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ICL PLASTICS EXPLOSION- Background & Prosecution

Workshop (Part 1) on 20th May 2009

UKLPG 2nd Annual ConferenceLeeds

by Rod Sylvester-EvansRSE Consultants Ltd

No part of this Presentation can be used without the express permission of RSE Consultants Ltd

RSE Consultants Ltd 20th May 2009


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Background - Overview

An explosion occurred on 11th May 2004 which destroyedthe Grovepark Mills Factory in Maryhill, Glasgow, owned

by ICI Plastics Ltd The explosion was caused by a leak from buried LPG

pipework which accumulated in an unventilated basement

of the factory. The explosion & collapse of the 4 storey building caused

the loss of 9 lives, injured 33, (22 receiving severe injuries)

and exposed a further 12 persons to risk of harm. Subject of a Public Inquiry held in July and Oct/Nov 2008

and currently awaiting Lord Gills Report.

(Following details based on the Crowns narrative at the Plea in Mitigation andTranscripts of the Public Inquiry)



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YARDENTRANCE

GROVEPARK

MILL

LPG TANK

FAILED LPGPIPEWORK

FABRICATIONSHOP

YARD



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(Photos courtesy of HSE)



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Ariel view of excavatedbasement with section of

steel floor structure replaced

Excavated basement area



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2 Tonne LPG Tank Installedin the corner of the Yard at

ICL Plastics Ltd

RSE Consultants Ltd 20th May 2009(Photos courtesy of HSE)


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Vapour Off-take pipeworkand LPG Cylinders in cornerof the Yard

1st stage pressure regulatorjust above pipe-riser

RSE Consultants Ltd 20th May 2009(Photos courtesy of HSE)


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Crack atelbow asseen inmirror

Into

Basement

After the explosion thepipework elbow at the entrypoint to the basement wasfound to be heavily corrodedand failed through more than70% of its circumference



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Unsleeved and unsealedentry into the Basement

though old bricked upwindow.

Failed elbow

Yard Basement

View from inside Basement



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History of LPG Installation -1969 to early 80s

Installed in 1969, with Calor Gas supplying the tank andan ICL Plastics contractor installing the pipework.

The pipework was galvanised steel with fittings ofungalvanised whiteheart malleable iron no corrosionprotection (unwrapped).

Pipework entry into the Mill was originally above ground.But level of yard was raised which buried the entry not

sleeved and unsealed.

Subsequently the basement area into which the pipework

passed was enclosed unventilated storage area.



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History of LPG Installation -1988 to 2004

In 1988 HSE concerned about size and siting of 2 tonne LPGtank. HSE recommended that buried pipework be excavated todetermine its state.

Agreement between HSE and Calor that the condition of theattendant vapour pipework would be ascertained by examinationof the riser-pipe when the LPG tank was replaced

The pipework was never excavated. Its state remained unknown.

In 1991, LPG tank replaced by two 1 tonne tanks.

In 1998, LPG Supplier changed to J Gas who substituted the twotanks with a 2 tonne LPG tank. Operating pressure was 1.4 barg

On 11th May 2004 explosion in basement & collapse of building.



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ICL Plastics Risk Assessment

At no time did ICL Plastics carry out any risk assessmentin relation to the buried LPG pipework.

An initial risk assessment was done (by a student) butconsidered only part of the pipework in the Mill Building.

Further risk assessments did consider the LPG tank(s)but never the buried pipework.

No consideration was given to the requirements of

DSEAR 2002.

Those undertaking the risk assessments received no

training. Outside assistance was rejected.



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Prosecution of ICL Plastics

The Indictment charged ICL Plastics Ltd and ICL Tech Ltdvariously with breaches of HWSA s 2, 3 & 4 and the

regulations MHSWR and DSEAR in relation to failures in: - Conducting a suitable & sufficient risk assessment

Appointing competent persons

Providing a proper system of inspection &maintenance

Maintaining the buried pipework

The Court had prepared 461 documentary productions,616 labelled productions and 321 witnesses

Both Companies pled guilty to H&S charges and were

fined 200,000 each.



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Issues Arising (1) based on Parties submissions

Poor LPG Pipework Integrity & its Ownership, e.g.

Lack of clarity of responsibilities out of sight andout of mind.

Operating buried LPG pipework of an unknownintegrity;

Lack of inspection & maintenance;

Lack of data recording the system design;

Lack of management of change; e.g. op pressure,raising the yard level and creating a basement

Lack of non-competent persons to lay thepipework and in terms of PSSR



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Issues Arising (2)

Poor Awareness and Management of LPG Hazards &Risks, e.g.

Lack of suitable and sufficient risk assessment;

Lack of appreciation of the potentialconsequences;

Lack of management control & mitigation of theLPG hazards & risks;

Lack of training in H&S and seeking competentadvice;

Lack of response to problems raised, their follow-up and effective resolution



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Issues Arising (3)

Poor Communication, Learning & Sharing of Knowledge,

Lack of clarity in communicating corrective actions;

Lack of supplementary guidance relating to risk-basedinspection of buried LPG vapour pipework;

Potential lack of sharing knowledge and engagementbetween LPG supplier and user;

Lack of regulatory inspection priority given to buried metallicLPG pipework;

Potential lack of training of HSE Inspectors in LPG risks and

awareness of damage potential to buildings Potential lack of understanding regarding the regulatory

interface between HSE and LA responsibilities

Lack of follow-up and close-out of regulatory inspectionissues



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ICL PLASTICS EXPLOSION- Public Inquiry

Workshop (Part 2) - 20th May 2009

UKLPG 2nd

Annual ConferenceLeeds

by Rod Sylvester-EvansRSE Consultants Ltd

No part of this Presentation can be used without the express permission of RSE Consultants Ltd



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Background to Inquiry

Phase 1 Scope for Lord Gill was to determine the cause & circumstances.

Parties had to prepare Statements of Case and submit Applicationsfor those witnesses who should give evidence with relevant questions. Phase 1 lasted 12 days during July 2008. Parties Closing Submissions addressed Findings in Fact derived

from Phase 1.

Phase 2 Scope was to consider the safety-related issues and make

recommendations in light of the circumstances.

RSE asked in August to consider possible safety improvements to thecurrent regime relating to bulk LPG at commercial/industrial users andto report in early September for parties to consider prior to Phase 2.

Phase 2 lasted 8 days (Days 13 to 20) in Oct/Nov 2008 and heard

evidence from some 11 witnesses. Written/Oral Closing Submissions made on 13th Nov 2008 (Day 21).



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Basic Principles for Improvements

Reflect Lord Robens responsibility for managing H&Srests with those who create the risks and work with them.

Minimise prescription in favour of goal-setting; Target changes to tackle current weaknesses; Prioritise the changes to address the greatest risks first; Encourage ownership and transparency;

Changes must be practical & robust, commensurate withthe risks mitigated

Where possible align knowledge, competency, incentives

and benefits; Changes should be self-consistent.

Directed to LPG pipework at small industrial/commercial

bulk LPG User sites



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Clarity ofResponsibilities

Ownership

Control &Mitigation of

LPG Risks

Site Record

Safety Dossier

Life Cycle

Integrity of LPGSystem

Communication,

Sharing/ Learning

Knowledge

Suggested Improvements e.g.

- Develop an inspection and maintenance strategy for LPG pipework- LPG User should retain all up-to-date information on its LPG system- LPG Supplier should provide the LPG User with a summary of its

asset register for the tank and pipework, safety features, inspections

and risk assessment for its equipment on the LPG users site



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Clarity ofResponsibilities Ownership


LPG Risks

Site Record

Safety Dossier

Life Cycle


Communication,Sharing/ Learning

Knowledge

LPG UserManagement Circle

Building Issues - Improvements

- LPG pipe entries should be aboveground with ECV- LPG Pipework should not routedthrough unventilated spaces- Where this is not feasible, then

acceptable (verified) alternatives only


- Safety dossier should demonstrate how the LPG User has met itsstatutory duties and describes the management of LPG safety on thesite, e.g. training, inspection, maintenance, managing change etc.- UKLPG & HSE provide guidance/template for a Safety Dossierand provide guidance on how LPG Users can fulfil their statutoryduties



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Clarity of

Responsibilities Ownership


LPG Risks

Site Record

Safety Dossier

Life CycleIntegrity of LPG

System

Verification

Process?


Knowledge

LPG User

Management Circle


- Consider provision of a verification scheme- Conducted by an independent competent person (ICP)- Site verification renewed periodically- Ensure adequate competencies, resourcing & accreditation of ICPs

- Scheme developed by UKLPG and HSE



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Clarity ofResponsibilities

Ownership

Control &Mitigation ofLPG Risks

Site Record

Safety Dossier

Life Cycle


Verification

Process?

Registration of

LPG Suppliers?


Knowledge

Review Process& Feedback

LegalSanction?

Metallic

Risk-Based

Replacement

Programme

Execution ofReplacement

Programme

Regulatory Oversight

LPG Supplier Communication & Knowledge

LPG User

Management Circle

Inspection Role


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