Case Study: the ICL explosion, 2004

Transcription

1 Case Study: the ICL explosion, 2004 Multiple failures of H&S Management Interfaces Highlands & Islands Branch February 2013 Ian Waldram, CFIOSH

2 Outline The Incident (2004) The Court Case (2007) The Public Inquiry ( ) What was missed? 2012 update Conclusions Images and wording from The ICL Report reproduced under the terms of Click-Use Licence C

3 The Incident Noon 11 May 2004 ICL, Maryhill, Glasgow 9 fatalities The ICL Inquiry, front cover 45 injured or exposed to serious risk

4 ICL premises 1860s mill, adapted Explosion in basement Almost all employees trapped History of worker concerns

5 Public/media speculation Gas-fired boiler (in-house modified) Weakened structure Chemicals History of complaints Natural gas or LPG? HSE

6 The immediate cause(s) Poor initial installation standards (1969) Joints not corrosion protected Pipe entered a basement, entry point not sealed Pipe buried under yard at later stage (1973) Never inspected or maintained HSE

7 The area of the explosion ( The ICL Inquiry, Figure 12)

8 The Court Case August 2007 Charges included No suitable & sufficient risk assessment No competent person(s) appointed No pipework maintenance system ICL plead guilty Fined 400, to allow the Group to trade

9 Reactions to Court Case Local concerns Victims & families, residents, politicians Exactly what happened? Role of HSE? University report published Wider H&S failures, including no worker involvement HSE failures Pressure for Public Inquiry

10 The Public Inquiry ( ) Phase 1: July 2008 Factual & issues arising Phase 2: Oct-Nov 2008 Regulation of ICL activities, lessons to be learned Report: July 2009 Responses & closeout IOSH submissions to Phase 1 & 2

11 Typical LPG bulk tank supply The ICL Inquiry, Figure 12

12 The LPG installation at ICL ( The ICL Inquiry) Figure 17 Figure 22 Figure 24 Figure 21

13 LPG supply at ICL - Missed opportunities (1) Dec Inexperienced contractor appointed (family) Pipework not all to Calor specification, entry not fully sealed 1973 Building inlet buried HSE concerns about bulk tank, but pipework not reviewed. ICL promised improvements not completed. No follow-up until 1988 Dec Sept Explosion in England due to underground pipe leak. HSE & Calor joint investigation, not publicised internally by either HSE inspect & define required improvements, by ICL, including underground pipework inspection

14 LPG supply at ICL - Missed opportunities (2) Jan Calor propose equivalent improvements, on behalf of ICL, eventually accepted by HSE March 1990 HSE planned check visit not done July 1993 May 1994 April 1998 Oct 2001 Calor inform customers of new duties under Pressure Systems Regs (PSR), no check whether any action taken ICL meet insurers re PSR, no follow-up by ICL or insurers HSE analysis of fires shows LPG not significant, no need for new initiatives ICL change LPG supplier, bulk tank changed, no questions asked about pipework ICL risk assessment, buried pipe not considered

15 Inquiry Conclusions re LPG Risks very low: fatality ~ 1 in 10 million/a Out of sight, out of mind Many non-technical customers Replace metal buried pipework Define a consistent equipment/responsibility interface between supplier & customer Additional customer duties Compile & keep Installation Record Arrange regular independent verification? Additional supplier duties Contribute to the Installation Record Confirm installation suitability before supply

16 Additional conclusions (1) ICL consistently misled HSE about their plans & closeout actions ICL Chairman delegated accountability to Directors of subsidiaries but did not ensure competence when doing so ICL incapable of identifying buried pipe hazards, even if properly motivated needed a competent advisor HSE handover system between inspectors was deficient. Possibly they were underresourced?

17 What else was missed at ICL? 1993 MHSW Regs require Risk Assessments, plus appointment of competent person(s). No action by ICL or checks by HSE or Insurer Sept Nov Oct July 1999 Fire Officer checks Certificate drawings, misses door to basement ICL ask engineer to check LPG oven. He declines due to obvious design faults, which he would have to report to HSE ICL commence RAs, after advice from Insurer. Project led by a student (family member) Leaks in natural gas oven supply. Engineer notes LPG oven still in use, with some repairs

18 What else was missed at ICL? Feb ICL contact H&S consultant re Hazardous Substances RAs after HSE enforcement. He advises there is wider RA non-compliance. ICL decline his quotation no added value No action by ICL to comply with DSEA Regs (ATEX Directive) June-Aug Unannounced HSE inspection following employee complaint re chemical exposures. Escalates rapidly to involve local MP. OH specialist later concludes employee symptoms not work-related

19 Additional conclusions (2) ICL widely deficient in H&S management Poor engagement of workers HSE follow-up not reliable No appointed competent person Many other blind eyes some knowingly, some did not know any better If the Duty Holder and the Regulator fail, is there no other back-stop?

20 Don t shoot the messenger! HSE Specialist Inspector Reminded of limited authority by Operational colleague Prevented by HSE from making an early apology to families, even though no longer an employee Criticised by Inquiry for not insisting Calor/ICL followed his original requirements Calor Technician Undergound leak in hotel kitchen, isolated supply Senior hotel staff very angry Refused to allow him back on site, other Calor Technicians had to make the repair

21 May 2012 Update UK-wide survey premises with significant risks ~600 person years to replace, insufficient qualified people Higher priority pipework replaced by end-2013 >10 years old in 2009 and Premises regularly occupied by public or > 5 persons Cellar, basement or under-floor void All other carbon steel pipework replaced by 2015 Expert review mid high priority resolved, 3000 to go by end others, extend target to 2020

22 Does your organisation ever have Significant hazards out of mind? Not understood by managers & workers Missed by insurers? Leaders who set & accept poor standards? Workers whose views are ignored? A less-than-perfect regulator? A culture that dislikes anyone saying Let s stop and think about this!? Who speaks up about these, if not you?

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