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The incidents
Fluidised Catalytic Cracker Unit (FCCU) Fire - 10th June 2000

Competent Authority investigation

Key Findings - Cause and Effects

Findings of the Competent Authority Investigation

The findings of the Competent Authority investigation in relation to the five themes identified earlier are given below.

Legislative Compliance

This was a major accident as defined under the COMAH Regulations that could have resulted in multiple fatalities under different circumstances. It was identified that there were a series of deficiencies which resulted in BP being prosecuted under the Health and Safety at Work Act 1974.

Best Practice/Guidance

Comparison of the organisational set-up with the "POPMAR" safety management system model in HSE Booklet HSG65 "Successful Health and Safety Management" suggested major weaknesses in failing to organise to meet the high standards required in the Major Accident Prevention Policy (required by COMAH) and in planning and implementing and in monitoring, audit and review. Underlying problems were identified in the following areas:

BP Grangemouth Safety Reports

The CIMAH FCCU installation safety report 1997/98 revision claims and concludes that – "hardware and software controls in place on the FCCU are adequate to prevent the occurrence of a major accident which could affect the general public, the personnel working on-site or the environment around it." Based on investigation findings, this was partly unjustified even in 1997 when it was submitted, and certainly did not reflect the reality by 10th June 2000 when the cumulative effects of unreliability, numerous plant start-ups, vibration and unsupported pipework factors came together. The safety report was not proactively used as a management standard for reviewing continued safe operation, nor used as an audit tool to verify the claims made for safe operation. There were serious deficiencies in the COMAH compliance regime and the safety report did not reflect the reality of the plant operations and maintenance.

BP Group objectives

BP failed to fully meet their own high performance standards in "Getting HSE Right (GHSER)".

Previous Incidents/Recent History of Operation

Between spring 1998 and June 2000 there was an increased number of start ups and shut downs on the Vapour Recovery Unit. Further, a number of  incidents had occurred over the previous two years in which vibration was a relevant issue. A summary list of these previous incidents is given below:

In addition to the incidents identified above there had been another incident in November 1999 when a prolonged start-up attempt on the FCCU resulted in an ignition of a torch oil vapour cloud within the ductwork of the CO boiler. Contrary to plant operating instructions in the master operating manual (1997), the torch oil had been admitted to the Regenerator when the unit was at too low a temperature. As a result ignition of the torch oil did not occur in the Regenerator. Although ignition had not been verified, a considerable further quantity of torch oil was injected and it is believed that hot spots in the slumped catalyst bed vapourised the torch oil. The provision of a temperature interlock had previously been considered and discounted, as it was decided that operating procedures alone were a sufficient control.

As a result of the torch oil incident the HSE issued an improvement notice to BP requiring an abnormal operations risk assessment procedure to be developed and recommended review of the operation of the FCCU to be undertaken. BP complied with the terms of the improvement notice.