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Esso blamed for Australian gas explosion
But Royal Commission obscures underlying causes
By Will Marshall
5 July 1999
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A Royal Commission into the September 1998 gas explosion in
Victoria has found Esso, a subsidiary of Exxon, responsible for
the disaster which killed two workers, injured eight and cut gas
supplies to the entire state for two weeks, causing millions of
people to suffer losses of employment, livelihoods, heating and
hot water.
Former High Court Justice Dawson rejected Esso's repeated attempts
to blame workers at the Longford plant, particularly James Ward,
the panel-operator in Gas Plant 1 (GP1) at the time of the accident.
The Commission's findings state that the major cause of the
accident was "the failure of Esso to equip its employees
with appropriate knowledge to deal with the events which occurred".
In doing so, Esso failed to provide a safe working environment
for its employees in breach of the state's Occupational Health
and Safety Act.
The report points out that Esso had not carried out a systematic
assessment of the risks and dangers involved at the plant. The
lack of adequate procedures for the identification of hazards
in GP1 contributed to the occurrence of the explosion and fire,
it states.
In particular, Esso did not carry out a HAZOP (hazard operability
study) in GP1. In such studies, engineers create scenarios that
exceed the usual operating parameters of equipment and examine
the overall impact on the entire plant. But Esso's failures were
many, right down to not monitoring the reports done by plant operators
over a period of time.
The explosion occurred when hot lean oil came into contact
with equipment that had been operating well below normal temperatures.
This caused the brittle metal to fracture and release massive
amounts of hydrocarbon gas, which came into contact with an ignition
source, causing a violent explosion. The equipment had reached
such low temperatures because the supply of lean oil had ceased
for over three hours due to the failure of two pumps.
Because of Esso's lack of training, none of the supervisors
and plant operators knew that this could occur. In the words of
the report: It is difficult to understand why operating
procedures dealing with a lean oil absorption plant did not include
any reference to the importance of maintaining lean oil flow in
the operation of the plant. Plainly that was something which was
fundamental...
The lack of knowledge on the part of both operators and
supervisors was directly attributable to a deficiency in their
initial or subsequent 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 on 25 September
1998.
Gas Plant 1 was 30 years oldit was the oldest of the
three units operating at Longford. Submissions made to the inquiry
suggested that Exxon had to decide, on the basis of profit considerations,
whether to update the equipment, work it into the ground, or abandon
the Longford plant altogether.
The Commission's findings indicate that Exxon took the second
option. They confirmed that Esso conducted HAZOPS on the more
modern units, but not GP1. After examining this issue at some
length, the Commission commented: Esso recognised the particular
significance of a HAZOP study for GP1, given the age of the plant,
the modification made to its initial design and the changes to
design standards since the plant was built. These reasons grew
stronger with the passage of time ... no formal hazard identification
or structured risk assessment of any kind took place in GP1 after
1994.
The Commission stated that a HAZOP study would, without doubt,
have revealed the factors that contributed to the fatal accident.
The Commission quoted from Esso's own documents showing that
in 1994 Esso deliberately limited a major aspect of its safety
efforts, its Periodic Risk Assessment, (PRA), on the pretext that
a HAZOP study was pending. The Commission concluded: Accordingly,
the 1994 PRA was directed away from process-related hazards and
concentrated on hazards caused by mechanical equipment failure
and operator error. Scenarios addressing the consequences of low
temperatures', high level' and no flow' were not used.
Esso's denials of culpability for the accident were exposed
by its own internal investigation, known as the McNeil Report.
A draft document obtained by the Coroner shortly after the explosion
said: The lack of a detailed HAZOP for GP1 is considered
a contributing factor to this incident. This passage was
omitted from the final report.
Not one of the McNeil team testified to the Royal Commission.
The Commission simply drew the following conclusion: All
the members of the investigating team were from overseas and were
no longer in Australia and available to the Commission at the
time of its hearings. Esso did not seek to call any member of
the investigating team to give evidence. In the circumstances,
the Commission concludes that the omission of the statement from
the final report does not in any way detract from its force.
As part of restructuring its operations, Esso transferred all
on-site engineers to Melbourne. This affected the running of the
plant, yet Esso made no analysis. The Commission found that: The
relocation of engineers qualified as a permanent change to operating
practices requiring risk assessment and evaluation before implementation
in conformity with Esso's management of change philosophy. Yet
such relocation was implemented without any such assessment ever
taking place.
While the Commission indicted Esso, its findings also serve
to obscure or at least minimise the significance of the driving
forces behind the cuts to safety. Over the preceding decade, Esso
had cut costs by dramatically lowering manning levels and contracting
out much of its maintenance, as well as winding back on safety
spending. Between 1992 and 1998, Esso cut the total workforce
by 224, or 16 percent. The most serious cuts occurred in maintenance,
where the number of jobs was halved.
The Commission limited itself to saying: Insofar as the
failure to conduct the HAZOP study for GP1 and the reduction of
supervision at Longford, including the transfer of engineers to
Melbourne, were a result of Esso's desire to control its operating
costs, asset management practices or policies may have been a
contributing factor to the explosion, fire and failure of gas
supply. However, it is not possible to establish any more direct
causal link.
In addition, the Kennett state Liberal government limited the
Commission's terms of reference in order to bury the government's
own role in scrapping health and safety measures and replacing
them by corporate self-regulation. The Victorian Trades
Hall Council, supported by Esso and the Labor Party, asked the
Commission to extend its inquiry but their application was rejected.
Nevertheless, the Commission's final report implies that the
Kennett government must also bear responsibility for the disaster.
Had Esso been required to submit a safety case (safety report),
with respect to its facilities at Longford before 25 September
1998, it is likely that it would have identified the very hazards
which were in evidence on that day, hazards which a proper HAZOP
study of GP1 would also have identified.
The report also notes that Esso adopted certain national safety
procedures in its offshore facilities, which come under federal
jurisdiction, but not in its onshore facilities, which are covered
by state law. This may be explained by the absence of any
obligation requiring it to do so, the report states.
Esso and the Kennett government have so far refused to comment
on the Commission's findings. Esso now faces a $1 billion class
action for losses suffered by domestic gas users and businesses.
It has attempted, unsuccessfully, to have the class action struck
out on four occasions. It may also face prosecution by the Victorian
WorkCover Authority for its breaches of safety. But there is no
suggestion of making the government legally liable.
Workers have for a long time warned of the dangers at Longford.
This was particularly apparent in their testimony to the Commission.
Many spoke of the constant trepidation they felt. Commenting on
the Commission's findings, James Ward told the Australian,
As operators of that gas plant we always had our own safety
uppermost in our thoughts. You will push your own wagon to get
your own benefit, but in this instance we saw the writing on the
wall and we highlighted it, flagged it time and time again.
By contrast, as the Commission's inquiry revealed, Esso disregarded
safety in its pursuit of profit. Its parent company, Exxon, with
a capitalisation of $US185 billion, had a gross profit margin
of 38 percent last year. It is currently planning to buy Mobil
Corp in a $US75 billion deal. Such buy-outs and mergers are part
of the intensified global competition between transnationals,
leading to ever-greater attacks on workers' safety and conditions.
See Also:
Australia: Sit-in at Esso gas
plant after worker blamed for explosion
[28 April 1999]
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