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The Control of Major Accident Hazards (COMAH) Regulations 1999 are implemented by a Competent Authority (CA) comprising the Health and Safety Executive (HSE) working jointly with the Environment Agency (EA) and the Scottish Environment Protection Agency (SEPA).
This report covers the period April 2002 to March 2003 and provides details of 3 COMAH major accidents in England, Wales and Scotland notified to the European Commission (EC). The report describes the causes of the accidents, their consequences and the enforcement action taken by the CA. In publishing it, the CA is aiming to show how the COMAH regime is working in an open and transparent way. The report will also enable lessons to be learned so that accidents can be prevented in the future.
This is the fourth report to be published in the series following reports covering 1999/00, F 2000/01 and 2001/02.
The COMAH Regulations 1999 apply to approximately 1100 establishments that have the potential to cause major accidents because they use, or store, significant quantities of dangerous substances, such as oil products, natural gas, chemicals and explosives. The general duty of the regulations is that 'Every operator shall take all measures necessary to prevent major accidents and limit their consequences to persons and the environment'. The regulations are unusual in that they are implemented by a Competent Authority (CA) comprising the Health and Safety Executive (HSE) working jointly with the Environment Agency (EA) and the Scottish Environment Protection Agency (SEPA). This arrangement reflects the requirements to ensure the protection of both persons and the environment.
The CA is required to notify certain major accidents to the EC. The criteria include; the release of a specified quantity of a dangerous substance, specified harm to persons (e.g. 1 death), specified harm to the environment (e.g. significant damage to more than 10km of river) or in some circumstances a 'near miss' of particular technical interest. This report describes the 3 EC Reportable Accidents (ECRAs) that occurred during the period 2002/03, their consequences and enforcement action taken by the CA. A summary is provided in tabular form at Appendix A.
The key points to note are that of the 3 accidents:
The principal conclusions are:
In April 1999 the Control of Major Accident Hazards (COMAH) Regulations came into force in England, Wales and Scotland, replacing the Control of Industrial Major Accident Hazards (CIMAH) Regulations that had been in place since 1984.
The COMAH regulations require the CA to notify the EC of certain major accidents. This is a continuation of the CIMAH requirements and there have typically been an average of 4 such accidents in the UK each year. The EC uses the data to inform its decisions on future changes to legislation regarding major accident hazards. The data is also made publicly available, including on the Internet, so that it can be used to learn lessons from the past and help to prevent accidents in the future.
This report provides details of the 3 COMAH major accidents notified to the EC between April 2002 and March 2003. It is the fourth report to be published in the series following the reports covering 1999/00, 2000/01 and 2001/02.
The first European Council directive concerned with controlling major accident hazards involving dangerous substances was adopted in 1982. Known as the 'Seveso' directive, (82/501/EEC), it was incorporated into UK law by means of the Control of Industrial Major Accident Hazards Regulations 1984 (CIMAH). In 1996, the 'Seveso II' directive (96/82/EC) superseded the earlier Directive. The principal changes were a broadening of scope to include a wider range of dangerous substances and enhanced requirements to protect the environment. Most of the requirements of 'Seveso II' have been implemented by the COMAH Regulations 1999.
The general duty of the COMAH regulations is that 'Every operator shall take all measures necessary to prevent major accidents and limit their consequences to persons and the environment'. The regulations apply to over 1100 establishments in England, Wales and Scotland. Approximately 730 are 'lower tier' sites, where operators must prepare a Major Accident Prevention Policy. The remaining 370 sites with larger inventories of dangerous substances are classified as 'top tier' and are subject to additional requirements. These include submitting a safety report to the CA to demonstrate how they are preventing or limiting the consequences of a major accident and providing information to local authorities to enable off-site emergency plans to be developed.
COMAH Regulation 21 requires the CA to notify the EC of any major accident meeting certain criteria. The criteria and the information to be provided are given in Schedule 7 of the regulations. Part 1 is reproduced as Appendix B of this report.
The notifications are sent to the Major Accident Hazards Bureau of the European Commission Joint Research Centre (JRC), based at Ispra in Italy. The Bureau gives support to Environment Directorate General (DG ENV) of the European Commission. There are 2 forms provided for the purpose; the short form is for immediate notification of an accident and provides basic information, the long form is to be sent later when the investigations have been completed and the causes of the accident have been established.
The data is entered onto the Major Accident Reporting System (MARS). The names and addresses of the operators are removed before the data is made available to the public on the JRC website. Data searches and analyses can also be carried out on-line. For further information contact Fesil Mushtaq European Commission, Joint Research Centre, TP 670, I-21020 Ispra (Va), Italy. Email: firstname.lastname@example.org or by fax: +39 0332 78 9007.
3 major accidents were reported to the EC because they satisfy one of the criteria given in paragraph 1 of Schedule 7 of the COMAH Regulations.
The 3 accidents are listed below in chronological order. Details are provided against each accident on the causes, consequences, the emergency response and the action taken by the CA.
This was a COMAH Lower Tier enclave site involved in manufacturing polyurethane resins and moulding it into car seat cushions. It was classified as a COMAH Lower Tier site by virtue of its inventory of toluene diisocyanate (TDI). On 24 July 2002 there was a fire in an area around a curing oven which spread and destroyed the factory
The incident occurred during a factory shutdown while various maintenance work was being undertaken including cutting out redundant pipework with an oxy-propane torch. A spark from the cutting operation ignited combustible material. The fire subsequently spread to the process and manufacturing areas, which resulted in the loss of the factory.
The Fire Service attended the scene, supported by the Environment Agency (EA), Ambulance Services and Police. A specialist contractor was also called in to pump out firewater to prevent contamination of a nearby watercourse. Approximately 110 people were evacuated for approximately five hours, with the site remaining under control of the Fire Service until 27 July 2002. Approximately 0.5 tonnes of TDI in day tanks in the process area was lost during the incident though fire protection and action by fire services in line with the emergency plan prevented any release from bulk or drum stores of TDI
There were no injuries sustained and no damage to the environment. The EA classed air pollution slight but none was detected at the watercourses.
This was an ECRA as laid out in Part 1 of Schedule 7 of the COMAH Regulations as it resulted in property damage exceeding 2 million Euros (approximately £1.4 million) and the evacuation of persons x hours where the value is at least 500.
This was a COMAH Top Tier site involved in the manufacture of chemicals. On 25 July 2002 approximately 30 tonnes of molten para-toluidine (PT) was released from a heated bulk storage tank during the replacement of a transfer pump in a bottom run-off line. PT is a toxic substance with cyanotic and narcotic properties. PT has a melting point of 44oC.
The tank contents (heated to 55oC) had been isolated by a single isolation valve and removal of steam trace heating around the line to create a frozen plug of PT. A maintenance technician had removed the faulty pump and was collecting a replacement from stores when the isolation failed and molten PT flowed from the pipe. The release over-flowed the spill bund and spread across the site contaminating a wide area with a solid layer of toxic material.
The alarm was raised and the on-site emergency team attended the scene. Several attempts were made to stem the leak, which eventually slowed after 2-3 hours sufficient to allow mechanical isolation.
There were no injuries sustained at the time of the release though 4 workers suffered exposure to PT during the subsequent clean up operation, 3 of which required hospital treatment. There was no damage to the environment.
This was an ECRA as it resulted in the loss of more than 5% of the qualifying quantity of dangerous substances as laid out in Part 1 of Schedule 7 of the COMAH Regulations.
The main cause of the incident was inadequate isolation of the tank contents during a high hazard maintenance operation. Reliance was placed on a single isolation valve and an assumed frozen plug of PT to seal the molten contents of the tank.
A prohibition notice was served on the company prohibiting the use of similar isolation techniques until a review of isolation practices has been made. The company complied with the notice.
Other issues/ factors relevant to the incident:
This is a COMAH Top Tier site involved in explosives testing and has a firing range. The range is operated by Qinetiq PLC, but is available to be used by others under commercial arrangements. The Defence Science and Technology Laboratory (Dstl), which is part of the Ministry of Defence (MOD), took advantage of these arrangements and secured a time to use the range. On Wednesday 14 August 2002 an ignition occurred which resulted in one fatality.
Dstl were engaged in testing certain energetic materials in explosive trials. These materials had only been subject to limited small-scale testing or assessment prior to their full-scale use. The method of preparing these materials involved mixing together the various ingredients - oxidisers, fuels and sensitisers - into a charge weighing a few kilogrammes. This charge would be filled by hand into a suitably sized container: a ten-litre paint tin was commonly selected for the smaller charges. The charges were primed by adding an amount of high explosive. The intent was to take each charge from the place of preparation to a firing point some distance away and fire the charge electrically.
At approximately 12.30 an employee of Dstl was injured in an incident at the range. A charge weighing about 10 kg had been made. He had decanted this into its container and was about to prime it when the energetic composition spontaneously ignited. He was caught in the fireball and received 75% burns. He was airlifted to a local hospital and from there transferred to a specialist burns unit in the Chelsea and Westminster Hospital in London where he died on Tuesday 20 August.
The Ministry of Defence Police (MDP) and the Health and Safety Executive (HSE) carried out independent investigations.
The root causes of the incident were determined to be significant failures of the management auditing system to recognise that risk assessment had not identified and addressed the hazards which were likely to be involved in the process of making the explosive charges. This was compounded by organisational and management failures at a number of levels and by systemic failures that led to confusion between the parties concerned over their respective roles and responsibilities.
This was an ECRA as laid out in Part 1 of Schedule 7 of the COMAH regulations, as it resulted in a death.
A Notice was served on Dstl to prohibit activities involving energetic compositions. Further legal action against Dstl is still being considered.
Two Dstl employees have been charged with gross negligence manslaughter. They are due to appear in Court on 20 February 2006.
There were 3 ECRAs in 2002/03. This is similar to the average number of major accidents reported annually under the previous CIMAH Regulations.
There is concern at the magnitude and frequency of these accidents and at the repeated underlying causes of major accidents. The CA will continue to use the COMAH Regulations as the vehicle for improving corporate governance of major hazard sites.
HSE is also working in partnership with the main chemical industry trade associations through the Chemical and Downstream Oil Industry Forum (CDOIF - a tripartite forum of HSE, industry and workforce representatives to discuss and set health and safety priorities and targets) to prevent major accidents and reduce the number of ECRAs by 20% by 2004, as part of the UK Revitalising Health and Safety Strategy.
This is the fourth annual report that has been published, giving details of EC reportable accidents in England, Wales and Scotland. The CA believes it will provide an insight into the safety performance of industry and its own performance as a regulator. It will also enable lessons to be learned from past accidents, thus helping to prevent similar accidents occurring in the future.
The CA would welcome feedback on any aspect of this report. Any comments or requests for further information should be addressed to the following contacts:
Gerry Adderley, Health and Safety Executive,
Hazardous Installations Directorate,
Chemical Industry Major Hazards Team, 4N.2 Redgrave Court, Merton Road, Bootle, Merseyside L20 7HS (email: email@example.com ) or;
Alex Radway, COMAH Policy Advisor, Environment
Richard Fairclough House, PO Box12, Knutsford Road, Latchford, Warrington, Cheshire WA4 1HG (email: firstname.lastname@example.org ), or;
Rob Ebbins, Policy Advisor, SEPA Edinburgh Office,
Heriot-Watt Research Park, Avenue North, Riccarton, Edinburgh EH14 4AP
(email: email@example.com ).
The Control of Major Accident Hazards Regulations 1999, S.I. 1999 No.743, ISBN 0 11 082192 0, The Stationery Office £5.80.
The Control of Industrial Major Accident Hazards Regulations 1984, SI 1984 No. 1902, ISBN 0 11 047902 5, The Stationary Office.
|Operator, Location & Date||Accident Description & Dangerous Substances||Accident Consequences & ECRA Notification Criteria||Causes and Actions Taken|
Fehrer (GB) Ltd Smethwick,
Ignition of combustible material.
A fire resulted which destroyed the factory. No injuries sustained, however 110 people were evacuated for approximately 5 hours. This was an ECRA as it resulted property damage exceeding 2 million Euros (approximately £1.4 million) and the evacuation of persons x hours where the value was at least 500.
A spark from the cutting operation ignited combustible material.
Hickson and Welch Ltd, Castleford, West Yorkshire
Release of approximately 30 tonnes of para-toluidine from a heated bulk storage tank.
No injuries sustained though 4 workers suffered exposure to para-toluidine (PT) during the clean up operation, 3 of which required hospital treatment. This was an ECRA as it resulted in the loss of more than 5% of the qualifying quantity of dangerous substances.
Isolation failure from a heated bulk storage tank during replacement of a transfer pump resulted in a release of para-toluidine. Prohibition notice served to review isolation techniques, which was subsequently complied with
Qinetiq PLC, Shoeburyness, Essex
A charge weighing about 10 kg had been made. The employee had decanted this into its container and was about to prime it when the energetic composition spontaneously ignited.
1 fatality as a result of receiving 75% burns. This was an ECRA as it resulted in a death.
Charge decanted into its container and was about to be primed when the energetic composition spontaneously ignited. Prosecution pending
Regulation 21(1) and (2)
CRITERIA FOR NOTIFICATION OF A MAJOR ACCIDENT TO THE EUROPEAN COMMISSION AND INFORMATION TO BE NOTIFIED
(This part sets out the provisions of Annex VI to the Directive)
The criteria referred to in regulation 21(1) are as follows-