The CSB issues safety recommendations to prevent the recurrence or reduce the likelihood or consequences of similar incidents or hazards in the future. Recommendations are issued to a variety of parties, including government entities, safety organizations, trade unions, trade associations, corporations, emergency response organizations, educational institutions, and public interest groups. Recommendations are published in CSB reports and are closed only by vote of the Board. The CSB tracks all recommendations and communicates regularly with recommendations recipients to ensure that the recommended corrective actions are implemented.

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Tesoro Anacortes Refinery Fatal Explosion and Fire (1 Recommendations)
Tesoro Anacortes Refinery (1 Recommendations)
Open: 0% | Closed: 100%

Final Report Released On: May 01, 2014


Implement a process safety culture continuous improvement program at the Tesoro Anacortes Refinery
including a written procedure for periodic process safety culture surveys across the work force. The
process safety culture program shall be overseen by a tripartite committee of Tesoro management, USW
representatives, Washington State Department of Labor and Industries – Division of Occupational Safety
and Health, and the U.S. Environmental Protection Agency. This oversight committee shall:

a. Select an expert third party that will administer a periodic process safety culture survey;

b. Review and comment on the third party expert report developed from the survey;

c. Oversee the development and effective implementation of action items to address identified process safety culture issues; and

d. Develop process safety culture indicators to measure major accident prevention performance.

The process safety program shall include a focus on items that measure, at a minimum, willingness to
report incidents, normalization of hazardous conditions, burden of proof of safety in plant process safety programs and practices, and management involvement and commitment to process safety. The periodic process safety culture report shall be made available to the plant workforce. The minimum frequency of process safety culture surveys shall be at least once every three years.


Status: Closed - Acceptable Alternative Action
Closed - Acceptable Alternative Action (C - AAA)

PDF Document Recommendations Status Change Summary