Statement by CSB Chairman Rafael Moure-Eraso Commending Unanimous Board Approval of "Landmark" Tesoro Refinery Accident Investigation

May 2, 2014
In a public meeting yesterday evening in Anacortes, Washington, the U.S. Chemical Safety Board approved a detailed and comprehensive investigation report with critical safety recommendations concerning the tragic heat exchanger explosion and fire that took seven lives at the Tesoro refinery in Anacortes in April 2010. 
As chairman, I was pleased to be joined by my fellow board members Beth Rosenberg and Mark Griffon in unanimously voting for what I believe is a landmark report, which recommends extensive improvements to the way in which refineries are regulated at the federal and state levels.  
We took the action following a public presentation by the CSB investigation team on the report’s highlights and changes made as a result of public comments submitted on the draft report that we released on January 30, 2014. 
You are invited to read the full report here. As reported previously, we found an immediate cause of the tragedy to be long-term, undetected High Temperature Hydrogen Attack (HTHA) of the steel equipment, which led to the vessel rupture on the day of the accident and the massive release of highly flammable hydrogen and naphtha.  We found the industry’s standard for determining vulnerability of equipment to HTHA, to be inadequate.  We also found Tesoro’s safety culture to be lacking, which led to a complacent attitude toward flammable leaks and occasional fires over the years.  The CSB made strong recommendations in these areas to both the industry group which issues guidance on HTHA, the American Petroleum Institute, as well as to Tesoro.  
These findings – and similar ones we have made in other refinery investigations – have led us to recommend sweeping changes to the regulatory system. We are calling on the Environmental Protection Agency to revise rules in its Chemical Accident Prevention Provisions to require the use of inherently safer systems analysis and what are called the “hierarchy of controls” to the greatest extent feasible when facilities are establishing safeguards for identified process hazards.  While this recommendation is groundbreaking for a federal agency, the application of inherent safety is broadly accepted and has been applied in industry good practice guidelines for many years.
In the current regulatory framework, companies may identify a hazard such as HTHA - which is very difficult to identify via inspection and can lead to major process safety incidents with severe consequences such as the April 2, 2010, Anacortes incident - but they are not required to install materials that are resistant to HTHA. Until the EPA can make this change in the regulations, the board recommends the agency use its authority under the Clean Air Act’s General Duty Clause without delay.  We call on EPA to work with industry on this important reform, which will without doubt be instrumental in preventing catastrophic accidents. 
The goal is to reduce the risk of major accidents to “as low as reasonably practicable,” a concept abbreviated as ALARP.  The CSB recommends that the EPA require facilities to perform inherently safer systems analysis for all management of change, incident investigation, and process hazard analysis reviews and internal company safety recommendations, prior to the construction of a new process, process unit rebuilds, significant process repairs, and in the development of corrective actions. Workers and the public might be surprised to know that this is not currently a requirement in the chemical industry.  
We made similar wide-ranging reform recommendations to the governor and legislature of the State of Washington and the state’s chemical industry regulator, the Department of Labor and Industries – Division of Occupational Safety and Health: We call on them to augment the existing process safety management regulations for petroleum refineries in Washington with more rigorous goal-setting attributes.  
Currently, most federal and state regulations tend to require certain process safety activities, such as management of change and incident investigations, but in fact do not require actual risk reduction or continuous improvements as required company goals.  We think they should.
We call on the legislature and governor to enhance the regulatory system in the state of Washington, and to provide more resources to fund more and better compensated inspectors. The CSB recommends that Washington require refineries to develop comprehensive process hazard analyses (PHAs) which include a rigorous analysis of process hazards and their safeguards, documented rationale of safeguard effectiveness, documented damage mechanism hazard reviews conducted by a diverse team of qualified personnel, and documented use of inherently safer systems analysis and the hierarchy of controls.  
This more comprehensive PHA will be subject to review by the regulator. We also call on the state to ensure its regulator is technically qualified, and can thoroughly review the comprehensive PHAs and perform preventative audits and inspections.  In addition, workers and the public must have greater involvement in the prevention of major process safety incidents, and the CSB also recommends significant improvements in this area to the state of Washington.  
To the loved ones, friends and colleagues of the seven who perished from this terrible accident, and to other workers and communities elsewhere who endure chemical plant fires, explosions and releases, we dedicate the Tesoro investigation report now unanimously approved by our board. 
The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.
The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website,
For more information, contact Communications Manager Hillary Cohen, cell 202-446-8094 or Sandy Gilmour, Public Affairs, cell 202-251-5496. 
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