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Major incident investigation report

BP Grangemouth Scotland : 29th May - 10th June 2000

A Public Report Prepared by the HSE on behalf of the Competent Authority

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Appendix 2 - previous HSE and SEPA involvement
COMAH

The COMAH Regulations are a “permissioning regime” that is designed to ensure that for sites with a major accident potential that high standards are achieved. In this case the “COMAH permissioning regime” requires the company to document in advance the hazards, risks and measures to eliminate or control them (in the form of a safety report). The Competent Authority has a duty to examine the safety report and report the results of the examination to the operator.

A requirement of the COMAH Regulations is that a major hazard site such as the Complex is required to prepare a series of safety reports for the installations present on-site to demonstrate safe and environmentally sound operation during the life cycle of facilities processing or storing dangerous substances.

The COMAH safety report is required to identify the potential for major accidents and describe the measures in place for preventing such accidents and limiting the consequences of any which do occur. The safety report is evidence that an operator has carefully scrutinised the preventative and control measures.

These safety reports (which are submitted to the Competent Authority for assessment and intended to be placed onto a public register) are a public statement by the company of the mechanisms that are in place on-site for the prevention of major accidents. Details to be provided in safety reports include not only technical measures but also the safety management systems that are in place.

The key requirement of a safety report is to demonstrate that the all measures necessary to prevent major accidents and to limit the consequences to people and the environment of any that do occur have been taken. The safety report provides the Competent Authority with a comprehensive description of the establishment, its surroundings, the associated risks and the control measures in place to enable verification of safety management systems by inspection over a 5 year period.

The safety reports comprised a three level report – BP Group, Grangemouth establishment and 28 top tier installation reports, and were submitted by BP in February 2000 as legally required. Initial examination by the Competent Authority identified significant weaknesses, which BP agreed to revise and resubmit, with an agreed resubmission timescale plan.

The failure of safety reports to meet the required standard did not necessarily equate with an unsafe site. If the examination had identified serious deficiencies in the safety report the Competent Authority had a duty to prohibit operations under COMAH Regulation 18.

The problem was genuine difficulty in meeting the higher standards of “demonstration” evidence (that is demonstrate in writing that all measures necessary to prevent or minimise major accidents are in place) which COMAH required compared to the previous CIMAH safety regime.

BP was not alone in the on-shore major hazard industry in having such difficulties with safety reports. Some of the simpler BP COMAH “top tier” sites safety reports did pass examination by the Competent Authority. The problem was the complexity of the multi-installation safety reports.

The Competent Authority examination of the resubmitted reports resulted in the issue of an improvement notice on 31st May 2001, with a compliance date of 1st May 2002. Similar improvement notices were also issued to other operators.

Further discussion took place with BP leading to a meeting at the headquarters of BP in London (Britannic House) on 23rd November 2001 which agreed a way forward to enable BP safety reports to meet the required standard. Under the provisions of the Health and Safety at Work Act BP formally requested a further extension to the compliance date in order to allow a phased re-submission of the safety reports.  The Competent Authority extended the improvement notice until the end of July 2003, with the first safety reports being required to be re-submitted at the end of June 2002.

If a major accident occurs (as defined under the COMAH Regulations) the Competent Authority has a duty to investigate the circumstances surrounding the incident and to produce a public report so that lessons can be learned.  COMAH Regulation 19 clearly identifies the inspection and investigation duties of the Competent Authority.

Parallels can be seen between the COMAH safety report regime for the major hazard industries and the issues raised during Lord Cullen’s enquiry into the Ladbroke Grove rail incident. Lessons can be learnt in terms of industry regulation, safety leadership and the safety report regime.