• Organisation
• Legislation
• Scope of the investigation
• Competent Authority investigations
• Actions and recommendations
• BP investigations and responses

Scope of the competent Authority investigation

Responsibility for regulation of the Complex in relation to health, safety and environmental affairs falls to the Competent Authority which in the case of Grangemouth comprises the HSE and SEPA, both of which have a long history of regulatory involvement at the Complex. Further details on the roles and functions of these regulatory authorities can be found at www.hse.gov.uk and www.sepa.org.uk respectively. See Appendix 2 for further details of the involvement of the HSE and SEPA on-site prior to the series of incidents. For the HSE, inspectors from Land Division, Hazardous Installations Directorate (HID) are responsible for the regulation of the Complex.

Immediately following each of the three incidents an investigation team was set up by the Competent Authority in line with the HID Major Incident Investigation Procedure of the HSE. As each incident had mainly safety implications it was agreed between the HSE and SEPA that the HSE would lead the investigations (this is in line with the Memorandum of Understanding between the different organisations).

Formal roles were allocated to an Investigation Manager and Investigation Team Leader.

The Investigation Manager was an HSE Inspector from outside of the HSE team routinely involved in regulating the Complex and his role was:

• To provide an overview of the investigation and independence from the HID Unit which normally dealt with the Complex;
• To keep the Health and Safety Executive Board informed of progress;
• To investigate the prior involvement of HID Inspectors at the Complex to see if HID needed to learn lessons from its regulatory approach.

The Investigation Team Leader was the HSE Principal Inspector who routinely manages the inspection team dealing with the Complex. He was also the HSE Inspector with responsibility for ensuring consistency of regulatory approach to all BP sites in the UK (BP Lead Unit Coordinating Inspector).

In view of the short period of time between the three incidents the Health and Safety Executive Board decided that a major incident investigation would look at the three incidents together and the findings would be made public in line with the HSE Major Incident Investigation Policy. The purpose of this public report is to fulfil that commitment and also:

• To inform the public and industry;
• To re-assure the public;
• To shift the approach of industry in relation to the control of major hazards.

The purpose of the Competent Authority investigations was to determine the underlying root causes of the incidents and identify any lessons that needed to be learned so that BP could then take corrective actions to prevent recurrences. The Competent Authority investigations initially focused on the incidents. Then where appropriate, and where wider issues were identified, the investigation was broadened to encompass these as necessary. For example, alarm handling was identified as a problem in relation to two of the incidents and as a consequence a specific investigation into alarm handling on the Complex was carried out by the Human Factors team from the HSE.