The Longford Catastrophe:
What Price Safety?

by Peter Mac

The Esso gas treatment facility at Longford in south-eastern Victoria 
comprises three gas plants which process gas from wells in Bass Strait, as 
well as a plant which processes crude oil from other Bass Strait wells. The 
facility is operated by the United States company Esso on behalf of a joint 
venture company formed by Esso and BHP.

Ian Kennedy was the acting day supervisor at Longford when a massive 
explosion occurred on September 25, 1998. He was working near the heat 
exchanger whose rupture started the fatal explosions and fire at GP1, the 
first gas plant constructed at Longford.

Although badly injured, Kennedy survived. His workmates Peter Wilson and 
John Lowery died in the initial blast, and seven others were also severely 
injured.

The explosion cut supplies of energy to industry and homes throughout 
Victoria, causing widespread disruption to industrial output, and major 
dislocation to the lives of millions of people.

The fire at the Longford plant raged for two days, and the supply of gas 
throughout Victoria did not resume until October 14, 1998.

The explosions and fire at the Longford plant constituted one of the worst 
accidents in the history of Australian industry.

The report of the Royal Commission into the accident was released last 
month. It concludes that: 

The causes of the accident on 25 September 1998 amounted to a failure to 
provide and maintain so far as practicable a working environment that was 
safe and without risks to health. This constituted a breach or breaches of 
Section 21 of the Occupational Health and Safety Act 1985. (P.238)

The fracture of the heat exchanger which began the series of explosions at 
the plant was preceded by a failure of the normal flow of hot oil through 
the equipment, which together with the continuing flow of very cold oil and 
condensate into the exchanger tank caused the temperature of the tank to 
fall well below freezing point.

When employees finally restored the flow of hot oil into the tank, the 
extremes of temperature variation within the tank caused it to fracture, 
leading to an explosion of volatile gases which subsequently ignited.

The bulk of the wording of the Royal Commission's report deals of necessity 
with the technical aspects of the case, i.e. the design of the plant, the 
condition of the equipment, the climatic conditions etc.

Inadequacies

However, the report also deals with the employee structure of the plant and 
the impact of changes to work practices. The report concludes that there 
were severe inadequacies in hazard procedures, as well as in the training 
and staffing levels of the personnel at the plant prior to the accident 
taking place.

The report identifies some deficiencies in the design of the plant itself, 
and some of the equipment, in particular the lack of an automatic system to 
isolate the various fuel components at the plant in the event of a fire.

It notes, however, that "even if reliance had been placed on manual 
isolation, there was no real plan or philosophy to guide such an 
operation." (P.235)

The Longford report describes most of the established operation and 
maintenance procedures as adequate. However, it is highly critical of the 
failure of the company to introduce a Hazard and Operability (HAZOP) Study 
at the plant. Although the introduction of such a study was discussed, it 
was never implemented.

The report notes that:

Had a HAZOP study for GP1 [the refrigerated lean oil absorption plant 
which extracted the flammable gases from the Bass Strait oil and gas 
drilling platforms] been carried out as planned, the operators and 
supervisors in that plant ... would not have remained ignorant of the 
hazards associated with loss of lean oil flow and consequent low 
temperatures.

They would have been instructed in the appropriate procedures to deal 
with the situation that arose that day.

The failure to conduct a HAZOP study or to carry out any other adequate 
procedures for the identification of hazards in GP1 contributed to the 
occurrence of the explosion and fire.

But the lack of a HAZOP study was not in itself the only factor in events 
leading to the Longford accident. The report makes clear that procedures, 
training and supervision were also critical issues in the light of other 
developments prior to the accident.

Some time before the accident occurred, the level of supervisory staff at 
the Longford plant was reduced as a cost-cutting measure, with more 
responsibility given to the remaining staff for the safe operation of the 
plant.

The company claimed that adequate training was given to the remaining staff 
to ensure that they could manage the plant effectively. However, the 
ensuing events tell a different story.

For example, although the existing operation and maintenance procedures 
were deemed appropriate for the previous conditions, there is no indication 
that they were modified to allow for the reduction in engineering staff.

The period prior to the accident saw a string of irregularities in the 
operation of the plant. The report notes:

Appropriate supervision of operators to ensure adherence to basic 
operating practices was also a responsibility of Esso management. [On] a 
number of occasions ... operators failed to  ... adhere to rudimentary 
operating procedures.... Had operating procedures been more closely 
monitored and supervised by Esso management, these departures from 
appropriate operating procedures would have been detected and remedied.

The report points to the probability that the reduced level of supervision 
contributed to the accident taking place, and states unequivocally that:

The reduction of supervision at Longford, including the transfer of 
engineers to Melbourne, necessarily meant a reduction in the quality of the 
supervision of operations there. There was a correspondingly greater 
reliance by Esso on the skill and knowledge of operators.

The report concludes that:

The training of its personnel to operate or supervise a potentially 
hazardous process was the responsibility of Esso and it failed to discharge 
that responsibility effectively.

Whilst criticism can otherwise be made of certain aspects of the plant, 
its design and operation, the ultimate cause of the accident on 25 
September was the failure of Esso to equip its employees with appropriate 
knowledge to deal with the events that occurred.

Not only did Esso fail to impart that knowledge to its employees, but it 
failed to make the necessary information available in the form of operating 
procedures." (p236)

Well, what price safety?

It's doubtless cold comfort to those who suffered as a result of the 
Longford accident, or to the families of the men who died there, to think 
that the Longford accident could have been worse.

However, the grim reality is that it could have been — in fact, four times 
as bad.

Although the explosions and fire only affected one of the gas plants, the 
report is sufficiently concerned about the possibility of the fire 
spreading to the other plants that it specifically requires Esso to ensure 
that in future the gas plants are isolated from each other and from the 
crude oil processing plant.

The industrial history of the world is littered with cases where cost 
cutting measures were implemented with little or no consideration of their 
effect on safe working conditions, with tragic results.

The catastrophe at Longford was no exception to this pattern.

The transfer of skilled engineering staff to other sites appears to have 
left the plant workers with inadequate means of dealing with the 
engineering problems of this huge and complex industrial plant.

The result was an accident waiting to happen, especially given the Kennett 
Government's "hands off" approach to government regulation of such 
facilities.

The Longford Report's calm, unemotional terms paint a picture of an 
industrial operation where the chase for the extra dollar led inevitably to 
the catastrophe of September 25, 1998. 

What price safety? Whatever you do, don't ask Esso.

* * *

What happened to Ian Kennedy

The Esso Longford Gas Plant Accident, a Royal Commission report, is 
available through Victorian Government Printer for $70.

When the explosion occurred (Ian Kennedy) ... was blasted into the air, 
struck a solid object with his head and hit the ground with liquid, dirt 
and stones pelting him at a high velocity. He felt as if he were being shot 
at by a machine gun. Wherever he crawled he continued to be pelted....

Eventually he saw a glimmer of light and crawled in that direction. He must 
have crawled out from behind something that was sheltering him because he 
was rolled over and again exposed to the blast.

He crawled into the clear and noticed two other blackened persons crawling 
towards the control room. ... (He) stood up but fell over. Blood was 
flowing from an injured eye.

Miller assisted him towards the control room. He glanced over his shoulder 
and saw white vapour everywhere. GP905 [the heat exchanger] had been skewed 
at an angle and there was still a loud roar of vapour and liquid.

Kennedy was taken into the lunch room and then into the control room.... 
alarms were still going off everywhere and someone was trying to contact an 
ambulance.

He could still hear the roar of escaping gas and liquid. Then he heard a 
loud whooshing sound of gas igniting, followed by two enormous bangs that 
shook the building to its foundations.

The control room lost all communications and the air conditioners shut 
down. Other injured personnel were brought into the control Room. Andy 
Noble escorted Kennedy to the first aid room and on the way he heard 
another loud bang.... 

He recalls seeing Lowry and Wilson about five minutes before the initial 
explosion. He estimates they were about five metres from where he was...

* * *

The Esso Longford Gas Plant Accident, Report of the Longford Royal 
Commission, June 1999, pp.61-2.