← Back to KB navigation
CSB Investigation
Report No. CSB-TESORO-ANACORTES-2014
2014
Explosion Explosion Fire Fire
Tesoro Anacortes 炼厂致命爆炸火灾
Tesoro Anacortes Refinery, Anacortes, Washington
Related equipment → Shell-and-tube heat exchanger (shell_tube_heat_exchanger)
7Fatalities
0Injuries
FailureMechanism code EXP
⌗Failure Mode · ISO 14224 Mapping
Damage mechanism (recorded in KB)
FailureEXP
Internal damage-mechanism code (not ISO 14224)
ISO 14224:2016 functional failure code
OTH · Other
Mapped to ISO OTH — Other.
1What Happened
2010 近 40 年老换热器检修切换时灾难性失效，7 名员工死亡
2Root Cause
老旧换热器机械完整性/检验不足，检修隔离缺陷
3Reliability Lessons (from investigation root cause)
- The 'Root Cause' above is the core lesson of this accident; not split further.
4Associated Failure Mechanisms (Keywords)
换热器 灾难性失效 检修 炼厂 超压
About the Failure-Mode Code (click to expand)
The mechanism code EXP shown on this card is the KB's internal damage-mechanism abbreviation (not an ISO 14224 code); it describes how the equipment failed. The 'ISO 14224 Mapping' block above maps it to the correct ISO functional failure code (which describes what the equipment failed to do) — these are two distinct dimensions in ISO 14224. The mechanism follows the narrative in the card body.
5Evidence Source (transparent)
Authority：U.S. Chemical Safety and Hazard Investigation Board (CSB)
Official Report：www.csb.gov ↗
Data Verification：verified_url_csb_investigations_list_2026-08-07（终报 2014-05-01）
↗Related Failure Modes · Traceability
This accident is not yet linked to a specific FM traceability card.