Catastropic rupture Heat exchanger Tesoro Anacortes

Accident Description of An explosion and fire that led to the fatal injury of seven employees when a nearly forty-year-old heat exchanger catastrophically failed during a maintenance operation to switch a process stream between two parallel banks of exchangers at the Tesoro refinery in Anacortes, Washington, USA.

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Significance score:

Clarity:

What are relevant lessons from others?

Target Group(s):

  • Otherwise
  • Policy makers
  • HSE managers
  • Maintenance managers
  • Educators
  • Operations managers
  • Operational leadership
  • Site managers
  • Strategic leadership
  • Tactical leadership
  • Supervisors

Risk Theme:

  • Risk | Control | Assurance - new risks
Category Publisher Maker Language

Incident onderzoek

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Chemical Safety Board (CSB)

English