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May 26, 1999

Fatal refinery fire investigation concluded with unprecedented $4.405 million compliance agreement

TUMWATER - The Department of Labor & Industries has concluded its six-month investigation into a fatal refinery fire in Anacortes last November with an unprecedented $4.405 million compliance agreement designed to make the Equilon-owned refinery safer and more healthful for workers. Equilon Enterprises is a joint operation of Shell and Texaco.*

Six workers died last November 25 as they were attempting to restart the delayed coking unit at the refinery following the previous day's power outage.

The tragic event marked the worst industrial catastrophe since the Department of Labor & Industries began enforcing the Washington Industrial Safety and Health Act (WISHA) more than 26 years ago.

The unique and innovative resolution to L&I's investigation of Houston-based Equilon was announced today by L&I Director Gary Moore at the agency's Mount Vernon service center.* The settlement, future-focused in approach, includes a record $1.1 million penalty, by far the largest monetary sanction ever levied as the result of a worker safety investigation in Washington.

The agreement is co-signed by the leadership of the Paper, Allied-Industrial, Chemical & Energy Workers International Union, Local No. 8-591.

Agreement highlights

In addition to paying the penalty and correcting deficiencies found in the investigation, Equilon agrees to:

  • Hire an independent consultant to conduct a comprehensive audit for compliance with process safety management requirements throughout the refinery.
  • Donate $1 million to the union's Fallen Worker Scholarship Fund in memory of the six workers.
  • Promote workplace safety and health beyond the refinery by donating $350,000 to the City of Anacortes for a new fire engine, and making an additional $1 million donation to an existing education organization within the state for the purpose of establishing a Workplace Safety and Health Institute.

Gov. Gary Locke lauded the innovative resolution to the investigation and its importance to the workers at the refinery.

"Nothing can ever replace the lives of the six workers or soften the loss to their families," Locke said. "This historic agreement also cannot guarantee that future tragedies will not occur. But it does take a giant and immediate first step toward a safer workplace at Equilon. Let this creative and significant enforcement action send a strong signal to all employers that workers' lives will not be compromised."

The six workers died Nov. 25, 1998, as the refinery was restarting operations following the storm that interrupted power and shut the refinery down the previous day. Two of the workers were employed by Equilon. The other four were employees of Western Plant Services, Inc., a subcontractor hired to remove coke from inside a large drum at the delayed coking unit where the fire occurred.

The delayed coking unit

The delayed coking unit is one step in the process of refining crude oil into petroleum products. The coking unit, basically consisting of two giant (six stories tall) pressurized steel drums, allows for the final extraction of vapors that are used to create gasoline, propane and other fuels. If there wasn't a coking unit at the refinery, the residual materials would have to be sold as bunker fuel.

The process involves a 16-hour cycle during which oil is heated to more than 900 degrees Fahrenheit and fed through a high-speed jet into one of the steel drums. The intense heat and pressure "crack" the oil into vapors that are siphoned off the top and piped elsewhere for processing. The leftover material crystallizes into a charcoal-like residue called petroleum coke. When the drum reaches capacity, the high-speed stream of heated oil is switched to the second drum.

The full drum is then cooled with water. Once the drum has cooled, a "safe work permit" system is used to turn the process unit over to a specialty contractor (Western Plant Services). The drum is then unsealed at the top and bottom, and the coke residue is cut with a high-pressure water drill and removed. The drum is then resealed, pressure tested and warmed up in preparation of another cycle.

Note: A graphic of the coking unit (in .pdf format) can be seen here

Incident details

A tragic series of events was put into motion in the early morning of Nov. 24, when a storm and high winds knocked out power, depriving the refinery of its ability to generate steam. Complicating matters was the fact that the refinery's only stand-alone steam boiler - the Erie City Boiler - had been taken out of service four months earlier.

The power outage occurred about one hour into the 16-hour process that fills the large drum with coke. The drum was about 16 percent full when the process was interrupted.

Although power was restored within two hours, the refinery's ability to produce steam, a critical component of the delayed coking process, was not restored until 10 hours later.

When steam was restored to the coking unit, refinery workers tried to clear the hardened material from lines and tubes to the partially filled drum, but were unsuccessful because of clogged lines. Although several attempts were made, data later indicated that little, if any, steam actually made its way into the drum.

Instead of the normal water-cooling process, Equilon decided on a major change, leaving the drum to cool by air for 37 hours. L&I investigators believe that it would have required 236 days for ambient air to cool the drum for safe removal of the material.

Workers then removed the drum's bottom to extract the coke, expecting a partially congealed mass of crude oil residue. Instead, they encountered a pocket of hot liquid fuel that broke through a crust of cooled material, rapidly poured from the drum and explosively ignited in flames as it was exposed to air. The flaming mass engulfed the two workers operating the controls and spewed off the second level of the unit, engulfing the four men below.

"There is nothing that we can say or do today that will make up for these needlessly lost lives," Moore said. "But we believe this agreement is the best result for the workers who remain at the refinery."


Equilon agrees to pay a $1.1 million penalty for two unclassified violations, essentially the administrative equilavent of a no-contest plea. First, Equilon violated worker safety requirements by:

  • Not adequately developing, reviewing and following procedures for the change from water cooling to ambient-air cooling the coking drum prior to its opening.
  • Not adequately following procedures to evaluate the change of conditions when the Erie City Boiler was taken out of service.
  • Not adequately training certain employees to deal with the potential danger of using a coke drum cooling procedure other than water cooling.
  • Not adequately training employees on the use of a coke drum cooling procedure other than water cooling prior to the opening of the drum on Nov. 25, 1998.
  • Not following current procedures for water cooling the coke drum prior to opening it on Nov. 25, 1998.
  • Not reviewing current operating procedures to reflect a change from the use of water cooling the coke drum. The consequences of deviating from the water cooling procedure were not reviewed during the most recent procedure reviewing process.

Secondly, Equilon failed to establish a system for promptly addressing a hazardous operations team's findings and recommendations. Additionally, the recommendations were not resolved in a timely manner. Specifically, certain safety items from a 1996 hazardous operations study on the delayed coking unit were not resolved in a timely manner.

Agreement details

The agreement culminated a six-month effort by a team of L&I safety inspectors and industrial hygienists who conducted dozens of interviews with witnesses, consulted technical experts and gathered more than 20,000 pages of documentation.

Moore, citing the team's comprehensive and thorough analysis of the facts, said the agency initiated the investigation with two goals.

"First, we wanted to find out what went wrong, " he said. "And secondly, we wanted to do everything within our power to ensure that employers meet their responsibility for providing safe and healthful workplaces. This needn't ever happen again.

"This agreement provides immediate benefit to Equilon workers and the workplace community as opposed to the uncertain outcomes that might eventually have resulted from a protracted legal battle had we proceeded with conventional enforcement."

The agreement is the largest monetary settlement ever reached by any state in a worker safety and health investigation. It also would rank among the top compliance agreements ever obtained by the federal Occupational Safety and Health Administration.

The agreement calls for Equilon to abate the identified deficiencies. The company has installed remote-controlled unheading (opening) equipment for the coking unit. The company said this was designed and installed at a cost of $575,000. The company also designed and installed, at an additional $30,000 cost, a natural gas backup system for purging the unit.

Other elements of the agreement, include:

Third-party consultant

Equilon agrees to hire an independent consultant to conduct a comprehensive audit of the refinery's compliance with L&I's Process Safety Management standard. L&I sees this as a key element of the agreement and a critical step toward making the Equilon refinery safer and more healthful for workers. The Process Safety Management standard and its requirements cover highly hazardous worksites, including refineries, because of the potential for fire, explosion or catastrophic release of highly hazardous materials. L&I and the union will receive quarterly progress reports from the consultant, including Equilon's plan and schedule to address the report. Equilon agrees to correct the deficiencies identified in the audit. The cost of the audit and responses to its findings will be at least $350,000.


Equilon agrees to donate $1 million to the union's Fallen Worker Scholarship Fund in memory of the six workers who needlessly lost their lives at the delayed coking unit. The fund will be administered by the union.

Safety and health improvements in the community

Equilon agrees to promote the establishment of programs to achieve lasting improvements in workplace safety and health beyond the refinery. Equilon will:

  • Donate $1 million to an existing educational organization within Washington to establish a Workplace Safety and Health Institute. The agreement calls for the parties to jointly identify the educational organization and then work with this organization to develop a governing structure and operating mission.
  • Donate $350,000 to the City of Anacortes Fire Department toward the purchase of a new ladder/pumper fire engine.

"The bottom line," Moore said in summary, "is that we believe this agreement gets us a long ways down that road toward making Equilon a safer and more healthful place for refinery workers to earn a living."

On-going investigations

In addition to the fatal fire investigation, L&I has four separate inspections in progress at the Anacortes site, involving Equilon or subcontractors. These inspections are a result of unrelated incidents since the fatal fire and involve other operations away from the delayed coking unit. These inspections are not affected by the agreement. They are on-going and in varying degrees of completion. Results will be available as the investigations are completed.

* This release was modified June 23, 1999 to clarify refinery ownership.


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