Last week, the Department of Labor & Industries released findings from its investigation of the April explosion at the Tesoro plant in Anacortes, which killed seven people.  L&I determined that the accident could have been prevented, and has issued a $2.39 million fine against Tesoro, citing the company for 39 “willful violations” and 5 “serious” violations of Washington state workplace safety and health regulations.  In an Oct 4th press conference, an agency spokesperson noted that, “While no amount of money can reflect the value of a person’s life, this is the largest fine in the agency’s history.”

Under state law, a “willful” violation occurs when an employer knowingly breaks a rule and exhibits an obvious indifference to correcting that violation; a “serious” violation is an incident involving a substantial probability of serious worker injury or death.

The accident occurred at Tesoro on April 2, 2010.  L&I concluded that the explosion was located in the refinery’s Naphtha Hydrotreater Unit, and occurred as workers were restoring a bank of 40-year-old heat exchangers into service after they had been shut down for maintenance. One of the heat exchangers ruptured, releasing hydrocarbon gas that quickly ignited.  Investigators determined that equipment was never tested in any way that would have indicated the problem.

L&I also found that for years, the exchangers had leaked extremely volatile and flammable vapor and liquid from its connections, particularly when the machinery was being started up or following a shutdown.  The company’s repair efforts, which included very simple clamps, were shockingly inadequate.  When these failed to correct the problem, Tesoro’s workers were forced to disperse the flammable vapors with tubes known as “steam lances” in order to try to prevent ignition. Employees carried out this hazardous work wearing hard hats, gloves, goggles and basic flame-resistant coveralls, which was insufficient protection for the hazards to which they were exposed.

According to the agency’s press release, “L&I inspectors found that Tesoro disregarded a host of workplace safety regulations, continued to operate failing equipment for years, postponed maintenance, inadequately tested for potentially catastrophic damage and failed to adequately protect their workers from significant risk of injury and death.”

Killing seven workers, the Tesoro explosion was the worst industrial tragedy since L&I began enforcing the state’s workplace safety law 37 years ago under the Washington Industrial Safety and Health Act.

Governor Chris Gregoire was among several officials to remark on the workplace accident and tragic loss of lives.  “The loss of seven lives is a tragedy not just for their loved ones but for our entire state. What makes the loss of these lives all the more painful is that these deaths could have been prevented,” she said. “I believe the action L&I is announcing today and the record fine they have assessed against Tesoro sends a clear message that these tragedies are not acceptable.”

Addressing a group of Seattle workers’ compensation attorneys,  Dr. Michael Silverstein—the assistant director of the Division of Occupational Safety and Health—reiterated the Governor’s remarks: “If Tesoro had tested their equipment appropriately and had followed their other safety requirements, we believe that they would have found the cracks that caused this explosion and, either by replacing the equipment or repairing it, prevented this from happening.”