Earlier this year the HSE, EA and SEPA jointly published another report about the Buncefield oil depot explosion and fire, entitled Buncefield: why did it happen?
There have been many reports, including interim’s and a final report in 2008, so you may be forgiven for thinking this is becoming like the farewell tours of some ageing rock star or crooner. This report promises to reveal the underlying causes of the debacle. But why the wait? Turns out that the regulators couldn’t reveal the whole story because of a pending prosecution. Now that’s out the way, all can be revealed.
You may remember that the Buncefield Oil Depot was a major hazard installation, falling under the COMAH regulations. It stored huge quantities of petrol products. One tank was overfilled during a transfer operation and subsequently leaked fuel out the top; the vapour cloud that formed ignited and caused a devastating explosion in December 2005. It was 5 days before the fire was eventually brought under control. Fire water runoff and fuel also contaminated groundwater.
The regulators have already published findings on the technical causes of the incident (both the level gauge and high level switch were defective, poorly designed for the environment and poorly maintained). Added to this, the bund and catchment drains also failed leading to environmental pollution.
But the purpose of this report was to reveal the deeper causes, the management failings. You might think that major hazard installations have it all covered but the reality is that they are just as prone as everyone else to the disease of complacency. We’re all prone to this; I’m not defending this position but it’s easy to point the finger after the event – and of course they paid the price and were prosecuted. That’s because complacency here has bigger consequences.
The reality is that the site did not manage tank filling operations properly – they were slack. But that’s too simplistic. There was a considerable amount of work pressure on staff and that made it more difficult for them to have a handle on fuel storage. According to the report, the priority became keeping the site operational (headless chickens?); they took their eye off the process safety ball. That’s a culture shift – you may remember that safety culture was the thing that was cited about the Chernobyl nuclear incident and one of the first places that the term ‘safety culture’ was coined. They got little support from head office too it seems. That meant that systems that were known to be dodgy (like the gauge and level switch) weren’t ever properly maintained, just fixed temporarily. Auditing seems to have been ineffective too – not making sure safe systems were actually being used, just checking a system existed.
Buncefield is not unique in its experience. There have been other such incidents and the underlying causes depressingly similar. The management failings may also be present in your workplace too. Beware the appearance (rather than the substance) of safety – it might just catch you out.
Though a management failing was cited but we have to realise that most serious incidents have been caused by oversight on equipment. I think this happen everyday in the industry. Companies still fail to realise how important it is to observe unsafe conditions in our equipment and fixing it. We get carried away with temporary fixing, cost management, cannibalisation etc and we get caught finally in the web of disasters.
It is advisable for companies to make the integrity, functionality and maintainability of their equipment/asset a priority. All should be engaged to carry out daily observation reports and weekly KPI on Preventive maintenance and Instections/Test carried out on these equipment.
Management commitment is the key to ensure recommendations are taken seriously.