Lessons Learned from the Longford Royal Commission Investigation into the Explosion and Fire on 25th September 1998 at the Esso Gas Processing Plant

摘要

On Friday, 25th September 1998, at about 12.26 in the afternoon, a vessel in the Esso Longford Gas Plant fractured releasing hydrocarbon vapors and liquid. Explosions and a fire followed. Two Esso employees were killed and eight others were injured. Supplies of natural gas to domestic and industrial users were halted for between 9 and 19 days. The State of Victoria, which is highly dependent on natural gas, suffered substantial disruption to the economy. The Government ordered a Royal Commission to investigate the causes of the accident and it published its final report (Government of Victoria, 1999). DNV acted as technical adviser. The main lessons to be drawn from Longford relevant to all companies implementing management systems to meet their own expectations and the requirements of Regulators (such as the PSM and RMP requirements) are, in the opinion of the authors, as follows: 1. Safety Management System - incomplete implementation. 2. Knowledge Stewardship - insufficient on old plant. 3. Management of Change - organizational change not subjected to this procedure. 4. Audit and Review - opportunities to discover gaps were missed.