Based on the investigative work carried out by the Competent Authority and by BP there are three key lessons that should be learned from the incidents at Grangemouth in relation to corporate governance and one lesson specifically relating to utility systems. The Competent Authority believe that if these lessons are learned it will assist the Major Accident Hazard Industry and individual companies to reduce the number of major accidents that occur in line with the HSE’s "Revitalising Health and Safety" Strategy.
Lesson 1: Major accident hazards should be actively managed to allow control and reduction of risks. Control of major accident hazards requires a specific focus on process safety management over and above conventional safety management.
BP have re-evaluated their major accident hazards and improved mechanisms for the management and control of these hazards in order to reduce the risk involved.
The Competent Authority consider that actively managing major accident hazards is consistent with the stated objective of reducing the number of major accidents that occur and would encourage industry to adopt this approach.
BP have recognised the importance of integrating the principles of process safety management into the operation of major hazard sites such as Grangemouth and have augmented existing process safety management systems by the introduction of a Group-wide standard on Process Safety and Integrity Management.
The Competent Authority consider that for major hazard sites, integrating the principles of process safety management into the site management systems is consistent with the stated objective of reducing the number of major accidents that occur and would encourage industry to adopt this approach.
Specific consideration should be given to adopting robust "management of change" procedures with all changes – including organisational changes – being fully evaluated before implementation to ensure that all potential hazards associated with the change have been identified.
Companies should place a greater emphasis on ensuring that a loss of containment does not occur. The integrity of all systems on a major hazard site is essential in order to avoid leaks and spillages that may result in a major accident occurring. Avoiding a loss of containment is important not only for pressure vessels and other large items of plant and equipment but also for the pipework systems which are often not subjected to the same rigorous levels of inspection and maintenance. A reduction in the number of flanges, the removal of dead-legs, a reduction in vibration and the correct securing and supporting of pipework systems can reduce the likelihood of a loss of containment and hence the probability of a major accident occurring.
The success of initiatives in the off-shore industry aimed at the reduction in the number of loss of containment events should be heeded by the on-shore major hazard industries. Failure mechanisms for pipework are already well established and should be well known leading to the conclusion that prevention of such failures should be manageable.
Lesson 2: Companies should develop key performance indicators (KPI's) for major hazards and ensure process safety performance is monitored and reported against these parameters.
BP has developed a series of KPI’s to complement traditional safety statistics in order to highlight the important areas in relation to the control of major accident hazards.
The Competent Authority consider the development of KPI’s for process safety to be consistent with the stated objective of reducing the number of major accidents that occur and would encourage industry to adopt this approach. Conventional indicators of safety performance such as "days away from work" (which are high frequency/low consequence events) do not give a measure of process safety relevant to the control of major accidents (which are low frequency/high consequence events) and may give a false impression of process safety performance.
Companies should benchmark their performance in relation to the control of major accident hazards against industry standards. Companies should be monitoring and taking account of industry trends in relation to improvements in safety technology and safety management systems.
Lesson 3: Disruption to utility supply systems (steam, electricity etc.) on a major hazard site can cause significant problems and have the potential to result in a major accident.
BP have recognised the important issues raised as a result of the power distribution failure and the MP steam main rupture and have re-evaluated their approach to the control of utility supply systems on-site.
The Competent Authority consider that a number of recent power loss incidents (including the incident at BP) have highlighted that power loss incidents have the potential to result in significant safety risks. The vulnerability, reliability and impact of failures of utility systems on major hazards are issues relevant to the preparation of a COMAH safety report and the Competent Authority will require evidence that these issues have been addressed.