The city of Anacortes – population about 16,000 – sits on shores of Fidalgo Island, the eastern-most island in the San Juan archipelago, the string of islands clustered off the northwest coast of Washington State. Located at the western end of Skagit County, known regionally for its agriculture, Anacortes’ petrochemical plants – Tesoro and Shell refineries and a chemical plant recently acquired by the Canadian company ChemTrade — together make up the city’s largest single-industry employer. On a rainy January evening, smoke plumes from these plants that sit near the water’s edge merge with low-hanging clouds above the bay.

On April 2, 2010, at 12:30 a.m., a heat exchanger in the Naptha Hydrotreater unit at Tesoro’s Anacortes petroleum refinery ruptured catastrophically, causing an explosion and fire that killed seven Tesoro employees: Daniel J. Aldridge, Matthew C. Bowen, Darrin J. Hoines, Matt Gumbel, Lew Charles Janz, Kathryn Powell, and Donna Van Dreumel. The workers had been in the final stages of preparing to restart the unit’s heat exchangers after several had been shut down for cleaning. The highly flammable hydrogen and naptha that were released at temperatures above 500ºF ignited explosively and burned intensely for more than three hours.

The US Chemical Safety Board (CSB) draft final report investigating the incident, released to the public the evening of January 29, 2014, concludes that several factors set the stage for the disastrous event:  severely cracked and degraded equipment that resulted in frequent leaks of flammable liquid and occasional fires; weak industry standards; a deficient refinery safety culture and an inadequate oversight and regulatory system.

Specifically, the CSB investigation found that a type of damage known as High Temperature Hydrogen Attack (HTHA) created cracks and fissures in the heat exchanger’s carbon steel that eventually caused the catastrophic break. The CSB report faults the American Petroleum Institute (API) standards that allowed such equipment to remain in use and notes the technical difficulties of inspecting for HTHA damage. Such inspection is, says the CSB, low in the hierarchy of controls – the tiered priority of safety measures – and that inherently safer design is the best approach to preventing HTHA.

The report also faults Tesoro and the refinery’s previous owner, Shell Oil, for inadequate implementation of safeguards that could have identified hazards and protected against HTHA and subsequent equipment failure. Instead of making changes that would have averted these problems, CSB said the refinery responded to them with procedures that exacerbated the potential for danger. The report additionally points to deficiencies in Washington state’s resources for oversight as well as inadequacies in US federal regulations that allow such problems to persist without correction.

CSB recommendations of what’s needed to prevent such incidents from occurring include: revision of API standards for equipment susceptible to HTHA and requirements for use of inherently safer design; revision of the US Environmental Protection Agency’s (EPA) Chemical Accident Prevention Provisions to require the documented use of inherently safer systems; improved oversight by Washington State and implementation of a process safety culture program at the Tesoro Anacortes Refinery that includes third-party oversight.

“This incident could have been prevented,” said CSB lead investigator Dan Tillema, presenting the report at a public meeting held to present the report in Anacortes on January 30, 2014.

Report finalization postponed

When first announced, the January 30 meeting – held in the Anacortes High School auditorium – was to include a vote by the CSB board that would finalize the CSB report on the incident and the agency’s recommendations to prevent similar problems in the future. But a week before the meeting, the CSB announced that instead of a CSB Board vote on the 30th, the draft final report would be released for a 45-day comment period and the meeting would be a “public listening session.”

While this may seem like an arcane detail, it was clear from the comments voiced by community members in Anacortes on January 30th that they were not happy the that nearly four-year long CBS investigation process would be prolonged.

“I’m very frustrated… by how long it’s taken,” said Steve Garey, machinist and President of United Steelworkers (USW) Local 12-591. According to USW members at the January 30th meeting, the majority of refinery workers in Anacortes are represented by United Steelworkers Local 12-591. “The owner operators have the responsibility to manage a safe workplace…they have that responsibility regardless of how capable the regulators are,” Garey said. “The entire industry is not doing what they should be doing…that’s why we had seven killed at Tesoro, that’s why we had 15 killed at Texas City eight years ago, that’s why we had 11 killed in the Gulf of Mexico…”

“Seven families were devastated,” said Ryan Anderson, a maintenance employee at the Tesoro Anacortes refinery. “Our community was devastated. For almost four years we’ve waited for a final CSB report. We’re still waiting,” he said.

USW safety and health specialist Kim Nibarger, who came from Pittsburgh to attend the meeting, called the change “troubling.”

In their remarks, USW and other community members asked CSB to return to Ancortes to hold the final vote on the investigation report. CSB director Rafael Moure-Eraso made no promises but explained that all public comments would be taken into consideration, and would be used to improve the report before it is finalized. “You are the most important stakeholders,” he told those gathered in Anacortes on January 30^th.

Worth noting is that the CSB, the independent federal agency tasked with investigating industrial chemical accidents, is chronically under-resourced. As West Virginia Senator Jay Rockefeller noted in a press release issued as the CSB began to investigate the January 2014 Freedom Industries chemical leak, “the agency’s proposed 2014 budget was slashed by the Republican-controlled House of Representatives earlier this year,” cutting nearly $2 million from the CSB’s roughly $11 million budget. The CSB currently has more than a dozen investigations underway and a staff of about 40.

Ongoing safety concerns

Until the report is finalized, the CSB’s recommendations are also not final. If implemented, those in the Tesoro Anacortes report could make significant improvements in refinery safety, not just at the Tesoro facility but at refineries across the country. As many who spoke in Anacortes on the night of January 30^th made clear – as does the CSB report – without these changes, workers at refineries nationwide may well be working under conditions with hazards similar to those present at the Tesoro Anacortes refinery on April 2, 2010.

“We’re still getting hurt out there,” said Maria Howling Wolf, a Tesoro Anacortes employee who vividly recounted the day of the catastrophe as it unfolded.

Families of six of the workers killed brought a wrongful death suit against Tesoro and the Shell Oil Company, the previous owner of the Tesoro refinery, that was settled in December 2013 for a reported $39 million. Tesoro has also been fined a record $2.39 million by the Washington Department of Labor and Industries, which cited Tesoro for 39 “willful” and five “serious” violations of state health and safety standards. Tesoro is appealing the Washington state fine and has, in a preliminary ruling, been granted a judgment potentially reducing the $2.39 million fine to $858,500. A previous OSHA investigation opened in 2008 found 17 serious violations but in negotiations 14 were “deleted” and the penalty fine reduced from $85,700 to $12,250.

Speaking at the January 30^th meeting, API representative David Miller said his industry is “committed to continuous improvement” and has a “long history of safe operation” and that “no incident is acceptable.”

Tesoro said in a statement sent the next day: “Tesoro deeply regrets the incident of that day. Our thoughts and prayers remain with the families and friends of our seven co-workers who lost their lives.” Tesoro said the company “acknowledges the efforts of the CSB investigation teams” but said, “We respectfully disagree with several findings in the draft report and, most importantly, take exception to CSB’s inaccurate depiction of our process safety culture. However, despite any disagreements regarding the draft report, Tesoro anticipates discussing the CSB’s recommendations with the agency once the report is finalized and will consider them in light of the steps we have taken and are continuing to take to improve the safety of our facilities.”

Speaking after the meeting, USW member Gaylen Prescott expressed concern about ongoing management pressure to keep the employee numbers down and resulting work loads and hours that can erode workplace safety. “We relied on hope and luck,” said USW Local 12-591 member George Welch in his comment for the record.

Toward the end of the January 30th meeting’s public comment period, an older man stood to speak. “My name is Eustus Ken Powell,” he said. “My daughter was one of the ones who was killed …my life was forever changed.”

The draft final CSB report is open for comment until March 16, 2014.

Elizabeth Grossman is the author of Chasing Molecules: Poisonous Products, Human Health, and the Promise of Green Chemistry, High Tech Trash: Digital Devices, Hidden Toxics, and Human Health, and other books. Her work has appeared in a variety of publications including Scientific American, Yale e360, Environmental Health Perspectives, Ensia, The Washington Post, Salon and The Nation.