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CSB Investigation Report No. 2010-05-I-WA 2010 Safety Safety
Tesoro Anacortes Refinery Heat Exchanger Rupture
Tesoro Anacortes Refinery, Washington
Related equipment → Shell-and-tube heat exchanger (shell_tube_heat_exchanger)
7Fatalities
0Injuries
Corrosive ruptureMechanism code STD
⌗Failure Mode · ISO 14224 Mapping
Damage mechanism (recorded in KB)
Corrosive ruptureSTD
ISO functional code (as recorded)
ISO 14224:2016 functional failure code
STD · Structural failure
ISO STD — Structural failure.
1What Happened

Naphtha hydrotreater heat exchanger (E-207) catastrophic rupture (shell-side corrosion / thermal fatigue)

2Root Cause

Undetected shell-side corrosion of exchanger + design did not consider shell-side integrity

3Reliability Lessons (from investigation root cause)
  • Undetected shell-side corrosion of exchanger
  • design did not consider shell-side integrity
4Associated Failure Mechanisms (Keywords)
tube bundle shell crack corrosion thermal fatigue rupture leak wall thinning
About the Failure-Mode Code (click to expand)

The recorded code STD is an ISO 14224:2016 functional failure code (describes what the equipment failed to do). The damage mechanism (how it failed) is shown in the Mapping block above. The two are distinct dimensions in ISO 14224.

5Evidence Source (transparent)
Authority：U.S. Chemical Safety and Hazard Investigation Board (CSB)
Official Report：www.csb.gov ↗
Data Verification：verified_url_csb_sitemap
↗Related Failure Modes · Traceability
Fouling/Plugging fouling_pluggingCorrosion Thinning corrosion_thinningErosion erosionStress Corrosion Cracking (SCC) sccFlow-induced Vibration Fatigue (Tube) flow_induced_vibration_fatigueExpanded Joint Leak expanded_joint_leakTube Sheet Corrosion tube_sheet_corrosionTube Hole Enlargement tube_hole_enlargementCladding Disbonding cladding_disbondingPartition Leak partition_leakChannel Flange Leak channel_flange_leakShell Internal Corrosion / Erosion fmShell Crack fm_2Baffle Corrosion / Wear -> Loss of Tube Support fm_3Baffle Vibration Fatigue fm_4Fatigue Cracking fatigue_crackingCorrosion Thinning fm_5Gasket Aging / Creep -> Leak fm_6Improper Gasket Installation fm_7Bolt Relaxation bolt_relaxationBolt Corrosion fm_8Valve Internal Leak fm_9Blockage fm_10Relief Valve Set-pressure Drift fm_11Valve Seat Leak fm_12Inlet Line Blockage fm_13Sensor Drift fm_14Loose Wiring / Terminals fm_15Fouling/Plugging fouling_pluggingCorrosion Thinning corrosion_thinningErosion erosionStress Corrosion Cracking (SCC) sccFlow-induced Vibration Fatigue (Tube) flow_induced_vibration_fatigueExpanded Joint Leak expanded_joint_leakTube Sheet Corrosion tube_sheet_corrosionTube Hole Enlargement tube_hole_enlargementCladding Disbonding cladding_disbondingPartition Leak partition_leakChannel Flange Leak channel_flange_leakShell Internal Corrosion / Erosion fmShell Crack fm_2Baffle Corrosion / Wear -> Loss of Tube Support fm_3Baffle Vibration Fatigue fm_4Fatigue Cracking fatigue_crackingCorrosion Thinning fm_5Gasket Aging / Creep -> Leak fm_6Improper Gasket Installation fm_7Bolt Relaxation bolt_relaxationBolt Corrosion fm_8Valve Internal Leak fm_9Blockage fm_10Relief Valve Set-pressure Drift fm_11Valve Seat Leak fm_12Inlet Line Blockage fm_13Sensor Drift fm_14Loose Wiring / Terminals fm_15结垢/堵塞 MECH-FOULING保温层下腐蚀 MECH-CUI冷却水腐蚀 MECH-CWC氯化物应力腐蚀开裂 MECH-CLSCC微生物腐蚀 MECH-MIC冲蚀/冲刷腐蚀 MECH-EROSION均匀/局部减薄（通用减薄） MECH-THINNING振动诱发疲劳 MECH-VIB-FATIGUE硫氢化铵腐蚀 MECH-ABS选择性脱合金 MECH-DEALLOY大气腐蚀 MECH-ATMOS机械疲劳 MECH-MECH-FATIGUE电偶腐蚀 MECH-GALVANIC脆性断裂 MECH-BRITTLE-FRACTURE结垢/堵塞 MECH-FOULING氯化物应力腐蚀开裂 MECH-CLSCC冷却水腐蚀 MECH-CWC密封失效 MECH-SEAL-FAILURE微生物腐蚀 MECH-MIC冲蚀/冲刷腐蚀 MECH-EROSION均匀/局部减薄（通用减薄） MECH-THINNING大气腐蚀 MECH-ATMOS腐蚀疲劳 MECH-CORR-FATIGUE选择性脱合金 MECH-DEALLOY机械疲劳 MECH-MECH-FATIGUE电偶腐蚀 MECH-GALVANIC脆性断裂 MECH-BRITTLE-FRACTURE
Report No. 2010-05-I-WA · Data from CSB public investigation conclusions, compiled by Reliability AI, for reliability demonstration purposes only. This case is derived from public incident investigation reports for learning purposes only. AIM does not endorse or guarantee its accuracy.