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Process Safety & Risk Management Topic: Name: Sahil Hariramani

Semester 1, 2018 Food For Thought Week 8 Group: 15

Workshop: Friday
Cornell Notes
Date: 04/05/2018
What were the root causes for the According to the Victorian Parliament [1], the root causes of the Esso
Esso Explosion? explosion can be summarised below:
 Pumps GP1201 failed to restart causing a vast number of vessels to
be deprived of hot lean oil, which allowed them to cool to a
temperature close to -48°C
 The cool temperature caused the embrittlement of the steel shell,
causing a fracture when hot oil was re-introduced into the system,
releasing a large volume of hydrocarbon vapour which soon ignited
causing an explosion and fires.
 One of the main causes of the failure of pump GP1201 is that high
levels of condensate in Absorber B led to condensate entering the
rich oil stream. This in turn led to an upset in the ROD which
resulted in a heavy carry-over of liquid and vapour from that vessel
into the lean oil stream. As a consequence, the level in the Oil
Saturator Tank was raised and the level controller for that vessel
closed a level control valve to restrict the flow from the GP1201
 Excessive alarm and warning systems had caused workers to
become desensitized to possible hazardous occurrences.
 The relocation of the plant engineers to Melbourne caused a
reduction in the quality of supervision at the plant.
 The company neglected its duty to conduct a HAZOP study of the
heat exchange system, which would almost certainly would have
highlighted the risk of tank rupture caused by sudden temperature
 The company’s "safety culture" was more focused on preventing
the loss of time due to accidents or injuries, rather than protection
of workers and their health.
 Lack of staff, plant manager was not present on the day of the
accident. The position of the Operations Superintendent was
vacant, and his replacement was ill. And the entire day crew was on
training at the time when extra manpower was requested [2].
Identify the similarities and Similarities:
differences between the Esso GP905  Both heat exchangers are handling hazardous and toxic
and the BP 818C Heat Exchangers. hydrocarbons.
 GP did not conduct a HAZOP study whereas BP did conduct a
HAZOP study.
 The GP905 Heat Exchanger has an extensive alarm system whereas
the BP818C heat exchanger does not have an alarm system.
 The GP905 system was uninsulated whereas the BP818C system is
insulated [2].


[1] S. o. Victoria, "Report of the Longford Royal Commission," Parliament of Victoria, 1999.
[2] R. B. Hutchison, D. M. Boult, R. M. Pitblado and G. D. Kenny, "Lessons from the Longford Gas Explosion and Fire".