Health and Safety
Executive / Commission
Press Releases
HSE press release: E160:03 -18 August 2003
The Health and Safety Executive (HSE) today published its Major Incident Investigation report into three events at BP's Grangemouth complex in 2000. The full report is available on the HSE website at: http://www.hse.gov.uk/comah/bpgrange/index.htm
The report describes the causes of three incidents in May and June 2000 - a power distribution failure causing refinery shut down, failure of a steam main resulting in minor injury to a member of the public and a serious fire at a process unit.
The report is the result of a joint investigation (led by HSE) with the Scottish Environment Protection Agency (SEPA). It highlights clear messages about the business case for health and safety as a key component of corporate governance for the chemical and refinery industries. The key lessons from the report for the chemical and refinery industries are:
Alistair McNab, HM Principal Inspector of Health and Safety who led the investigations said:
"This was a thorough and wide-ranging investigation which extended beyond the plant and installation to examine human factors, management of health and safety and the safety culture. The investigation started immediately after the first incident in May 2000 and at its peak involved up to 20 Inspectors.
"BP have cooperated fully throughout the investigation and
have given their commitment to the lessons and messages in the
report. Since these incidents there has been a sustained
improvement of safety performance across the Grangemouth
complex.
"I am also pleased to say that the UK Petroleum Industry
Association the Chemical Industries Association and the Chemical
and Downstream Oil Industry Forum (a tripartite HSE/industry/trades
union advisory body) will be encouraging use of the lessons learned
from the report as an agent for change in the industry."
1. HSE gave a commitment to publish a report following the conclusion of legal proceedings in January 2002. (See Note 6).
2. This is a particularly thorough report of over 130 pages. This reflects the complexity of the investigations, and the action BP has taken to date to learn lessons and improve performance. It is unique in that it is the first internet-only public investigation report published by HSE. Electronic links have been provided throughout to enable readers to cross-reference the report's various sections, and to select the depth of detail required.
3. HSE considers that Major Hazard process industries need to learn lessons from the report and incorporate these lessons into managerial procedures to ensure that process safety is properly managed. Process safety requires specific managerial focus on major hazard control as distinct from "conventional" health and safety management (to prevent falls from height etc).
The ability to properly measure major hazard performance is crucial to allow companies to detect deteriorating performance and enable managerial intervention before a major accident occurs.
4. BP Grangemouth is part of Grangemouth petrochemical complex.
5. There are approximately 1,093 sites in the UK that are regulated under the Control of Major Accident Hazard (COMAH) Regulations 1999.
6. Following the investigation BP were prosecuted by the procurator fiscal service (Scotland's independent public prosecution service).
Details of the charges are:
7. HSE and SEPA jointly investigated as the Competent Authority for the enforcement of the COMAH Regulations 1999. HSE led the investigation as safety issues predominated.
8. HSE and SEPA have continued the follow-up of the agreed actions to ensure that the performance of the complex improves in line with the commitments given by BP.
9. An Executive Summary of the report is attached. The full report can be obtained on the HSE website http://www.hse.gov.uk/comah/bpgrange/index.htm
Call HSE's InfoLine, tel: 0845 345 0055, visit http://www.hse.gov.uk/contact, or write to: HSE Information Services, Caerphilly Business Park, Caerphilly CF83 3GG.
Paul Clement 020 7717 6016
The BP Grangemouth Complex (the Complex) is a Major Accident
Hazard (MAH) site as defined under the Control of Major Accident
Hazard Regulations (COMAH) 1999 which implements the Seveso II
Directive in the UK. It is one of the largest of the 950 COMAH
sites in the UK.
The Complex is an important centre of UK operations for BP and of
major strategic importance for the BP Group.
The COMAH Regulations require a MAPP (Major Accident Prevention
Policy) to be produced for the Complex which requires a very high
standard of management of major accident hazards to be demonstrated
and that the operator will take all measures necessary for the
control and prevention of major accidents.
Operators of "top tier" sites are also required to
prepare safety reports which identify the systems used by the
operators to ensure their processes are operated safely at all
times and that adequate steps are taken, so far as is reasonably
practicable, to prevent major accidents or in the event of such
accidents, to limit the effects on people and the
environment.
Such reports for the top tier installations at the Complex
(incorporating a MAPP for the Complex) had been prepared and
submitted to the Competent Authority for examination and assessment
and were under review in May 2000 when the incidents took
place.
Under the COMAH Regulations, operators are also required to provide
information on safety measures at their establishments to persons
likely to be affected by a major accident occurring at their
establishment. On and off-site emergency planning is also a key
component. The Complex had provided such information to the local
authorities for inclusion in an off-site emergency plan and
prepared an on-site plan.
The Competent Authority is required to carry out significant
regulatory activity including inspections in order to ensure that
the operations are being conducted in accordance with both
legislative requirements and company claims as evidenced in the
COMAH safety reports. Prior to the series of incidents that
occurred in May/June 2000 the Complex was already the subject of
significant regulatory activity and the HSE were in discussion with
the management at the Complex concerning a number of safety issues
which were of concern. The new Complex Director appointed in
October 1999 had accepted that the Competent Authority concerns
were valid at a meeting in November 1999 and a major management
action plan was already underway to improve safety performance
on-site prior to the incidents.
During the period between 29th May and 10th June 2000 three
incidents occurred at the Complex. These incidents were
subsequently investigated, as required under COMAH Regulation 19,
by the Competent Authority and by BP in order to determine the
underlying root causes of the incidents and to identify any lessons
that needed to be learned.
In addition the Complex Director also immediately set up a BP Task
Force to undertake a wider review of all operating units and
functions across the Complex and commissioned some external
independent investigations and assessments. These were aimed at
determining the overall effectiveness of current arrangements at
the Complex for health, safety and environmental affairs. The BP
Task Force was the largest audit team ever assembled for a
petrochemical complex and completed 4 man years of work in 8
weeks.
The power distribution failure (29th May), the medium pressure (MP)
steam main rupture (7th June) and the Fluidised Catalytic Cracker
Unit (FCCU) fire (10th June) each had the potential to cause fatal
injury and environmental impact, although no serious injury
occurred, and there was only short term impact on the environment.
BP were prosecuted on indictment in Falkirk Sheriff Court on 18th
January 2002 and pleaded guilty to two charges relating to the FCCU
fire and the MP steam main rupture incidents. BP Chemicals Limited
were fined £250,000 and BP Oil Grangemouth Refinery Limited
were fined £750,000.
This public report into the series of incidents is designed to
summarise the incidents and the following investigations carried
out by the Competent Authority and by BP. Full details of all the
detailed investigative work carried out by the Competent Authority
and BP and all the detailed incident specific findings and legal
work are not presented here.
The report seeks to reassure the public that a series of thorough
and detailed investigations into the causes of the incidents have
been carried out by all parties concerned. In addition the report
is intended to demonstrate that a number of lessons have been
learned both by BP and by the regulators and actions have been
taken in order to improve safety performance at the Complex. The
report is also intended to be viewed by a wider audience of
companies, safety professionals and Trade Union representatives
involved in the major accident hazard industries and to serve as a
reminder of many of the issues that need to be addressed by safety
reports for major hazard installations. Operators of COMAH sites
are expected to carefully consider the contents of this report and
the HSE will use Trade Association contacts plus site inspection
plans and other means to publicise the incidents and to ensure the
lessons are widely learned.
On 29th May 2000 at 18:07 p.m. all power was lost to No. 1, 5 &
10 electrical substations that supply electrical power to the North
Side of the Complex which contains the Oil Refinery, various
chemical plants, utility plants and logistics facilities.
As a result, emergency shutdown of the Oil Refinery and the
chemical plants on the North Side occurred and the utility plants
were also affected due to a loss of power to the main cooling water
pump systems. (There was some smoky flaring visible as a result of
the emergency shutdown.)
In addition because of the duration of the power failure, a
controlled shutdown of some other facilities elsewhere on-site
(some chemical plants on the South Side and the Kinneil operations)
was also necessary because the supply of steam for the correct
operation of the flare system could not be maintained.
No injuries resulted.
MP Steam Main Rupture - 7th June 2000
An 18" medium pressure (MP) steam main located near to the
A904 Bo'ness road ruptured at 23:18 p.m. on 7th June 2000
resulting in a significant loss of MP steam directly into the
atmosphere. The steam leak damaged fencing immediately adjacent to
the ruptured pipework. Debris and steam was blown across the road
until the leak was isolated. The leak also caused significant noise
(similar to a jet engine) being heard in the Grangemouth area. A
member of the public walking the dog 300 metres away sustained rib
injuries from tripping over the dog.
There was significant disruption to the steam supply system for the
Complex for approximately one hour until the steam leak could be
isolated and as a result of the incident the A904 Bo'ness road
was closed for public access until 22nd June whilst repairs were
carried out.
Fluidised Catalytic Cracker Unit (FCCU) Fire - 10th June
2000
The Fluidised Catalytic Cracker Unit situated on the Oil Refinery
had been shutdown on 29th May 2000 following the power distribution
failure. On 10th June 2000 at approximately 03:20 a.m. during start
up procedures which commenced on 9th June there was a significant
leak of hydrocarbons from the Fluidised Catalytic Cracker Unit
(FCCU or Cat Cracker) creating a vapour cloud which ignited
resulting in a serious fire. On and off-site emergency services
were mobilised, the BP Incident Management Team (IMT) were called
in and the Grangemouth Petrochemicals Complex Major Incident
Control Committee (MICC) was convened. The fire was brought under
control in approximately 90 minutes and totally extinguished by
10:30 a.m.
During the fire and in the fire-fighting efforts some damage
resulted to asbestos cladding surrounding pipework and vessels.
Some hydrocarbons in the contaminated firewater run-off were
discharged directly into the River Forth.
No injuries occurred to the workers in the vicinity. They followed
the emergency response procedures. However, there was the potential
for injury to people and greater damage to equipment.
Competent Authority Response
Following the incidents major public and political concern was
expressed to the Competent Authority and the Competent Authority
was concerned due to the frequency and pattern of the serious
incidents, their major accident potential and the apparently
deteriorating performance of the Complex.
It was apparent that the main concerns centred on health and safety
issues so it was agreed at an early stage with the Scottish
Environment Protection Agency (SEPA) that the HSE would take the
lead in the investigations with assistance from SEPA as necessary.
The FCCU fire in particular was a reportable major accident under
the COMAH Regulations and a major accident investigation was
therefore required.
The HSE Board called for a "Level 1" Major Accident
Investigation to be carried out by Land Division, Hazardous
Installations Directorate (HID) in accordance with the then
corporate major accident investigation procedures.
A series of incident specific investigations for the power
distribution failure, MP steam main rupture and FCCU fire in order
to examine the direct and underlying causes were accompanied by a
series of further investigations into related issues from the
incidents such as the emergency response, the environmental impact
and the response to the presence of asbestos during the FCCU
fire.
Evidence of the extent of the Competent Authority's concern is
provided by the scale of investigations carried out which involved
significant HSE Inspector, HSE Specialist Inspector and Health and
Safety Laboratory (HSL) resource as well as involvement from SEPA
Inspectors. Investigations continued until February 2001, when the
"Summary of Findings and Recommendations Report" was sent
to BP and the prosecution report was sent to the Procurator Fiscal
(the public prosecutor in Scotland).
Consideration was given by the Competent Authority to carrying out
a full-scale audit of the entire Complex of the type the HSE had
carried out at BNFL Sellafield and UKAEA Dounreay. The Complex
Director set up a BP Task Force to carry out an extensive safety
and environmental audit of the Complex led by a senior executive
from outside the Complex. The setting up of such a major BP Task
Force, which involved independent overview from a respected expert,
allied with the thoroughness and open sharing of findings with the
Competent Authority eliminated the need for a Competent Authority
audit running alongside the major accident investigation. The
Competent Authority received regular electronic updates of the
current status of audits, actions and tracking of progress from BP.
BP reported to the HSE daily any issues that were identified during
the 6 week period over which the units in the Complex were brought
back into operation.
Direct and Underlying Causes
Power Distribution Failure
The loss of electrical power was caused by damage to a 33kV
underground electricity feeder cable which eventually resulted in
an earth leakage (electricity flowing to earth) from the cable. The
damage had been caused to the electrical cable during excavation of
a trench for the installation of a new cable, sometime before the
distribution failure occurred.
The local circuit breaker on the distribution system failed to
operate due to the insertion of small plastic connectors which
isolated the relay. Two circuit breakers located elsewhere in the
distribution system subsequently tripped to clear the fault
resulting in the loss of power supply to significant parts of the
Complex.
Subsequent investigations revealed a number of weaknesses in the
safety management systems on-site over a period of time which
contributed to the succession of events that resulted in the power
distribution failure.
MP Steam Main Rupture
The site wide power distribution failure on 29th May 2000 resulted
in excess amounts of water (associated with the shutdown of utility
supplies) being sent to drain, as well as the unavailability of
electrical power to drainage pumps. This led to the flooding of
culverts (service tunnels) beneath the A904 Bo'ness road
through the site which contained medium pressure (MP) stream
distribution lines. During the following investigations to
determine whether the flooding had caused any damage to the
pipework a steam trap located in a low point in the section of
pipework beneath the road in the West Gemec culvert was closed to
allow safe access for inspection. The steam trap was subsequently
not re-opened and this prevented the removal of condensate (hot
water produced by the condensation of steam) from this section of
the system. As the liquid condensate level built up in the pipework
a quantity of steam (or "steam bubble") was trapped
between the hot condensate and closed isolation valves on the
southern side of the culvert beneath the road. Eventually collapse
of the steam bubble resulted in a phenomenon called
"condensation induced water hammer" which led to a gross
overpressure and the subsequent catastrophic failure of the
pipeline.
Subsequent investigations revealed a number of weaknesses in the
safety management systems on-site over a period of time which
contributed to the succession of events that resulted in the MP
steam main rupture.
Fluidised Catalytic Cracker Unit (FCCU) Fire
The Fluidised Catalytic Cracker Unit had been shutdown as a direct
consequence of the power distribution failure. During start-up of
the unit on 10th June there was a leak of hydrocarbons which were
subsequently ignited and resulted in a fire on the plant.
Investigations revealed that the leak was as a result of failure of
a tee-piece connection at the base of the Debutaniser column which
then found a source of ignition nearby (probably an uninsulated hot
flange).
During the investigations the tee-piece connection which had
originally been installed in the 1950s was found to be correctly
specified but incorrectly fitted and then covered in lagging. (A
set-on tee-piece had been installed whereas a seamless forged weld
reducing tee-piece had been specified.) There had been no
subsequent amendment to the plant layout drawings to identify the
change.
Prior to the mid 1980's modifications had been made to the
pipework at the base of the column and a valve removed which
resulted in there being inadequate support for the remaining
pipework and the tee-piece connection.
Further modifications to the FCCU in 1996/1998 had resulted in the
FCCU being increasingly difficult to operate reliably. This had
resulted in an increase in the number of start-up/shutdown cycles
for the plant and pipework.
Failure of the tee-piece connection pipework was probably caused by
a combination of the incorrectly fitted tee-piece connection, the
inadequately supported pipework and the cyclic stresses/vibration
caused by the increased start-up/shutdown activity on the plant.
Eventually this led to "fatigue" failure of the pipework
in the vicinity of the welded connection.
Subsequent investigations revealed a number of weaknesses in the
safety management systems on-site over a period of time which
contributed to the succession of events that resulted in the FCCU
fire.
Findings and Recommendations
The investigations carried out by the Competent Authority
identified a number of key findings for each of the three
incidents. Further investigations into alarm handling, the overall
safety management systems at the Complex, the response to the
presence of asbestos during the incidents, the overall
environmental impact of the incidents and the emergency response
during the incidents were also carried out by the Competent
Authority and also identified a number of issues. Key
recommendations relating specifically to the circumstances
surrounding each of the incidents were made and are included in the
main text of this report.
The investigations also identified a number of common themes and a
number of wider conclusions were drawn as a result of the
investigations relating to the health, safety and environmental
management system at Grangemouth. These were:
The investigations into the circumstances surrounding the three
incidents at the Complex have resulted in a number of issues being
identified from which BP and the HSE consider lessons can be
learned. These lessons are of relevance to all companies who are
regulated under the Control of Major Accident Hazards (COMAH)
Regulations 1999 for major hazard installations and also to a wider
audience throughout industry.
These lessons should be addressed by other operators, and
management systems put in place to prevent any major accidents
(including a repetition of any of the three incidents reported
here) from occurring.
The HSE consider that these lessons will assist the major hazards
industry in reducing the probability of major accident incidents
occurring and in reducing the severity of any events which do
subsequently occur.
This should help in achieving a significant reduction in the number
of reportable incidents. The "Revitalising Health and
Safety" strategy document from the HSE sets a goal to
"prevent major incidents with catastrophic consequences
occurring in high-hazard industries" and sets a target of
"a 20% reduction in RIDDOR dangerous occurrences and COMAH
Regulation 21 major accidents (accidents of sufficient seriousness
to require notification to the European Commission)" by 2004.
These lessons, if learned, should help to achieve this target which
has been set as an industry objective and signed up to by many of
the leading companies in the major hazard industries.
A summary of the key lessons for industry from the series of
incidents at Grangemouth is given below. Full details can be found
here and it is recommended that these lessons are read in
full.
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.
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.
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.
In addition the Competent Authority considers that it is important
to re-iterate some important messages for industry at this stage of
the implementation of the "Revitalising Health and Safety
Strategy". Full detail can be found here and it is recommended
that these messages are read in full.
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.
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.
Message 3 The COMAH safety regime is "living
process" and should be used as a management tool to assist in
process safety management.