workers on duty on the day of the explosion. The findings of the Royal Commission, however, cleared Ward of any negligence or wrongdoing. 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 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 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