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Executive summary - Background

The BP Grangemouth Complex (the Complex) is a Major Accident Hazard (MAH) site as defined under the Control of Major Accident Hazard Regulations (COMAH) 1999 which implements the Seveso II Directive in the UK. It is one of the largest of the 950 COMAH sites in the UK.

The Complex is an important centre of UK operations for BP and of major strategic importance for the BP Group.

The COMAH Regulations require a MAPP (Major Accident Prevention Policy) to be produced for the Complex which requires a very high standard of management of major accident hazards to be demonstrated and that the operator will take all measures necessary for the control and prevention of major accidents.  

Operators of "top tier" sites are also required to prepare safety reports which identify the systems used by the operators to ensure their processes are operated safely at all times and that adequate steps are taken, so far as is reasonably practicable, to prevent major accidents or in the event of such accidents, to limit the effects on people and the environment.

Such reports for the top tier installations at the Complex (incorporating a MAPP for the Complex) had been prepared and submitted to the Competent Authority for examination and assessment and were under review in May 2000 when the incidents took place.

Under the COMAH Regulations, operators are also required to provide information on safety measures at their establishments to persons likely to be affected by a major accident occurring at their establishment. On and off-site emergency planning is also a key component. The Complex had provided such information to the local authorities for inclusion in an off-site emergency plan and prepared an on-site plan.

The Competent Authority is required to carry out significant regulatory activity including inspections in order to ensure that the operations are being conducted in accordance with both legislative requirements and company claims as evidenced in the COMAH safety reports. Prior to the series of incidents that occurred in May/June 2000 the Complex was already the subject of significant regulatory activity and the HSE were in discussion with the management at the Complex concerning a number of safety issues which were of concern. The new Complex Director appointed in October 1999 had accepted that the Competent Authority concerns were valid at a meeting in November 1999 and a major management action plan was already underway to improve safety performance on-site prior to the incidents.

During the period between 29th May and 10th June 2000 three incidents occurred at the Complex. These incidents were subsequently investigated, as required under COMAH Regulation 19, by the Competent Authority and by BP in order to determine the underlying root causes of the incidents and to identify any lessons that needed to be learned.

In addition the Complex Director also immediately set up a BP Task Force to undertake a wider review of all operating units and functions across the Complex and commissioned some external independent investigations and assessments. These were aimed at determining the overall effectiveness of current arrangements at the Complex for health, safety and environmental affairs. The BP Task Force was the largest audit team ever assembled for a petrochemical complex and completed 4 man years of work in 8 weeks.

The power distribution failure (29th May), the medium pressure (MP) steam main rupture (7th June) and the Fluidised Catalytic Cracker Unit (FCCU) fire (10th June) each had the potential to cause fatal injury and environmental impact, although no serious injury occurred, and there was only short term impact on the environment. BP were prosecuted on indictment in Falkirk Sheriff Court on 18th January 2002 and pleaded guilty to two charges relating to the FCCU fire and the MP steam main rupture incidents. BP Chemicals Limited were fined £250,000 and BP Oil Grangemouth Refinery Limited were fined £750,000.

This public report into the series of incidents is designed to summarise the incidents and the following investigations carried out by the Competent Authority and by BP. Full details of all the detailed investigative work carried out by the Competent Authority and BP and all the detailed incident specific findings and legal work are not presented here.

The report seeks to reassure the public that a series of thorough and detailed investigations into the causes of the incidents have been carried out by all parties concerned. In addition the report is intended to demonstrate that a number of lessons have been learned both by BP and by the regulators and actions have been taken in order to improve safety performance at the Complex. The report is also intended to be viewed by a wider audience of companies, safety professionals and Trade Union representatives involved in the major accident hazard industries and to serve as a reminder of many of the issues that need to be addressed by safety reports for major hazard installations. Operators of COMAH sites are expected to carefully consider the contents of this report and the HSE will use Trade Association contacts plus site inspection plans and other means to publicise the incidents and to ensure the lessons are widely learned.

2010-10-25