First of all may I say thank you for the invitation to speak to you at this event today. I've chosen as a title for my talk today, 'Past, Present and Future -Making the connections and learning the lessons'. I am not entirely sure which particular hat I am here wearing today - much of what I will say is related to the work we have been doing, and are doing, in HSE on process safety and asset integrity management. But as you will be aware I am also a Fellow of IChemE, a member of Council and I have recently been asked to Chair IChemE's safety centre which brings together the Institution's many activities related to safety including publications, subject groups, training programmes and events like this one today. Just two weeks ago, I spoke at the Dinner of the IChemE NW Branch Hazards XXI forum held in Manchester and attended by over 400 people.
Given my own background it is perhaps unsurprising that major hazard industries and process safety have continued to be a major subject of interest - and concern - to me since I become Chair of HSE just over 2 years ago. I belong to the generation of engineers whose attitude to process safety was shaped by Flixborough. I suspect that may also be true for some of the other speakers here today.
But for those of you from a different generation let me just remind you what happened at Flixborough. On a Saturday afternoon in June 1974 there was a large explosion at the Nypro site in the North East of England. 28 workers were killed in the explosion and a further 36 suffered injuries. The numbers of casualties would have been many more if this incident had occurred on a weekday rather than a Saturday. There were a further 53 reported injuries to members of the public in the neighbourhood and there was considerable damage to offsite property.
In March, prior to the explosion it had been discovered that there was a vertical crack in the fifth of a series of reactors in the process and the crack was leaking cyclohexane. After shutting down to investigate the problem the decision had been taken to remove the leaking reactor and to install a bypass connecting reactors 4 and 6. On the afternoon of the 1st of June that bypass system ruptured resulting in a large leak of cyclohexane which formed a vapour cloud and exploded. All 18 people in the control room were killed when windows shattered and the roof collapsed. Fires burned onsite for over 10 days.
So when I graduated from University in 1975 and joined my first employer - Exxon - I went through rigorous training in process safety management. I don't suppose for one minute that it was any different in Shell, BP, ICI, Dupont or many other large oil and chemical companies. Flixborough had been a huge wake-up call to industry and the lessons were being learned far and wide. Everyone was committed to the principle that "it must never happen again".
Every process change had to be fully, and properly, reviewed by a multidisciplinary team. Every significant project was subject to a full Hazop review. The process required you to consider what was the worst that could happen and what could be done to prevent / mitigate it. Decisions to delay or not carry out critical maintenance and inspection work had to be referred to senior safety specialists and full management review -and performance across the industry improved as a result of the diligence which went into process safety management.
However, I hope that some of you might already be considering those things which I said went wrong at Flixborough and might even be thinking - "but there are some striking similarities there with other more recent events I've read about like Texas City and Buncefield" This is something I will come back to.
But before I do that I just want to say something about the world's worst disaster which has ever occurred in the offshore industry - which was of course Piper Alpha, in July 1988. Of the 226 people on the platform at the time of the incident 165 died and also 2 rescue workers on a standby vessel.
Piper Alpha was a large fixed platform located - 190km North East of here in Aberdeen. It was originally installed for the production of crude oil and was later converted to gas production. Because the platform was originally designed for crude oil production the location of key operations and the siting of firewalls were built to a set of design criteria which were compromised when the platform converted to gas production. The Cullen inquiry into the disaster concluded that the initial cause of the explosion and fireball which engulfed Piper Alpha had been a condensate leak which was the result of maintenance work being carried out simultaneously on a pump and related safety valve. The maintenance and safety procedures were found be inadequate - as were the arrangements for refuge and evacuation of personnel and key aspects of the design of the facility were not fit for the purpose for which they were being used.
When I was at school, I was never a great fan of history lessons. That's probably one of the reasons why I became an engineer rather than a classicist, but I am now convinced that history needs to be a fundamental part of every engineer and manager's training. Because when we forget the lessons of the past, history has a horrible habit of repeating itself. Of course we assume no one in Aberdeen will ever forget the tragedy of Piper Alpha - but even the worst memories fade over time and many of today's offshore workers were only young children or not even born at the time. Despite that we reassure ourselves - that lessons have been learned, that new control systems will prevent those sequences of events from happening again. Complacency starts to creep in to people's thinking. With the passage of time a number of other factors also have an effect:
Having spent some time on the history, I want to turn now to the present. Or more precisely to the work HSE has been doing over the last few years in relation to the Offshore industry.
Between 2000 and 2004 HSE's offshore division (OSD) ran a major programme called Key Programme 1 (KP1) aimed at reducing the number of hydrocarbon releases which were being reported to us from offshore installations and focussing on the integrity of process plant. The programme was effective in that it resulted in a considerable reduction in the number of major and significant hydrocarbon releases. However, during this time OSD became increasingly concerned about the more general decline in the integrity of fabric, structures, plant and systems. Our response was KP3, which ran between 2004 and 2007.
KP3 revealed a number of concerns which fell into 3 basic categories:
On major hazard leadership the report highlighted:
With respect to engineering standards the report highlighted:
And on learning:
My first visit to Aberdeen as Chair of HSE was for the launch of the KP3 report in October 2007. The report received widespread media coverage at national level as well as locally. Some of the meetings I attended during that first visit were not easy - there was a good deal of discomfort within the industry at the approach we had taken in making the report public, not least because we were reporting on what had been found over a 3-4 year period and some of the specific problems we were highlighting has since been fixed. I remember very clearly being asked at the time what it was that I wanted to see from the offshore industry. The answer was very simple - "Ownership and Leadership".
It was true that problems were being fixed when they had been identified but there was a real problem with a system which relied on the regulator carrying out an inspection and review to identify problems before they were fixed. Responsibility for finding problems lies with the owners and operators, not the regulator - better still systems need to be in place to address emerging conditions before they become problems which are obvious to a third party conducting an inspection.
In April 2008, HSE hosted a conference in London for all of the major hazards industries which we entitled "Leading from the top". We invited Chief Executives and senior managers from the nuclear industry, from onshore major hazards, offshore, the rail industry and power generation. We had over 200 delegates at the conference. We talked about the need for leadership, we reminded them of the importance of process safety management and how this needed to be happening not just at operational level but that it needed to be understood, managed and led from the very top of the organisation. We also explored in that conference the dangers of considering the challenges in one sector as being unique or different from those of other sectors. No one denies for example that the conditions in the North Sea are more challenging than those onshore but many of the problems faced by the industries are similar - ageing plant, change of ownership, loss of corporate memory, the need for systems in place from the top to the bottom of the organisation to manage process safety and asset integrity.
I have been encouraged by the response I have seen from industry since 2007/8. Encouraged, but not yet convinced or fully reassured, because that can only come with time.
Operators of major hazards facilities are now talking to one another and learning lessons from each other. There is now an onshore Process Safety Leadership Group which has produced some key principles of what process safety looks like in practice. Industry leaders from all sectors meet together in a forum chaired by someone from the nuclear industry - without HSE in attendance - so that they can share and discuss more openly without the regulator present.
What has also become clear to me is that this is not a challenge which is unique to the UK. Only last week I had the opportunity to speak to John Bresland, Chair of the US Chemical Safety Board, and it was clear from our discussion that many of the issues and concerns are common. Likewise I have now made 3 presentations on process safety issues as part of IChemE activities in Australia. Every one of the events has been sold out and every one has reinforced that the challenges of ageing plant, loss of corporate memory, and the risk of creeping complacency are issues there as well.
In July 2008, on the 20th anniversary of the Piper Alpha disaster the Secretary of State for Work and Pensions commissioned HSE to review the progress being made by the offshore oil and gas industry in addressing the issues identified by the KP3 report. The review found that the industry had allocated considerable resource and effort to improve offshore assets and comply with standards, and that the offshore industry leadership had responded well. The review also highlighted that offshore safety and the security of UK energy supplies will continue to depend on successful management of oil and gas asset integrity. Oil prices had bounced back in the early years of the decade from the lows of the 80s and 90s, which had in part led to the lack of maintenance and to assumptions that North Sea operations would soon phase out, but since KP3 - and with the advent of the world recession - oil prices had started to decline again adding significant economic pressures, which could threaten the programme of work. But it is clear that fluctuating economic environments cannot be allowed to slow progress on management approaches to achieve and sustain the improvements KP3 identified as necessary.
The offshore industry continues to get older and remedial work in some areas is still to be undertaken. Momentum must be maintained to continue the build up of improved asset integrity, not just to maintain the current status achieved or, even worse to allow things to fall back to the unacceptable state we found when we conducted KP3. In 2010 OSD plans to launch an inspection programme which will focus on ageing and life extension - it is key that these become clear and distinct features within the asset integrity management process. Safety is fundamental to good business for the offshore industry. The long-term future and sustainability of the UK continental shelf depends on plant and equipment begin properly maintained for the long term.
How long is long-term - none of us know that for sure. Given that we are already well beyond the expected design life of many facilities we are already in somewhat uncharted territories. But we also know that there are new challenges ahead. New thoughts on how the offshore industry may evolve in the future. I believe that it would be a mistake for us to make any further assumptions about when we might no longer be needing to use offshore facilities and work instead on the assumption that we are here for the long haul and the assets must be maintained indefinitely.
Within the last year, HSE has established a new working group who are looking at the Health and Safety Challenges associated with new and emerging energy technologies. It is common knowledge of course that our Nuclear Installations Inspectorate are heavily engaged in carrying out the Generic design Assessment process for new nuclear. But out Emerging Energy technologies team are looking at five other Energy-related work streams:
Our aim is to provide guidance on a proactive basis so that we can enable the safe introduction and expansion on new energy technologies. This requires us to think about an appropriate regulatory regime for new processes and new types of operation. But that also requires us to think about some of the potential process safety implications - to consider what might happen with these new technologies in the worst case.
In the case of Carbon Capture and Storage, CO2 will be compressed into a liquid at very high pressures and pumped through long pipelines to be stored in deep offshore formations. A conventional coal fired power plant in the UK emits around 30,000 tons CO2 each day. Integrity and containment performance of process plant, pipelines and wells when handling dense phase CO2 at such scale is not yet fully understood, and neither is the dispersion behaviour of CO2 upon catastrophic release. We do know that CO2 is an asphyxiate and it has toxicity in humans and the environment.
There is also a need to understand its potential to cause embrittlement to pipework and equipment. In order to store CO2 in deep geological strata - such as exhausted oil and gas fields - it may be necessary and desirable to reuse some of the equipment which has previously been used for extracting that oil and gas. Some of it may well involve equipment which is already beyond its original design life. Here again we are into the territory of changed design assumptions and there is a significant engineering challenge ahead of us all in assessing and satisfying ourselves that this can be done safely and effectively. Innovation and change is the lifeblood of any successful economy or business. We need to figure out how we can make the transition to new energy technologies, but how to do that safely and to do that we will need to apply some of the lessons and the experience we have gained from the past in handling new situations and circumstances.
The past has a lot of lessons to offer for us to learn from. Despite the best of intentions, some recent events and major incidents have demonstrated to us all that we have not learned those lessons in a way that they have become sustained and long lasting. Our memories have allowed the shock and some of that commitment to ensuring history doesn't repeat itself to fade. I have no doubt that all of you, like me, have been involved in emergency exercises and have conducted Hazop studies. Sometimes these things can feel a bit hypothetical and / or something of a technical exercise. What we have to remember is that we are working to stop catastrophe from happening - catastrophe where people's lives are lost and businesses are destroyed.
Never allow yourselves to see this simply as engineering challenge but remember that the mission is to prevent catastrophe, and on that note I'd like to close by showing you this video of what catastrophe really looks like. This is why we must not forget the history and the lessons of the past.