During the initial investigations into each of the incidents the Competent Authority decided to carry out a site wide investigation by members of the HSE’s Human Factors team into overall health, safety and environmental management at the Grangemouth Complex to consider whether underlying human and managerial factors provided a possible explanation for the incidents. The investigation addressed the safety management system and safety culture and explored wider human factors issues both as possible explanations for the incidents and to establish the current situation across the entire Complex.
The occurrence of three separate incidents on the Complex within a two week period was of concern not only to the Competent Authority and BP, but to others including the Local Authority, Trade Union safety representatives, Members of Parliament (MP’s), Members of the Scottish Parliament (MSP’s) and the local Grangemouth population. There was, in addition, some public speculation of whether issues such as alleged lack of investment or de-manning were contributory factors to the incidents. In the event the Competent Authority did not find any evidence to support the allegations that either a lack of investment or de-manning were contributory factors to the incidents. Further the information considered by the Competent Authority did not justify the view that there had been a lack of investment at the Complex. BP provided evidence that the investment level in the Complex was above relevant industry benchmark levels.
Previous concerns about health, safety and environmental management on COMAH issues at Grangemouth had been expressed directly to the management of the Complex by the Competent Authority in November 1999. These concerns were accepted as valid by the Complex Director and as a result there were already on-going discussions between BP and the Competent Authority, prior to the series of incidents, about how to effect improvements.
It had been recognised by BP prior to November 1999 that the historical management and business structure at the Complex required to be changed. As a result a new Complex Director was appointed in November 1999 with specific responsibility for integrating and unifying the management structure. The Complex Director immediately took action to strengthen the senior management team and in April 2000 established the Grangemouth Leadership Team. A new single site health and safety management system and standard was also introduced as an integral part of the new unified management structure. Implementation of these initiatives had not been fully completed by the time of the incidents.
The single health and safety management system introduced at the Complex was directly linked to BP’s health, safety and environmental management system framework "Getting HSE Right (GHSER)". This overriding commitment to excellence in health, safety and environmental matters can be summed up in three simple goals:
The incident specific investigations and key findings have been discussed in the previous sections and each identified a number of technical issues for the incidents. Each separate incident investigation also highlighted some weaknesses in the management systems and procedures which contributed to the series of events leading up to each incident. Similar findings were also found by the BP Task Force audit team.
The investigation by the HSE’s Human Factors team found that, due to the history of decentralised management, strong differences in systems, style and culture persisted across the Complex. This history had also inhibited development of a strong, consistent overall strategy for major accident prevention, and had been a barrier to cross-site communication and sharing of lessons. The key findings of the Human Factors team explained why, notwithstanding the high standards set by BP, those standards were not always implemented and met consistently over each part of the Complex. The consequences of a non-unified management structure and differences resulting from the three historical business streams operating at the Complex, in large part provided a compelling explanation of the incidents which occurred.
The following schematic sets out the relationship between the various investigations.
The HSE’s Human Factors team interviewed a sample of people from all levels across the Complex either individually or in groups. The questions were aimed at looking for behaviours that were known from published research to be indicators of safety culture. For example questions were asked about visible leadership and employee involvement, as well as on more specific issues raised by employees or HSE Inspectors, such as management of change, de-manning and commercial pressures.
Historically there were three business streams operating at the Complex - Oils, Chemicals and the Forties Pipeline System ("FPS" - Exploration). Although a unified management and health and safety management structure had been introduced there remained significant differences in both culture and management systems. The investigation concentrated on the former Oils business, with Chemicals and the FPS mainly functioning as useful comparisons. The conclusions reached by the investigation refer therefore in the main to the former Oils business and are not consistent features of the Complex as a whole.
The Human Factors team found that whilst shortcomings were present in the Oils business, health, safety and environmental issues were nevertheless taken very seriously. However the tendency was to place relatively high emphasis on short-term benefits of cost and speed and to be readier to make compromises over longer-term issues like plant reliability. Management was perceived by technicians as hurried, and managers expressed similar concerns about technicians. In the Oils business considerable effort and enthusiasm were put into capital projects and fixing problems, but less focus was given to longer term programmes of review and continuous improvement of existing plant than was evident in other parts of the Complex.
The investigation also found that there was a more optimistic perception of safety performance than might be borne out by comparison with different performance indicators. This was due to real and commendable success in managing personal injury rates down to a very low level, together with a failure to adequately distinguish these successes from process safety management. This imbalance between the effort put into personal injury versus major accident prevention was by no means unique to BP. The Competent Authority and others have found similar tendencies in other comparable businesses.
While the investigation team found deficiencies in management style and culture in the former Oils business these shortcomings were not replicated in other parts of the Complex. The FPS was, in particular, found to have a more careful and considered approach to management and general health and safety issues. The investigation also found that while the Chemicals business in the Complex did require to improve in some respects there were many examples of good practice.
BP also employed an independent consultancy to carry out a detailed analysis of the procedures and systems in place at the Complex for health and safety management. (See Appendix 3 for further details).