JUDY SCHURKE
Morning everyone.  We thank you for joining us to day at the Labor and industries Mt Vernon office. My name is judy Schurke and I am the director of Labor and Industries. We’re here today, as you know, because of the tragic April 2, 2010 explosion at the Tesoro Refinery in Anacortes, just a few miles from here. Seven workers died that day.  Five men and two women ages 29 to 50. All of them members of the Tesoro refinery family and known and loved by people in this community.  They were:  Mathew Bowen, Darrin H____, Danielle Aldridge, Katy Powell, Donna Van Drummel, Lou Jans, and Matt Gumbel.  

It was a sad and terrible day in our state. These seven lives were lost, but scores of friends, family and coworkes had their lives completely changed as a result fo this incidient.  Last week we conducted our investigation, closing conference with Tesoro, provided them with information about our investigation.  Just before this press conference we spent just about an hour and half with the families of the victims of this disaster, to share with them the results of our investigation.  I would like to let you know that I am deeply moved by loss that they continue to suffer, as a result of this incident. 

In April when this disaster happened, I said that Labor and Industries would take a hard look at the circumstances fo this explosion and determine if any work place safety and health practices ere violated.  We have completed our investigation and found numerous violations. The bottom line is this incident, the explosion and these deaths were preventable. With me today is Dr. Michael Silverstein, the Assistant Director of Division of Occupational Safety and Health, to explain what we found during our investigation in more detail.  For those of you who are less familiar with labor and industries we function as OSHA for Washington state and inforce all work place safety and health regulations. Our safety and health division has the job of investigating work place complaints, fatalities, hospitalizations and doing routine inspections. In addition to Dr. Silverstien, some of our investigation team is here today.  Chris Vanek, was our lead investigator on the case.  Chris is sitting back there in the white shirt.  Bob Parker, our compliance manager for this region, as is David Puente our state wide compliance manager. Also wendy Drapeau and Eric Wiseman.  Now I would like to turn over the podium to Dr. Silverstein. 

MICHAEL SILVERSTEIN
Thank you Judy and good morning. After six months of a very thourough safety and health investigation, one conclusion stands out among all the others. The seven deaths caused by the Tesoro explosion, the morning of April 2, 2010 could have been prevented and should have been prevented. We’ve cited Tesoro 39 willful violations and five serious violations of work place safety and health rules. We classify safety and health violations in several categories. The willful violations are the most significant category. They are those employers who have knowingly disregard for or to, or plainly ________ the requirements.  A serious violations are those where willfulness was not demonstrated but were nonetheless there was a signfican probability of death or serious injury.  In summary our investigations found the following:

First, Tesoro did not test and inspect aging equipment in accordance with its own policies. And with the industries recognized, and generally accepted engineering practices. This equipment had been weakened by forty, nearly forty years of exposure to chemical and physical stresses resulting in cracks. Cracks in the metal that could have been discovered with proper testing that had not been done in more than ten years. Well over a long history of significant leaks had not been corrected and had instead workers were assigned to work in that danger zone with inadequate training inadequate workers comp. We have fined Tesoro $2.39 million dollars. A figure that does not in anyway represent the value of human life. But nonetheless, is the hgihtest penalty our agency has ever issued for work place safety and health violation. Over the coming weeks expect to differ with Tesoro in our discussions about the causes of and the responsibility of the explosion. However we are not going to let these differences stand in the way of working together, as best we can with Tesoro and with the united steel workers and with the refineries workers to improve their refinery safety and health program so they can begin again safely, as soon as possible. We share with Tesoro, we believe, and the united steel workers, to take care of every possible step so a catastrophy of April 2nd will not be repeated. And we understand that Tesoro has already been taking steps in this direction, and we look forward to ongoing discussions with the company and the union about these new measures. As a matter of fact we will be meeting again with Tesoro management at 2:30pm this afternoon to try to get some momentum going in this regard. 

What I want to do now is explain in a little more detail in how we got to this point.  The refinery of course has been around for many years. Shell built it in 1955, and Tesoro bought it and took over operations in 1998. When in operation, Tesoro processes about 120 or 130 thousands barrels of crude oil a day. It’s the third largests production of the five refineries in the state of Washington. Part of the refinery process, leading to high octaine fuels, requires that nafta, that is a high and involitible oily liquid, gets treated with hydrogen in order to remove sulfur and other contaminates. This hydragent treating takes place in an area call the nafta treater unit. And that is the blackened area in the photography here to my left, that was taken shortly after the explosion,. You can see the bigger picture that gives an overview of the whole area, which by the way is just a small fraction of the entire refinery. But you can see in the middle of the bigger picture the blackened area, and in the inset is a more closer picture of the nafta hydro unit. The heat exchangers, including the one that blew apart on April 2nd are right in the middle of this blackened area here.  The hydrogen treating process, heats the nafta to very high temperatures and then reduces it back down.  And this temperature control takes place in a group of six heat exchanges, in two stacks of three. You can see on my right an illustration of the six heat exchangers. As you can see on this illustration there are two b___ of three. These a, b, & c, and these d,e, and f operate as two units. Each one of the heat exchangers is a cylinder about 30ft long, that’s made of steel, with a bundle of tubes on the inside you can see here. The nafta gets treated with hydrogen and then it passes through these heat exchangers twice. The first time is coming in this direction and going through the tubes on the inside and going to one vessel to the next and going up, and then out this way to a furnace and reactor where the temperature is raised even higher. And then before the nafta can go onto the rest of the refinery it has to cool back down a bit. So it passes back down into the same heat exchangers to the outer shell. And it moves down this way and out here to the next unit. In overly simplified since, the heat exchanges function very much like a radiator on your car. Periodically Tesoro would shut down one of the two banks for maintenance and cleaning and then bring it back up to the proper temperature and pressure. In the abc exchangers, these, had been cleaned in march 2010. And on april first and the early morning of april 2nd they were being brought back into service. As that happened the temperature and the pressure in these vessels was rising. And it was rising faster and with more force than Tesoro policies allowed. There was, we know now, an unplanned spike in the temperature and pressure in the E exchanger. Shortly before it blew apart at its welded seems with incredible force. At the time of the blast there were eight people involved in the start up process. One of them was an manager operating a control board in a protected room who survived. The other seven, all those who died, were stationed in and around these heat exchangers. Our department, labor and industries began investigation immediately. Oru regional compliance manager bob parker was on site within a couple of hours and we put together a full team very quickly. In the past six months our inspectors have interviewed dozens of employees, they have reviewed thousands, tens of thousands of documents, diagrams, technical designs and drawings and visited the site numerous times. The b and e exchangers, these two, the one that exploded and its pair.  The b and e exchangers were sent to an independent testing laboratory in Ohio, where they were dismanteled for specialized metical testing. And those tests, as long as some that were done on site. Before they were sent to the lab in Ohio. These tests showed cracks, physical cracks along several of the welds in the e exchanger. And showed that the rupture occurred along those crack lines, along those weakeend areas.  And you can see in the diagram here that this pressure vessel blew apart in the longitudinal direction and then in the direction of the its circumfrance. Opened up this heavy gauge steel, opened it up like fish mouth. And as it did that, it spewed out volatile liquids and vapors that exploded immediately, caught fire and killed seven workers. The heat exchanger that blew apart, this e exchanger, had been subjected to nearly 40 years of stress from extreme heat, pressure and chemical exposures.  Its well known in the refinery industry that this can cause steel to become brittle and can cause cracks in other forms of damage. The heat exchangers become more vulnerable due to swings in temperature and pressure, making a sudden rupture more likely as the years go by. There are a number of tests that are required by state safety regulations, required by engineering industry practices, and more importantly by Tesoro’s own policies. That would have revealed cracks in the e exchanger before it exploded. But the last time Tesoro tested the e exchanger with a specific type of testing that would have revealed the cracks was back in 1998. And even that testing was not done on the most vulnerable part of the heat exchanger. Now Tesoro did have plans to inspect for cracks again in 2008, but that was never done. If they had, we believe they would have found the cracks that caused this explosion. They would have repaired the vessel or replaced it. And they would have prevented this horrible incident from ever happening. In addition to trying to understand why the heat exchanger ruptured. It was really important for us to try and understand why it was there were seven workers in the danger zone early that morning, late that night, early that morning. After all if they had not been there we would be talking about propery damage not the loss of lives. What our inspectors discovered is the heat exchangers had a long history of leaking flamible liquids and vapors from the various flanges, valves, gaskets and other components. That leaking was particularly true during the start up periods. Tesoro had over the years tried to successfully stop those leaks, but ultimately accepting them as inevitable, Tesoro workers with pieces of equipment called steam lances, basically hose type apparatuses, that directs steam so it can dispurse leaks of material as they occur. We found that those workers would be positioned around those heat exchangers waiting for leaks. In addition, although Tesoro policy called for a slow increase in temperature and pressure during the start up process. It had become the practice to speed things up in an effort to reduce the leaks. This not only subjected the heat exchangers to added thermal stress during the start up process but it also required some workers to go into the danger zone to turn some of the valves necessary to raise the temperature and pressure. In the explosions aftermath investigators discovered steam lines in charged with steam (17:07)