESULTS__PART_6600-E_HEAT_EXCHANGER_E_ALL_PARTS_DAMAGE_DEPTH_AND_PART_17_MOUNTS_
Feb 13, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198,_TESORO_LS2_AND_LS2CS2_TEE_FINDINGS_PART_6600E_HEAT_EXCHANGER,_LS2_22_IN,_LS2_T2L_SEM_FRACTOGRAPHY_AND_PART_22_LS2-CS2_TEE
Feb 13, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10329,_TESORO_EXCHANGER_E6600B_EXAMINATION_DATA_PARTS_6600B_HEAT_EXCHANGER,_PARTS_1B,_2B,_AND_3B
Feb 13, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
PARTS: E6600B HEAT EXCHANGER, PARTS 1B, 4B, DATE: MARCH 8, 2011 AND 5B
Feb 12, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-02_PART_6600-E_HEAT_EXCHANGER_CS4_PART_19___20_Part 5 of 5
Feb 12, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-02_PART_6600-E_HEAT_EXCHANGER_CS4_PART_19___20_Part 4 of 5
Feb 12, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-02_PART_6600-E_HEAT_EXCHANGER_CS4_PART_19___20_Part 3 of 5
Feb 12, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
ETA_LAB_NO.M10198-_CS4-02_PART_6600-E_HEAT_EXCHANGER_CS4_PART_19___20_Part 2 of 5
Feb 12, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-02_PART_6600-E_HEAT_EXCHANGER_CS4_PART_19___20_Part 1 of 5
Feb 12, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-01_LS3_BOTTOM,_REV._1_PART_6600-E_HEAT_EXCHANGER_CS4_01BOTTOM_PART_1814_Part 5 of 5
Feb 12, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-01_LS3_BOTTOM,_REV._1_PART_6600-E_HEAT_EXCHANGER_CS4_01BOTTOM_PART_1814_Par 4 of 5
Feb 12, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-01_LS3_BOTTOM,_REV._1_PART_6600-E_HEAT_EXCHANGER_CS4_01BOTTOM_PART_1814_Part 2 of 5
Feb 09, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-01_LS3_BOTTOM,_REV._1_PART_6600-E_HEAT_EXCHANGER_CS4_01BOTTOM_PART_1814_Part 1 OF 5
Feb 08, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-01_LS3_BOTTOM_PART_6600-E_HEAT_EXCHANGER_CS4_01BOTTOM_PART_1814_Part 6 of 6
Feb 08, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-01_LS3_BOTTOM_PART_6600-E_HEAT_EXCHANGER_CS4_01BOTTOM_PART_1814_Part 5 of 6
Feb 08, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-01_LS3_BOTTOM_PART_6600-E_HEAT_EXCHANGER_CS4_01BOTTOM_PART_1814_Part 3 of 6
Feb 08, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-01_LS3_BOTTOM_PART_6600-E_HEAT_EXCHANGER_CS4_01BOTTOM_PART_1814_Part 4 of 6
Feb 08, 2014 PDF Document Beta Laboratory Reports (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA_LAB_NO.M10198-_CS4-01_LS3_BOTTOM_PART_6600-E_HEAT_EXCHANGER_CS4_01BOTTOM_PART_1814_Part 2 of 6
Feb 08, 2014 PDF Document Beta Laboratory Report (Appendix H) - Beta Laboratory Reports (Appendix H)
BETA LAB NO.M10198 CS4-01_LS3_BOTTOM_PART_6600-E HEAT EXCHANGER CS4 01BOTTOM PART 814 Part 1 of 6 documents
Feb 07, 2014 PDF Document Beta Laboratory Report (Appendix H) - Beta Laboratory Reports (Appendix H)
TESORO 6600E EAT_EXCHANGER E SUMMARY OF THE_RESULTS PART 6600-E HEAT EXCHANGER
Feb 07, 2014 PDF Document Beta Laboratory Report (Appendix H) - Beta Laboratory Reports (Appendix H)
TESORO 6600E HEAT EXCHANGER E SUMMARY OF THE RESULTS PART 6600-E HEAT EXCHANGER E, ALL PARTS, DAMAGE DEPTH AND PART 17 MOUNTS
Feb 05, 2014 PDF Document Beta Laboratory Report (Appendix H) - Beta Laboratory Reports (Appendix H)
6600 E Heat Exchanger
Feb 05, 2014 PDF Document Beta Laboratory Report (Appendix H) - Beta Laboratory Reports (Appendix H)
660 E Heat Exchanger
Feb 05, 2014 PDF Document Beta Laboratory Report (Appendix H) - Beta Laboratory Reports (Appendix H)
6600 E Heat Exchanger
Feb 05, 2014 PDF Document Beta Laboratory Report (Appendix H) - Beta Laboratory Reports (Appendix H)
6600 E Heat Exchanger
Feb 04, 2014 PDF Document Appendix J - Appendix for Tesoro Report
Additional HTHA Evaluation Report
Feb 04, 2014 PDF Document Appendix G - Appendix for Tesoro Report
Spectrum Inspection Reports
Feb 04, 2014 PDF Document Appendix A - Appendix for Tesoro Report
AcciMap Causal Analysis
Feb 04, 2014 PDF Document Appendix I - Appendix for Tesoro Report
Metallurgical Review
Feb 03, 2014 PDF Document Presentation from 1.30.2014 Public Listening Session - Public Listening Session Presentations
Jan 29, 2014 PDF Document Tesoro Draft Report for Public Comment - Draft Report for Public Comment
Results: 55 Records found.
 
 
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