Incident Report

Subject:                  CSB Releases Safety Message Encouraging Industry to Spend more on Preventative Maintenance   

Date of Email report:   Wed 06/04/2011

Report Detail:


Washington, DC, April 1, 2011 – Marking the one year anniversary of the tragic accident at the Tesoro Refinery in Anacortes, Washington, the U.S. Chemical Safety Board (CSB) released a video safety message in which Chairperson Rafael Moure-Eraso urges refinery companies to “make the investments necessary to ensure safe operations,” concluding, “Companies that continue to invest in safety and recognize its importance will reap benefits far into the future.”  The video highlights the CSB’s ongoing investigation into the April 2, 2010, accident that killed seven workers. At the time of the incident a heat exchanger was being brought online when the nearly forty-year-old piece of equipment catastrophically failed, spewing highly flammable hydrogen and naphtha which ignited and exploded.  In the safety message CSB Chairman Moure-Eraso notes, “The Tesoro accident is only one of several fatal incidents that occurred in the oil and gas production and refining sector in 2010 alone. Serious incidents at refineries continue to occur with alarming frequency.”  The CSB’s safety message notes leading insurance industry statistics indicating that the US refining sector has more than three times the rate of property losses of refineries overseas.  Dr. Moure-Eraso urges companies to take action to prevent accidents, including: 

  • Implement a robust mechanical integrity programs with an emphasis on thorough inspections of critical equipment 
  • Monitor process safety performance using appropriate leading and lagging indicators to measure process safety before major accidents occur
  • Maintain an open and trusting safety culture where near-misses and loss of containment incidents are reported and investigated

The CSB is an independent federal agency charged with investigating serious 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. CSB’s final report including can be viewed at www.csb.gov.