Built in 1969, the plant at Longford is the onshore receiving point for oil and natural gas output from production platforms in Bass Strait. The Longford Gas Plant Complex consists of three gas processing plants and one crude oil stabilisation plant. It was the primary provider of natural gas to Victoria, and provided some supply to New South Wales.
Esso initially blamed the accident on worker negligence, in particular Jim Ward, one of the panel workers on duty on the day of the explosion.
There is no evidence that Esso blamed the operator.
The findings of the Royal Commission, however, cleared Ward of any negligence or wrong-doing. Instead, the Commission found Esso fully responsible for the accident:
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.
Other findings of the Royal Commission included:
- the Longford plant was poorly designed, and made isolation of dangerous vapours and materials very difficult; สาเหตุระบุชัด ออกแบบห่วย!!!
- inadequate training of personnel in normal operating procedures of a hazardous process;
- excessive alarm and warning systems had caused workers to become desensitised to possible hazardous occurrences;
- the relocation of plant engineers to Melbourne had reduced the quality of supervision at the plant;
- poor communication between shifts meant that the pump shutdown was not communicated to the following shift. Certain managerial shortcomings were also identified:
- the company had neglected to commission a HAZOP (HAZard and OPerability) analysis of the heat exchange system, which would almost certainly have highlighted the risk of tank rupture caused by sudden temperature change;
- Esso's two-tiered reporting system (from operators to supervisors to management) meant that certain warning signs such as a previous similar incident (on 28 August) were not reported to the appropriate parties;
- the company's "safety culture" was more oriented towards preventing lost time due to accidents or injuries, rather than protection of workers and their health.