Exchang­er E‑6600E, part of a bank that had kept run­ning while the oth­er one was down, had come apart and dis­gorged hydro­gen and a com­po­nent of crude oil called naph­tha, which ignit­ed. Moore called each of the sev­en work­ers on the radio and got no response. Thir­ty or 40 sec­onds lat­er he heard the strained voice of the crew’s fore­man, Lew Janz. ​“Lew said, ​‘Get some­one up here. We’re all dying.’”

Moore was mon­i­tor­ing the job by radio. ​“They were maybe two-thirds of the way to putting the bank online when I heard a noise from out­side,” he said. ​“I felt a tremen­dous vibra­tion in my feet,” fol­lowed by the whoosh­ing sound of ​“a match hit­ting a barbecue.”

Up the hill from Moore, in the Naph­tha Hydrotreater unit, sev­en work­ers were restor­ing to ser­vice a bank of heat exchang­ers — radi­a­tor-like devices , con­tain­ing flam­ma­ble hydro­car­bons, that had been gummed up by residue and cleaned. Most of the work­ers didn’t need to be there; it was, for them, a train­ing exercise.

Moore was mid­way through a 6 p.m.-to‑6 a.m. shift as an oper­a­tor at the Tesoro Corporation’s oil refin­ery in Ana­cortes, an island town 80 miles north of Seat­tle. It was 35 min­utes after mid­night on April 2, 2010.

The fol­low­ing is an excerpt of an arti­cle first post­ed by The Cen­ter for Pub­lic Integrity.

Mem­bers of the refinery’s first-respon­der team raced to the unit. They sprayed water on flam­ing, man­gled equip­ment and burn­ing bod­ies, which reignit­ed from the heat. Debris flew. The con­fla­gra­tion last­ed until 4 a.m.

Three of the work­ers died at the scene. Two more suc­cumbed to their injuries with­in hours. A sixth — Janz — sur­vived 11 days, a sev­enth 22. The Wash­ing­ton State Depart­ment of Labor & Indus­tries inves­ti­gat­ed and pro­posed a record fine against Tesoro, hav­ing found that it ​“dis­re­gard­ed a host of work­place safe­ty reg­u­la­tions, con­tin­ued to oper­ate fail­ing equip­ment for years, post­poned main­te­nance [and] inad­e­quate­ly test­ed for poten­tial­ly cat­a­stroph­ic dam­age.” The com­pa­ny has since set­tled law­suits filed by the fam­i­lies of the sev­en work­ers but is still appeal­ing the state cita­tion.

In a writ­ten state­ment, Tesoro said that while it dis­agrees with the Depart­ment of Labor & Indus­tries’ con­clu­sions, this ​“does not alter our focus on con­tin­u­al­ly learn­ing from inci­dents and improv­ing the safe­ty of our oper­a­tions.” Moore, now retired and in frag­ile health, takes a dark­er view. ​“They’ve fought every­thing tooth and nail,” he said, ​“and refused to take the blame for anything.”

There are 141 oil refiner­ies in the Unit­ed States. Where they are clus­tered — east and south of Hous­ton, south of Los Ange­les, north­east of San Fran­cis­co — they are prodi­gious sources of air pol­lu­tion and inflict a sort of low-grade mis­ery — rank odors, bright flares, loud nois­es — on their neighbors.

They also pose an exis­ten­tial threat, as evi­denced by the more than 500 refin­ery acci­dents report­ed to the U.S. Envi­ron­men­tal Pro­tec­tion Agency since 1994. The Ana­cortes dis­as­ter occurred five years after the BP refin­ery in Texas City, Texas, blew up, killing 15 work­ers and injur­ing 180. It came two years before a fire at the Chevron refin­ery in Rich­mond, Cal­i­for­nia, sent a plume of pun­gent, black smoke over the Bay Area, and five years before an explo­sion at the Exxon­Mo­bil refin­ery in Tor­rance, Cal­i­for­nia, near­ly unleashed a ground-hug­ging cloud of dead­ly acid into a city of almost 150,000 people.

These episodes and oth­ers call into ques­tion the ade­qua­cy of EPA and U.S. Depart­ment of Labor rules that have been in place since the 1990s. The for­mer is fin­ish­ing an update, due out in ear­ly 2017, that crit­ics say doesn’t do enough to safe­guard the pub­lic; the lat­ter is years away from float­ing a pro­pos­al to pro­tect workers.

The U.S. Chem­i­cal Safe­ty Board, an inves­tiga­tive body mod­eled on the Nation­al Trans­porta­tion Safe­ty Board, lists among its high­est pri­or­i­ties upgrades to process safe­ty — pro­ce­dures that can help pre­vent indus­tri­al fires, explo­sions and chem­i­cal leaks. The board, which makes rec­om­men­da­tions but has no reg­u­la­to­ry author­i­ty, has inves­ti­gat­ed 15 refin­ery acci­dents in its 19-year his­to­ry and just com­mit­ted to an inquiry into a Nov. 22 fire at the Exxon­Mo­bil refin­ery in Baton Rouge, Louisiana, that injured six work­ers, four crit­i­cal­ly. It has issued 112 refin­ery-relat­ed rec­om­men­da­tions, near­ly half of which have not been adopted.

“Under­ly­ing so many prob­lems in this indus­try is pro­duc­tion pres­sure,” board mem­ber Rick Engler said. ​“Shut­ting down part or all of a major refin­ing unit costs an enor­mous amount of mon­ey, so there are pres­sures not to do so from management.”

The board’s final report on Ana­cortes is an indict­ment of Tesoro’s safe­ty ethos: The bank of heat exchang­ers on which Lew Janz, Daniel Aldridge, Matthew Bowen, Kathryn Pow­ell, Dar­rin Hoines, Don­na Van Dreumel and Matthew Gum­bel were work­ing had a ​“long his­to­ry of fre­quent leaks and occa­sion­al fires” dur­ing start­up, inves­ti­ga­tors found. Tesoro ​“did not mon­i­tor actu­al oper­at­ing con­di­tions” of two of the exchang­ers, includ­ing the bad­ly degrad­ed one that rup­tured, ​“even though it would have been tech­ni­cal­ly fea­si­ble to do so.”

Tesoro could have redesigned the exchang­ers and auto­mat­ed start­up pro­ce­dures — things it did after the fact — so the sev­en work­ers would not have been in per­il, the board said.

Instead, Tesoro chose to tempt fate. It was a mind­set for­mer work­ers like Maria Redin had com­plained about for years.

“Very few peo­ple exer­cised their right to stop work because of peer pres­sure,” said Redin, who lives in Bel­court, North Dako­ta, and went by her mar­ried name, Maria Howl­ing Wolf, in Ana­cortes. When she, an oper­a­tor, would raise a con­cern, man­agers would ​“pat me on the head like a good lit­tle dog” and tell her not to worry.

Redin and her col­leagues used to say they worked at ​“God’s favorite refin­ery,” a wry ref­er­ence to the many close calls that some­how hadn’t end­ed bad­ly. This run of luck expired at 12:35 a.m. on April 2, 2010, when Redin, who had just gone to bed, heard the explo­sion. ​“I auto­mat­i­cal­ly assumed it was the refin­ery,” she said. ​“You could see the fire from my house. I knew they were going to need help.”

Redin got dressed and drove her pick­up truck to the main gate. Sent first to a break room where the sev­en work­ers’ belong­ings lay untouched, she next was dis­patched to the bot­tom of the hill on which the Naph­tha Hydrotreater unit was perched. Redin arrived by bicy­cle and went upstairs to an old con­trol room. There she saw Matt Gum­bel, a 34-year-old oper­a­tor with whom she had worked. His eye­lids had been burned off. His body smoldered.

“I didn’t even rec­og­nize him,” Redin said. ​“He was all swollen up and lay­ing on the floor with a blan­ket over him. He was naked. He was cooked, lit­er­al­ly cooked.”

Gum­bel began talk­ing. ​“He was telling me to tell his dad [Paul, who also worked at the refin­ery] he was fine. I said, ​‘Matt, you’re not OK. You look like shit.’ He kind of laughed and said, ​‘I know.’” The ban­ter con­tin­ued as para­medics tend­ed to Gum­bel and Redin held his hand. Even­tu­al­ly, it sub­sided. ​“I could tell he was going down,” Redin said.