Incident Report

Subject:                     Tesoro Anacortes Incident Citations

Date of Email report:   Tue 02/11/2010

Report Detail:

The final two findings in the citations will be of particular note to JOIFF members.  Ask yourself the question - are your fire-fighters participating in certified hot fire training and regular gun drills on site?  Is the training competence certified or simply attendance based?

Overview

• 2 parallel banks of 3 feed / effluent exchangers;
• SS lining in top shells and first 4’ of 2nd shells (spec break);
• 2nd shell on one bank (Unit E) failed in the carbon steel portion;
• the failure mechanism was high temperature hydrogen attack (HTHA)

Other Facts Inferred

• Inspections of shells was deferred beyond 10 years which did not meet internal procedures or code;
• there was history of S/U leaks on the flanges between hot shells – clamps installed;
• there were changes to the warm up piping used on start up (not clear what);
• it is not clear how warm up piping or start up procedures impacted the failure

Citation Overview

• $2.4 MM Penalty
• 44 Citations – 39 Willful, 5 Serious
• Willful Citations Avg Penalty is $60K - 97% of Penalty
• Tesoro plans to contest the citations

Willful Citations Summary

• Mechanical Integrity (15 citations)
• Inspection procedures did not follow RAGAGEP – 4 xers
• Failure to follow inspection procedures (2 procedures – 2 xers)
• Inadequate wet-mag inspection frequency – 4 xers
• Failures to correct MI deficiencies – warm up line, A/B & D/E xer companion flanges and temp clamps
• Operating Procedures/Operator Training (8 citations)
• Employees inadequately trained in op procedures
• Did not develop & implement written start up procedure
• MOC (7 citations)
• Op procedures changes for warm up line & s/u procedure, min limit on H2/oil change, mechanical clamps, corrosion awareness program changes
• PHA revalidation process excluded corrosion/MI review,
• inspection procedure not followed
• PHA (1 citations)
• PHA reval process not followed,
• Other (9 citations)
• Inadequate PPE – each of 7 persons killed
• Failure to update PSI,
• Failure to investigate incidents (related to leaks

Serious Citations Summary

• Did not ensure warm up lines were installed properly
• Did not ensure the E-6600 bellows assemblies were adequate for the service
• Did not ensure operators understood training on the E-6600 start up procedure
• Emergency responders did not coordinate all communications through the IC
• Fire Brigade member did not have live fire training or participate in drills