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“Safety culture deficiencies” by the refinery operator and state officials led to the 2010 explosion at an oil refinery in Anacortes, WA, a new report said.

Seven people died in the explosion and fire in the early morning hours of April 2, 2010 at the Tesoro facility in Anacortes. The investigation by the U.S. Chemical Safety Board (CSB) chronicles the deadliest oil refinery accident in the nation since 2005.

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Heat exchangers, located in the part of the plant which turns crude oil into gasoline, had been leaking for years and directly led to the fire, federal investigators said.

According to the report, the exchangers were in the process of turning back on after company workers cleaned them out, a task made more dangerous by the weak quality of the equipment.

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The CSB released a chilling animation that recreated the blast and fire. The five-minute video illustrates how the heat exchanger suffered damage and weakened over the years.

All of the fatally injured employees lacked fire retardant safety equipment, and Tesoro management accepted the leaking as part of the process, even though federal officials said they could have avoided the incident.

Tesoro ended up fined more than $2 million by Washington Labor and Industries, but federal investigators found issues with state officials as well. In addition, the families of the killed workers settled with Tesoro and Shell Oil for $39 million, according the families’ lawyer.

The CSB reported “significant gaps” in the competency of state investigators, citing frequent swaps with Tesoro over citations and fines in exchange for increased audits by the company. Those audits, the CSB wrote, are inadequate.

The CSB also uncovered “concerns” raised by the United Steelworkers Union prior to the accident with the heat exchangers.

Tesoro released the following statement in response to the report:
“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. The Company recognizes the public receipt of the CSB’s draft investigation report and acknowledges the efforts of CSB investigation teams, despite the significant and successive turnover in the agency’s assigned personnel over the years. 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.”

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