SEVEN deaths in April 2010 at the Tesoro refinery in Anacortes will only be a tragic cost of doing business without substantial changes in attitude and behavior within the industry, and by state and federal regulators.

The final report, approved last week by the U.S. Chemical Safety and Hazard Investigation Board, does not represent any kind of closure for the deadly explosion four years ago.

Instead, it is a template for change at U.S. petroleum refineries where accidents, injuries and fatalities are routine. As noted in the draft report as well, “The refinery process safety culture required proof of danger rather than proof of effective safety implementation.”

As the chemical safety board noted, there were 125 significant refinery incidents in 2012 across the country.

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“Tesoro management also allowed worker exposure to hazards from fires and significant hydrocarbon leaks during startup of the NHT [Naphtha Hydrotreater Unit] heat exchangers to become an accepted ‘normal’ practice,” according to the report.

The board concluded, rather belatedly, the frequent occurrence of refinery accidents demonstrates the pressing need to examine the current regulatory structure.

State and federal regulators are challenged to get deeper into how the industry manages safety processes well beyond this state’s infrequent inspections — which have no credible follow-up to correct deficiencies.

The safety board would have regulators look at the materials and designs used to build and expand refineries. Improve the quality of materials and design to compensate for things not revealed by inspections, or the industry’s ineffective hazard analyses.

Members of Congress, including U.S. Sen. Patty Murray, D-Wash., and Rep. Rick Larsen, D-Everett, who expressed their frustration with the pace of the safety board’s review, have a new challenge.

They need to prod political and budget processes to make these changes. Gov. Jay Inslee needs to look at what can be done at the state Department of Labor and Industries.

The greatest weight falls on the refinery industry to confront its casual attitude toward safety.

Editorial board members are editorial page editor Kate Riley, Frank A. Blethen, Ryan Blethen, Sharon Pian Chan, Lance Dickie, Jonathan Martin, Erik Smith, Thanh Tan, William K. Blethen (emeritus) and Robert C. Blethen (emeritus).