Although the report is predominantly concerned with the series of incidents that occurred at the BP Grangemouth Complex in 2000 it is being published at a time when the HSE has embarked on the "Revitalising Health and Safety" strategy. This strategy aims to "prevent major incidents with catastrophic consequences occurring in high-hazard industries". The opportunity is therefore also taken to remind industry of its responsibilities with some messages from the HSE.
Message 1: Major hazard industries should ensure that the knowledge available from previous incidents both within their own organisation and externally are incorporated into current safety management systems.
The Competent Authority wish to re-iterate this message since an incident investigation often identifies causes that have previously been identified and reported but for which no action has been taken. Prevention of some major accidents would therefore have been possible with the correct focus.
The Competent Authority considers that industry should be aware of previous major accident histories within their own company and within their industry sector. The conclusions and recommendations from published accident investigation reports are designed to ensure that information is available to a wider audience. Companies need to monitor and close-out actions from these reports to ensure lessons are learned.
For example valuable lessons can be learned from an analysis of historical accident data. Data from Marsh analysing large property damage losses in the hydrocarbon-chemical industries over a thirty year period is available. The lessons from this historical data centre around process safety management issues and "suggest the necessity for a strong safety commitment from senior management as well as local plant management and the need to employ the best available technology to mitigate risk".
In many companies Corporate memory needs to be improved to ensure that the knowledge gained from the incidents of the past is available and heeded by those who are involved today. Each generation of employees should not have to learn anew by repeating the mistakes of the past.
The Competent Authority encourages operators of other major hazard sites to review this report and to incorporate the lessons into their operations.
Message 2: Operators should give increased focus to major accident prevention into order to ensure serious business risk is controlled and to ensure effective Corporate Governance.
The failure to comply with the requirements of COMAH and the associated major accident potential for a site should be considered as a significant business risk which needs to be addressed as part of effective corporate governance as discussed in the Turnbull Report. Major accidents can prove to be costly in terms of lost production, clean up, fines imposed by the courts and damage to the company reputation as a result of adverse publicity. Major accidents are intolerable to the public, politicians and the regulators. Guidance on the costs of accidents at work is given in the HSE publication HSG96.
The Turnbull report states that directors should, at least annually, review systems of control including risk management, financial, operational and compliance controls that are the key to the fulfilment of the company’s business objectives.
The HSE has prepared guidance for directors in order to help them ensure that the health and safety risks arising from their organisation’s activities are properly managed. Directors should be fully aware of their corporate responsibilities in relation to the control of major accident hazards. Failure by a corporate body and the directors of a company to adequately manage health and safety can result in prosecution of the company and the individual directors responsible.
As previously stated the underlying causes of major accidents (technical, managerial and human factors) are well established from analysis of hundreds of major accidents worldwide. Directors have a duty to manage these known factors to prevent major accidents.
Message 3: The COMAH Safety Regime is a "living process" and should be used as a management tool to assist in process safety management
Regular inspection of plant, equipment and safety management systems along with periodic auditing is an essential requirement in the control and prevention of major accidents. Inspection and auditing must be rigorous and targeted at process safety aspects.
The Competent Authority will require evidence of a comprehensive inspection and auditing programme and that it is being rigorously applied during the inspection regime under the COMAH Regulations. Companies should use the inspection and auditing programmes to verify that the descriptions of equipment and management systems contained within the safety reports for major hazard sites are still valid.
The Cullen Report on the Ladbroke Grove rail incident stated the following in relation to safety cases which is relevant to the COMAH safety case regime.
"While it is clear that the safety case can become over bureaucratic, it has the potential to be a valuable tool, by, for example, bringing about a systematic approach to safety and providing a record of management’s commitments to safety. The evidence showed that it (the safety case) can be a "living document", part of the direct management of safety".
Companies should use safety reports as a "benchmark" against which to monitor and audit compliance and to ensure that safety standards are being maintained.
The Competent Authority consider that human factors is a relevant COMAH issue and require consideration to be given to human factors issues in process safety management and in COMAH safety reports. The Competent Authority has identified inadequate consideration of human factors issues as one of the main causes for the rejection of COMAH safety reports.