Lessons from Longford
Lessons from Esso’s Gas Plant Explosion at Longford
In September 1998 Esso Australia’s gas plant at Longford in Victoria suffered a major fire. Two men were killed and the state’s gas supply was severed for two weeks, causing chaos in Victorian industry and considerable hardship in homes which were dependent on gas. What happened was that a warm liquid system (known as the “lean oil” system) failed, allowing a metal heat exchanger to become intensely cold and therefore brittle. When operators tried to reintroduce warm lean oil, the vessel fractured and released a large quantity of gas which found an ignition source and exploded. In what follows I shall trace the reasons for this event, relying on evidence provided to the Royal Commission which investigated the disaster. (For further details see Hopkins, 2000). Operator error? There is often an attempt to blame major accidents on operator error. This was the position taken by Esso at the Royal Commission. The company argued that operators and their supervisors on duty at the time should have known that the attempt to reintroduce a warm liquid could result in brittle fracture. The company claimed that operators had been trained to be aware of the problem and Esso even produced the training records of one operator in an attempt to show that he should have known better. However, the Commission took the view that the fact that none of those on duty at the time understood just how dangerous the situation was, which indicated a systematic training failure. Not even the plant manager, who was away from the plant at the time of the incident, understood the dangers of cold metal embrittlement. (Dawson, 1999:197). The Commission concluded that inadequate training of operators and supervisors was the “real cause” of the accident (Dawson, 1999:234). It is clear therefore that operator error does not adequately account for the Longford incident. This is a general finding of all inquiries into major accidents (Reason, 1997).
In September 1998 Esso Australia’s gas plant at Longford in Victoria suffered a major fire. Two men were killed and the state’s gas supply was severed for two weeks, causing chaos in Victorian industry and considerable hardship in homes which were dependent on gas. What happened was that a warm liquid system (known as the “lean oil” system) failed, allowing a metal heat exchanger to become intensely cold and therefore brittle. When operators tried to reintroduce warm lean oil, the vessel fractured and released a large quantity of gas which found an ignition source and exploded. In what follows I shall trace the reasons for this event, relying on evidence provided to the Royal Commission which investigated the disaster. (For further details see Hopkins, 2000). Operator error? There is often an attempt to blame major accidents on operator error. This was the position taken by Esso at the Royal Commission. The company argued that operators and their supervisors on duty at the time should have known that the attempt to reintroduce a warm liquid could result in brittle fracture. The company claimed that operators had been trained to be aware of the problem and Esso even produced the training records of one operator in an attempt to show that he should have known better. However, the Commission took the view that the fact that none of those on duty at the time understood just how dangerous the situation was, which indicated a systematic training failure. Not even the plant manager, who was away from the plant at the time of the incident, understood the dangers of cold metal embrittlement. (Dawson, 1999:197). The Commission concluded that inadequate training of operators and supervisors was the “real cause” of the accident (Dawson, 1999:234). It is clear therefore that operator error does not adequately account for the Longford incident. This is a general finding of all inquiries into major accidents (Reason, 1997).
References: Appleton, B. (1994). Piper Alpha. In T. Kletz (Ed.), Lessons from Disaster: How Organisations Have No Memory and Accidents Recur . (pp. 174-184). London: Institute of Chemical Engineers. Bahr, N. (1997), System Safety Engineering and Risk Assessment: a Practical Approach London: Taylor and Francis Dawson, D &B Brooks, (1999) The Esso Longford Gas Plant Accident: Report of the Longford Royal Commission. Melbourne: Parliament of Victoria Hopkins, A. (1999) Managing Major Hazards: the Lessons of the Moura Mine Disaster, Sydney: Allen & Unwin Hopkins, A. (2000) Lessons from Longford: The Esso Gas Plant Explosion. Sydney: CCH Australia, phone1300 300 224 NOHSC -National OHS Commission - (1996) Control of Major Hazard Facilities: National Standard. Canberra: AGPS Reason, J. (1997), Managing the Risks of Organisational Accidents. Alderlshot: Ashgate Txxxx. This refers to the transcript page number which were obtained from http://www.vgrs.vic.gov.au/client?file.wcn. There is no hard copy of the transcript available publicly; interested readers should contact the author who has a downloaded version. Hopkins: Longford Publication version 8