Near-misses and deadly tragedies like Friday's explosion and fire at the Tesoro refinery in Anacortes still occur with alarming frequency, according to the men and women who investigate them.

It was supposed to be the moment after which everything changed.

On a March afternoon in 2005, overflowing gas sparked an explosion at a BP refinery in Texas City, Texas, killing 15 workers and injuring 180 more.

An investigation showed years of warnings had gone unheeded. It uncovered hundreds of safety problems at BP — many common throughout the refining industry. It revealed that federal regulators almost never focused refinery inspections on the potential for catastrophic accidents — even though Congress had called for exactly that in 1992.

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A panel that included former Secretary of State James Baker and former U.S. Sen. Slade Gorton urged a safety overhaul across the refinery sector.

But five years later, near-misses and deadly tragedies like Friday’s explosion and fire at the Tesoro refinery in Anacortes still occur with alarming frequency, according to the men and women who investigate them. Just last fall, another fire at a Tesoro refinery in Salt Lake City started under circumstances eerily similar to those in the 2005 Texas disaster.

“We are concerned that we are seeing a repeat of issues that we thought had (already) received widespread communication and attention,” said Don Holmstrom of the federal Chemical Safety Board, which investigates manufacturing accidents involving hazardous chemicals.

Until last week, explosions or releases at six refineries around the country had killed at least three workers and injured 10 more since 2005.

After Friday’s explosion left five more petrochemical workers dead and two others critically injured, John Bresland, the frustrated chairman of the Chemical Safety Board, said the nation’s 150 refineries need a transformation. They must become more like the nuclear-power or airline industries, he said, where not even the tiniest safety hiccup is tolerated.

“If the aviation industry had the same number and types of incidents as the refining industry, I don’t think people would be flying too much,” Bresland said.

The refining industry insists its track record is good, especially considering that it works daily with hazardous and flammable materials under pressure and at high temperatures. And it’s true that refinery workers are far less likely to get sick or injured on the job than others in manufacturing. And injury rates have dropped even further in the last decade.

“We do make safety a top priority,” said Ron Chittim, a refinery policy adviser with the American Petroleum Institute (API). “Not only for the workers, but for contractors and neighbors and surrounding communities. It’s to everybody’s benefit to have things work smoothly.”

But when accidents happen, as Friday’s explosion showed, the consequences are often disastrous.

Dangerous patterns

It could take months to learn what went wrong in Anacortes.

Investigators say refinery accidents are each slightly different, but they see rough patterns: Companies don’t replace equipment enough or don’t have systems in place to insure that pipes and machinery are in top order. Workers are fatigued or lack training. Accidents typically happen during or shortly after restarting equipment that has been taken offline for repairs or maintenance, and typically involve several things going wrong at once.

Congress recognized these problems 20 years ago. After 23 people died in 1989 at a Phillips 66 plant in Pasadena, Texas, lawmakers amended the Clean Air Act so the Occupational Safety and Health Administration (OSHA) could conduct exhaustive inspections to prevent “low-frequency, high-consequence” accidents.

But during its investigation of BP in 2005, the Chemical Safety Board learned OSHA had almost never performed such inspections. The ones it did conduct weren’t always thorough. Only one fully trained OSHA team existed in the country and employed three or four inspectors. The agency said doing the inspections was too time consuming and expensive.

After the 2005 accident, “we said OSHA needed to do more inspections — and they have,” said Daniel Horowitz, spokesman for the Chemical Safety Board.

One of those was conducted by Washington state inspectors last year at Tesoro’s Anacortes refinery, which was cited last April for 17 “serious” safety violations that posed a risk of death or serious injury to workers. In total, that inspection found 150 safety citations, mostly failures to keep accurate records and information on possible hazards to workers. Most of the citations were dismissed as part of a settlement agreement.

It’s not clear yet whether any of those deficiencies are linked to Friday’s accident. A third-party safety audit is due later this year.

But investigators and union members say refineries have struggled to learn from their own seemingly inconsequential mistakes, or from the serious mistakes of others.

While no one was injured in October’s fire at the Tesoro facility in Salt Lake City, for example, the Chemical Safety Board said the fire started after hydrocarbons escaped from a stack after a restart — just like BP’s 2005 explosion.

“In our industry we’ve seen a significant number of releases, fires and equipment failures since Texas City,” said Kim Nibarger, a safety expert with the United Steelworkers. “They seem to be responsive to smaller events in the nuclear industry. The refining industry seems to take a lot of small events in stride.

“It’s not that Tesoro is a bad actor,” Nibarger added. “It’s just the way the industry is run.”

Far different from nukes

By comparison, not one of the nation’s 103 nuclear-power plants has had a major accident in 30 years, said Bresland, of the Chemical Safety Board.

“The nuclear-power industry has decided it has a vested interest in never having another incident like Three Mile Island,” he said.

Chittim, with the American Petroleum Institute, disagrees that refinery accidents reflect systemic issues. He also says nuclear power is more heavily regulated than refineries, but “our industry already is heavily regulated. I don’t think trying to regulate it further is necessarily going to make things safer.”

Chittim also said API has at least 75 industrywide standards it urges companies to follow to make sure workers are not harmed on the job. The Chemical Safety Board, after the BP accident in Texas, asked API to work with outside interest groups to set even more safety guidelines.

Gary Beevers, an international vice president with the United Steelworkers, sat on the panels developing the new guidelines, but walked away from negotiations last summer. He said the industry made clear it wasn’t interested in workers’ input.

“We got shot down with everything we tried to do,” Beevers said.

Chittim disagrees with Beevers’ characterization of the events, but what happened next is not in dispute.

Earlier this year, the union started a national refinery-worker-safety campaign. It passed out fliers that detailed deadly fires and other accidents. The pamphlet complained that refineries weren’t serious about addressing root causes.

The headline read: “It’s only a matter of time … “

Seattle Times staff reporters Hal Bernton and Steve Miletich contributed to this story. Craig Welch: 206-464-2093 or