| The Conclusions Of The Royal Commission |
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| Recommendations Of The Royal Commission |
| Gas Blast Esso's Fault |
| Gas Plant Warning |
| Explosion Terror |
Conclusions Of The Royal Commission
Headed by former High Court judge Daryl Dawson
Recommendations Of The Royal Comission
Headed by former High Court judge Daryl Dawson
Gas Blast Esso's Fault
by Rachel Hawes — Headlines The Australian Tuesday June, 29th, 1999
ESSO'S failure to train its workers to cope with emergencies left the multi-national responsible for the Longford gas plant explosion that killed two of its workers and cut gas supplies to Victoria for a fortnight.
Esso's decision to blame its staff — including control room operator Jim Ward — back-fired, with Longford royal commissioner and former High Court judge Daryl Dawson finding that the company's failure to equip workers with the "appropriate knowledge" was the ultimate cause of the explosion in September last year.
Sir Daryl said the tragedy could have been averted "had appropriate steps been taken" to deal with process upsets on the day.
In a 287-page report, Sir Daryl also criticised Esso's handling of safety issues at the plant, including incident reporting procedures and a decision to slash the number of supervisors ahead of the explosion.
The report said the causes of the blast — which killed maintenance supervisors Peter Wilson and John Lowery, and injured eight other staff — amounted to a breach of the Occupational Health and Safety Act by Esso, a subsidiary of US energy conglomerate Exxon.
"The ultimate cause of the accident on September 25 was the failure of Esso to equip its employees with appropriate knowledge to deal with the events which occurred," the report said. "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 appropriate operating procedures."
The report found the explosion occurred when a heat exchange unit in gas plant one ruptured after workers attempted to pump hot oil through freezing equipment. Wilson, 51, and Lowery, 49, died instantly.
Gas supplies to Victorian homes and businesses were cut for almost two weeks at an estimated loss to industry of $1.3 billion.
Key recommendations by the royal commission include calls for stricter training obligations on Esso and the establishment of a State government body to specially administer safety procedures at "all major hazard facilities" within the State.
As the Government's safety watchdog, WorkCover, reopened its investigation to consider laying charges against Esso for safety breaches, the multinational, which is facing a $1 billion class action, refused to comment on the specific findings until after talks with the Government and regulators.
"Esso's highest priority has always been the safety of our personnel and integrity of our operations, and we are deeply saddened by the accident," Esso chairman Robert Olsen said.
Premier Jeff Kennett also declined to comment, except to say the Government would "consider" recommendations for legislative action to extend safety case management to all major hazardous facilities, and the establishment of the specialist monitoring agency.
The main union at the site, the Australian Workers Union, claimed the report vindicated Longford workers, and it demanded an apology from Esso.
AWU State secretary Bill Shorten said union members were meeting to consider the recommendations and he called on the company to quickly implement them.
"Esso ignores the royal commission at their peril," he said.
After hearing 53 days of evidence, the commission found conditions at the plant on September 25 did not constitute a safe working environment.
Sir Daryl and commissioner Brian Brooks said operators and supervisors did not understand the dangers associated with a loss of lean oil flow which was "directly attributable" to a deficiency in training.
"Not only was their training inadequate, but there were no current operating procedures to guide them in dealing with the problem which they encountered" the report said.
The commission found repeated delays to a safety audit known as a HAZOP, and the relocation of company engineers to Melbourne, were a result of "Esso's desire to control its operating costs" and may have been contributing factors to the explosion.
The report also said failure to report a cold temperature incident on August 28 last year
"deprived Esso of an opportunity to alert its employees to the effect of loss of lean oil flow and to instruct them in the proper procedures to be adopted in the event of such a loss".
However, the commission found plant design short-comings and maintenance policies were not to blame for the September blast.
Gas Plant Warning Of Impending Trouble
by Ruth Lamperd — The Courier-Mail, Wednesday, December 16th, 1998
A CRITICAL valve at Esso's Longford gas plant could have been faulty for weeks before a fatal explosion in September, a royal Commission heard yesterday.
And there were "very obvious warning signs" of impending disaster hours before the blast which cut off gas supplies to nearly all of Victoria for a fortnight.
It was not clear whether at least one instruction to close down the gas plant had been carried out, the Commission heard.
Counsel assisting the commission, James Judd, QC, said a defective valve caused temperature levels in volatile equipment to fluctuate wildly hours before the disaster.
Mr Judd said workers and contractors struggled to fix a catalogue of problems occurring at several points in the plant.
The royal commission is investigating the September 25 explosion at Longford near Sale, which killed two Esso workers and cut gas supplies to Victoria for two weeks.
In his opening submission to the inquiry, Mr Judd said the imminent danger of workers trying to fix two volatile hydrocarbon leaks from equipment appears "not to have been anticipated".
It would appear that TRC3B (the valve) had been out of operation for days, and probably weeks prior to the incident," Mr Judd said.
He said that for some hours before the incident occurred, GP905 (a heat exchanger) and other vessels in the immediate vicinity displayed
"what in hindsight might be regarded as very obvious warning signs".
He said these pieces of equipment were operating outside parameters for which they were designed.
The commission was set up to investigate what caused the explosion and inquire whether it could have been avoided. Eyewitnesses will appear before the commission with evidence that one of the plant's towers, which would normally burn if touched, was covered in ice.
The hearing will continue today before commission chairman Sir Daryl Dawson.
Esso Worker Tells Of Explosion Terror
By Ruth Lamperd— The Courier-Mail, Thursday, 17th December, 1998
AN ESSO worker fled for his life minutes before an explosion ripped through part of the Longford gas plant near Sale, Victoria, on September 25.
Maintenance fitter Shane Vandersteen acted on gut feeling that things were not right, grabbing a workmate and telling another who was shortly to be killed in the explosion "I'm out of here".
Mr Vandersteen said he stayed on the premises with a few workmates to fight the fire that followed, but he said 90% of the men headed for the gate.
In a statement prepared for the Longford royal commission before chairman Sir Daryl Dawson, Mr Vandersteen, 41, described what he called an out-of-control scene of men working to stop volatile liquid spills.
"It appeared the situation was not being controlled well, as there were too many chiefs ... no one seemed to know who was in charge," he said in his statement.
"I was going on my gut feeling that it was a place that I would rather not be. There just seemed to be too many things happening at once causing alarm bells to ring in my head."
He said he rode his bicycle with workmate Andrew Knight to the maintenance workshop where he heard a muffled sound which made "my heart skip a beat".
"It shook the whole building. A second explosion ... shortly afterwards ... was a deep whoomph which you can feel in your chest," Mr Vandersteen said.
He said he could not find fire-fighting gumboots or gloves in the fire shed where a few men mustered to combat the blaze.
"All of us in the fire shed were waiting for instructions, but none came ... we were struggling to scrape up a hose team," he said.
Mr Vandersteen defended the 90% of men who evacuated immediately.
"I do not blame people for going straight out the gate. They have families to consider and it was obvious this was a major situation," he said.
Before the explosion, Mr Vandersteen had been called on to re-tension flanges of critical heat exchangers which were leaking and operating "way out" of normal temperature ranges.
"In my opinion, trying to equalise the exchanger to stop the leak is something I would not do. As soon as it started leaking, I would have shut it down and isolated it," he said.
During cross-examination, Insurance Council of Australia counsel Ross Gillies, QC, suggested management appeared to be giving less attention to maintenance at the Longford site in the past year.
Mr Vandersteen said he could not recall any engineers being on site at the time of the disaster.
He said Esso had sold its Sale office in the early l990s and moved management, including engineers, to Melbourne.
The commission is looking into what caused the explosion on September 25 which killed two men, seriously injured eight and cut gas supplies to nearly all Victoria for two weeks.
It was due to continue today.