SEATTLE -- A report released late Wednesday night into the 2010 explosion at an oil refinery in Anacortes concludes "safety culture deficencies" by the refinery operator and state officials contributed to the accident.
Seven people died in the explosion and fire in the early morning hours of April 2, 2010 at the Tesoro facility in Anacortes.
The investigation by the U.S. Chemical Safety Board chronicles the deadliest oil refinery accident in the nation since 2005.
Heat exchangers, located in the part of the plant which turns crude oil into gasoline, had been leaking for years and directly led to the fire, federal investigators said.
According to the report, the exchangers were being turned back on after being cleaned, a task made more dangerous by the weak quality of the equipment.
All of the fatally injured employees lacked fire retardant safety equipment, and Tesoro management accepted the leaking as part of the process, even though federal officials said it could have been avoided.
Tesoro was already fined more than $2 million by Washington Labor and Industries, but federal investigators found issues with state officials as well. In addition, the families of the killed workers settled with Tesoro and Shell Oil for $39 million, according the families' lawyer.
The Chemical Safety Board reported "signifigant gaps" in the competency of state investigators, citing frequent swaps with Tesoro over citations and fines in exchange for increased audits by the company. Those audits, the CSB wrote, are inadequate.
The results have some family members scratching their heads.
"You can't stop wondering how could this have been prevented," says Hershel Janz, father of Lew Janz who was killed in the blast.
"We have better regulations on cars and buildings all the time. Why can't we have better oversight with the refineries."
The CSB also uncovered "concerns" raised by the United Steelworkers Union prior to the accident with the heat exchangers.
Wednesday, the union hosted a private meeting with family members of the deceased to discuss the report, and a public event Thursday night where the CSB will present its findings to the community.
"There are unanswered questions for me," said Cory Bowen, who works at the Tesoro plant and lost his brother in the explosion, "We as humans aren't taught how to grieve. The grieving process for my family has been very difficult."