Hopkins Essay

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1 An AcciMap of the Esso Australia Gas Plant Explosion Andrew Hopkins* Abstract This paper presents an AcciMap (causal diagram) of an accident at Esso’s gas plant at Longford in Victoria. The AcciMap is used to show how factors quite remote from the immediate accident sequence contributed to the accident. Parties at the Royal Commission which investigated the accident were quite selective in the causes they emphasised. The paper identifies three principles of selection which were used: self-interest, accident prevention and legal liability. The interested reader will find full details of this accident in my book (Hopkins, 2000) * Australian National University address: Social Sciences, Building 24, Arts, ANU, ACT, 0200, Australia phone: 61 2 6249 4793 fax: 61 2 6249 0525 e-mail: andrew.hopkins@anu.edu.au . 2 On 25 September, 1998, an explosion occurred at an Esso gas plant at Longford, near Melbourne, which killed two men and interrupted the gas supply to the state of Victoria for two weeks. Because of the economic cost of this disruption the state government set up a Royal Commission - the most powerful inquiry possible. The inquiry uncovered an intricate causal network, ranging from front line operator error right back to company and even government policy. This paper will outline the causal network by providing an AcciMap of the incident (Rasmussen, 1997). A number of features of the map will be explained in the next sections. The paper will then examine the strategies of causal explanation used by the parties represented at the inquiry. The accident sequence Level 1, the bottom level of the diagram, lays out the events - physical processes and operator actions - which constitute the accident sequence. The two irregular stars represent the critical outcomes – explosion and loss of gas supply. The circles represent the operator errors which

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