Letter from Judith Hackitt
The Rt Hon Yvette Cooper MP
Secretary of State for Work and Pensions
Department for Work and Pensions
London SW1H 9DA
27 August 2009
Dear Secretary of State,
ICL inquiry report
1. I write to report back to you on how Lord Gill's recommendations can be taken forward and in particular how we are addressing Lord Gill's criticisms of HSE's actions since the explosion. This response provides additionally detailed information on many of the issues raised and also provides detailed information on the work that is being undertaken to address the specific risks associated with LPG pipework.
2. Before addressing these issues however I want to reiterate our belief that Lord Gill's account of the factors which led to the 2004 explosion is fair and accurate. The report reflects all the information available to HSE and confirms the view that, whilst the primary responsibility rested with the site user, there were other failings including some within HSE itself which need to be addressed. Geoffrey Podger (our Chief Executive) and I have gone on record to acknowledge and apologise for these failings, including during the Inquiry itself. Let me reiterate my commitment to you, in my earlier letter of 28 July, that we have learned the lessons from this tragic incident and we have in place arrangements to assure ourselves that actions are being implemented.
3. There is good reason to believe that even during the time period leading up to the explosion, HSE's dealings with ICL were far from typical of our normal interactions with dutyholders. Thousands of HSE inspections were carried out every year in those days, as now, where inspectors identified problems and ensured that improvements were made in a timely manner. Significant changes to our internal management systems since then have further provided assurance that we will follow up quickly where duty holders fail to act on recommendations made at inspections. HSE's inspection programmes, supported by campaigns, research and guidance are a key contributor to the UK's world leading workplace health and safety performance.
General management improvements
4. Our approach to improving health and safety is to target those topics that have the potential to cause the most injuries and ill health. Matters pursued at inspections are a balance of centrally directed topics based on analysis of the causes of accidents and ill health, local factors such as the performance of a particular company, matters of evident concern and any hazards that could cause multiple injuries or ill health from a single incident. Inspectors apply a diagnostic approach to determine how well duty holders manage health and safety and to ensure that areas of immediate concern are addressed. This puts the duty holder's health and safety management at the core of what inspectors discuss, ensuring those responsible for creating risks are prioritising them correctly and controlling them - a fundamental principle enshrined in health and safety law.
5. The approach outlined above is not a static one - HSE constantly develops, changes and improves its methods to continue to operate effectively in a changing economy and society. The culture, systems, and processes in place in the 1980s and 90s reflected the knowledge that existed then about health and safety risks. However, a number of changes have taken place since then which have relevance to this incident. In particular, we have:
- Introduced an Enforcement Policy Statement (first published in 1995) and Enforcement Management Model (1999) to improve regulatory decision-making by clearly outlining the enforcement action that should flow from any breach of law. This is supported by a framework which ensures structured and consistent decisions are taken when deficiencies are found during inspections.
- A more modern managerial culture based on Principal Inspectors who ensure the quality of inspectors' work, and support an increased emphasis on developing staff competence.
- Reviewed our scientific and engineering base in 2006, making significant improvements to how we share knowledge and advice and use it to best effect.
- Improved IT systems, which now record all inspection activity and enable better tracking of issues and resolution.
- Strengthened assurance processes, with increased audit and review of our regulatory decision making processes, providing significant assurance that professional judgements exercised by our inspectors in enforcement decisions are sound.
With regard to the specific issues raised by Lord Gill's inquiry.
Timescale of HSE's response post explosion
6. The joint police/HSE investigation, which involved substantial forensic work along with taking over 900 statements, concluded successfully in September 2005. In addition, HSE's dedicated laboratory (HSL) started work in July 2004 to identify and understand the full range of risk factors at work in typical installations. To understand the picture on the ground, this was supplemented by a study of over 400 sites where LPG was used. Both HSE and the industry worked to improve and update inspector and industry knowledge of buried pipework issues through public and internal guidance. For example, in 2006 a new inspection pack for buried pipework was published on our web site, and a leaflet for industrial and commercial users setting out their responsibilities for pipework inspection and maintenance. At the same time the LPG industry were approaching customers and undertaking remedial action where necessary.
7. Building on the investigation and initial HSL research, further work was undertaken on the scale and nature of the commercial and domestic LPG market along with a survey of installations to identify those presenting the greatest risk. This was followed by additional exploratory work with the industry during 2007 and 2008. This then formed the basis for agreeing a programme with the industry, planning the logistics of the replacement work and developing an HSE and Local Authority inspection programme for commercial premises to back up the LPG industry's efforts.
Improvements to the LPG safety regime and pipework replacement programme
8. HSE agreed a programme for the replacement of metal service pipework on bulk LPG installations at commercial and domestic premises with the trade association, UKLPG, in June of this year. The agreement represented the culmination of several years of work begun following the 2004 explosion. More detail on the programme is in Annex 1.
9. This work has been complex as it has been critical to ensure that there is a sound evidence base for future action in this area. It started with establishing the causes of the explosion as described above.
10. We have decided to include domestic premises within scope of our joint agreement with the industry. This goes beyond Lord Gill's recommendations. Although complicating the development of the programme as a whole, and recognising that HSE has very limited legal remit and powers in the domestic arena, we feel it is important, in the public interest, to include such premises in the scope.
11. We do not underestimate the extent of this programme; it involves a considerable mobilisation of effort. There are between 15,000 and 40,000 commercial installations with buried metal pipework and between 24,000 and 54,000 domestic installations of a similar kind, though this latter figure is a rough estimate only at this stage. The effort required of the LPG industry to complete this programme is in the order of 600 staff years. There are associated difficulties with this in that the current number of competent LPG qualified Gas Safe registered engineers is not adequate. We anticipate that arrangements to increase the number of suitably qualified engineers can be put in place by the end of 2009, but that it will take the following year to build up the numbers of personnel with the required competencies. Current plans are to complete the LPG metallic pipeline programme by the end of 2015, with the highest risk pipework completed sooner. It should be recognized that the cost of replacing the pipework would fall to the user.
12. We will keep the programme under review to ensure timely delivery and to take account of any new information that emerges on risks that might affect the prioritisation of the effort.
13. It is perhaps worth noting that timeframes of this kind are normal and necessary for major pipeline replacement programmes. Notwithstanding the terrible events at ICL Plastics, little problem has been experienced elsewhere with pipework of this kind. As Lord Gill points out in his report, the risk of gas explosions of all kinds is small in relation to many everyday risks to which we are all exposed. Current estimates are that the risk of a fatality from fires and explosions involving LPG is less than that for natural gas. Replacement of pipework is a task which must be undertaken with care and requires careful assessment and training of the workforce if it is not to give rise to greater safety issues than those it is designed to address.
14. In line with better regulation principles and following our normal practice of seeking stakeholder views on proposals for change, we have begun a process of consultation on Lord Gill's specific recommendations for a new LPG safety regime, we plan a two-stage consultation. The first phase seeks views on Lord Gill's recommendations, unless we are already taking action such as on the pipework programme. The second stage will present proposals based on the wider range of views and supported by a formal impact assessment. The first stage consultation began on 27 August and will run until 19 November. The consultation document for the first stage is at Annex 2.
Existing regulations on risk assessments
15. Lord Gill's recommendations have broader implications for the health and safety system than simply LPG, particularly in relation to the whole process of risk assessment. We will therefore canvass views from a wide range of stakeholders as part of our consultation process.
16. In considering any possible changes or additional guidance in this area we will need to explore the distinction between what is required to comply with existing regulations and problems which may arise when dutyholders fail to comply with those requirements particularly when changes are made within a facility.
17. Local authorities are key stakeholders in this respect as they will be the enforcing authority for the Health and Safety at Work Act in many of the premises within scope of the programme.
18. The Board and staff of HSE take the lessons of this event very seriously and will continue to scrutinise our systems to ensure that we maintain the highest standards of management and oversight.
19. The general improvements made to processes and systems have been, and continue to be, many and varied. Many have been part of the normal process of continuous improvement which have taken place within the organisation and some have arisen because of specific learning from events.
20. The development of the LPG pipework programme has taken some time but this was due to the need to act on the basis of evidence and to do the necessary preparation for such a major undertaking, not because of a lack of urgency on our part.
21. We have moved to consult on Lord Gill's specific recommendations and also incorporated his broader questions regarding risk assessment in a timely manner.
22. The HSE Board will formally consider the outcome of this consultation, alongside the Inquiry's recommendations, and provide consolidated advice for your consideration. I will also keep you up to date with progress of the pipework replacement programme.
Judith Hackitt CBE
Chair, Health and Safety Executive
- Annex 1 - High level plan to replace LPG buried metallic service pipework
- Annex 2 - Consultation document