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Knowledge Management System; Design a knowledge management system providing one model with diagrams to improve the organization in the case study you analysed in assignment
Assignment 2 – Design a knowledge management system providing one model with diagrams to improve the organization in the case study you analysed in assignment 1
The 1998 Esso Longford gas explosion was a catastrophic industrial accident which occurred at the Esso natural gas plant at Longford in the Australian state of Victoria’s Gippsland region. On 25 September 1998, an explosion took place at the plant, killing two workers and injuring eight. Gas supplies to the state of Victoria were severely affected for two weeks and shut down most of Victoria’s industry and significantly affecting cooking and heating for most Victorian households.
The Case
In 1998, the Longford gas plant was owned by a joint partnership between Esso and BHP. Esso was responsible for the operation of the plant. Esso was a wholly owned subsidiary of US based company Exxon, which has since merged with Mobil, becoming ExxonMobil. BHP has since merged with UK based Billiton becoming BHP Billiton.
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.
During the 1980s, the State of Victoria sold off its gas supply business to the private sector, which then rationalised the infrastructure into a single supply and distribution operation based out of Longford. In an effort to retain engineering expertise and reduce overheads, Esso also relocated its plant engineers to Melbourne with visits to Longford for maintenance cycles or upgrades to plant.
Additional training, electronic alarms and monitoring systems were put in place to assist plant operators.
The feed from the Bass Strait platforms consists of liquid and gaseous hydrocarbons, water (H2O) and hydrogen sulphide (H2S). The water and H2S are removed before reaching the plant, leaving a hydrocarbon stream to be the feed to Gas Plant 1. This stream contained both gaseous and liquid
components which are then separated. More gas is extracted form the “rich oil” by means of a shell and tube heat exchanger, in which hot “lean oil” is cooled and cold “rich oil” is heated.
During the morning of Friday 25 September 1998, a pump supplying heated lean oil to heat exchanger GP905 in Gas Plant No. 1 went offline for four hours, due to an increase in flow from the Marlin Gas Field which caused an overflow of condensate in the absorber.
A heat exchanger is a vessel that allows the transfer of heat from a hot stream to a cold stream, and so does not operate at a single temperature, but experiences a range of temperatures throughout the vessel. Temperatures throughout GP905 normally ranged from 60 °C to 230 °C.
An Exxon consultant advised that a similar gas plant heat exchanger ruptured in the US in the 80s due to brittle fracture. Fortunately, there was no ignition and no loss of life or injury. Exxon engineers undertook extensive analysis and discovered that the cause of the failure was due to a brittle failure as the heat exchanger steel was found to be susceptible to very low ductility at low temperatures.
Exxon issued two separate publications raising concerns about the poor ductility of vessels constructed prior to 1971. Similar heat exchangers were operated in several other plants around the world, including Longford. Exxon identified brittle fracture as a hazard and put tight controls in place for the operation of the equipment at risk. The Esso managers, engineers and operators were
unaware of this hazard and Esso was strongly criticised in the Inquiry as to why this had been missed in their Hazard Identification process.
In the early 1990s Esso introduced an Operations Integrity Management System but this did not address what to do when a lean oil circulation pump is lost. However, in an out-of-date handbook there was an instruction which required the shutting down of the absorbers in the case of loss of lean oil flow, thus reducing the extent of thermal shock.
Prior to the failure of the heat exchanger GP905, the plant operators were subjected to numerous visual and audible alarms from the control panel. However, this was not unusual as there was often an alarm of some type going off at the plant during the day. The plant and the vessel had been functioning outside its operating envelope for several days, desensitising the plant operators to the type and extent of the alarms raised.
Investigators estimated that, due to the failure of the lean oil pump, parts of GP905 experienced temperatures as low as -48 °C. Ice had formed on the unit, and it was decided to resume pumping heated lean oil in to thaw it. When the lean oil pump resumed operation, it pumped oil into the heat exchanger at 230 °C – the temperature differential (thermal shock) caused a brittle fracture in the heat exchanger (GP905) at 12.26pm.
About 10 metric tonnes of hydrocarbon vapour were immediately vented from the rupture. A vapour cloud formed and drifted downwind. When it reached a set of heaters 170 metres away, it ignited.
This caused a burning vapour cloud that reached back to the rupture in the heat exchanger creating a fierce jet fire that lasted for two days.
The rupture of GP905 led to other releases and minor fires. The main fire was an intense jet fire emanating from GP905. There was no blast wave – the nearby control room was undamaged.
Damage was localised to the immediate area around and above the GP905 exchanger.
Peter Wilson and John Lowery were killed in the accident and eight others were injured.
The fire at the plant was not extinguished until two days later. The Longford plant was shut down immediately, and the state of Victoria was left without its primary gas supply. Within days, the Victorian Energy Network Corporation shut down the state’s entire gas supply. The resulting gas supply shortage was devastating to Victoria’s economy, crippling industry and the commercial sector (in particular, the hospitality industry which relied on natural gas for cooking). Loss to industry during the crisis was estimated at around AUD$1.3 billion.
As natural gas was also widely used in houses in Victoria for cooking, water heating and home heating, many Victorians endured 20 days of cold showers and cold nights.
Gas supplies to Victoria resumed on 14 October. Many Victorians were outraged and upset to discover only minor compensation on their next gas bill, with the average compensation figure being only around $10.
Royal Commission
A Royal Commission was called into the explosion at Longford, headed by former High Court judge Daryl Dawson. The Commission sat for 53 days, commencing with a preliminary hearing on 12 November 1998 and concluding with a closing address by Counsel Assisting the Royal Commission
on 15 April 1999.
Esso blamed the accident on worker negligence, in particular Jim Ward, one of the panel workers on duty on the day of the explosion.
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;
. 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.
Legal ramifications
Esso was taken to the Supreme Court of Victoria by the Victorian WorkCover Authority. The jury found the company guilty of eleven breaches of the Occupational Health and Safety Act 1985, and Justice Philip Cummins imposed a record fine of $2 million in July 2001.
In addition, a class action was taken on behalf of businesses, industries and domestic users who were financially affected by the gas crisis. The class action went to trial in the Supreme Court on 4 September 2002, and was eventually settled in December 2004 when Esso was ordered to pay $32.5 million to businesses which suffered property damage as a result of the incident.
Following the Longford accident, Victoria introduced the Major Hazard Facilities Regulations to regulate safety at plants that contain major chemical hazards. These regulations impose a so-called “non-prescriptive” regime on facility operators, requiring them to “demonstrate” control of major chemical hazards via the use of a Safety Management System and a Safety Case.
• Review of system effectiveness
• Annual competency assessment undertaken
• Risk analysis undertaken to justify ROI
Conclusion
By introducing and maintaining the Naval Knot Knowledge Management System (NKKMS) aims to improve the competency of Customs boat crews in tying knots and through that, reduce the risk of loss to personnel and equipment
How the NKKMS will function
• Integrated in to initial boat crew training
• Delivered by senior boat crew
• Supported through Intranet page and you tube video
• Refresh every 12 months with testing
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