On April 2, 2010, a catastrophic fire occurred within the naphtha hydrotreating unit in the Tesoro refinery in Anacortes, Washington. The final CSB report, including recommendations, was issued in May 2014, more than four years after the incident that resulted in the tragic loss of seven lives. This work critically reviews the CSB analysis of this incident and several of its resulting recommendations.
On April 2, 2010, a catastrophic fire occurred within the naphtha hydrotreating unit in the Tesoro refinery in Anacortes, Washington. An internal investigation by Tesoro personnel was issued on July 21, 2011.1 The US Chemical Safety Board (CSB) released a draft report for public comments in January 2014. The final CSB report, including recommendations, was issued in May 2014, more than four years after the incident that resulted in the tragic loss of seven lives.2
The resulting CSB recommendations will improve industry safety performance only if the true root causes of the incident are discovered, and if appropriate recommendations are developed and implemented by other sites. This work cri
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