This is a really interesting report which explored the extent that Australian major hazard facilities (MHF) had learnt from the 1998 Esso Longford disaster, three years after the event.
I’ve referenced this report a lot in my writings, so thought it was time to post a summary. You should be able to freely access the full report and if you’re interested in this topic then I recommend going straight to the original report from James Nicol.
Note: This report is from 2001 – things may and likely have have changed substantially since then. However, even three years following the accident the below was found.
The author examined the findings from the Longford Royal Commission and sent out a questionnaire to relevant MHF across oil & gas, petrochemical and others. The questionnaire sought to understand the “extent and significance of any engineering, operational or cultural changes that have occurred as a result of Longford, and how their organisation’s changes reflected the lessons learned” (p4).
This included info on HAZOPs, maintenance standards, deployment of engineers, engineering supervision, maintenance & design, safety cases and more.
Results
In answering the question “Have Australia’s Major Hazard Facilities learnt from the Longford Disaster?”, the author highlights the challenge in trying to neatly answer this.
However, based on these findings, it’s suggested that the “industry and the engineering profession have not learnt as much as they might have from the tragedy” (p5, bold added).
Before unpacking this, a number of positive developments did develop post-Longford. This includes: (p.5)
· A renewed focus on HAZOPs
· More focus given to operating procedures and SMSs in general and driven by MHF legislation
· Technical recruitment strategies, which may prompt organisations to “[think] twice before reducing or eliminating their on-site process engineers”
· Recognition for the need for better inter and intra-company communication
· Plus more factors.
Floating back to the main conclusion that industry hadn’t (at that time point) learnt all of the relevant lessons, it’s argued that: (p6)
· There exists a belief by some MHF staff that “Longford is only applicable to the oil and gas industry, rather than to all MHF” [*** Which we argued in my first paper, “Fantasy planning: the difference between safety systems and systems of safety” that this may reflect “distancing by differencing” (see David Woods, Richard Cook et al.)].
· Some areas of senior management at MHFs “see engineering as a cost centre rather than as a contributor to profit” and thus, downsizing on-site engineering resources is seen as cost reduction and less about consequences to safety risk and technical resources. This decline of engineering capacities results in reduced ability to maintain safe and viable production and particularly during abnormal and emergencies.
· Little apparent action taken to offset the increase in the age profile of engineering staff and ensuring that corporate knowledge is transferred to younger engineers.
· “Some MHF have been lulled into a false sense of security as their post-Longford reviews of safety and engineering failed to identified any significant new hazards” (bold added). It’s also said an over-reliance on management systems at the expense of adequate resources for engineering capabilities.
It’s discussed that key findings from the Longford disaster aren’t unique to oil & gas but can be found across virtually all MHF sites.
The importance is compounded by the increasing age of MHF plants, greater outsourcing of engineering services, greater age profile of engineering staff without a concomitant transfer of knowledge to younger engineers and a “loss of a critical mass” of experienced in-house engineering staff and technicians.
Quoting the report, it’s argued that unless we “learn these lessons and apply them professionally and with sensitivity, the possibility of a second Longford will always be with us” (p29).
Furthermore, I’ve extracted some quotes from another paper to provide more context on distancing by differencing. Woods (2003, “Creating Foresight …”) defined it as: “those reviewing new evidence or incidents focus on differences, real and imagined, between the place, people, organization and circumstances where an incident happens and their own context. By focusing on the differences, people see no lessons for their own operation and practices or only narrow well bounded responses”.
And further, Woods argued to “not discard other events because they appear on the surface to be dissimilar. Rather, every event, no matter how dissimilar on the surface, contains information about underlying general patterns that help create foresight about potential risks before failure or harm occurs”.
Author: James Nicol, 2001, Institution of Engineers
Study link: http://158.132.155.107/posh97/private/Case/ESSO.Longford.Explosion(1998).pdf
Study link 2: https://catalogue.nla.gov.au/Record/3009008
Link to the LinkedIn article: https://www.linkedin.com/feed/update/urn:li:ugcPost:6937885338828685312?commentUrn=urn%3Ali%3Acomment%3A%28ugcPost%3A6937885338828685312%2C6937886059888291840%29
SafetyInsights.org 