The ICL Inquiry Report

The ICL InquiryHC 838

The ICL Inquiry ReportExplosion at Grovepark Mills, Maryhill, Glasgow11 May 2004Presented to the House of Commons and the Scottish Parliament under S26 Inquiries Act 2005Presented to the House of Lords by Command of Her MajestyOrdered by the House of Commons to be printed on16 July 2009Laid before the Scottish Parliament by the Scottish MinistersJuly 2009HC 838 Edinburgh: THE STATIONERY OFFICE £34.55SG/2009/129

© Crown Copyright 2009The text in this document (excluding the Royal Arms and other departmental or agency logos) may be reproduced free ofcharge in any format or medium providing it is reproduced accurately and not used in a misleading context. The materialmust be acknowledged as Crown copyright and the title of the document specified.Where we have identified any third party copyright material you will need to obtain permission from the copyright holdersconcerned.For any other use of this material please write to Office of Public Sector Information, Information Policy Team, Kew,Richmond, Surrey TW9 4DU or e-mail: licensing@opsi.gov.ukISBN: 9780102952247

THE ICL REPORTIntroduction by the Right HonourableLord Gill, Chairman of the InquiryThe tragedy that occurred at Grovepark Mills on11 May 2004 has blighted the lives of manypeople. My purpose in this Inquiry has been tofulfill my Terms of Reference, which are set outbelow, and to make proposals for a new safetyregime for LPG installations that will minimise therisk that such an event will be repeated.Terms of Reference• To inquire into the circumstances leadingup to the incident on 11 May 2004 atthe premises occupied by the ICL groupof companies, Grovepark Mills, Maryhill,Glasgow.• To consider the safety and related issuesarising from such an inquiry, including theregulation of the activities at Grovepark Mills.• To make recommendations in the light of thelessons identified from the causation andcircumstances leading up to the incident.• To report as soon as practicable.This is the first joint inquiry to be held underthe Inquiries Act 2005 (the 2005 Act) and thefirst to be conducted under the the Inquiries(Scotland) Rules 2007 (SSI 2007 No 560) (the2007 Rules). The 2005 Act has introduceda new framework for public inquiries that willgreatly increase the efficiency with whichthey are conducted without compromising thethoroughness of the process. The essence of thisapproach is that inquiries will be inquisitorialprocesses, in which the relevant questions willbe determined by the inquiry, rather than theadversarial, litigation-based processes typicalof major inquiries in the past in which theinquiry agenda has been set by the participantsthemselves. In this new approach, there is noreason to fear that the truth-finding process willbe compromised. On the contrary, there is everyreason to think that it will be enhanced.I hope that this Inquiry has demonstrated thestrengths of the new procedures.Since this has been the first joint inquiry underthe new procedures and since it has been thefirst of its kind to be held in Scotland, I have setout the history of the Inquiry in Appendix 4 tothis Report. I hope that this history will be helpfulto those who have to conduct similar inquiries ofthis kind.I am grateful to the Inquiry Team who collectedand analysed a mass of evidence quickly,organized the inquiry hearings efficiently and,above all, assisted the core participants at everystage.I am grateful too to counsel to the Inquiry, both ofthem outstanding lawyers, for the benefit of theirskill and experience; and to the core participantsand their representatives for the help that theyhave given me in fulfilling my terms of reference.Lastly, I am grateful to the staff of the MaryhillCommunity Central Hall for their unfailing helpthroughout the Inquiry hearings.This was an avoidable tragedy. My Inquiry hasexamined its causes and considered how the riskof a similar tragedy can be minimised. I hopethat my recommendations will put LPG safety ona new footing: But I am conscious that progressin LPG safety will have been achieved at greatcost to the victims of this disaster and theirfamilies. I extend to the families of the deceasedand to those who were injured my heartfeltsympathy.Brian GillJuly 2009iii

CONTENTSPart 1 1Chapter 1 – The explosion, the rescue operation and the victims 2Chapter 2 – The cause of the explosion and its effects 4Chapter 3 – The prosecution 7Part 2 9Chapter 4 – Liquefied petroleum gas 10Chapter 5 – LPG installations 12Chapter 6 – The LPG industry 25Part 3 27Chapter 7 – The regulatory system 28Part 4 31Chapter 8 – The ICL group of companies 32Part 5 35Chapter 9 – The history and the layout of the Grovepark Mills site 36Chapter 10 – Calor and Johnston Oils and the installation at the site 39Chapter 11 – The installation of the LPG tank and external pipework 44Part 6 51Chapter 12 – A narrative account of the involvement of HSE at Grovepark Mills 52Chapter 13 – ICL and risk assessments 79Chapter 14 – The approach to LPG safety at Grovepark Mills 85Part 7 105Chapter 15 – What caused the disaster 106Part 8 111Chapter 16 – The responses of HSE and of the industry in the aftermath of the disaster 112iv

THE ICL REPORTPart 9 119Chapter 17 – LPG safety: an overview 120Chapter 18 – The action plan 130Appendices 147Appendix 1 – List of core participants 148Appendix 2 – List of witnesses before the Inquiry 149Appendix 3 – Chronology of legislation, regulations, codes of practice and guidance 152Appendix 4 – The history of the Inquiry 164Appendix 5 – The ICL Inquiry Team 178Appendix 6 – Definitions and glossary 179v

The deceasedMargaret BrownlieAnnette DoylePeter FergusonThomas McAulayJames Stewart McCollTracey McErlaneKenneth MurrayTimothy SmithAnn TrenchThe injured survivorsJames AitkenWilliam AitkenheadGordon BellAlan ByrneAlan DonaldsonNicholas DownieNicole EagleshamStacey EagleshamMonica FlynnDaniel FraserAndrew GallowayWilliam GiffordDaniel GilmourDavid HamiltonMartin HamiltonCharlene HowarthDerek KingLinda KinnonArchibald LindsayElizabeth LogieSheena McColl (now O’Brien)Christopher McGinleyJames McGoldrickMaureen McPhailClaire McShaneWilliam MastertonIan MaversElizabeth MillsTammy NelsonChristopher ProvanCharles RobertsonJohn TurnerMatthew WylieThose exposed to the risk of death or injuryJames AndersonDavid AndrewsJames BaxterWilliam ChapmanPatrick FeggansDavid FordeLinda JohnstonRobert McMillanAnthony NorthcoteJoyce RussellJason StewartRobert Warrenvi

THE ICL REPORTPart 11

THE ICL REPORTIncident Commander had declared a MajorIncident, had put in place arrangements for coordinatingthe rescue effort and had establishedsecurity cordons. By 1.00 pm, the SouthernGeneral Hospital Mobile Medical Team wason site. Soon after, Assistant Firemaster WilliamMcDonagh took command of the rescueoperation. At first, there were five fire crews.Fourteen more were called in. The medicalteams established a triage procedure andhad the injured taken to various hospitals inthe Glasgow area. By mid-afternoon, twentyfour casualties had been removed to hospital,sixteen persons were believed to be still buriedin the rubble and the rescuers were in contactwith five persons who were trapped. At 9 pmthe last survivor was rescued. By the end of theday, there were thirty seven known casualtiesand six fatalities.the rescue operation. This was an occasionwhen ordinary people did extraordinary acts.Hundreds of emergency service personnelfrom across the United Kingdom offered help,including the members of specialist rescueteams throughout Scotland and the north ofEngland. Over the next three days the bodiesof the deceased were recovered. The last wasremoved from the site at 11.25 am on 14 May.At the end of the rescue phase, the Fire andRescue Service gave control of the scene to thePolice.The members of the emergency serviceswho attended the scene showed ourstandingprofessionalism and dedication. Theyworked tirelessly in difficult and harrowingcircumstances. The staff of the nearbyCommunity Central Hall in Maryhill providedsupport and refuge to the relatives andfriends of the casualties in the difficult hoursimmediately after the disaster and throughout3

PART 21at the lowest point. It can permeate throughsubterranean structures. Its exact route could notbe determined with certainty in this case.When the pipe was excavated, it wasdiscovered that when the level of the yard hadbeen raised, the section of the pipe in whichthe main leak occurred had been packedaround with loose fill material. Beneath thesurface hard-standing a large concrete slabrested on top of the pipe where it turned andentered the building. The main leak at the finalbend had been caused by external corrosionaggravated by the weight of the piece ofconcrete that rested on it.The leak developed in three stages: there wasinitial corrosion, then a combination of loadingand corrosion which accelerated the failure,and a final opening of the crack because ofits weakened state. The rate of release of LPGwould have increased during the final stage. Itwas not possible to determine for how long thegas had been leaking into the basement.aggressive’ in respect of their corrosivequalities, and the rubble in-fill containedlarge pieces of concrete that had beenbearing directly on the undergroundpipework;5. there was a further small leak in the sectionof the pipework that was situated aboutone-third of the distance from the tank to thebasement. It resulted from perforation byexternal corrosion.There was LPG in the soil around the pipe trackin a pattern consistent with leakage from theunderground pipework before the explosion.The possibility that the explosive atmosphereresulted from any other potential source, suchas natural gas, dust or ground methane can beexcluded completely.Further examination of the pipe showed that1. the steel pipework had originally beengalvanised but otherwise had no othercorrosion protection;2. the screwed malleable iron fittings, straightcouplings, bends and elbows joininglengths of pipework were, with oneexception at the tank end, ungalvanisedand had no other corrosion protection;3. the pipe lengths and fittings weresubstantially corroded, with a significantreduction in wall thickness in the pipeworkoverall;4. the material used to form and fill thepipe track comprised a range of soiltypes classified as ‘aggressive’ to ‘very6

THE ICL REPORTChapter 3 – The prosecutionIn the week after the explosion the then LordAdvocate announced that the Health andSafety Executive (HSE) and Strathclyde Policewould conduct a joint investigation and reportto the Procurator Fiscal. On completion of theinvestigation, the need for a Fatal AccidentInquiry or for any other form of public inquirywould be considered.had been caused by the leakage of LPG froma corroded underground pipe that connectedan above-ground LPG storage tank to an ovenwithin the premises.On 28 August 2007, ICL Tech and ICL Plasticswere each fined £200,000.In November 2006 the Crown took proceedingson indictment against ICL Plastics Limited and ICLTech Limited under section 33(1)(a) of the Healthand Safety at Work etc. Act 1974.The charges alleged inter alia that therehad been failures (1) to make a suitable andsufficient assessment of the risks to the healthand safety of employees while at work infailing to identify that the pipework conveyingLiquefied Petroleum Gas (LPG) from the bulkvessel storage to the premises presenteda potential hazard and risk; (2) to appointone or more competent persons to assist incarrying out such risk assessments; (3) to havea proper system of inspection and maintenancein respect of the LPG pipework concerned,and (4) to ensure, so far as was reasonablypracticable, that the pipework was maintainedin a condition that was safe and without risk toemployees.On 17 August 2007 at Glasgow High Court,the companies pled guilty as libelled to thecharges.The Crown and the defence agreed thatthe cause of the collapse of the building atGrovepark Mills had been an explosion; thatthe cause of the explosion had been the ignitionof an accumulation of LPG in the basementarea of the building; and that this accumulation7

PART 218

THE ICL REPORTPart 29

PART 2Chapter 4 – Liquefied petroleum gasLiquefied petroleum gas (LPG) is the genericterm for hydrocarbon fuel gases with theprimary active constituents propane and butane.These constituents are derived from petroleumand can be readily converted to liquid formby the application of moderate pressure and/or refrigeration. LPG is normally supplied in theform of commercial propane.In liquid form, it occupies a smaller volumethan the corresponding volume of gas. Atatmospheric temperature and pressure, 1m³of liquid vaporises to form 274m³ of gas. Asa liquid at ambient temperature, LPG exerts apressure equivalent to its vapour pressure. It musttherefore be stored in a suitable pressure vessel.The compressibility of LPG makes it particularlysuitable for bulk storage and transportation.Due to the possibility of its expansion, LPGtransported as liquid presents a greater hazardthan that transported as vapour.Vaporised LPG at atmospheric pressure isapproximately one-and-a-half to two timesheavier than air. Escapes of LPG therefore tendto flow along the ground or the floor and toaccumulate at low points such as pits, sumps,drains, basements and the bilges of boats.Natural gas is lighter than air and thereforedissipates more easily into the atmosphere.When LPG is released to atmosphere itvaporises and mixes with air. The mixtureis flammable at concentrations of between2% and 10%. It burns most energeticallywhen the mixture is about 4% to 5% in air (a“stoichiometric mix”). At concentrations below2% the mixture does not burn as it is tooweak to sustain combustion. At concentrationsabout 10% it does not burn as it is too rich.By contrast, natural gas is flammable in air atconcentrations between 5% and 15% and burnsmost energetically at a mix of about 9%.Because of its greater density and itsflammability in air at lower concentrations, LPGpresents a greater hazard than natural gas.The special hazards of LPG have been wellunderstood for many years.LPG fire and explosion incidents are relativelyuncommon in relation to other incidents andwhere they do occur they relate mostly to LPGin liquid form. Only a small number of incidentscan be found on HSE’s databases involvingLPG leaks from pipes. Only one of these wasidentified by the Inquiry as having occurredbefore May 2004 involving vapour rather thanliquid. This incident occurred at LightweightBody Armour in Daventry in 1988 and involveda vapour leak from a buried pipe operating at30 psi (2 bar).The greater risk presented by the loss of LPGin liquid phase has resulted in priority beinggiven by HSE to producing guidance on liquidphase releases. According to HSE, “this isdue to the fact that one volume of liquid willexpand to give approximately 250 volumesof gaseous LPG and 12000 volumes of LPGat the lower flammable limit. As a result, thepotential consequences of a leak of liquidcompared with a similar sized leak of vapourare that much greater” … “Whilst both LPGstorage tanks and LPG pipework carry withthem the inherent hazard of leakage of LPG,the risk of leakage and its consequences,are generally much greater for bulk storagevessels containing liquid LPG. The pressuresare generally higher and the quantities thatcould escape are larger than for LPG pipeworkcontaining liquid, which in turn are greater10

THE ICL REPORTthan that for vapour pipelines. This is borne outby the known incident record. The majority oflarge scale incidents involving releases of LPG,both nationally and internationally, are knownto have involved bulk vessels as opposed topipework... In contrast, the incident recordsuggests that the risk of deaths or injuriesresulting from a low pressure LPG leak from apipe is low, especially where bulk storage is notinvolved.”Although HSE considered the risk of arelease of liquid LPG to be low, the potentialconsequences of such a leak can be high.There may also be serious consequences ifLPG leaks into an unventilated void. Users andsuppliers must therefore adhere to the highestpossible standards when storing and handlingLPG.Since LPG, like natural gas, is odourless in itsnatural state, a stenching agent is added tomake it detectable, by persons with a normalsense of smell, at concentrations of one fifth ofthe lower limit of flammability. The stenchingagent is an important safeguard against therisks of fire and asphyxiation which arise whenhigher concentrations of LPG accumulate inconfined spaces.Several witnesses in this case said that theydid not smell the LPG stenching agent beforethe explosion. The explanation is that since thepropane gas was heavier than air the smellwould probably have been evident only in thebasement.11

PART 2Chapter 5 – LPG installationsTypical LPG installation for smallcommercial customersThe industry norm is for the LPG supplier tosupply both the product and the tank to theindustrial and commercial customer. Installationsvary according to the supplier.The following description relates to two ofthe industry’s typical installations. It should benoted that, save for regulations 37, 38 and 41and subject to regulation 3(8), the Gas Safety(Installation and Use) Regulations 1998 (GSIUR)as matters stand do not apply generally to‘factories’ within the meaning of the FactoriesAct 1961.The pipework within an LPG installationis defined by reference to the part of theinstallation within which it is incorporated. Theservice pipework is that which runs from thetank regulator to the emergency control valve(ECV). The GSIUR definition of service pipeworkmeans “a pipe for supplying gas to premisesfrom a gas storage vessel, being any pipebetween the gas storage vessel and the outletof the ECV”. The installation pipework runs fromthe ECV to the isolation valve at the appliance.The GSIUR definition of installation pipework“means any pipework for conveying gas for aparticular consumer and any associated valveor other gas fitting including any pipework usedto connect a gas appliance to other installationpipework and any shut off device at the inletto the appliance, but it does not mean (a) aservice pipe; (b) a pipe comprised in a gasappliance; (c) any valve attached to a storagecontainer or cylinder; or (d) service pipework”.The “appliance pipework” runs from theappliance servicing valve to the appliance itself.Calor supplied details of the set-up of theirtypical LPG installation. For the most part itis typical of the industry. The diagram belowillustrates this.Figure 2 - Calor diagram12

THE ICL REPORT3 IN-LINE VESSEL LOW PRESSURE INSTALLATION1st StageRegulator2nd Stage Regulatorwith UPSO/OPSOCombination (Combo) Valve1. Filler Valve2. Liquid Offtake Valve3. Vapour Offtake ValveFloatGaugePressure ReliefValve (PRV)5 IN-LINE VESSEL LOW PRESSURE INSTALLATIONServicePipework2nd Stage Regulatorwith UPSO/OPSO1st StageRegulatorPressure ReliefValve (PRV)FillerValveLiquid WithdrawelValveVapourOfftake ValveFloatGaugeFigure 3On top of the tank, there are three valves,which may be located separately, or maybe grouped together in a single combinationvalve. Those valves are the filler valve, usedin the filling of the tank; the liquid withdrawal‘off-take’ valve, used for the removal of liquid formaintenance purposes; and the vapour off-takevalve, from which the vapour travels out of thetank into the pipework.There are two further items on the top of thetank itself; the float gauge, which indicates thelevel in the tank, and the pressure relief valve.An installation with a combination valve,pressure relief valve and float gauge is referredto as a three-in-line. Where the filler, liquid offtakeand vapour off-take valves are separatedon the top of the tank it is referred to as a fivein-line.13

PART 2Pressure ReliefValveFigure 4 – ICL tank with the hood offFigure 5 – Pressure Relief ValveRelief ValveAdaptorFigure 6Figure 7 – Relief Valve AdaptorThe LPG is stored as liquid within the tank, atnormal vapour pressure of about 7 bar. Afterleaving the vapour off-take valve, the vapourpasses through the first stage regulator, whicheffects an initial reduction in pressure fromabout 7 bar to 0.7 bar. Thereafter, it passesthrough a second stage regulator, whichreduces the pressure from 0.7 bar to about 37millibar, the usual and safe operating pressure.Underpressure and overpressure valves arenormally incorporated within the second stageregulator. The former shuts off the supply if thereis a drop in pressure at the tank end of theinstallation; for example, if the tank runs dry. Thelatter shuts off the supply if there is an increasein pressure; for example, if the regulator fails.14

THE ICL REPORTFiller valveFillervalveLiquid offtakevalveVapour offtakevalveFigure 8 – 3-in-line valve installationFigure 9 – 5-in-line valve installationOverpressure shut-off(OPSO) valveUnderpressure shut-off(UPSO) valveFigure 10 – 2nd stage regulatorFigure 11 – 2nd stage regulatorThe positions of the first and second stageregulators vary. The first stage regulator is oftenconnected directly into the combination valve.The second stage regulator is often connecteddirectly to the first stage regulator. Alternatively,the first stage regulator may be sited somedistance away from the tank. The two regulatorsmay be widely separated, with the first stageregulator sited at or near the tank, and thesecond stage regulator close to the entry pointto the building that the installation serves. In thatcase, any section of underground pipework thatconnects the two regulators will be carryingvapour at about 0.7 bar, rather than at thereduced pressure of 37 millibar. The first stageregulator is commonly sited away from the tank15

PART 2Figure 12 – Typical single bulk vessel operating with vessel mounted regulators and low pressure underground pipeworkFigure 13 – Installation with 2nd stage regulator close to building entry point16

THE ICL REPORTFigure 14 – 1st stage regulator serving 2 tankswhere there is a manifolding or joining togetherof two tanks and the first stage regulator servesboth. In that case, the first stage regulator isusually supported on the pipework which entersthe ground (Fig. 14).Exceptionally, installations may have a singleregulator effecting a one-stage reduction ofoperating pressure. In more modern installations,the pressure reduction may be effected in threestages.Where an installation incorporates a section ofunderground pipework, the vapour leaves thelast of the valves on the tank by way of metallicpipework, which connects to a polyethylene(PE) upright by way of a transition coupling.17

PART 2The typical installation used by Johnston Oilsis different from Calor’s in only minor respects.Johnston Oils prefer not to use a combinationvalve on top of the tank. Where the secondstage regulator is installed on the tank, theygenerally place it further along the pipeworkleading from the vapour off-take valve, at adistance from the first stage regulator. JohnstonOils, like Calor, have installations with one orboth of the regulators sited further downstreamfrom the tank.Figure 15 – Typical Emergency Control Valve (ECV) onoutside of propertyThe upright section is covered by a GlassReinforced Plastic (GRP) sleeve, which protectsthe PE against both mechanical damage anddegradation by U V light. Where it enters theground, the PE pipework is covered by blacktubes, known as “hockey sticks” which give astandard radius to the pipe thereby preventing itfrom over-bending or being crushed.Where the pipework re-emerges from the groundnear the building, it will again be protected by ahockey stick and GRP sleeve. It passes througha transition fitting into the emergency controlvalve (ECV), which can turn off the supply. Afterthe ECV, the pipework often changes to copperwhich is sleeved as it passes through the wall ofthe building. There is generally a warning signbeside the ECV, specifying what is to be done ifthere is a gas escape.If the pipework between the tank and thebuilding is above ground, galvanised steel isused rather than PE.The use of metal and polyethylene inburied service pipeworkPipework of various materials has beenused in underground sections of servicepipework. In the past, service pipework wasusually metallic. Such pipework was usuallygalvanised, often with a thin zinc coating, toprotect against corrosion. It was often alsowrapped with Denso tape, a proprietary tapeused as corrosion protection. For Denso tapeto be effective the pipework must be carefullyprepared and the tape must be applied in aparticular way. This is a difficult procedure. Itis often not adhered to properly. Unprotectedburied metallic pipework is likely to have alifespan of about thirty years; but corrosionleading to failure and leakage can occurconsiderably sooner than that.Polyethylene first came into use in the 1980s. Atthat time, only a limited number of installationswere installed with all-polyethylene pipework.From 1983 to about 1992 the practice wasto use polyethylene for the buried section ofthe service pipework, with metallic risers ateither end. The understanding at that time wasthat the metallic riser gave better protectionthan polyethylene against fire and mechanicaldamage. In due course, the LPG industry18

THE ICL REPORTThe standard material currently used forunderground service pipework is polyethylene.The norm is that all the pipework incorporated inan installation will be made of polyethylene. MrTomlin of Calor Gas said that it is not susceptibleto corrosion and has a lifespan of about fiftyyears. Dr Fullam of HSE said that “polyethylene(PE) pipe is impervious to most corrosionmechanisms including those that are biologicallybased. Medium density PE is manufacturedwithout a plasticiser and it is therefore less likelyto become brittle over time as a result of the lossof the plasticizer. PE pipes can last in excess of25 years. The main reason for failure is humaninterference, for example, someone digging it up”.Figure 16 – Typical ECV labelbecame less concerned about that risk andcame to use polyethylene risers protected byGRP sleeves. Where risers were made of steel,the parts of them below ground level weregenerally protected against corrosion by beinggalvanised and wrapped with Denso tape.From about 1993 onwards, the great majorityof new installations used only polyethylenepipework. Recent research into installationsinstalled before 1993 disclosed that of thoseexamined, 73% had polyethylene servicepipework with metallic risers, 13% hadpolyethylene pipework only, 9% had metallicpipework only, and 5% had pipework ofcopper or multiple materials.Tightness test and proof testA tightness test may also be described as asoundness or leak test. It is a pneumatic pressuretest to ensure the gas tightness of pipeworkfittings and components. It may also be used tocheck the effectiveness of shut-off devices. It iscarried out on an exchange of tanks, and afterany work is carried out on a gas fitting that mightaffect the tightness of the overall installation.The definition of a tightness test in IGE/TD/4polyethylene and steel gas services and servicepipework is “a specific procedure to verify thatpipework meets requirements for gas tightness”.GSIUR details the legal requirements fortightness testing LPG installations. Regulation6(6) provides that:“Where a person carries out any work inrelation to a gas fitting which might affectthe gas tightness of the gas installationhe shall immediately thereafter test theinstallation for gas tightness at least asfar as the nearest valves upstream anddownstream in the installation.”19

PART 2A proof test, otherwise known as a strength test,is a pressure test to establish that the mechanicalintegrity of pipework, fittings and componentsmeets the required standard. It is carried out ata higher pressure than a tightness test, abovethe operating pressure of the installation, andis used to determine the strength of a systemfollowing its construction. A proof test shouldnot be carried out on an installation with whichthe engineer is not familiar. If an engineer raisesthe pressure of a system above the normaloperating level without knowing how theinstallation was designed, what it is constructedof and how it was constructed, he risks his ownsafety and that of others in the vicinity. Thedefinition of a strength test in IGE/TD/4 is “aspecific procedure to verify that pipework meetsthe requirements for mechanical strength”.When Maurice Coville of Calor gave adviceabout the ICL installation, as I shall laterdescribe, a tightness test was understood bythe LPG industry to be an appropriate methodfor determining the integrity of an undergroundpipe. I deal with that part of the history later.It is now recognised that a tightness test carriedout on existing buried pipework gives noindication of its integrity. Even though a tightnesstest is satisfactory, the pipework may be in poorcondition and may be about to develop a leak.A tightness test should be used in conjunctionwith other appropriate methodologies todetermine the overall suitability of the pipeworkfor its continued use; for example, a leakagesurvey, records, operating pressure, material ofconstruction, and so on.Responsibilities for the Commercial/Industrial LPG InstallationThe responsibilities of the supplier and the userfor an LPG installation are determined by theterms and conditions of the supply contract. Ingeneral, the supplier is responsible for the tank,together with the associated pipework up toeither the vapour off-take valve or the first stageregulator. I discuss this important distinction later.The supplier is generally not responsible for theservice pipework downstream of either point.Any service pipework between either point andthe emergency control valve, whether buried ornot, is the responsibility of the user.The responsibilities of supplier and user in thenatural gas industry are different. Responsibilitiesfor natural gas are divided into two categories:transportation and supply. A natural gastransporter is responsible for the transportationand conveyance of the gas as far as theemergency control valve, while the supplier hasresponsibility for supplying from the emergencycontrol valve through to a meter regulator, whichis regarded as the end of the network. The userhas responsibility for the installation after themeter. Therefore, the transporter will generallyhave responsibility for any buried servicepipework up to the emergency control valve,whether it is outside or inside the building.Regulation 37 of the Gas Safety (Installationand Use) Regulations 1998 (the GSIUR) carrieswith it certain responsibilities in the event of agas leak. In particular, it imposes an obligationto prevent an escape of gas within twelvehours of its being notified. In relation to naturalgas, that obligation lies with the transporter. Inrelation to LPG, it lies with the supplier.There is a difference of approach betweenLPG suppliers as to the point up to which thesupplier takes responsibility for the installation.Calor’s responsibility for it ends at the vapour20

THE ICL REPORToff-take valve. Johnston Oils takes responsibilityup to the first stage regulator, a position thatseems to be regarded by UKLPG as the industrynorm. Suppliers such as Johnston Oils take thatapproach whether the first stage regulator issituated at the tank or is remote from it. It is myimpression that before evidence on the pointcame out at the Inquiry, the industry seems notto have regarded these differences in approachas being significant.It is usual industry practice for the supplier toinstall the service pipework up to the emergencycontrol valve, although the supplier will nothave ultimate responsibility for it. Nothing isvisible on the installation in terms of a notice orcolour coding to indicate where responsibilitypasses from the supplier to the user. The usualpractice is that users are made aware of theirresponsibilities for service pipework throughthe contract and, in the case of Calor, by theprovision of a welcome pack.Tank exchangeIt is relatively common for LPG users to changesupplier at the end of a contract. The outgoingsupplier removes its tank, and the incomingsupplier connects its own tank to the installation.The LPG industry considers that the use of anintegrated system makes it easier for the userto change suppliers. An exchange of tanks ofthis kind is generally described as a like-for-likeexchange. The result is that the new suppliermay know nothing of the history and conditionof the pipework to which its tank is beingconnected.Different approaches are adopted by differentsuppliers when taking over the supply to anexisting installation. Calor’s procedure is toinstall the tank, carry out a visual inspection ofpipework that is above ground, and carry outa tightness test on the installation. Calor assumethat the customer has fulfilled all responsibilitiesin relation to any section of underground servicepipework and that it is in safe condition. Calor’sprocedure in this respect has not changedsince 2004. Johnston Oils adopted the sameapproach as Calor until 2004; but since2005, in response to the ICL disaster, theyhave carried out a full risk assessment of theinstallation when taking over a supply. This maylead to their recommending replacement ofthe underground service pipework should therebe any doubt as to its age or condition. If theuser does not follow such recommendations,Johnston Oils will refuse to supply to theinstallation.It is now recognised by the industry that thecarrying out of a like-for-like exchange maygive rise to difficulty where the outgoing andincoming suppliers operate different regimesof responsibility for the installation. Industrypractice seems to have been to assume that ina like-for-like tank exchange there was a like-forlikeexchange of responsibilities.But if the outgoing supplier takes responsibilityto the first stage regulator, and the incomingsupplier takes responsibility only to the vapouroff-take valve, the user may not realise thatit has assumed responsibility for the servicepipework in between.Strengths and weaknesses ofthe present system regardingresponsibility for service pipeworkIt was accepted by all relevant witnesses thatit was undesirable that different approachesshould be adopted by different suppliers withregard to responsibility for pipework.21

PART 2Bulk Propane Tank Propane Cyclinder LPG OvenLPG BurnerMill WallLPG Oven BurnersGround LevelPilot LightsRegulator &Pressure GaugeUndergroundPipeFigure 17Figure 18 – The vapour take off valve fitted to the onetonnepropane storage tankAll of the witnesses who discussed the pointwere unanimous in their view that responsibilityfor service pipework should remain with the LPGuser. They reached that view on the basis thatit is the user who has day-to-day control overthe site and, therefore, the service pipework,together with knowledge of the installationdownstream of the tank and associatedvalves. A supplier would also face difficultiesin obtaining insurance for a liability in respectof the service pipework since that was a riskwhich it could not control. There is an importantdistinction between the natural gas and theLPG industries in that the natural gas customerhas no control over a gas escape upstream ofthe emergency control valve, whereas an LPGcustomer can control the supply of gas into theservice pipework by simply closing the isolationvalve at the tank in the event of an escape. Theproper comparison to be drawn, I think, is notbetween LPG and natural gas, but between LPGand other packaged fuels and chemicals, suchas oil and compressed gas.One of the important questions in this Inquiry iswhether the supplier’s responsibility should endat the vapour off-take valve, in accordance withCalor’s practice, or at the first stage regulator,in accordance with the general industry view.Calor consider that making the demarcation atthe vapour off-take gives a degree of certaintythat is not present if the first stage regulator isregarded as the relevant point, because thefirst stage regulator may be located at differentplaces at different sites. On the other view, itmay be desirable for the pipework up to the22

THE ICL REPORTFigure 20 – The witness marks (arrow) in the circlip grooveleft by the missing excess flow valve circlipFigure 19 – The witness marks (arrow) left by the missingexcess flow valve springFigure 21 – The one-tonne storage tanFigure 22 – The two manifolded 47kg propane cylindersfirst stage regulator to remain the responsibilityof the supplier, since it contains high pressurevapour. I shall discuss this question later.The ICL InstallationThe diagram (Fig. 17) represents the ICLinstallation at the date of the explosion. Thecomplete LPG system consisted of a one tonnetank, two 47 kg cylinders, surface pipeworkand regulator, underground pipework to thebasement of the building, pipework within thebuilding, LPG oven and ancillary items.The one-tonne tank that had been fitted byJohnston Oils on 29 November 1998 wasfitted with a vapour off-take valve (Fig. 18).23

PART 2Figure 23 – The position of the LPG pipe as it enters theground from the one-tonne propane storage tank end.Figure 24 – The LPG underground pipeline enters thebuilding in an alcove in the basementAlthough the valve appeared to have beenoriginally fitted with an excess flow valve,which fitted into the base of the valve, the innerworkings of the valve were absent when DrHawksworth inspected it. There was evidencethat the working components of the valve hadbeen in place at some time. This type of excessflow valve is intended to protect against a fullpipe failure, or shear. It is not intended to offerany protection against a crack or a split in thepipe; nor to protect an underground pipe. TheICL installation was unusual in that there wasno second stage regulator because of the highoperating pressure of the oven.section of pipe that incorporated a furthervalve and a high pressure regulator. Below theregulator the pipe went underground.The underground pipe went from the positionclose to the tank to enter the building in analcove in the basement. It then went up throughthe dispatch floor to the ground floor ceilingeventually to connect to the LPG oven. Thevalve shown (Fig. 24) was, in the past, used toisolate the LPG supply into the building.The pipework from the tank was initially 10mmouter diameter (OD), nominal internal diameter(ID) 8.4mm, copper tubing connecting to 1 inchsteel pipe about 0.5m from the outlet. The oneinch pipe fed back to a T-coupling (through anin-line valve) where a further flexible hose, alsofitted with an in-line valve, connected to two 47kg propane cylinders. The other side of the pipeT-coupling then dropped down to a vertical24

THE ICL REPORTChapter 6 – The LPG industryUKLPGThe trade association of the LPG industryis UKLPG. UKLPG was formed in January2008, by amalgamation of the LPGA (the LPGAssociation) and ALGED (the Association forLiquid Gas Equipment Distributors), which wereformed in 1947 and 1975 respectively. Its mainpurpose is to promote the highest safety andtechnical standards. It encourages its membersto assist it on such matters. It keeps its membersinformed of forthcoming changes that mightaffect the industry and provides them with allrelevant Codes of Practice. I discuss these inmore detail in Part 3.Most of the members of UKLPG are retailsuppliers to direct end users, who are generallysmall customers. The industry is dominatedby four majors, namely Calor Gas, Flo Gas,Shell and BP. Several wholesale suppliers aremembers, including Total, Conoco Philips andTexaco Chevron. The membership of UKLPGaccounts for 95% of suppliers of LPG in the UK.The remaining 5% account for only about 1%of the total quantity of LPG supplied in the UK.They are mostly independent companies, oftenoperated by individuals who have previouslyworked for larger suppliers. For the most partthey observe the UKLPG Codes of Practice.I am impressed by the quality of UKLPG’s workin its field. It has produced an updated Code ofPractice that is comprehensive and incorporatesthe lessons of experience. The Code hasfollowed a careful process of consultation withinthe industry and with HSE. The paramount aimof the Code is safety. UKLPG’s approach is notbased on considerations of cost.UKLPG has made an outstanding contributionto this Inquiry. It has provided a detailed surveyof the history of the practice of the industry anda reasoned and constructive response to therecommendations of Mr Sylvester-Evans.Institute of Gas Engineers andManagers (IGEM)The Institute of Gas Engineers and Managers(IGEM) is the chartered body for gas industryprofessionals and draws representation fromboth the natural gas and LPG industries. IGEMhas published industry standards since the1960s, including those on gas and mainsservices.Members of UKLPG are obliged to adhere toits Articles of Association and to comply withits Codes of Practice. UKLPG has the powerto suspend or expel members for breaches ofits Codes of Practice. It will generally find outabout a member’s failure to adhere to a safetyrequirement through a complaint by the publicor by a fellow member. The Board reviews anycomplaints received. In twenty years, UKLPGhas had to suspend only one member for aserious breach of safety.25

26PART 2

THE ICL REPORTPart 327

PART 3Chapter 7 – The regulatory systemIntroductionThe regulatory regime is extensive in relationto LPG, but in most cases is not specific to it.It consists of primary legislation, secondarylegislation, codes of practice, HSE guidance,industry guidance, and building, planning andfire legislation. I do not propose to analysethis wealth of material in detail. It is sufficientfor the purposes of this inquiry to say that thelegislation is complex and is spread over amultiplicity of statutes and regulations. Much ofit reflects the changes in emphasis in health andsafety legislation over the years.The diversity of these sources and the manyproblems of interpretation of them make itdifficult for the layman to understand the law.That in itself is a significant weakness in thepresent safety regime.Health and SafetyHealth and safety in essence means themanagement of the risks to people’s health andsafety from work activities. To be truly effective,health and safety has to be an everydayprocess supported by everyone involved as anintegral part of workplace culture - employers,employees, third party organisations such asSTUC, TUC, employer organistaions, tradeassociations (notably UKLPG in the context ofthe subject matter of this report) consultant firmsand voluntary organisations producing healthand safety guidance.The Health and Safety at Work Act 1974 andits underlying principles and philosophy providea legislative framework that is adaptable.The Act established the simple principlethat those who create risk are best placedto manage it. This applies whether the riskmaker is an employer, is self-employed oris a manufacturer or supplier of articles orsubstances for use at work. Each risk maker hasa range of duties that must be implemented tomanage the risk.All workers have a fundamental right to workin an environment where risks to health andsafety are properly controlled. The primaryresponsibility for this lies with the employer.Workers also have a duty of care for their ownhealth and safety and for the health and safetyof others who may be affected by their actions.The legislation requires that workers shouldco-operate with employers on health and safetyissues.The Act led to the setting up of the Health andSafety Commission (HSC) and the Health andSafety Executive (HSE) and established HSEand local authorities as joint enforcers of healthand safety law. On 1 April 2008 HSC andHSE merged to form a single entity known asthe Health and Safety Executive (HSE).HSE is the national regulatory body responsiblefor promoting the cause of better health andsafety at work within the United Kingdom. Itworks in partnership with local authorities toprovide strategic direction and to lead themanagement of the risks to health and safetyfrom work activities as a whole. To do this itconducts research, proposes new regulationswhere and when needed, introduces newor revised regulations and codes of practice,alerts duty holders to new and emerging risks,provides information and advice and promotestraining. Its focus is on identifying practical stepsand measures which can be taken by dutyholders to reduce the risks that people may bekilled, injured or made ill by work activities.28

THE ICL REPORTIts key role is to ensure that duty holders aremotivated to do the right thing because itmakes sense and to support the duty holders inintegrating health and safety into their functionsand responsibilities in a commonsense andproportionate way.Enforcement has three main objectives: 1) toseek to compel duty holders to take immediateaction to deal with the identified risk; 2) topromote sustained compliance with the law; 3)to look to ensure that duty holders who breachhealth and safety requirements, and directors ormanagers who fail in their responsibilities, areheld to account for their actions.Better RegulationThe Better Regulation Commission’s summary,updated in December 2007, is that the fiveprinciples of good regulation should be:• Proportionate: Regulators should onlyintervene when necessary. Remedies shouldbe appropriate to the risk posed, and costsidentified and minimised.• Accountable: Regulators must be able tojustify decisions, and be subject to publicscrutiny.• Consistent: Government rules and standardsmust be joined up and implemented fairly.• Transparent: Regulators should be open, andkeep regulations simple and user friendly.• Targeted: Regulation should be focused onthe problem, and minimise side effects.CompetencyThere is confusion in the health and safetyenvironment between a qualified person anda competent person. The legislation makesrequirements for engagement of a “competent”person. In essence a person is to be consideredcompetent if he has the ability to applyknowledge in a way that is proportionate,meaningful and useful to the intended audience.The essence of competence is said by HSEto be relevance to the workplace with therequirement that there is a proper focus onboth the risks that occur most often and thosewith serious consequences. Competence is theability for every director, manager and workerto recognise the risks in operational activitiesand then apply the right measures to controland manage those risks.Hierarchy and status of legislationThe primary legislation is the Health andSafety at Work Act 1974 (HSWA). It allowsfor secondary legislation, usually in the form ofregulations and approved codes of practice.Regulations are made by the appropriateMinister, normally on the basis of proposalssubmitted by HSE after consultation. They haveto be laid before Parliament for a period of 21days before coming into force. It is a criminaloffence to fail to comply with any requirementof a regulation.Approved codes of practice (ACoPs) areapproved by HSE with the consent of theappropriate Secretary of State. They do notrequire agreement from Parliament. ACoPs havea special authority in law. Failure to complywith an ACoP may be taken by a court incriminal proceedings as evidence of a failureto comply with the requirements of the Act or ofregulations to which the ACoP relates, unlessit can be shown that those requirements werecomplied with in some equally effective way.ACoPs therefore provide flexibility to cope withinvention and technological change without alowering of standards.29

PART 3HSE also publishes non-statutory guidanceto accompany regulations. Guidance is notcompulsory. In comparison with subject-specificregulations, guidance is more straightforwardand quicker to produce. It is also simpler tokeep up to date. Health and safety inspectorsmay refer to guidance to illustrate goodpractice.The industry is often best placed to produceits own guidance and codes of practicesfrom its collective experience and knowledgeof the hazards, risks and best practice. Onthis approach the industry itself advocatesand promulgates best practice. Since 1998much of this guidance has been producedin collaboration with HSE. Codes of Practiceproduced by UKLPG are prepared inconsultation with HSE. Some carry an HSEforeword stipulating that the UKLPG Codesof Practice are not to be regarded as anauthoritative interpretation of law but that tofollow them will be regarded normally as doingenough to comply with the health and safetylaw. There is a strong demand from users fornon-statutory guidance of this kind.statement published in 1996, HSE emphasisedthe continuing importance of standards as aform of guidance in promoting health andsafety.The history of the legislation,regulations codes and guidanceTo assist in the interpretation of the history of thiscase, I set out in Appendix 3 a table showingthe legislation, regulations, codes and guidancethat were in force at the key dates. As indicatedin the table, some of the earlier guidancereferred to was internal to the FactoriesInspectorate and the HSE.The relevant dates relating to the ICL installationhave been marked on this table. They are thedate of installation (1969), the date at which theyard was raised (January 1973), the date onwhich the LPG tank was exchanged by Calor(1982), the date of the Ives/Coville compromise(1988), the change of supplier from Calorto Johnston Oils (1998) and the date of theexplosion (11 May 2004).Information from HSE’s inspections andinvestigations is used when identifyingstandards, which may be published as informalguidance or as formal standards. The BritishStandards Institution is the national bodyresponsible for the development of Britishstandards. The great majority of these aretransposed European or international standards,for example BS5482 – Code of Practice forDomestic Butane and Propane Gas BurningInstallations. They are sometimes referred toin HSE’s published guidance. Occasionally,compliance with standards is required in healthand safety regulations and codes. In a policy30

THE ICL REPORTPart 431

PART 4Chapter 8 – The ICL groupof companiesThe ICL group consists of privately ownedlimited companies. ICL Plastics Limited is theholding company. ICL Technical Plastics Limitedand Stockline Plastics Limited are two of its sixoperating subsidiaries.ICL Plastics LimitedICL Plastics Limited (ICL Plastics) wasincorporated on 17 November 1961 with itsprincipal object being:“to carry on the business of processingplastics by all methods including ‘fluid bed’plastic dip coatings in various finishes, coldplastic spraying, plastic sheet welding,plastic slush moulding, plastic vacuumforming and fibreglass resin bondedmoulding”.Campbell Downie was the sales and financedirector. Ronald Cunningham was theproduction director. He resigned in 1966.Latterly, Campbell Downie had non-executiveduties.Campbell Downie’s wife Lorna was appointedcompany secretary on 26 April 1972. On25 May 1972, Ronald Ferguson and StewartMcColl were appointed as directors.In May 2004 Campbell Downie’sshareholding, and minimal shareholdings heldby his children, amounted to 68% of the sharesin ICL Plastics. Ronald Ferguson held 28% andStewart McColl held 4%.Between 1973 and 1975, subsidiarycompanies were created for the manufacturingand distribution operations. ICL Plastics, as theholding company with Campbell Downie aschairman, became responsible for maintainingthe group’s financial resources, providingaccounting and IT services, carrying outstrategic market analysis and undertakingresearch and development. Mr Downiewithdrew from all executive duties in thesubsidiaries after executive directors wereappointed.ICL Technical Plastics LimitedICL Technical Plastics Limited was incorporatedon 26 November 1973 to continue to developand specialise in production methods. Itsprincipal object was the same as that of ICLPlastics.The ownership and responsibility for the fixedplant and equipment to carry out this functionwere transferred from ICL Plastics to ICLTechnical Plastics Limited. There was no transferof the title to the site.Campbell Downie and Lorna Downie were theinitial directors. Lorna Downie resigned on 13December 1973 and was replaced by RogerWoodford. He resigned on 27 September1977 when Stewart McColl was appointedas a director with responsibility for sales. FrankStott was appointed on 27 April 1978 in placeof Campbell Downie and was managingdirector until 31 October 1998. He remained adirector until 22 January 2004. Peter Marshallwas managing director from 12 October 1998until he resigned on 1 October 2000.ICL Plastics owned about 83% of the sharesin ICL Tech. The minority shareholder in ICLTech was Frank Stott who held 17% of theshares. Campbell Downie also held a minimalshareholding.32

THE ICL REPORTOn 19 August 1999 the company changedits name to ICL Tech Limited (ICL Tech). At thetime of the disaster, ICL Tech employed 33people.Stockline Plastics LimitedStockline Plastics Limited (Stockline) wasalso incorporated on 26 November 1973.Its main function was to stock and distributeall forms of plastic, acrylic, polystyrene,polythene and other similar materials. In2004 its main operations were conducted inthe warehouse building adjacent to the mainbuilding.Campbell Downie and Stewart McColl wereboth appointed directors of Stockline in January1973.The offices for ICL Plastics and ICL Tech werein the main building at Grovepark Mills inwhich ICL Tech carried out its industrialprocesses.The directors of companies in the ICLgroup as at 11 May 2004As at 11 May 2004, Campbell Downie wassemi-retired chairman and non-executive directorof ICL Plastics, Stewart McColl was the salesdirector, Margaret Brownlie was the financedirector and Lorna Downie was the personneland company secretary. Ronald Ferguson wasa director but had no management role atany time. Stewart McColl was the managingdirector of ICL Tech.The directors were paid a salary and couldhold up to 25% of the shares in their company.Salaries were set against what each companycould afford to pay and remuneration fluctuatedaccordingly. There were no mechanisms toaward directors’ bonuses.The ICL Plastics group was self-financing andhad no borrowings.Campbell DownieMr Downie took semi-retirement from ICL Plasticsin the mid 1980s. From then on his mainfunction was to provide financial and strategicguidance to ICL Plastics.The financial management of the companieswas tightly monitored. Mr Downie developeda funds flow system of financial accounting toallow his fellow directors to see exactly whereeach company stood on a month to monthbasis.In the early days Mr Downie spent about athird of his time on the ICL premises. His visitsbecame more irregular from the mid 1980sas the ICL Group expanded and he had tobe away from Glasgow more frequently.Following his semi-retirement, he left the dayto day running of the operating subsidiaries tothe individual directors and rarely worked onthe premises. From the 1990s onwards he metwith Margaret Brownlie at ICL’s office once ortwice a week to discuss finance, IT programmedevelopment and related matters.Although semi-retired, Mr Downie was regularlyconsulted by directors of both ICL Plastics andICL Tech in relation to any decisions that werefinancially significant.Mr Downie did not regard himself as havingthe ultimate control and responsibility for theoperating decisions for ICL Plastics, ICL Techor any of the other subsidiaries. He described33

PART 4the ICL company structure as flat rather thanhierarchical. The directors of each subsidiarymade their own decisions. At board meetingsMr Downie presided but did not exercise a voteexcept if there was disagreement between thedirectors. As chairman, he had a casting vote.34

THE ICL REPORTPart 535

THE ICL REPORTThe despatch area was used for the packagingof goods for delivery and the processing ofgoods received at the factory. The first floor ofthe main building was used mainly for storageby ICL Tech. It had a variety of store roomsand other equipment including CNC millingand grinding machines. The second floor wasoccupied by ICL Plastics, ICL Tech and Stockline.It contained the personnel offices, training room,computer rooms, accounts department andboard room. The third floor was used for lightstorage by ICL Plastics and ICL Tech.The basement below the despatch areacreated from the open pit was used partly byICL Tech for the storage of components thatwere no longer in use, but primarily by AndrewGalloway and Kenneth Murray for storageof building tools, equipment and materials.They had been employed by ICL Plastics sincearound 1987 as handymen, mostly doingmaintenance work. The ceiling of the basementwas the steel plate that formed the floor of thedespatch area.In the basement there was a fireproof storethat Andrew Galloway and Kenneth Murrayhad built around 1996-1998. In the area ofthe fireproof store there was reinforcement ofthe steel ceiling. Between the steel beams thatsupported the steel ceiling there were concretelintels. These were cemented onto the beams onthe underside of the steel floor.There was an opening between the groundfloor and the basement through the steel floorwhere the base of the shot blasting machine,located in the coating shop, extended intothe basement. Occasionally access to thebasement was required to clean and repair themachine.History of the fabrication shopSome years before the explosion ICL Plasticsacquired on behalf of ICL Tech a modern,rectangular single-storey portal-framed steelstructure with an asbestos sheeted roof andexternal brick wall panels to the north ofGrovepark Mills. It was then known as TheScooter Centre. It had about two-thirds of thearea of the main building. ICL Tech moved itsfabrication operations into it from the first floorof the main building.The fabrication shop was where the shaping,drilling, cutting and welding of plastics andmetals took place. Wood was also cut to makemoulds, jigs and frames. A wide variety ofmachinery was used to perform these functions.The fabrication shop was accessed from theback yard security door. At the entrance therewas a receiving area for stock and materials.There was also a cabinet there which storedvarious chemicals. There were two electricovens in the fabrication shop.The only LPG that was used in the fabricationshop was in a flamer that worked off apropane bottle. The bottle was kept in acubicle. It was used about once a week forabout an hour. It was not used on the day ofthe explosion.History of the Stockline warehouseAt the time of the disaster, Stockline occupied thewarehouse next to the main building on a leasefrom ICL Plastics. ICL Plastics had bought thisfrom John Russell Joiners on 27 February 1981.This building survived the explosion.The main business of Stockline was thestorage and sale of bulk plastic sheeting. Thewarehouse had a small amount of machinery37

PART 5for cutting and altering sheets of plastic tocustomers’ specifications. At the time of thedisaster, all of the Stockline office staff workedin the main building.The yardTo the south side of the main building was atriangular shaped yard. A bulk storage tankfor LPG was located there at a distance ofabout 15.5 feet from the building. The tankwas connected to the underground piperunning beneath the yard that I have alreadydescribed. This pipe originally rose to enterthe main building above ground through abricked up window into the open pit area. Tocounter problems with flooding, the level of theyard was raised in 1973. As a result, the LPGpipework was covered over where it enteredthe building. I refer to this in greater detailelsewhere in this report.CoatingShopLPGOvenOriginalVoidDespatchAreaLPG SupplyPipeRaisedYardRampBuried LPGPipe EntryFigure 25 – Model of the Grovepark Mills premises38

THE ICL REPORTChapter 10 – Calor and Johnston Oilsand the installation at the siteLPG was supplied to the Grovepark Mills site byCalor Gas Limited (Calor) between 1969 and1998 and by Johnston Oils Limited, trading as JGas, between 1998 and 2004.Calor Gas LimitedCalor have been one of the major UK nationalsuppliers of LPG since the fuel was first usedand have been supplying bulk tank installationssince the mid 1950s. Calor have played anactive part in setting technical standards. Theyhave a substantial technical department.It has not been possible to ascertain theprecise events and procedures followed atthe Grovepark Mills premises. Calor’s generalpractice is as follows.Standard installation procedure for all premisesContracts are generally arranged by salesstaff who have knowledge of tank locationand installation requirements but no in-depthtechnical expertise. Technical queries arepassed to the technical department. During theinitial detailed discussion with the prospectivecustomer, the salesman would establish thepurpose of the LPG installation; whether Calorwas being asked to supply any appliances;and how much of the pipework, includingpressure regulators and isolation valves, theprospective customer wished Calor to supplyand install.The contractual arrangements made betweenCalor and the customer would determine theresponsibility for installation and maintenance.Normally, any part of an installation beyond,or downstream of, the vapour off take valve,would be the customer’s responsibility. Thiswould mean that the first stage regulator, itsfittings and all pipework between the firststage regulator and the appliances within thepremises would be the responsibility of thecustomer.This would all be set out in the initial contractualdocumentation.To calculate the size and number of the tanksrequired, and the size of the pipe required,it would be necessary to consider a numberof factors including the exact locations of theappliances, the gas input capacities of theappliance burners and their burning pressures,the pipe-run distances from the appliance tothe point of entry into the building and from thebuilding to the storage tank, and to allow for aminimum four weeks supply in the tank basedon usage.In accordance with regulations, the tankagewould have to be sited at a set distance fromthe nearest building, boundary, propertyline and any other fuel sources. There wouldhave to be adequate access for the vehicledelivering the tank, for the tanker and for fireservice vehicles. The siting distances of tanksand other associated requirements are laiddown in various Health and Safety Executivepublications. The prospective customer and thesalesman would then agree on the position ofthe tank site.The salesman would then sketch the installationand price the work agreed. The salesmanwould produce a specification and list ofmaterials, and a contract. On agreement andacceptance of the proposal by the customer, acontract would be completed and signed.The Sales Force Manual prepared by Calorprovides sales staff with instructions that they39

PART 5are to follow. The Manual instructs sales staff torefer to the technical staff where the installationis not straightforward. Every proposedinstallation involves a drawing.If Calor were to install any pipework, anyrelated drawings would indicate the pipeworkroute, its termination and tank location. Thedrawings would show all measurements. Beforeprogramming an installation, the salesman’spaperwork and drawing would be checkedby a member of Calor’s Technical ServicesDepartment. Further checks would be carriedout by the fitter installing the tank and by thetank delivery driver, both of whom would visitthe site with a site drawing.The fitting of LPG bulk installationsCalor have regional fitters who carry out LPGinstallations. A standard installation in noncommercialpremises would comprise the tank,first stage regulator, second stage regulator ifrequired, external pipework, isolation valve,and internal pipework to point of usage. Theextent of Calor’s involvement in the installationoverall depends on the terms of the agreement.Calor work to HS(G)34 guidelines and to theLPGA Codes of Practice/British Standards andtheir own specifications. In the absence of anyformal procedures and guidelines, as was theposition in the 1960s, Calor drew up theirown guidelines. With a new installation, safetyinformation and an emergency service cardwould be provided to the customer.For a new installation in commercial premises,Calor would now generally provide a tankand a first stage regulator and offer to installthe pipework to the exterior wall of thebuilding.The ownership of, and responsibility for, thepipework depends on the individual contractbetween Calor and the customer. If thecustomer is required to lay pipes, the onus willbe on the customer to follow the specificationprovided by Calor. If requested, Calor can laythe pipes.Calor will connect to existing pipework onlyafter inspecting and pressure testing thepipework.Calor normally retains ownership of a tank andleases it to the customer. All other items suppliedby Calor are sold to the customer. Calor wouldsell tanks only in exceptional circumstances. Byretaining ownership, Calor ensures that the tanksare tested under their testing regime. Testingtanks is mandatory. The test dates are displayedon the tanks.Having agreed the siting of the tank, thecustomer would be required to lay a solidconcrete tank base of prescribed dimensions.In the case of a 2-tonne tank, this would be 12feet by 6 feet by 6 inches. The customer wouldbe informed of the dimensions and the route ofthe trench for the underground pipework fromthe tank base to the pipe entry point at thewall of the building. Calor would deliver thetank and place it onto the concrete base andinstall the vapour off-take valve on the tank andthe vapour off take pipe as far as ground leveladjacent to the trench where the undergroundpipe would be laid. The tank would bedelivered tested onto the base.To activate the delivery of a tank, the customerwould notify Calor when the base had beenprepared and the trench opened. If Calor hadcontracted to do so, the Calor fitter would install40

THE ICL REPORTthe necessary equipment, pipe and fittings. Ifpart of the pipework had been installed by thecustomer, the tank would not be commissionedfor use until the Calor fitter had carried out asoundness test on the entire installation. If Calorhad fitted the customer’s internal pipework, Calorwould normally check the soundness of thepipework in 2 stages - from the tank to the firststage regulator and from the first stage regulator tothe customer’s appliance. A pressure gauge wouldbe fitted to the customer’s appliance to monitorthe test. Once the customer’s entire installationwas completed, Calor would commission thetank. Only then could the tank be filled withgas. Bulk tanks to be installed would sometimescontain 50 litres of gas to enable the fitter tocarry out a pressure test and to commission thetank. A soap test of all joints would be carriedout. If any leaks became apparent, these wouldbe repaired by the tank fitter. During installationand commissioning of the system, safety signswould be located in close proximity by the fitter.Emergency contact numbers would also beprovided. Thereafter, gas would be delivered tothe tank.Once the tank and pipework had beeninstalled, the customer would be given a safetyleaflet explaining the arrangements for pipeworkinspection. A 5-year inspection of the pipeworkis currently recommended, tying in with the5-year tank inspection. This would include apressure test. Excavation of pipework would beconsidered necessary only if a problem or aleak had been reported.Periodic testingCalor carry out 5-, 10- and 20-year tests ontheir bulk tanks. A 5-year test involves a visualinspection and, until more recently, a changeof the pressure relief valve. No soundness teston the pipework is carried out at the 5-yeartest. A 10-year test involves an ultrasonic testto measure the thickness of the metal at variouspoints of the tank. The pressure relief valve ischanged at this time. There is also a soundnesstest of the pipework between the tank andthe emergency control valve. A 20-year testinvolves either an exchange of the tank or anenhanced in-service test which involves the testscarried out at 10 years and tests of the valvesand pipework on the tank itself. A soundnesstest is also carried out. It is open to customersat any time to request Calor to carry out asoundness test of their pipework. The cost ofsuch a test is charged to the customer.The filling of tanksOnly Calor can fill Calor tanks. This is a termof their contract with the customer. Deliveriesof gas made by Calor require the deliverydriver to complete a Bulk Installation DefectReport (BIDR). If the driver has encountered anydifficulties, he is required to contact Calor’semergency response immediately to have anengineer sent to the site.Installation of LPG pipework in basement areasSince LPG is heavier than air, Calor state thatthey would not knowingly connect pipework toan appliance in a basement or pit. Where itwas necessary for pipework to be installed in abasement, it would not be approved by Calorunless there were appropriate safety measuresin place, such as having as few joints aspossible, having gas detection equipment, andhaving the pipe protected against mechanicaldamage.41

PART 5Johnston Oils Limited trading as JGasJohnston Oils Limited (Johnston Oils) is aprivately owned supplier of fuels. It also tradesunder the name J Gas. The company is basedin Bathgate and has been trading for 40 years.Johnston Oils supplied gas to the GroveparkMills site from 1998 to the date of the disaster.The contract between Johnston Oils and ICLPlasticsThe supply of LPG by Johnston Oils to ICLPlastics began on 22 April 1998. The termsand conditions of the supply are set outin a document dated 10 February 1998.They provided that the risk in the productsdelivered would pass to the buyer immediatelyupon delivery. Condition 3(c) provided thatJohnston Oils were responsible for insurance,maintenance and testing of tanks, regulatorsand pipework supplied. The pipework wasalready in situ when Johnston Oils took over thesupply. ICL Plastics drew up a diagram whichwas attached to the agreement showing wherethe tank was and where access could begained by Johnston Oils’ delivery vehicles.Under the bulk supply agreement, if thecustomer moved to another gas supplier thepipework would remain the responsibility ofthe customer. Johnston Oils considered that,as new suppliers taking over an existinginstallation under their agreement, they wouldbe responsible for the pipes only up to thefirst stage regulator. There was nothing in theUKLPG Guidelines issued at that time thataffected the position. The industry practice wasthought always to have been, and to continueto be, that the responsibility for pipework restedwith the owner or the customer. HSE guidancewas interpreted as supporting that view.When Johnston Oils took over the supplythey carried out a soundness test. Neither ICLPlastics nor ICL Tech asked Johnston Oils toinspect the pipework. If either had, JohnstonOils would have carried out a risk assessmentand investigated the type of pipes being usedat the site, their location and their estimatedage. Given the nature of the pipework,Johnston Oils would have recommended thatit be replaced. This would have been doneby Johnston Oils only on receipt of a writteninstruction.Johnston Oils were never aware of any problemwith the pipework at Grovepark Mills. If a driverhad reported any problem with the pipeworkdownstream of the first stage regulator, hewould have been instructed to turn off the gas.The customer would have then been contactedand advised to have repairs carried out to thepipework. If the customer had asked JohnstonOils Ltd to carry out the repairs, they wouldhave done so.Mr Alan Elliott of Johnston Oils consideredthat LPG pipework should not be installed ina basement or open void. He considered thatif such pipework existed, it should be subjectto a risk assessment. He did not know thatthe pipework from the tank was routed belowground into and through the basement. If hehad known of this, he would have advised ICLPlastics to dig up the buried pipework becausethat would be the only way to establish its typeand condition.Regular inspectionsJohnston Oils had a written scheme ofinspection for bulk tanks. This was Johnston Oils’standard specification for all installations.42

THE ICL REPORTThe annual testing and inspection of thevalves and fittings of a tank was a commonpractice. Johnston Oils issued their drivers witha checklist, which was returned to the mainJohnston Oils’ offices once tests had beencompleted. If a leak was identified, the normalpractice was that the delivery driver contactedJohnston Oils’ headquarters.Past practice dictated that at every 5-yearexamination the pressure relief valve wouldbe replaced. Research carried out by Calorin conjunction with HSE concluded that thereasonable life of the valve was 10 years. Asa result the industry changed its practice toreplacement every 10 years rather than every 5years. The replacement of the valve had nothingto do with the integrity of the tank itself. After20 years the tank would be refurbished.Johnston Oils’ tanker drivers carried out annualinspections of the bulk tank on 8 August 2001,10 June 2002 and 9 June 2003. The tankwould have been inspected and the valves andfittings leak tested, but there was no testing ofthe pipework. There was no indication that a5-year examination of the tank was carried out.Other circumstances relating to theLPG installation at Grovepark MillsAt some point before the disaster, twoadditional 47 kg LPG cylinders were fitted toa branch in the pipework which led from thetank to the first stage regulator. They providedback-up if the LPG in the tank ran out. It is notknown who fitted those cylinders. The presenceof these cylinders did not play any part in thecausation of the explosion.43

PART 5Chapter 11 – The installation of theLPG tank and external pipeworkThe Original LPG installationIn 1969 Campbell Downie, on behalf of ICLPlastics, concluded an agreement with Calor forthe purchase of bulk supplies of LPG for the LPGoven and for the hire of a bulk storage tank.On 29 May 1969, Mr J V Halhead, contractsmanager of Calor, wrote to ICL Plastics with aquotation for the hiring of a 2-tonne LPG tank.Mr Halhead said, inter alia:“It is noted should our quotation beacceptable to you, the galvanised ironpipe, pipe fittings, et cetera, required toconnect from the two ovens to the bulkpropane supply should be carried out byyour own labour force.”The quotation offered:“(a) one type 2-tonne capacity bulk propanestorage vessel on outright purchase for thenext sum specified or, alternatively,(b) one type 2-tonne capacity bulk propanestorage vessel on annual hire at a rate perannum which is specified.”The notes to the quotation specified that “itwould be the customer’s responsibility toexcavate and subsequently infill a suitabletrench to accommodate the high pressurepipeline from the Bulk Storage Vessel to themain building.”There is no evidence that any Calorrepresentative saw the trench or the pipeworkbefore it was backfilled. Had a Calorrepresentative noted any problem with theinstallation of the pipework, it is likely that hewould have reported that to Calor and thatCalor would have written to ICL Plastics askingthem to remedy the problem.On 15 December 1969 Calor wrote to ICLPlastics indicating the correct siting of the tank.A Calor plant and equipment hire proposalform dated 16 August 1969 showed that thehirer was ICL Plastics. The document detailedthe supply of one 2-tonne liquid LPG capacitytank, serial number 260458. This serial numbermost likely related to the original single 2-tonnetank that was installed at the ICL premises. It islikely that Calor provided to ICL Plastics a leafletthat included safety information and contactdetails in the event of an escape of LPG. Itis also likely that if ICL Plastics had indicatedthat they intended to arrange for the laying ofthe pipework, Calor would have provided aspecification and a method of working for theinstallation. No evidence of any such leaflet orspecification and working method has beenfound. There has been no evidence availableto the Inquiry as to whether or not Calor wasconsulted on these points.The agreement with Calor expressly stated thatICL Plastics carried the responsibility for installingand designing the pipework from the pressureregulator to the oven.Calor received a letter dated 17 December1969 from ICL Plastics confirming that“our installation conforms to the necessaryprecautions for tank installations.”In due course Calor installed a 2-tonne LPGtank.A building warrant would not have beenrequired for the creation of the LPG installation,including the tank and the pipework.The original contract was between ICL Plasticsand Calor. Invoices for the supply of LPG44

THE ICL REPORTwere rendered to and paid by ICL Plastics. ICLPlastics then re-charged these costs to ICL Tech.When first installed, the main length of theLPG pipework was about 0.3 metres belowthe surface of the yard. It was galvanised butotherwise unprotected. The final section ofpipework at the outside of the main buildingrose vertically to about 0.45 metres above theoriginal surface of the yard before passing byway of a right-angled bend horizontally into thebuilding. The section of LPG pipe that enteredthe building was therefore clearly visible.The pipework entered the building through abricked-up window into the original open pitarea within the building. It was therefore alsovisible in the pit area. This open pit area laterbecame part of the basement. The pipeworkwas not sleeved or sealed where it passedthrough the bricked-up window and entered theopen pit.After the disaster tests with tracer gasesdemonstrated that there was a leakage pathbelow the pipe entry point. It has not beenpossible to determine exactly the path bywhich the LPG entered the building through thebasement wall.Where the pipework entered the open pit area,there was a shut-off valve that controlled theflow of gas into the premises. It was used inearlier years to turn the gas on and off eachday. In later years, when Johnston Oils werethe suppliers and the tank had been replaced,this arrangement was changed. The LPG supplywas isolated at the external isolation valvelocated at the tank. Access to the basement forthis purpose was no longer required and thevalve in the basement remained open.From the shut-off valve in the basement thepipework travelled up to the ceiling of theground floor and ran along the length ofthe coating shop, bracketed onto the ceilingbeams, to the LPG oven.The installation of the LPG pipeworkICL Plastics engaged Grieben Plant Limitedto supervise the installation of the undergroundpipework by a subcontractor. The identity ofthat sub-contractor is not known. The principalof Grieben Plant was the late Frank Semple,a former marine engineer who was CampbellDownie’s brother-in-law. It is not known whetherGrieben Plant had any experience in the layingof underground gas pipes. The specificationfor the installation, if it existed, has not beenfound.Between the installation of the buried pipeworkin 1969 and the disaster in 2004, ICL Plasticsremained the heritable proprietor of the landin which the pipework was buried. From theirincorporation in 1973 until the disaster in2004, ICL Tech were the occupiers of that partof the premises in which the LPG oven wassituated and used the gas that was suppliedthrough the buried pipework.The raising of the yardIn 1973, because of problems with floodingand drainage in the yard and the need for avehicular access from Grovepark Place, ICLPlastics decided to raise the level of the yard.The other proprietors on the site agreed tothis. At their own suggestion, Alex Milne &Son, Builders carried out the works. CampbellDownie’s only involvement in the raising of theyard was to pay for it and to complete theapplication for a building warrant.45

PART 5The yard level was raised by about 1.1 metresusing rubble infill which was covered withconcrete hard standing. The riser for the LPGpipework became buried in the hard core andunder the concrete hard standing.This work brought the level of the yard to about0.6 metres below the level of the ground floorof the building.A copy of an application form dated 4 January1973 for a building warrant to raise the levelof the yard was found among the rubble. Itwas completed by ICL Plastics. The worksapplied for were described in the documentas ‘Levelling Access, Drainage at our yardat Grovepark Place’. The application wassigned by Campbell Downie. At the bottomof the application form it was indicated thatthe Scooter Centre, the then owner of thefabrication shop building, and Mr A J Milneon behalf of Alex Milne & Son had acceptedservice of the application.The application was granted by decree of thethen competent authority, the Dean of GuildCourt. The Senior Archivist, Culture and Sport,Glasgow confirmed to the City Council thatno trace of any drawing or other technicalinformation supporting the application couldbe found. These works may also have requiredplanning permission should they have impactedon drainage provisions.Without the specification or plans submittedin support of the application for the warrant,it cannot be known whether the presence ofthe LPG pipe entering the building was noted;nor whether the work was carried out with anytechnical advice. It seems that no thought wasgiven to the existence of the LPG pipework or tothe potential consequences of burying the riserin this way.When the riser to the building becameencased in rubble and earth and coveredwith concrete, it became invisible at the pointat which it entered the building. Internally, thepipe remained visible and accessible; but whenthe open pit was later covered over by thesteel floor of the despatch area, the LPG pipebecame invisible.Campbell Downie’s enquiry aboutpressure in the LPG pipeworkIn a letter dated 13 February 1974 CampbellDownie referred to recent discussions withCalor concerning the repositioning of thetank. He enquired whether there was anysimple metering equipment available to givean indication as to gas usage throughout theplant and “b) a means of confirming that tightline pressure is being maintained in the pipingsystem.” The question appears to have beenraised for the purpose of avoiding waste. Nofurther information concerning this enquiry, or itsresponse, has come to light.The history of the open pit areaThe open pit area existed for the purposes ofthe manufacturing processes carried on beforeICL bought the building. It extended above theexternal ground area. There were bricked-upwindows at that level.In the 1970s, HM Factories Inspectorateand later HSE made a series of visits to theICL Plastics premises in connection with fireprecautions. In 1975 the use of the basementarea gave cause for concern. At that time, theonly entrance to the pit and basement area wasby the stair tower. On 9 October 1975, HSE46

THE ICL REPORTserved an Improvement Notice on ICL Plasticsrequiring improvements to fire precautions,including the provision of an additional meansof escape from the basement at the north westcorner directly to the open air.Although some of HSE’s requirements wereimplemented, the additional means of escapefrom the basement was not installed. On 13January 1976, HSE served a Prohibition Noticeon ICL Technical Plastics prohibiting the useof a corridor adjoining the east stairway andforming part of an escape route, and anotheron Stockline prohibiting its use of the basementother than for the removal of material in a storeand the dismantling and removal of machineryfrom the work room area. HSE was thereaftersatisfied that the basement was no longer in useas a place of work.In 1977, responsibility for fire safety enforcementpassed from HM Factories Inspectorate to thefire service. In 1979, ICL decided to extend theground floor level over the pit area to createa despatch area that would be level with theramp from the yard. This was done by erectinga free-standing mezzanine structure consistingof steel chequer-plate flooring supported onlateral steel beams, in turn supported on steelcolumns footed on concrete plinths. The structuremeasured about 11.5 by 5.5 metres.On 13 July 1979 Campbell Downie wrote toJGN Reid Brothers Limited, structural engineers,requesting a written quotation for the supplyand construction of the steel floor structure.The letter enclosed a plan and a specificationfor the floor. On 15 February 1980, JGNReid submitted a quotation of £3,742. ICLPlastics accepted the quotation on 20 February1980.When the pit was covered over, no mechanicalventilation was installed. Beams criss-crossedunder the steel floor and the suspendedconcrete floor. Steel support pillars ran downthe middle of the closed-over pit from thefireproof store to the rear. A brick pillar wasbuilt around each steel pillar to ensure that,in the event of a fire, the brickwork round thesteel pillars would deflect some of the heat.Mr Downie instructed Andrew Galloway andKenneth Murray to carry out the work.A wall divided the closed-over pit from theremainder of the original basement area. It ranbelow the edge of the steel plated floor. It hada door giving access to the rest of the basementarea. Mr Downie required steel beams to beinstalled between the pillars to provide supportfor the areas over which forklift trucks ran.There was also scaffolding supporting railwaysleepers below the concrete floor. A distinctiveblue paint on the concrete floor of the despatcharea indicated the path for forklift trucks.An additional steel floor structure, constitutingnew floor space and being an alteration withinthe building, would have required a buildingwarrant even though it was a free-standingstructure. It is not known whether such anapplication was made.Mr Campbell Downie said that he thoughtthat a building warrant would have beenunnecessary as the floor was a free-standingstructure. It was not embedded into or attachedto the main structure of the four-storey buildingand no brickwork alterations were required toaccommodate it. He said that he would haveexpected JGN Reid, who at that time werewell-known structural engineers in Glasgow, toindicate if a building warrant was necessary.47

PART 5It is unlikely that the steel floor structure wouldhave required planning permission as it did notinvolve development external to the building.While the construction of the steel floor mayhave reduced any natural ventilation, it didnot create an unventilated void. The voidalready existed. In the absence of mechanicalventilation it was possible that, even withany natural ventilation available in the void,the LPG could reach a critical explosive mix,notwithstanding the presence of the steel floor.The particular significance of the introduction ofthe steel floor was that the LPG pipework, onentry into the building, became less visible andless accessible. It also made the detection ofany leak of LPG by smell less likely.Composition of the pipeworkThe sections of the pipework within the yardwere galvanised steel. The fittings werewhiteheart malleable iron. All but one wereungalvanised. The pipework between thestorage vessel and the point of entry to thebasement did not have a waterproof coating.Before the disaster, James McGoldrick, anemployee of ICL Tech, had noticed that theLPG pipework above the batch oven hadchanged colour. A colleague told him that thiswas because of corrosion. He knew that thecompany was attempting to get quotationsto have this pipework replaced. GordonBell recalled that the quotations were for thereplacement of LPG pipes within the coatingshop that had come free from their fasteningsabove the LPG oven. So far as he knew, onequotation had been received in February orMarch 2004. It was in the possession ofWilliam Masterton. The company was awaitinga second quotation.Operating procedureEach day an employee, usually JamesMcGoldrick, would open the coating shop/despatch area and switch on the machineryand ovens. He would turn on the gas supplyto the LPG oven at the shut-off valve in thebasement, light the pilot lights with a gaslighter and activate the burners. At the end ofthe working day, Gordon Bell would switchthe LPG oven off before James McGoldrickturned the gas off at the shut-off valve in thebasement. After Johnston Oils became suppliersthe practice was to turn the gas off at the LPGtank in the yard. The valve in the basementremained open. There was also a shut-off valvein the propane supply pipe to the oven withinthe coating shop.Inspections 1975 - 1988Between 1975 and 1988, various HSEinspections were carried out at Grovepark Mills.I refer to these later. HSE repeatedly expressedconcerns about the siting of the LPG tank andthe storage of combustible materials in thevicinity of it. Between 1988 and 1991, variousproposals and counter proposals were madeon the matter.During the period 1988-1991 Kenneth Platt,an employee of Calor, carried out a 5-yearinspection of the tank and replaced the pressurerelief valve.On 3 June 1991, Calor carried out a 10-yeartest on the tank and certified it. A checklistwithin the certificate indicated that the tank hadpassed the requisite tests.A Calor computer screen print and installationsheet indicated that on 17 June 1991 twotanks with serial numbers 214031 and 21364848

THE ICL REPORTwere delivered to ICL Tech. The two 1-tonnetanks each had a 2,000-litres capacity. Calordisconnected and removed the existing 2-tonnetank. This operation could have been carriedout by a Calor engineer or by a sub-contractor.It may be assumed that the engineer whocarried out the exchange carried out asoundness test on the installation and thepipework through to the first available isolationvalve.The Johnston Oils installationOn 10 February 1998, Margaret Brownlie,finance director, completed and signed acustomer account application form for JohnstonOils. On the same day she wrote to Calor totell them that ICL Plastics had entered into theagreement with Johnston Oils and to ask them toarrange a tank uplift with Johnston Oils.On 19 March 1998 Alan Elliott of Johnston Oilswrote to Calor confirming that ICL Plastics wereterminating their supply contract with Calor andseeking confirmation that the change over toJohnston Oils would take place on 25 March1998.On or about 25 March 1998, Johnston Oilsinstalled a single 1-tonne tank, with the serialnumber S38768. Before the installation,Johnston Oils did not carry out any kind ofinspection of the existing pipework, includingthe buried pipework, as it was a like-for-likeexchange of tanks, and the existing pipeworkwas the responsibility of ICL Plastics. JohnstonOils therefore had no knowledge as to the ageor condition of the buried pipework or as to itsroute through the basement.Uplift of the Calor tanksBy letter dated 16 April 1998, Johnston Oilsinformed Calor that ICL Plastics wished Calor’stanks to be removed by 16 April 1998. ACalor uplift request form was drawn up dated17 April 1998 requesting that Ankor Gas upliftthe two tanks that had been installed on 17June 1991. The work order was signed by ICLTech on 20th April 1998. On the same day thetwo tanks were removed.The supply of LPG by Johnston Oils to ICL Techbegan on 22 April 1988.Johnston Oils subcontracted the installation ofthe tank at Grovepark Mills to IB Contracts. Theinstallation was carried out by David Inglis whohad been with the company since he was 16years old. He was an accredited engineer withthe Construction Industry Training Board (CITB).He was certified in the installation of LPG tanksand pipework. He had experience of fittingover 200 tanks.David Inglis connected the tank to the existingpipework via the vapour off-take valve and thento the first stage regulator. After connecting thetank, he carried out a leak test on the visiblesection of the pipework by turning on thevapour off-take valve to release gas into thepipework, before spraying the visible pipeswith a leak detector fluid. He then carried outa soundness test to ensure the integrity of theoverall system. He repeated that test. The testdid not indicate any loss of pressure.The soundness test was carried out at thenormal working pressure of the system. Itwould normally be carried out between thefirst stage regulator and a shut-off valve onthe outside of the building where one existed.49

PART 5There was no such valve at the ICL premisesand, as a consequence, this test was carriedout on the pipework to the valve beside theoven in the coating shop. If the soundness testhad indicated a leak, David Inglis would haveshut off the LPG supply, disconnected the tankand plugged the pipework. He would haveinformed Johnston Oils and recommended thatthe pipework should be replaced.Johnston Oils assumed no responsibility for theexisting pipework.On or about 29 November 1998, JohnstonOils removed the tank that had been fitted on25 March 1998 and installed a 1-tonne tank,serial number S14627, in its place. It is likelythat the replacement was carried out by DavidInglis. He would have carried out the sameprocedures as before.Johnston Oils’ records give no indication as towhy this tank exchange took place. The mostlikely explanation is that the contents gaugewas not working.Johnston Oils’ tanker driver, Russell Flemingexamined tank S14627 on 8 August 2001.He reported that the tank was operatingsatisfactorily. The examination report andcertificate of compliance indicated the tank hadbeen manufactured on 29 January 1992.On 8 April 2002, IB Contracts changed theregulator on the tank. The work was done byDavid Inglis. He carried out a soundness test onthe system. There is nothing in IB Contracts’ invoiceto indicate why the regulator was changed.50

THE ICL REPORTPart 651

PART 6Chapter 12 – A narrative account ofthe involvement of HSE at GroveparkMillsThe involvement of the HSE atGrovepark MillsThe general history of HSE dealings with ICLThe Factories Inspectorate undertook a numberof visits to the ICL premises between 1970 and1975. These visits were generally recorded byInspectors on a Report on Visits form, knownas Form FI.42. The Factories Inspectorate wassuperseded by the Health and Safety Executiveafter 1975 when the Health and Safety atWork Act came into force.The Factories Inspectorate visits between 1970and 1975 indicate that particular attentionwas paid to fire risks. The local fire authoritybecame the enforcing authority for generalfire precautions in factories under the FirePrecautions Act 1971 with effect from 1 January1977, other than in respect of certain types ofpremises for which responsibility remained withHSE. The ICL premises were not within thosespecial categories.Between the mid 1970s and the early 1990s,the main concerns of the HSE officers whovisited Grovepark Mills in so far as they relatedto the LPG installation centred on the sizeand siting of the bulk storage tank and theconsequent risks.On 16 April 1970, Mr W A Dolling, anInspector with the Factories Inspectorate,visited the site at the request of Mr Smart, a fireprevention officer. Mr Dolling saw Mr Downieand noted that “the standard in this factoryleaves something to be desired” and that “thesepremises are a high fire risk premises.” Thiswas followed by a further visit. An entry for 3December 1970 records that Mr Downie wasseen; that “this firm have acted speedily onthe items drawn up on the F119 of 19 June,”that the only item not dealt with were sanitaryconveniences for women employees and that“the firm appear to have every intention ofcomplying with the provision of an extra toilet.”In 1971, an inspection showed that fire alarmshad been fitted, that fire fighting equipmentwas suitably maintained, that fire exits wereavailable and that a suitable fire routine was inplace for employees. A recommendation wasmade to remove the premises from the high firerisk list. A note was made that suitable toiletaccommodation had been provided for officewomen employees. A fire certificate had not yetbeen issued.In 1972, there was a visit at which Mr Downiewas seen. It related to a visit by the FirePrevention Officer. An electrically operatedbreak-glass fire alarm system was in the courseof installation. A note records “No fire certificatehas as yet been issued for this building whichis now well maintained.” The report noted thatthe means of escape were clear and wellsignposted and that the doors were openableat all times, and that the staff were clear as towhat to do in an emergency, there being drillsabout every six months. The inspector notesthat “due to the responsible attitude now beingshown by management, I believe that this firmcan now be taken off the high fire risk list.”All the recommendations in the Fire PreventionOfficer’s report had been carried out, withthe exception of an item relating to electricalinstallations. The report noted that the firmemployed a full time electrician who seemedsensible and competent. Old conductorswere mostly no longer used and were beingprogressively replaced. The new wiring52

THE ICL REPORTappeared to be excellent. An accident givingrise to a complaint was noted as having beeninvestigated. There is no trace of this complaint.In April 1973, the Fire Prevention Officer madea complaint to the Factories Inspectorateabout the occupation of a small office on thesecond floor, there being no alternative meansof escape in the event of a fire. The originalmeans of escape had been blocked off forsome time and not re-opened. Mr Downiewas informed that there was a risk of trappingand that the original alternative exit should beunblocked. The local authority was to be askedto carry out an inspection for fire certificationas a matter of urgency. However, because onlya small number of employees worked on thesecond floor and the existing means of escapewere well protected, it was not consideredthat the matter demanded any more urgentattention.On 22 August 1973, Mr A D Sefton and MrJohn A Powell of the Factories Inspectoratevisited the site. They noted that an alternativemeans of escape from the second floor wasnow available. Works were being undertakento increase office space. Mr Downie told MrSefton that the Master of Works Department andGlasgow Corporation were involved and that aFire Prevention Officer was paying regular visits.The report of the visit noted that the firm wasexpanding rapidly and “because of the materialsused and stored, it does present a considerablefire hazard. Mr Downie, the occupier does nottake a responsible attitude, especially as far asfire matters are concerned and for this reason Ibelieve the firm should be kept on the high firerisk list.” This recommendation was not followed.This is the last entry in which Mr Downie isrecorded as having been seen by Inspectors.On 1 October 1975, an inspector visitedthe site and spoke with Mr Woodford,managing director of ICL Technical Plastics,and Mr Wilson, electrician. The inspectornoted that conditions at the premises werepoor: “Conditions in this factory havedeteriorated considerably. In particular, themeans of escape, the storage and use ofhighly flammable liquids and materials, andthe guarding and machinery [sic] gives rise toserious concern.”The report records the building as being “fourstoreys with a basement area at the HopehillRoad end of it. The top floor and part of thesecond floor are unoccupied and it is proposedto seal off the top floor in the near future.The staircases at the front and the rear of thebuilding will make good means of escapeonce the partitions have been brought up to thenecessary standard.”In respect of highly flammable liquids andmaterials, the report noted that “There isa 1½ ton LPG (propane) installation in thesmall yard at the side of the building, whichserves the ovens and ground floor and theheating throughout the premises. Glass fibrework is carried out on the first floor and thereis a spray booth on the ground floor. Also,highly flammable plastics are stored and usedthroughout the premises. All these mattersgive rise to serious concern.” This was the firstrecorded note by HSE as to the presence ofthe LPG installation on the premises. The reportnoted that guarding was required for nearly allthe machines.A report of a joint visit by an inspector and fireprevention officers on the same day records that“since my visit earlier in the day a considerable53

PART 6amount of effort had been put into tidyingup the place. Most of the rubbish had beenremoved and most of the machines had beenput out of use.” The highly flammable liquidshad been collected and a covered skip wasdue to be delivered. While the fire officerswere concerned about the means of escape,they did not consider there to be an immediaterisk. The firm had agreed to stop all work inthe basement area and to improve the meansof escape from the corner of the ground floorwhere spray painting and coating processeswere carried out. A subsequent visit was madeon 3 October 1975 with a fire preventionofficer and building control officer to ensure thatthe required alterations to the means of escapewould meet building control standards.After a report from Strathclyde Fire Brigade,Mr Powell visited on 9 October 1975 anddelivered to Mr McColl and Mr Woodford anImprovement Notice (22/247/75) in connectionwith the means of escape. This required thatthe partitions for the west and east stairwayshould be constructed from materials with a fireresistance of at least one hour; that the lift shaftshould be totally enclosed with similar materials;that the plant room should be totally enclosedlikewise; that the basement should have a newexit to the air at the north-west corner, that thealarm system should be extended and thatadditional lighting should be installed to the fireexits. This was an improvement notice becausethe fire authority did not consider these matters tobe of immediate concern. The notice was servedon ICL Plastics Limited as employers and asowners. It required remedial action by 9 January.Mr Powell visited the site again on 14 October1975 to serve six improvement Notices on ICLPlastics, ICL Tech and Stockline in connectionwith heating and decoration of staircases andworkrooms. The heating was described asbeing provided by LPG gas fires. There wasconcern that these presented a fire hazard.There was also concern about fumes. Theprovision of heat was assessed as inadequate.The file was marked to be brought forward inJanuary for a check visit.The check visit took place on 13 January 1976.Mr Powell attended with a fire preventionofficer. They saw Mr Woodford. They notedthat only a few of the various works specifiedin the schedule to the Improvement Notice hadbeen carried out and that the means of escapestill gave rise to concern. Other fire preventionofficers attended and saw Mr Woodfordand Mr McColl. Mr Powell then issued threeProhibition Notices, 1, 2 and 3/247/76,to ICL Plastics Limited; ICL Technical PlasticsLimited and Stockline Limited respectively. TheProhibition Notice on ICL Technical PlasticsLimited was immediate. It related to the use ofa corridor that was part of a means of escape.It did not refer to the basement included inthe original Improvement Notice 22/247/75.The Prohibition Notice on ICL Plastics wasa deferred notice giving 28 days until 10February 1976 in which to bring the means ofescape up to standard and related to the “useof the premises at Grovepark Mills as a placeof work” as “safe means of escape in caseof fire have not been provided for all personsemployed in the premises.”The Prohibition Notice on Stockline Limitedrelated to the use of the basement as astoreroom and/or workroom and hadimmediate effect. The Notice did not apply topersons authorised to go into the basement toremove the remainder of the material in the store54

THE ICL REPORTand to dismantle and remove the machineryfrom the work room store. This was to permitthe closing up of the basement. The prohibitionwas to continue until an adequate means ofescape from the basement was provided. Inthe event the basement ceased to be used as aplace of work. Mr Powell’s evidence was thata Prohibition Notice was not supposed to lastin perpetuity. Once the requisite remedial workshad been complied with, it would cease tohave effect. After 1 January 1977 responsibilityfor fire precautions passed to the Fire Authority,other than in certain specialised cases. ICL wasnot one of those cases.Another visit followed on 13 January 1976.The file records that Mr McColl had takenover responsibility for the building and for otherhealth and safety matters. The purpose of thevisit was to collect evidence for a prosecutionin respect of Improvement Notice 22/247/75served on ICL Plastics Limited on 9 October1975. HSE sent a report to the Procurator Fiscalin Glasgow proposing prosecution in light of thefailure to comply with the Improvement Noticesto provide a proper fire escape. In a letter tothe Procurator Fiscal, John Powell described MrDownie as having an irresponsible attitude inconnection with fire matters.A further visit took place on 23 January 1976at the request of Mr McColl. Mr McColl gavean assurance that action would be taken onthe Prohibition Notices and was in hand on allmatters. It was noted that the work in relationto the means of escape from the corridor, thesubject of the deferred Prohibition Notice, waswell in hand and that it appeared that it wouldbe complied with. It appears that Mr Powellwas satisfied that the basement was no longerin use.On 10 February 1976, Mr Powell visitedwith fire prevention officers and found thatthe deferred Prohibition Notice relating to thecorridor had been satisfactorily complied with.He noted that there had been “a dramaticchange of attitude by the management of thisfirm. The threatened prosecution and closurehad the desired effect and according to MrMcColl, the necessary work to comply withthe outstanding Improvement Notices andother matters requiring attention is in hand”. Henoted that the standard of guarding on the oldmachinery was poor and gave advice aboutbringing it up to standard.Mr Powell passed his prosecution report tothe Procurator Fiscal. In it he said that “A MrDownie is the Chairman of Directors of ICLPlastics Limited and he has consistently shownan irresponsible attitude in connection with firematters (see form 211, 22nd August 1973).He has refused to see both myself and theFire Brigade and he delegated his duties,first of all, to Mr Woodford and then to MrMcColl, Director of both ICL Plastics Limited andStockline Limited”. He now added a note: “MrMcColl outlined his proposals in connectionwith the outstanding Improvement Noticeand other matters requiring attention. Themanagement’s change of attitude is amazing.They are a little embarrassed that it has takenthe Factory Inspectors to turn a slum into afactory.” He made a recommendation thatthe proposed prosecution should not proceedin view of the steps that the companies hadtaken. The Procurator Fiscal accepted thisrecommendation.Campbell Downie regards these circumstancesas demonstrating that health and safety mattersfrom at least as early as the mid 1970s had55

PART 6been accepted by subsidiary directors as theirresponsibility within each company. My viewson Campbell Downie’s role are expressedelsewhere in this report.On 17 February 1976, Mr Powell served afurther Improvement Notice on ICL PlasticsLimited as owners of the buildings in respect ofa lack of an escape route from premises at therear of the building occupied by a printer, MrForsyth.In April 1976, a further visit was made atthe request of Mr McColl to discuss theImprovement Notices. Stockline had completedits redecoration. Both ICL Plastics Limited andICL Technical Plastics had completed someworks and requested an extension for theremainder. Mr Forsyth was due to finish workon 16 April. ICL Plastics Limited requestedan extension of time to allow him to removemachines and materials. The report noted:“Although they are now trying to deny all legalliability towards Mr Forsyth and the property,they do not deny ownership of the buildingwhich is occupied by Stockline Plastics as wellas Forsyth Printers. A deferred Prohibition Noticewould be issued.”A further visit took place on 27 May 1976.It was recorded that Mr Forsyth had left thepremises, that the Prohibition Notice in thatrespect had been complied with and thatone of the Improvement Notices relating todecorations had been complied with in full.A visit on 3 June 1976 confirmed thatdecorations required under the ImprovementNotices and the machinery guarding hadreceived satisfactory attention. Heatingremained the only outstanding matter. It wasnoted that “Both the premises and the attitudeof management have undergone significantchanges in the last 6 months. These changeshave been for the better and the workingconditions are at last acceptable. The changeshave affected the employees who appear to bemore safety conscious.” This change appears tohave coincided with Mr McColl’s taking overresponsibility from Mr Woodford. The questionsabout the occupation of part of the premises bythe printer, Mr Forsyth who was not connectedwith ICL, had been resolved by his vacating thepremises.John Powell carried out a follow-up visit on 17September 1976. While not entirely satisfiedwith the work carried out, he noted that extraheating appliances had been installed and thatthe Improvement Notices had been compliedwith. His report also said that “it was also notedthat a plinth has been built for the LPG storagetank and it is hoped to re-site this tank in thenext few weeks.”A further visit took place with the Fire Authorityon 6 October 1976 when Mr McColl andMr Stott, “new director of Stockline Plastics”,were seen. Asbestos sampling was carried outand there was a familiarisation tour for the FireOfficer.Mr Powell’s last involvement with the premiseswas a follow up telephone call to Mr McCollon 27 October 1976 regarding the previousvisit and the asbestos sampling. Mr McColl isrecorded as requesting a list of recommendedmasks.The 1978 Inspection Visit recorded that therehad been a meeting with Mr Woodford andMr Stott and that the premises were “maintained56

THE ICL REPORTin a clean but not particularly orderly state”; thatMr Stott had informed the Inspector that it washoped to move the factory into more suitablepremises within the next two to three years, andthat to facilitate this it was hoped to develop anadjacent empty site. The offices were noted as“spacious and providing a good standard ofaccommodation.”In 1980 there was a visit to investigate anaccident involving an injury from a circularsaw. There was also a planned special visit toexamine the extraction system. It was noted thatthere was a new paint spraying booth with agood level of extraction. It was proposed thatthere be no further action. A request was madeby ICL shortly after this visit for HSE to talk tosafety representatives and interested employeeson health and safety in general and inparticular in respect of wood working machinesregulations. It was noted that the followingdiscussion was fruitful and that “management’sattitude in this firm is obviously improving. Thelecture was given as part of the firm’s ownseries of health and safety items following anumber of minor accidents in this firm. I believethis firm’s attitude towards health and safety isnow very good.”In February 1981 a visit was made toinvestigate an injury sustained from the use of acutter board. Several deficiencies in machineryguarding were noted. Guards were not beingused. According to the HSE file, “While thisfirm maintains that it relies largely on supervisionand training to ensure safety in the use of theirmachinery, a band saw was noted in operationwith the guard hopelessly out of adjustmentand the foreman was noted to walk past thiswithout commenting. A general discussionon machinery safety followed. Managementshowed concern in safety but I do not feel thatthis concern has yet been effectively translatedinto action”.The next reference to the LPG tank was on11 June 1981. John Ives, then a PrincipalInspector Training Officer, visited the premisesof ICL Tech together with Sue Johnston, then atrainee inspector. Mr Ives had accompaniedher to observe and assess her performance.It was a check visit to check the guarding oncircular saws. Nothing had been done sincethe visit earlier in the year. They met FrankStott, managing director, and Ian McAlpine,the production manager at ICL Tech. Thecompany argued against the use of guardsfor the machines in question. Eventually it wasagreed that wherever possible guards would beprovided and used. If guards were impossible,then jigs were to be deployed. It was madeclear that should any employee have anaccident on an unguarded machine, it wouldnot be taken lightly and might result in legalaction against the company.The penultimate paragraph of Ms Johnston’sentry on the Reports on Visits form referred tothe bulk tank:“Also during the visit a tank containing propane(probably 2 tons) was seen within the premises.Material and equipment, including smaller LPGcylinders were being stored too close to thelarger tank. The company were advised onthis.”Sue Johnston wrote on 16 July 1981 to ICLPlastics Ltd, with a copy for employees.She made recommendations concerningcircular saws and the woodworking machineregulations. She recorded seeing scraps of57

PART 6wood and small LPG cylinders stored in closeproximity to the tank. She said that these shouldbe moved immediately and stored outsideminimum separation distances.The letter informed ICL that a further visit wouldbe paid to ensure that this had been dealt with.The letter recommended that the companyshould calculate the separation distances forthe LPG tank and compare this against theappropriate separation distances given in thetables in Guidance Note CS5 Storage ofLPG at Fixed Installations. The CS5 Guidanceindicated that minimum separation distancesto boundaries, buildings and properties werenecessary to ensure that ignition sourceswere kept away from the tank. Ms Johnstonsuggested that if ICL Plastics discovered thattheir tank was sited too close to any boundary,building or property line, if at all possible itshould be moved and re-sited so that the correctseparation distances might be obtained. If thepremises were too small and it was not possibleto re-site the tank, they were to contact herfor further information and advice. They wererequested to advise her within two months ofthe action that they proposed to take in relationto this.On 10 October 1981, Ms Johnston visited thepremises at ICL Tech alone to carry out a checkvisit on the storage of materials around the bulktanks. Stockline Plastics had moved out andmost of their material had been cleared fromthe yard; but there was still a problem about thesiting of the tank. She expressed concern thatthe yard was cramped and that the separationdistances between the tank and the boundarywalls were “nowhere near” that required byCS5 (May 1981) and LPGA Code of PracticePart 1 (1978).Ms Johnston also referred to concern aboutthe filling of the tank from bulk road tankers.She made a request on 23 November 1981for specialist input from the Field ConsultancyGroup (FCG) of the HSE to see whetheranything could be done to improve the locationof the tank.In consequence of that request, MsJohnston visited again on 20 January 1982accompanied by Mr (later Dr) Alistair Gunn, anHSE specialist inspector with expertise in fireand explosions. They met with Mr Stott. Thepurpose of the visit was to check on the siting ofthe tank.Ms Johnston noted that since her last visit, andon the advice given, ICL had altered the fillingprocedure for the LPG tank which now tookplace with the delivery tankers parked outsidethe yard. She also recorded that “Mr Gunnagreed that this was probably one of the worstsitings of an LPG tank that he had ever seen.I propose to write to the company with therecommendations that Mr Gunn makes in hisreport.”Ms Johnston’s evidence was that if Dr Gunn hadthought that there was imminent danger of anykind, he would have said so, and she would havethen considered formal enforcement action.Dr Gunn became aware that some of hisrecommendations might impinge on accessto the tank by the Fire Brigade. Consequently,a further inspection was undertaken on 2February 1982. Dr Gunn and Ms Johnstonattended together with a fire prevention officerin order to obtain an opinion on the point. MrStott was away at the time of this visit. Theyspoke to Mr McColl.58

THE ICL REPORTFollowing those inspections, Dr Gunn wrote areport dated 8 February 1982 making severalrecommendations which, if carried out, wouldachieve an acceptable installation although itwould not comply fully with Guidance Note CS5.The tank could not be sited so as to achievethe recommended separation distances. His firstreaction was that the tank should be removed.However, in his evidence to the Inquiry, Dr Gunnindicated that he thought that this referred torelocation rather than removal. He noted that theadjoining wholesaler’s yard was 1.5 metres lowerthan the factory yard and that at its lowest pointabout 3 metres from the tank there were drains.The existing small wall along the boundary wouldprevent a liquid spill into the lower yard and actas a vapour barrier or diversion.Dr Gunn’s recommendations were that aradiation wall should be built adjacent to thetank. Although this would reduce the ventilationin the area, he could see no alternative. Thebuilding of the wall would make it less easyfor the Fire Brigade to put cooling water onthe tank if a fire were to occur nearby. Herecommended that a water drench systemshould be installed for the tank. A majorconcern for LPG storage is a Boiling LiquidExpanding Vapour Explosion (BLEVE), causedby the overheating of the liquid pressurisedcontents of the storage vessel. The water drenchsystem was intended to consist of a watersupply to a series of sprinklers, which would beactivated in the event of fire. A drench systemcan be automatic or manually operated. DrGunn recommended a manual system.On deliveries, the road tanker was to be outsidethe factory yard and under the supervision of anemployee trained in the storage and handling ofLPG and in the steps to take in an emergency.There was to be an earthing point provided forthe road tanker, and strict control exercised overactivities in the yard during the delivery process.Extinguishers were to be provided by the tankand there was to be no combustible materialwithin six metres of it. The security covers wereto be secured. Dr Gunn made a note that asthe tank was over ten years old, there shouldbe a check that it had been recently thoroughlyexamined, internally and externally.Dr Gunn said that at the time he would havehad the current LPG ITA Code of Practice andthe HSE’s then guidance note CS5, and that hetended to use the industry standards more thanthe HSE guidance. The industry standards weremore generally referred to. His practice wouldhave been to show the relevant requirements tothe duty holder when discussing what he wouldrecommend.Dr Gunn said that the request to him forspecialist assistance related to the siting of thebulk installation. It was not part of the request toconsider what happened once the LPG enteredthe building. Consideration of the undergroundpipework did not arise from his remit or fromthe circumstances of his visit to the site. Thevisible pipework did not appear to have anyconstruction, support or maintenance failings.Consideration of that too was outside his remit.Dr Gunn was aware of HSE internal circularFIC 286/43 - Underground pipes conveyingLPG. This FIC described the recommendedstandards for the installation, commissioning andinspection of underground pipes conveying LPGprimarily in liquid form, but it said that “similarstandards could be applied with advantage tounderground pipes conveying LPG vapour.” Itsaid that59

PART 6“For convenience LPG is often supplied tothe relevant process via underground pipes.These pipes have often been laid in an earthtrench, not always protected by lagging and/or wrapping tape and covered with sand. Atleast four such installations are known to havefailed, resulting in the release of substantialquantities of gas. In one case, an explosiveconcentration was created in a cellar 400metres from the leak and such concentrationshave also occurred in cellars, drains, wells,electrical mains conduits and other undergroundcavities… In all cases the leak has been causedby corrosion from outside the pipe as LPGitself is not corrosive. Protective coverings havebeen penetrated by sharp stones, particularlyunder the influence of vibration from overheadtraffic, and corrosion has eventually penetratedthe pipe wall. A resulting leak may not bediscovered for a period of weeks or months.”FIC 286/43 further recommended that after fiveyears an annual pressure test should be carriedout and that after ten years all undergroundpipes carrying LPG should be uncovered andphysically examined, if reasonably practicable,or otherwise should be surveyed annually, thesurvey to include a pressure test. FIC 286/43recommended that firms with inaccessible pipes,or pipes not installed to modern standards, oughtto be advised of the danger from leaks andencouraged to install pipes to a good modernstandard. Mr Tyldesley, a specialist inspectorwho subsequently visited the site, confirmed thatthis was an internal circular of HSE, but, being atechnical one, would usually have been sharedwith the major suppliers before it was published.He did not know if this had been the case withthis document. FICs were primarily for generalinspectors but were also available to specialistinspectors.The underground pipework at the GroveparkMills carried LPG in vapour form; but thecircular noted that the recommendations couldbe applied with advantage to pipeworkcarrying LPG in vapour form. Dr Gunn knewof this and of the risks associated with thecorrosion of underground LPG pipes and thecollection of leaked LPG into voids, trenches,basements and other underground areas. Hewas aware that the LPG tank and pipeworkat the premises were over ten years old butin the course of his inspections on 20 Januaryand 2 February 1982 he did not considerthe buried LPG pipework between the tankand the building as it did not form part of therequest for his assistance. Consequently, hemade no recommendations regarding it. DrGunn accepted that if he had realised thatthe pipework went into a void, he would haveconsidered the implications of this. He saidthat had no reason to do so since all that hesaw was the pipe going off from the tank andthrough the wall of the building. He did not seeit going underground.Ms Johnston said that the the normal processwould be to lift the recommendations from thespecialist’s report and put them in a letter to thecompany, rather than to send out a completecopy of the report.On 2 March 1982 HSE sent a letter to MrStott, describing him as managing directorof ICL Plastics Ltd. Correspondence from MrStott to the HSE described him as managingdirector of ICL Technical Plastics Limited. Thesame letter was sent to Mr Sarton, the ICLworkers’ representative, relaying the contents ofDr Gunn’s report. In the letter to Frank Stott, SueJohnston indicated that the recommendationswere of serious concern, that they should60

THE ICL REPORTreceive immediate attention and that a furthervisit would be paid in three months. She furthernoted, in the HSE Inspection File, that a checkvisit was to be carried out in May 1982.The check visit that she scheduled for May 1982did not take place until 3 December 1982.Mr Michael Wilcock attended on 19November following a death on the premisesthat was found to be from natural causes.Mr Wilcock said that it was possible that onconsidering the file he had noticed that theMay 1982 visit had not taken place and hadput it out for an immediate check visit.Mr Wilcock made the check visit on 3December 1982. After it he received a callfrom Frank Stott, who said that the companyhad met all the recommendations in relation tothe LPG storage contained in Dr Gunn’s report.The only exception was the drench system.Frank Stott said that it had been delivered andwould be installed in the Christmas shutdownperiod. Frank Stott is recorded as saying thathe would confirm everything in writing. On20 December 1982 he wrote to Mr Wilcockreiterating that the LPG tank had been replacedwithin the last 18 months; that the drench systemwas to be installed over the Christmas break;that all the materials were in the factory andthat it was intended to operate this from aforty gallon tank high on the building runningto a spray system. Details of the internal ICLdialogue between Frank Stott and CampbellDownie concerning the drench system are setout elsewhere in this report.A subsequent note by Mr Wilcock dated 29December 1982 stated that no further actionwas required.The next relevant visit took place on 13November 1985. One this occasion MsJohnston was accompanied by Dr A D Scott.This visit was to ascertain ICL Tech’s use ofchemicals and other toxic materials. The noteof the visit does not refer to LPG, but it wasnoted that a check visit was to be carried outin respect of the guarding, the LPG storage andthe spray booths. Subsequently an unidentifiedhandwritten note was added that this check visitshould be carried out in May 1986.On 18 December 1985 Ms Johnston wroteto ICL Plastics Ltd to confirm matters discussedduring the visit. This letter referred to the BulkLiquefied Petroleum Gas Storage and to theletter sent in February 1982 outlining therequirements for improving the LPG “insulation”[sic] and requesting ICL Plastics Ltd to let HSEknow whether all the requirements had beenmet. The letter noted that wooden pallets andother timber were being stored immediatelyadjacent to the tanks; that combustible materialshould not be within six metres of the tankand that this had been previously brought toattention. The letter requested a reply in writingsetting out the action that ICL proposed to takewithin the next four months on all the mattersoutlined. A further visit would be made tocheck on all the items raised in May 1986. Anadditional copy of the letter was enclosed to bebrought to the attention of employees.On 13 January 1986 Mr Stott, as managingdirector of ICL Technical Plastics Ltd, repliedindicating the steps that had been taken orwere in hand. In respect of the Bulk LiquefiedPetroleum Gas Storage he reported that lorriesno longer entered the yard; that the conductorwas in place and was being used on eachrecharge; that they would again clear the area61

PART 6around the tank but that they had not founda practical solution for spraying it. On 15January 1986 Ms Johnston created an HSE fileinspection entry that a letter had been receivedfrom Mr Stott indicating that the items broughtto attention had received or were receivingattention. This note appears to have overlookedthe information from Mr Stott that no practicalsolution for spraying the tank had been found.A handwritten note on the copy of her letter toICL Plastics dated 18 December 1985 next tothe section headed “Bulk liquefied petroleumgas storage” recorded “little done.” This notewas added by Alex Keddie, another inspectorwho visited the site.The HSE files disclosed that the check visitproposed for May 1986 did not take placefollowing the receipt of Mr. Stott’s letter of 13January 1986. This suggests either that thecheck visit was overlooked or that HSE bythen accepted that no drench system would beinstalled.The next recorded visit was on 7 April 1988,almost two and a half years later. Alex Keddieattended at the site for a planned visit. Henoted that the check visit proposed for May1986 had not taken place; that the letter of 13January 1986 confirmed that a water drenchsystem had not been fitted; that the bund wallhad been damaged and that he planned tovisit with someone from the Field ConsultancyGroup as soon as possible for enforcementaction. The other matters were noted ashaving received attention. As it was his firstvisit, Mr Keddie checked to see if outstandingmatters had been dealt with. His referenceto enforcement action was an expressionof his view before he obtained advice. Hedid not carry out his own assessment ofthe LPG installation but concluded that therecommended improvements had not beencompleted. The bund wall had also beendamaged.On 11 April 1988, Mr. Keddie wrote toICL Technical Plastics Ltd, for the attentionof Mr Stott, mentioning that the bund wallwas collapsing; that combustible materialwas stacked around the tank and that therecommended fire extinguishers were notto be seen. Another specialist inspectorwould be asked to attend at the premises tocheck whether the earlier advice remainedappropriate. The combustible material shouldbe removed from around the tank but it wasacceptable for non-combustible material to bethere if adequate access was maintained.On 13 April 1988 Mr Stott replied. Hesaid that the combustible material had beenremoved from the area of the LPG cylinder andthat builders had been instructed to repair thewall. He said that he would appreciate a visitfrom a specialist inspector to discuss the LPGstorage problems and try to resolve them. Heasked that the visit should be in May as hewould be out of the country from 22 April.On 25 April 1988 Alex Keddie referred thecase to a specialist inspector in FCG andrequested a visit. On 26 April 1988 FCGacknowledged Mr Keddie’s request. No visittook place until August. Mr Keddie said thathe was not surprised by that delay as theindication that he had given was that, while itmerited immediate work, he did not considerit to represent a particularly imminent risk. Hisfocus was on the location and spacing of thetank and not on the pipework. He had norecollection of raising the pipework as an issue.62

THE ICL REPORTMr Keddie could give no reason why the waterdrench system had not been installed, otherthan to say that while sometimes it is easy tomake recommendations, it can be practicallydifficult to apply them. In some instances that heknew of, there had not been a sufficient watersupply.Mr Keddie moved to Newcastle in June 1988and handed his files to John Ives, his linemanager, then Principal Inspector in charge ofthe Operational Group for the maritime andchemical industry.At about the time of Mr Keddie’s letter of 11April 1988 to ICL Technical Plastics Limited, theHSE recommendations were the subject of anexchange of internal memos between CampbellDownie and Frank Stott. On 13 April 1988, MrDownie wrote to Mr Stott recording that a “bundwall around the tank (with railings)” was part ofan early recommendation in siting the tank, butthat later inspectors had reversed that decisionand railings were removed. One inspector hadsuggested removal of the bund wall, but thishad not been implemented. The exchange alsorefered to the requirement for a drench system. Ishall refer to this exchange in a later chapter.Neither Mr Downie nor Mr Stott advised MrKeddie of their position on the drench system,the installation of which had been outstandingsince 1982. Mr Keddie confirmed that, so faras he could recollect, no one at ICL had triedto talk him out of the requirement for the drenchsystem.The events concerning the visit toGrovepark Mills on 9 August 1988The visit by a specialist inspector requestedby Mr Keddie in April took place on 9August 1988. John Ives attended for that visitwith Alan Tyldesley, who had recently beenrecruited as a Specialist Inspector workingwith the Field Consultancy Group dealingwith fire and explosion. This visit was to “seethe unsatisfactory LPG installation.” It led to aconsideration of the underground pipework. Itwas neither a general inspection nor a checkvisit. It was recorded as “miscellaneous.”It was clear to Mr Ives that the siting of the tankdid not comply with the separation distancescontained in HSE guidance HS (G) 34.This was a publication that contained HSE’sworking guidelines for bulk storage. It hadreplaced the earlier Guidance Note CS5. MrIves had received the HS (G) 34 guidancearound August 1987 and thought that it wasconsiderably clearer than CS5. Mr Tyldesleyconfirmed that FIC 286/43, the earlier internalHSE guidance, was not referred to in itsbibliography because FIC 286/43 was not apublished document and at that time was aboutto be cancelled.Mr Ives and Mr Tyldesley met Frank Stott on9 August 1988. Mr Ives said that he foundMr Stott to be pleasant and amenable. Theprincipal concern of Mr Ives and Mr Tyldesleyin the course of the visit was the location of theLPG tank and the storage of materials in thevicinity of it, a problem on which Mr Stott hadsuccessfully stalled for so long.There was a further exchange of memosbetween Frank Stott and Campbell Downiewhich are detailed elsewhere in this report.Frank Stott’s memo of 18 August concerned thevisit by Mr Ives and Mr Tyldesley. He advisedMr Downie that the two-tonne tank in the yardhad once more become the focus of attentionwith the factory inspectors; that they had63

PART 6expressed extreme concern at the continueduse of the tank above the surface and that theyseemed highly displeased that ICL Tech had notcomplied with their request for a water drench.Following the visit, Mr Ives noted:“Visit with Mr Tyldesley FCG; Mr Stott,Managing Director seen. Visit to see theunsatisfactory LPG installation. Mr Stott wasadvised to take immediate action to removeall materials stored within the separationdistance. This tank is one of the worst sitedI have ever seen and it is difficult to knowwhat to do with it. I propose to await MrTyldesley’s report and perhaps discuss thematter further with him before taking action.”During his visit with Mr Ives, Mr Tyldesleyinspected the external LPG installation aboveground and the vapour off-take pipe within thebasement. Following the visit he prepared aReport for Mr Ives.Mr Tyldesley’s report dated 22 August 1988detailed that the tank had been previouslyinspected by Dr Gunn of FCG in 1982who had recommended a package ofimprovements, intended to be implemented asa whole, but which had been followed only toa limited degree leaving “a still unsatisfactoryinstallation”. Mr Tyldesley said that, in short, thesafety issues relating to the tank had not beeneffectively dealt with since Dr Gunn had visitedthe premises. Mr Tyldesley noted that progresshad been made since 1982 in that the brickwall had been extended to create a fire wallseparating the tank from the roadway.Mr Ives explained in evidence that wherea company was unable to meet separationdistances for an LPG tank, there was thepossibility of building a “radiation wall”between the tank and the boundary. Thepurpose of the radiation wall was to protectthe tank from fires or any other heat sourceemanating from outside the site. However ifthere was an absence of ventilation at a lowlevel then if there was a leak, the gas couldaccumulate around the base of the tank andpresent a hazard.Mr Tyldesley explained that the separationdistances were inadequate. They wereimportant. A nearby fire could cause a tankto overheat and explode should gas not bereleased from the pressure relief valve. Smallreleases of gas above ground could dispersesafely if the location was well ventilated.Separation distances could provide someassurance of this, if adequate. A solid wallprovided protection from a nearby fire, butwould also hinder the dispersal of a leak.No fixed drench system had been installed andthere was no water supply immediately by theinstallation. Mr Tyldesley told the Inquiry that therecommendation for a drench was unusual for atank of that size. In his view, tanks of 25 to 50tonnes might possibly have been recommendedby HSE at that time to have a water drenchsystem. He doubted whether a case couldhave been shown for a drench for the tankthen in place at the site. Mr Ives said that hedid not think it was normal practice to have adrench system on a small tank and would haveexpected it to be suggested for a 100-tonnetank rather than a 2-tonne tank. Mr Ives hadno recollection of ever having seen Mr Stott’sletter of 13 January 1986 informing HSE that nopractical solution to spraying the tank had beenfound.64

THE ICL REPORTMr Tyldesley recorded that road tankersnow stood outside the yard during filling, asrecommended by the HSE. This took place atabout four-weekly intervals. Mr Tyldesley notedthat there was an unsealed drain cover locatedwhere this took place. This created a potentialrisk as gas releases were more likely at the fillingof the tank than at any other time. If this occurrednear an open drain the gas could enter andaccumulate, which could lead to an explosion.Mr Tyldesley thought that the earthing pinused to draw any static electricity from thetank, supplied in response to Dr Gunn’srecommendation, was of doubtful effectiveness.There were no dry powder extinguishersprovided at the time of the visit, although it wasclaimed that these had been obtained.The clutter close to the tank was considerable.Various metal items and some rubbish wereimmediately adjacent to it. A steel dismountableroad container some four metres away from thetank contained large quantities of cardboard.Mr Tyldesley said that he recommendedthat the occupiers should get rid of this. Thisadded to the enclosed state of the tank, witha consequent reduction in ventilation. Theclutter was obstructing ventilation and it wasflammable. Combustible items situated close tothe tank could lead to an explosion.The tank was only 0.3m from the boundarywall at the adjoining factory roadway and only0.6m from the wall dividing the factory yardfrom the waste ground used as car parking. Ifgas were to leak or to be spilled near the tank,it would be difficult for the LPG to disperse.Mr Tyldesley’s conclusion was that there wasinsufficient space within the yard for a 2-tonnetank. It was not possible for it to comply withthe separation distances in Guidance NoteCS5 or its replacement booklet HS(G)34. If itwere to be located below ground, it would notcomply with the required separation distancesand would give rise to a different set ofregulations altogether.The only way to achieve a satisfactory installationwould be to reduce the total inventory and themaximum size of an individual tank. Mr Tyldesleynoted that if this option was unacceptable, theoccupier would still have the option of tryingto convert his LPG-fired equipment to burnnatural gas supplied elsewhere in the factory,or attempting to lease some of the waste landnearby for siting an LPG tank.In summary, Mr Tyldesley’s recommendationswere:Recommendation 1: the quantity of LPGshould be reduced to a maximum of750kgs.Recommendation 2: no individual tankshould have a capacity exceeding 250kgs. The benefit of having three 250 kgtanks, rather than a 2-tonne tank, was thatthere would be less gas to expand in theevent of a BLEVE.Recommendation 3: the separation wallto the west, between the yard and theopen land from the existing gateway to thecorner by the adjoining premises, should beremoved and replaced with a substantialwire mesh fence or metal paling type fenceat least 1.8 metres high. It transpired thatthis recommendation gave rise to securityconcerns.65

PART 6Recommendation 4: no tank should becloser than 2.5 metres from the new fenceor the factory building; that at least 1 metreshould be left between the tanks and notank should be closer than 0.3 metres fromthe wall separating the factory yard fromthe adjacent roadway.Recommendation 5: combustible materialsand vegetation were not to be allowed toaccumulate within 2.5 metres of any tankand the storage of equipment or materialswithin the yard, which would impedeventilation of the area around the tank,should not be permitted.Recommendation 6: a 19 mm hose reelcapable of delivering at least 30 litres aminute of water should be provided at theLPG installation. Alternatively, two 9 litrewater extinguishers could be provided.In either case, the equipment should beprotected from freezing in cold weather.Recommendation 7: two 9 kg dry powderextinguishers or equivalent were to beprovided at the installation.Recommendations 6 and 7 were simplestandard fire precautions that were normalfor an installation of that size. They were notrecommended in place of the drench system.Recommendation 8: during LPG deliveriesat least one factory employee shouldbe present who had been trained andhad received written instructions in theprocedures to be followed during filling, thehazards of LPG and the action to be takenin an emergency. The employee wouldhave a role in telephoning or raising thealarm if anything went wrong.Recommendation 9: if the tanks were tobe manifolded together for vapour off-take,a shut-off valve should be at the manifoldso that the supply to the building could beisolated by the closure of a single valveoutside working hours or when the burnerswere to be out of use for an extendedperiod. Mr Tyldesley was looking tominimise the risk of a leak into the buildingby turning the gas off every time thebuilding shut down and the oven was not inoperation. This was an unusual suggestion.Recommendation 10: a “T” joint in the LPGpipework in the basement of the buildingnoted to be sealed by a single valve wasrecommended to be sealed with a screwedplug or other appropriate fitting. MrTyldesley wished it to be properly sealedto avoid the risk that the valve might beopened accidentally.Recommendation 11: “Part of theunderground pipework carrying LPG vapourinto the building should be excavated. Thestate of the pipework and any corrosionprotective coating should be examined by acompetent person and any recommendationsmade as a result of this inspection should becarried out. A pressure test of the pipe workshould also be carried out.Recommendation 12 recommendedfinding out the nature of services under themanhole cover immediately outside thefactory yard gate. The manhole shouldbe protected with a cover sealed againstingress of liquid or the tanker should notstand over it during deliveries and shouldbe as far away from it as reasonablypracticable.”66

THE ICL REPORTMr Tyldesley went into the basement, havingasked where the pipe went from the tank. Hecould not recall, but believed that he could nottell what the pipe was made of and whetherit was corrosion-protected, and that he wouldhave asked ICL Tech about it but got no clearanswers. He remained concerned to find outthe condition of the underground pipeworkbetween the tank and the building andconcluded that that this could be ascertainedonly by excavating it.When questioned about LPG pipework passingthrough the basement, Mr Tyldesley said thatthis was poor practice and that it was one ofmany things that caused him concern at the site.The degree of risk in all instances depended onwhere the ventilation for such areas came from.Mr Tyldesley explained that a “competentperson” in the context of Recommendation 11could be someone with the relevant theoreticaland practical experience, including knowledgeof the current guidelines; for example the gassuppliers or someone recommended by them.He recommended a pressure test as it wasquick and easy and would indicate whether thepipework was leaking at that time, but it wouldnot determine the condition of the pipe, whetherit was protected or whether it was showingsigns of corrosion. Such a test would be carriedout at a higher than operating pressure so thatthere was some degree of reassurance that thepipe would not fail quickly after the test.Mr Tyldesley said that a pressure test was notan alternative to excavation. Excavation gavesome idea of the risks in future which pressuretesting might not identify.The summary of Mr Tyldesley’s inspection reportdated 22 August 1988 recorded that there was“a 2-tonne tank located in very crampedconditions close to the site boundary ina small factory yard and was the subjectof an earlier FCG report. Some earlierrecommendations had been implemented,but current conditions were now worse”and that“Support is given for an Improvement Noticerequiring LPG storage to be reduced to amaximum of 3 x 250 kgs, together withvarious associated improvements to ventilation,first aid, fire fighting and other matters.”Mr Tyldesley noted that co-operation from theoccupier without enforcement action seemedunlikely and that his recommendations wereintended to form the basis for an ImprovementNotice under the Health and Safety at WorkAct 1974. Mr Tyldesley explained that hiscomments on the unlikelihood of co-operationwould have been based on the lack of actionbetween 1982 and 1988.A further question mentioned was that that therewas a “matter of evident concern to generalfire precautions within the factory.” This questionrelated to the storage of a propane bottleon the stairs from the basement to the floorsabove the ground. This was a matter properlycontrolled under the Fire Precautions Act 1971.In Mr Tyldesley’s view, the proper course was toreport the matter to the Strathclyde Fire Brigadeas the responsible fire authority.Mr Ives was happy to accept Mr Tyldesley’srecommendations on the basis of Mr Tyldesley’s67

PART 6judgment. Mr Ives considered that therecommendations were based on Mr Tyldesley’sexpertise, were consistent with policies, andwere entirely reasonable.Mr Ives confirmed that he had been aware ofconcerns about underground pipelines and theneed for inspection, including pressure testing.In 34 years in the HSE he had attended anumber of training courses on LPG but couldnot recall there ever being any discussion ofthe issues involving LPG pipelines. In 1988 LPGwas not highlighted as an issue for HSE. Thefocus was on the tanks and not the pipework.Mr Ives decided to go back to the premisesto discuss Mr Tyldesley’s report with Mr Stott.Mr Ives went there with William Reilly, anotherinspector, on 1 September 1988. In Mr Ives’view it was difficult to resolve the problemsconcerning the tank. Given the history of theclutter around it, he thought that the best solutionmight be for it to be dispensed with. The entryin the Reports on Visits form recorded that:“Mr Stott opened the meeting byannouncing that he was transferringhis oven from LPG to mains gas whichwill reduce the need for the LPG store.It appears that a small tank will still beneeded for the central heating system. Letterand CV proposed to ensure that Mr Stottkeeps his word.”The entry “CV” is a reference to a “check visit”marked for November. Mr Ives explained thatin his view Mr Stott did not have a good trackrecord of delivering and it was necessary tokeep pressure on him although he did appear toaccept advice. Mr Ives had subsequently markedthe file to cancel the check visit as negotiationswere underway. He could not recall why, whenhe cancelled it, it was not marked up for a latervisit.Mr Ives went through the recommendations inMr Tyldesley’s report with Mr Stott during themeeting. In relation to the pipework, Mr Stott didnot think that excavating the pipe was a practicaloption as it would mean digging up the yard.Mr Ives did not discuss any alternatives with him.Mr Ives was clear that Mr Stott’s view on theproposed excavation had no effect on the HSE’srecommendation that part of the pipework shouldbe inspected through excavation. Neither did MrStott’s suggestion that he might dispense with theLPG installation altogether. Mr Ives’ recollectionwas that Mr Stott had indicated that he wasgoing to discuss the whole issue with Calor andwould approach them for a new proposal. MrIves thought that Calor had put the pipework inbut he could not recall why he thought this. Norepresentation to this effect had been made tohim by Mr Stott.Following this meeting the matter effectivelywent into abeyance pending Mr Stott’sdiscussing the position with Calor.On 8 September 1988 HSE wrote to ICL Techwith the recommendations that had been set outin Mr Tyldesley’s report.Mr Stott replied on 1 December 1988. Hesaid that ICL Tech had issued new instructionsto employees as to procedures to be followedwhen the LPG tank was being filled. Mr Stottalso wrote to Calor enclosing a copy of theprocedure that would be displayed on the ICLpremises as a sign. He asked Calor to instructtheir personnel accordingly. A copy of this letterwith its enclosure was sent to Mr Ives.68

THE ICL REPORTMr Ives said that, on receiving the letter fromMr Stott, he telephoned Mr Coville, whom heknew well. He and Mr Coville had had regularcontact where persons with LPG installationssought guidance and where they were trying toresolve difficulties regarding such installations.When incidents occurred they would worktogether to try to improve practices.On 6 December 1988, an internal CalorGas memo was sent from Mr R Love toMr Alexander Clezy attaching a copy ofMr Ives’ letter of 8 September 1988, setting outthe questions raised by that letter and attachinga plan of the LPG tank in relation to the yardand the factory. The memo was annotatedas being passed to Mr Coville to enable himto deal with the questions arising from it. MrCoville had no recollection of seeing it butassumed that he must have done so. Parts ofthe memo are illegible. It refers to there beingattached to it a copy of the letter from Mr Ivesof HSE to ICL Technical. It refers also to the2-tonne tank being only 7.3 metres from thebuilding and being too close to the radiationwall. It suggests the problems could be resolvedby replacing the 4,000 litre tank with a 2,000litre tank but that this would not appear tosatisfy Mr Ives.Mr Coville by reference to his log said that hehad been to the ICL premises on 19 Decemberand was aware then of the contents of Mr Ives’letter. His log reference indicates that he hadcarried out a Bulk Report, containing all theinformation relating to the tank, details of testingand other relevant information gleaned at thevisit to the premises. The reference for this reportwas BR05969. There is a reference to “the planto HSE for approval”.Mr Coville also visited the premises on 4January 1989 and wrote to Mr Ives on thesame day.The letter was in the following terms:”I refer to your letter to the subjectCompany, dated 8 September 1988,regarding our bulk LPG storage facilitylocated there.On behalf of ICL Technical Plastics Ltdand following my telephone call to you on23 December 1988, the attached sketchplan outlines suggested suitable remedialaction, to be taken by Calor Gas Limited,in order to meet the recommendationsmade at paragraphs 1, 2, 3 & 4, only ofyour above-referenced letter. With regard toparagraph 11 of your letter, the conditionof the attendant vapour-off take pipe wouldbe ascertained, during vessel exchange, byexamination of the “riser pipe” at the vessel,and by a pressure test on the pipeline.I trust you will consider the above measuresto form an acceptable compromise to yourrecommendations, and that they meet thespirit of the Guidance Note HS (G) 34 (thestorage of LPG at Fixed Installations) whilstmaintaining security of the installation, andthe premises it is to serve, in an area witha reputedly-high incidence of “unauthorisedentry” to property.It is understood the remainder of your letterwill, in due course, receive the addressee’sattention for reply but, meantime, yourearly return to this letter will be greatlyappreciated; prompt remedial action willthen follow”.69

PART 6Mr Coville explained that the purpose of thisletter and accompanying plan was to suggestpossible remedial action in respect of therecommendations made by Mr Ives in his letterof 8 September.Calor were unable to supply tanks as small as250 kgs. Mr Coville indicated that the installingof a 1-tonne tank to replace the 2-tonne tankat ICL would reduce the capacity held onsite. He understood that this would complywith the necessary regulations in the broadercircumstances. The plan indicated that theHS(G)34 recommendations as to separationdistances could be met with the exception of thenarrowest point of distance from the west wallwhere the wall ran past the tank at an angle.The gap at its narrowest was 0.5m to thecorner of the tank. If a radiation wall was solidand of a certain height then it could be that thetank could be closer than that recommended inthe table of separation distances in HS(G)34.Mr Coville also said that if ICL Technical Plasticshad owned the land outside the western sideof the wall and the gate, the requirementsof HS(G)34 would have been met. Hisrecollection was that ICL Technical Plastics wereintending to acquire that land and subsequentlydid so. I will return to this point.Mr Coville also proposed the installation of avehicular barrier, which he suggested mightbe of a steel “motorway” type, or strategicallyplaced concrete bollards. This would reducethe likelihood of any contact with the tank in theevent of a forklift or other vehicle being usedin the yard. It would act essentially as a crashbarrier. He marked on the plan the radiationwall suggesting that the existing height of thewall was to remain as it was, stepping upbetween 1.8 metres to 2.6 metres. He alsonoted that no building, combustible materials,non-flame proof electrics or car parking shouldbe within a line to be painted round the tank3 metres from it. His plan showed that that lineshould be “suitably extended to beyond theventilated gate-wall.” He highlighted that thisarea should be clearly defined, for example byfloor-painted lines. He also indicated that thegate wall should be vented at floor level by thestaggered removal of some bricks along thefull length of the wall. This would prevent therebeing a solid return on the radiation wall thatcould allow LPG to accumulate in that area ifthere should be a leak.Mr Coville knew that his proposals did notwholly meet the requirements of HS (G) 34, butthey were an attempt to reach a compromiseon vessel size. In his letter he was clear thatthe “suggested suitable remedial action, to betaken by Calor Gas Limited”, was “in order tomeet the recommendations made at paragraphs1, 2, 3, and 4 only of your above-referencedletter.”Mr Coville said that he would have consultedthe technical department in Calor in relationto paragraph 11 in accordance with Calor’spolicy and that he would not have madethe suggestion about recommendation 11“off his own bat.” He would have spoken tothe Regional Technical Manager, Mr Clezy,because the recommendation involvedpipework. Mr Coville explained that thevapour off-take pipe is the whole length ofthe pipework from the tank to the applianceor equipment using it. The riser pipe was thevisible part of the vapour off-take pipe fromthe tank to the ground level. The proposal forpressure testing the pipeline is said to haveaccorded with prescribed practice current at70

THE ICL REPORTthe time. Mr Coville had no recollection of thereasoning for this response nor could he recallany details of any discussions with the RegionalTechnical Manager.Mr Clezy died before the conclusion of thecriminal proceedings. After the disaster, hegave two statements to the authorities. Thesewere available to the Inquiry. Mr Clezy wasa member of the Institute of Gas Engineers.Mr Clezy is recorded as having recalled thatthe position of the tank posed problems onaccess to the tanks and in relation to separationdistances. He had recommended that a 2-tonnetank be replaced with a 1-tonne tank. Hewas not involved in any pipework from theregulator as Calor’s responsibilities ended atthe regulator. He said that he agreed with MrCoville’s letter of 4 January 1989. He said “Theword compromise means we are offering anequivalent alternative standard of safety.” MrClezy said that when he took over as technicalmanager in the mid 1970s he required that alljoints in underground LPG vapour pipeworkshould be wrapped with Denso tape. Hehad not heard of any explosion from anunderground vapour pipeline. He notedthat there was a different standard for liquidpipework.Mr Ives considered the letter and plan receivedfrom Calor and the remedial suggestions.Mr Ives said that whereas Mr Tyldesleyhad recommended a wire mesh fence, heunderstood from the Calor’s letter that ICLneeded walls to keep out vandals.The fact that the Calor letter of 4 January waswritten on behalf of ICL Technical PlasticsLimited was acceptable to Mr Ives becauseCalor owned the tank. If the installation wasnot to Calor’s standards, they could refuse tosupply the customer. Mr Ives took the viewthat ICL Plastics had authorised Mr Coville tomake these proposals. Mr Ives commentedthat they wrote most of the guidance andwere the major player in the industry. HSE’sown top LPG specialist had been recruitedby them to be their group safety manager tomanage their regional safety inspectors and tohelp to formulate Calor’s safety policy. HSE’srequirements had to be both practical androbust to avoid criticism if, for example, thematter proceeded to enforcement action. MrIves explained that the problem that he sawin this context lay with the counter proposalsfrom Calor and with Mr Tyldesley’s advice inrelation to the tank sizes. Calor could not supplya 250kgs tank, as HSE recommended. Therecommendation to excavate the undergroundpipework was not an issue in this context. MrIves considered HSE to have been on certainground in respect of that recommendation. TheCalor letter of 4 January appeared to form areasonable solution to a difficult problem froma siting point of view. A smaller tank was beingsuggested, there were proposals to improveventilation and they had tried to take action toavoid clutter. Mr Ives considered the proposal,though not perfect, was a major step forward.Mr Coville had suggested a test of theunderground pipework by inspection of the riserpipe at the vessel together with a pressure testwhen the tank was replaced, rather than byexcavation. Mr Ives did not feel competent todecide if that was a reasonable compromise.He passed the proposals to Mr Tyldesley for hiscomments. Mr Ives confirmed that he was awarethat pressure testing of a vapour off-take pipewould have revealed whether the pipework wasleaking at the time of the test, but not whether71

PART 6it was corroded. He could not recall at twentyyears distance whether he had been aware ofthe HSE circular FIC 286/43 Rev.Having seen Calor’s counter-proposal, MrTyldesley sent a memorandum to Mr Ives dated17 January 1989. At paragraph 3 he said:“If the occupier can somehow gain controlof extra land outside his existing premises,so that he has full control over all landwithin 3 metres of the proposed tank, thenthese proposals are acceptable. If thiscondition cannot be met, then I stand bymy earlier recommendation and wouldbe prepared to support enforcementaction in respect of them. In respect ofRecommendation 11 regarding examinationof the underground pipework from theinstallation, then the proposals by MrCoville are acceptable.”At paragraph 4 he said:“This is a particularly poor LPG installationwhich has been in existence for anexcessive time. I hope that appropriateenforcement action will now be taken toensure that the installation is improvedwithout delay”.Mr Tyldesley confirmed he was prepared tosupport enforcement action if the occupiershould fail to gain control of the extra landoutside the premises and thereby gain fullcontrol of all land within the 3 metre separationdistance. There was concern that since ICLTech did not control the land beyond the wall,it meant that activities could take place beyondthe wall which could create a risk to the tank.Mr Tyldesley did not explain in his memo whythe counter proposals to recommendation 11were acceptable. He said that he believed thathe would have taken Mr Coville’s proposal tomean that he was going to dig down a shortway to ascertain the condition of the pipeworkand would have taken the reference to the riserpipe to have been a reference to the verticalsection of the pipework, including that whichwas underground. This was because examiningthe pipework above ground would tell no oneanything that could not already be seen. Inhis memo to Mr Ives, Mr Tyldesley referred to“regarding examination of the undergroundpipework from the installation.” This indicatedthat he had not interpreted Calor’s proposalto relate solely to the visible pipework. Hespeculated, with hindsight, that he must havethought that there were four possibilities: thatMr Coville did not appreciate the risks andconsequences of an underground leakage,but had nevertheless given advice; that Calordid not wish to take responsibility for a pipethat they knew was not theirs; that they didunderstand the risks but thought it reasonable tolook at the above ground section; or that theydid intend to excavate the pipe, but that theinstruction was not carried out when the tankswere changed two years later. It would beconvenient to examine pipework when the gaswould be turned off as Mr Tyldesley consideredthat there would be a fair chance of putting aspade through a pipe if it was very corroded.Mr Tyldesley’s view was that Mr Coville,acting on Calor’s behalf, was taking on theresponsibility of a “competent person”. Hehad felt entitled to assume that Mr Coville andother technical employees of Calor would haverecognised the significance of the undergroundpipework and taken steps to follow his72

THE ICL REPORTrecommendations. He took for granted that MrCoville’s proposal would involve some form ofinvestigation below the surface of the groundsince without this it was impossible to determinethe composition and state of the pipe or whatcorrosion protection it had. Mr Tyldesley nowconsidered that the letter from Mr Covillewas ambiguous, but at the time he thoughtthat Calor were competent. He had assumedthat Calor would understand the problem, itspossible consequences, and how it could beresolved. He had not clarified the position. MrCoville has said that he was responding onbehalf of Calor in relation to the areas of theinstallation that were owned by Calor.Mr Tyldesley considered that a competent personwould advise a factory owner what needed tobe done in respect of the safety of the pipeline.Mr Tyldesley considered that the problem withMr Coville’s letter was that it made suggestionsas to what was to be done without making itclear who was to do it. He had not clarified theposition. He said that he had perhaps trustedthat Calor had understood the hazard and thatthey would do what was necessary to ensurethat ICL were given sound advice. Mr Tyldesleywas clear that his recommendations had been apackage and that it had not been a case wherethere could be picking and choosing.Mr Ives responded to Mr Tyldesley’s report by amemo dated 20 January 1989. He said:“I would remind you that enforcementpolicy in this matter rests with myself and Iwill take appropriate action as I see fit todeal with this matter.The problem that has arisen is that CalorGas are telling the occupier and myselfthat they do not produce tanks for bulkLPG which meet the standards of youroriginal report. In other words if I were toenforce the letter of your report then this sitewould have to cease using LPG. In thosecircumstances I deem it better that we tryand reach a reasonable compromise andsolution than rush into enforcement actionwhich will backfire. In view of Calor’sclaims perhaps you could confirm that it ispossible for them to supply tanks of volumeno greater than 250 kgs”.In terms of HSE protocol, it was Mr Tyldesley’sresponsibility to report to Mr Ives and make anyrecommendations. While Mr Tyldesley held awarrant that enabled him to take formal actionby issuing an Improvement Notice or instigatinga prosecution, it was not his responsibility to doso. That responsibility lay with Mr Ives. It wasfor Mr Ives to take such action as he thoughtnecessary. It was open to Mr Ives to disagreewith an FCG inspector. On rare occasions hehad done so. If it was a technical matter, MrIves would accept a specialist inspector’s advicesince a specialist inspector was an expert onprocess safety. He had done so in this case. MrIves did not give any further consideration to theproposal in respect of recommendation 11, norMr Tyldesley’s acceptance of it. HSE protocolmeant that all actions and correspondence weredirected through a general inspector. It wastherefore commonplace that specialist inspectorsdid not know whether their recommendationshad been applied or not. In Mr Tyldesley’s viewit would not have been practicable for him tohave chased up every specialist recommendationthat he issued.Mr Ives confirmed he was aware of the LPGITA code of practice, but had not consulted it73

PART 6in relation to the ICL premises. Where matterswent beyond basic issues of siting and storagehe brought in a specialist. Mr Ives did not recallFIC 286/43 and FIC 286/43 Revised.Mr Ives was shown by the Procurator Fiscala report dated 13 January 1988 on an LPGexplosion in an underground firing range inDaventry in December 1987. Mr Ives had hadno prior knowledge of this incident. He thoughtthat there had been a system of circulatinginformation of this nature among specialistinspectors, but not among general inspectors.If he had been aware of such a seriousincident occurring as a result of unsatisfactoryor corroded pipework he might have lookedat things differently at Grovepark Mills. Suchreports should have been circulated as a highpriority to make people aware of the hazardsattaching to LPG pipework.Mr Tyldesley explained that the report onDaventry would have been entered in acomputer database called “marcode” but hewas unable to give further information about thesystem as that database was not used by thespecialists. Mr Tyldesley was sure that he hadnot been aware of this report at the time of hisvisit to ICL premises. From the circulation detailson the report, it seemed that it had not beensent to the Fire and Explosion Specialist Groupin the Bootle headquarters. In consequencethere was no obvious route by which it couldhave reached the fire and explosion specialistsin HSE. Where headquarters staff at Bootlereceived reports they would raise commonpatterns but they generally circulated only newand interesting reports. Mr Tyldesley confirmedthat he was aware, without having knowledgeof this particular incident, that an escape of LPGinto a basement could cause an explosion. Henoted that the report appeared to have beensent to the Public Utilities Group, which was agroup of factory inspectors who would liaiseand co-ordinate HSE’s response for the majorpublic utilities.After the exchange with Mr Tyldesley, Mr Iveswrote to Mr Coville on 23 January 1989. Thisletter noted that the plan showed that one endof the replacement tank would be only 0.5metres from an existing brick wall and that thiswall was to be ventilated; that the other sideof the wall consisted of open ground not underthe control of the factory occupier; that it wasused for car parking and other purposes andthat while the appropriate 3-metres separationdistance for the size of tank was marked withinthe yard it was somehow suggested that thisshould be extended beyond the ventilated wall.Mr Ives said that the proposal in respect of thetank “is only acceptable provided the occupiercan somehow gain control of extra land outsidehis existing premises so that he has full controlof all land within 3m of the proposed tank. Ifthis can not be achieved then I regret that theseproposals are not acceptable and we return tothe requirements of my letter of 8 September”.Frank Stott responded directly to Mr Ives byletter dated 25 January 1989. He said:“I can now confirm that we are in fact incontrol of the land outwith our main factorygate and that we have already movedthe car parking facility to the far side ofthe gate, which would be in excess of 20metres from the proposed site of the tank.There is no reason why we should notremove bricks from the wall and we will infact put up a “No Parking “ sign to prevent74

THE ICL REPORTother people form using this area as aparking spot If this proves ineffective we willfind some other form of preventative in thismatter.I trust that the above information will allowyou to accept the Calor proposals, whichwe will implement with Calor as soon aspossible.”Mr Tyldesley sent a memorandum to MrIves on 2 February 1989 which referred toMr Ives’ note of 20 January. Mr Tyldesleyrecorded that he understood Mr Ives to havesubsequently heard that ICL Technical PlasticsLimited now proposed to purchase or obtaincontrol of a small area of land close to theLPG tank and that this should allow a greatlyimproved arrangement around the tank. MrTyldesley repeated his recommendation 6.3 ofAugust 1988 that the tall brick wall adjacentto the gates giving access to the factoryyard should be removed and that a robustnon-combustible open mesh fence or similarsecurity arrangement should be installed at theappropriate separation distance for whateversize of tank was required. He noted withsurprise that Calor were unable to supply a tankof capacity of less than one tonne. Telephoneenquiries to other gas suppliers indicated thattanks of capacity of 200 kg or 600 kg wereavailable elsewhere.Mr Stott’s letter of 25 January 1989 was plainlyuntruthful and designed to mislead. Mr Downieconfirmed that neither ICL Tech, nor any of theother ICL companies were, either at the dateof Frank Stott’s letter or at any time before orsince then, the heritable proprietor of the areaof land immediately outwith the boundary wallto the west of the yard, which was owned bythe predecessors of Glasgow City Council. Atabout that time the land was used for parkingby ICL. Mr Stott must have been well awarethat no ICL company had any legal control overit.Mr Coville visited the premises again on 7December 1989 and drew up a further plandated 19 December 1989.This was a revised version of the earlier plandated 28 December 1988. Mr Coville thoughtthat this must have been in consequence of hisbeing told that ICL Plastics had gained controlof the land outwith the gate. The plan showedtwo 2,000 litre tanks. Mr Coville proposed thefollowing:• The wall on the west side to be ventilated atfloor level• The property boundary (radiation) wallwhich appears to have existed at a heightbetween 1.8 metres and 2.6 metres toremain in place• Vehicular impact protective barriers of metalmotorway type or strategically placedconcrete bollards to be put in place• A separation distance line to be clearlydefined by, for example, painted lines on thefloor (ground) a distance of 3 metres from thevessels, coming out from the south wall thenheading west along towards the boundarywall where the sliding gate is and continuingbeyond the sliding gate into the area overwhich the company had gained control. Thedistance between the radiation wall and thevessels to be 1.5 metres• The separation distance between the twoproposed tanks to be 1 metre.From HSE records, it appears that on 17January 1990, Mr Coville either visited Mr Ives,75

PART 6or visited the premises and then spoke to MrIves. On the relevant Reports on Visits form, MrIves recorded in his own handwriting, which isnot entirely clear:“Visit by M Coville, Calor Gas SafetyAdviser to say work not yet [correct reqs]but provided new drawing of a proposal –seems satisfactory.”Later eventsOn 17 June 1991 Calor replaced the 2-tonne(4,000 litre) tank with two 1-tonne tanks. Theinstallation of the two tanks was consistent withthe final drawing prepared by Mr Coville andapproved by Mr Ives. There is no evidence asto whether Calor ever inspected the riser pipe.Mr Ives marked the file for a check visit in“3/90”. Mr Ives said that this should havebeen entered into the computer system knownas SHIELD which HSE used at the time. Thisshould have resulted in the file being passedby administrative staff to the Inspector whohad marked it for a check visit; that is to say,Mr Ives. The check visit was not carried outin March 1990. Mr Ives suggested it waspossible that the follow-up visit was not enteredinto the SHIELD system and with the pressureof other things it may have been forgotten inconsequence of administrative error.By the time of the explosion the proposal toremove bricks from the lower part of the wall tothe west of the tank so as to provide ventilationhad not been carried out.The next visit is noted in the Report on VisitForm as being on 9 January 1992. Mr AlistairMcNab, an HSE Inspector, visited GroveparkMills on 9 January 1992 and met Mr Stott. MrMcNab carried out a diagnostic inspection.He described this as sampling activities witha view to diagnosing any problems with themanagement of health and safety. The purposewas not to check every single hazard or riskor activity in the factory, for it was impracticalfor him to do so and that was in any event theresponsibility of the duty holder. He assessedthe LPG installation in line with the HSE’spriorities at that time. He concentrated on theseparation of tanks and buildings, ignitionsources, tanker filling, fire precautions, watersupply and staff training and awareness inthe risks and precautions affecting LPG. Heconcentrated on the management and thedirector roles. He noted that Mr Stott hadadmitted that health and safety was nota regular feature on the agenda and hadpromised to rectify this. He also noted thatMr Stott was a managing director “who does‘inspect’ the factory. I feel that [improvementnotices] are unnecessary on COSHH andNAW as the company is nearly there and aletter should suffice.”Mr McNab was concerned that the companyshould be ready to audit itself for risk. His visitwas in part to prepare ICL for its obligationsto appoint one or more ‘competent persons’ toassist in identifying risks within the workplaceand to develop measures to minimise these.These obligations became mandatory foremployers on 1 January 1993 under theManagement of Health and Safety at WorkRegulations (MHSR) 1992, later modified by the1999 Regulations.Mr McNab considered that there was a rangeof hazards wider than was normal for a siteof ICL’s size. He concentrated on pushing thedirector to manage health and safety betterrather than to rely on the annual inspections,76

THE ICL REPORTas ICL appeared to be doing. He consideredthat this reliance was not unusual and that selfregulation was rarely encountered.This visit was the overdue check visit followingMr Tyldesley’s recommendations and theacceptance by HSE of Mr Coville’s responseto them. There is no record of a follow up byMr McNab on the examination of the riserproposed by Mr Coville and the undergroundpipework does not appear to have receivedany attention. Mr McNab’s record of visitcontains a handwritten addition “LPG seemsto meet 1990 agreement”. He confirmed thatthe manuscript addition was in his handwritingand that it would have been done at the timeto avoid his having to put the whole file backto the typing pool for a minor amendment. MrMcNab could not recall why he had usedthis phrase as shorthand on the file. In fact,the agreement with Calor had not been fullyimplemented.Mr McNab believes that he made thehandwritten entry between the visit on 9January 1992 and his follow up letter to ICLTech dated 23 January 1992.On 23 January 1992, Mr McNab wroteto Frank Stott on the matters covered duringhis visit and enclosed an appendix listingthe legislation and guidance likely to applyto the business. He made it clear that hisinspection was not intended to cover everyhealth and safety issue in the factory. Theguidance included procedural and otherrecommendations, including a recommendationto consider and discuss hazards and risksin the business and to develop safeguardsand procedures to eliminate or minimise theidentified risks. In respect of COSHH, MrMcNab advised that consideration be givento the issues of adequate assessment of therisks from hazardous substances and theprotection required for employees. Data sheetswith analyses of tasks were identified by MrMcNab as the starting point of an adequateassessment. He also suggested that they mightwish to engage an occupational hygieneconsultant to assist them. He thought that it wasalso necessary to provide sufficient informationand training for employees about risks andprecautions.Mr Stott replied on 24 February 1992. He saidthat they had obtained the publication SuccessfulHealth & Safety Management which was beingpassed to all managers and foremen to read.They were to sign to indicate that they had doneso. Various actions had been taken in respect ofCOSHH and the Noise at Work Regulations.Since Mr McNab’s visit they had becomeaware of their precise obligations regardingthe reporting of incidents. This was now beingcomplied with and was public knowledge withinthe company. A copy of the HSE letter and itsappendix had been placed on a notice boardby the time clock and they were attempting tocreate an “awareness” among employees. Hesaid that health and safety was now on theagenda of their monthly management meetingsand certain specific points in the letter of 23January were being considered.Mr McNab thought that this was a positiveresponse and that a check visit was notrequired.On 18 February 1993, Inspector BrianCousland attended at the factory. He had ameeting with Mr Stott, Mr Brown, Mr Mastertonand Mr Ferguson. After his visit he noted:77

PART 6“Progress appeared to have been madeon COSHH and noise assessments.Monitoring of exposure to substances iscarried out routinely and noise enclosureshave been constructed for certainoperations. The management appeared tobe unclear on what action had been takenwith regard to the LPG tanks. A numberof other matters were noted includingguarding of circular saws (see letter fordetails). I propose a return visit to check onguarding of circular saws and to clarify thesituation regarding LPG.”Mr Cousland returned to Grovepark Mills on5 March 1993 and carried out an inspection.He rated the risk, on a worst case scenario, tobe small in relation to employees and nonexistentin relation to the public. Mr Couslandfollowed up his visit with a letter to Mr Stottdated 10 March 1993. He referred to the needto comply with COSHH regulations but madeno mention of the LPG installation. Mr Couslandwould not have picked up the problems withthe pipework even if he had gone back to thefactory as it was the siting of the tanks that wasthe HSE’s main focus of concern.After 1993, there was no further mention of theLPG installation at the site in the HSE files.78

THE ICL REPORTChapter 13 – ICL and risk assessmentsRisk assessmentsFormal risk assessment in the workplacebecame mandatory for employers on 1 January1993. This was imposed by the Managementof Health and Safety at Work Regulations(MHSWR) 1992, as modified by the 1999Regulations. Those regulations provided thatevery employer was under an obligation toappoint one or more ‘competent persons’ toassist in identifying risks within the workplaceand to develop measures to minimise these. A‘competent person’ is described as someonewho has ‘sufficient training, experience orknowledge or other qualities to enable him toproperly assist’ in undertaking risk assessmentand risk elimination duties.When these requirements came into force, theICL Plastics personnel department prepared arisk assessment on the models available fromHSE and related it specifically to the processesin which the ICL group was involved. It alsoadopted HSE’s best practice for health andsafety policy in drafting policies that werepassed to subsidiary directors and managers.The personnel department’s role did notcover the management or approval of riskassessments specific to individual subsidiaries.ICL Plastics’ own staff shared the second floorwith Stockline and ICL Tech. It appears thatICL Plastics’ and ICL Tech’s employees werecovered under the risk assessment carried outfor the entire floor by Stockline.ICL Tech and Risk AssessmentsOn 17 October 1996, a health and safetymeeting was held in ICL Tech at which FrankStott, William Masterton (a manager), andAndrew Stott, son of Frank Stott, were present.The purpose of the meeting was to establishthe terms of reference for a risk assessmentprogramme. The minutes record inter alia:“Secondly, it was concluded that our firstpriority must be to develop an exhaustivelist of any hazards that exist at ICL Tech.This it is hoped, shall be complied [sic] bythe 31 October 1996Finally, it was proposed that thedevelopment of plant maintenance hazardbooklets should be continued. Thesebooklets are to come under the headingof Fire, Machinery, Compressed Air,Electricity/Gas and Buildings.”Andrew Stott was asked to carry out the riskassessment by his father or William Masterton.He thought that it was being carried out as goodpractice and that it represented a genuine desireto address problems identified and to demonstratea concern for workers’ welfare. He startedwith a risk assessment specific to the premises,together with an existing list of potential hazards,as a starting point for building a comprehensivematrix for a risk assessment of all of ICL Tech’sactivities. Frank Stott, together with Mr Masterton,supervised Andrew Stott’s work. Andrew Stott wasa student at Strathclyde University nearing the endof a four year BA course in industrial relations atthe time; but he was working on two morningseach week at ICL Tech. He had recently carriedout a training needs assessment, something whichhad been part of his degree. This had involveda systematic review of every process withinthe fabrication plant and the coating shop. Helisted every process taking place, drew up a listof employees, put ticks against their skills in thecategories of activities and then compiled a gridto assess how developed they were.79

PART 6He had never carried out a risk assessmentbefore; but the approach that he adoptedappears to have been both systematic andthorough. He read materials on risk assessment,used the HSE hotline and discussed the taskwith Peter Ferguson, who had carried outa similar exercise. Moreover, he had hadexperience of working in all the departmentssince he was in his teens. He surveyed theentire premises. He noted everything thatseemed to him to be a potential hazard. Heconsidered the machinery, storage, trip hazards,lighting, fire hazards and chemical hazards. Hediscussed his work with all of the experiencedmanagers and employees.It is clear he was familiar with and understoodthe environment in which he carried it out.His work was subject to analysis, discussionand progress reviews at meetings with Mr FrankStott and Mr Masterton. The matrix preparedscored the risks in terms of low, medium or highand then in terms of severity and likelihoodof outcome, being given one of 3 prioritycategories - ‘low priority risk-insignificant’;‘medium priority risk-important action within days’,or ‘high priority-action immediately’. This was therating system recommended by the Royal Societyfor the Prevention of Accidents. A course of riskreduction was agreed. Meetings were to beheld within the factory. Thereafter implementationof the agreed recommendations was to begin.The papers relating to this that were recoveredafter the explosion were confused andincomplete. Some dated from 2001. Somewere not prepared by Andrew Stott. The onlyentry relating to gas pipework was under ahazard grouping headed “ICL Technical PlasticsLimited Health & Safety, electricity, gas”. Thefirst item was ‘Gas pipes in coating shop areold’. This was the only LPG pipework referred toin any of the risk assessments recovered.Andrew Stott said that on a matrix he wouldhave shown this risk as catastrophic, butimprobable.In the result, the buried LPG pipework and thesection passing through the basement were notincluded in any of the risk assessments. AndrewStott had not thought about it; nor had Mr FrankStott or Mr Masterton. Mr Frank Stott shouldhave thought about it since he knew that theburied pipework had been an issue with HSEin 1988. Mr Masterton, who was concerned inthis and later risk assessments, said:“The pipework in the basement was notchecked. I think the underground pipeworkwas overlooked on the risk assessments.On reflection perhaps this should havebeen checked because it was potentiallyhazardous”.No one on the premises appears to havethought of this. The whole question wassimply overlooked then and in the later riskassessments.The existence of the tank should have promptedanyone preparing a risk assessment toconsider the pipework conveying the LPG tothe appliance; but no one thought of that. Foreveryone involved, hazards that were out ofsight were out of mind.Andrew Stott’s involvement in preparing thedraft risk assessment ended in late January1997. The final form of this assessment wasdated 16 July 1997.80

THE ICL REPORTIt was entitled “ICL Technical Plastics Limited,Health and Safety Programme, Risk AssessmentExercise AS/TM/16/7/97.” The papersrecovered were incomplete for 1997.Andrew Stott was an impressive and entirelycandid witness. I am satisfied that heapproached his risk assessment responsibly andconscientiously. It is unfortunate that he missedthe underground pipe; but that should havebeen picked up by the senior management whosupervised his work. His father, for example,had every reason to think about that particularhazard. If it was not picked up when AndrewStott prepared his draft, it should have beenpicked up by those who prepared the finalisedassessment in 1997 and the assessmentsthereafter.Stewart McColl, Peter Ferguson, Ian Mavers,and William Masterton carried out the laterrisk assessments. The defects in the initial riskassessment exercise were perpetuated by themwhen they used it for later assessments. All ofthe risk assessments gave an opportunity forthe underground pipework to be identifiedas a risk. No one, with the exception of MrTyldesley, thought about the undergroundpipework, let alone assessed whether itpresented a risk.The risk assessment carried out in2001A risk assessment was completed in October2001 by William Masterton, Stewart McColl,Ian Mavers and Peter Ferguson. An assessmentrelating to the building itself was carried outby William Masterton. It included the hazardssubject to COSHH. William Masterton hadneither received nor requested training onrisk assessments. He considered himself tobe adequately skilled in conducting a riskassessment from his experience as a qualifiedengineer, his knowledge of risk assessments inother companies, his general abilities and hiscommon sense. He also recalled HSE visitingand looking at the risk assessments. They didnot question them. He took it that they wereacceptable.William Masterton also carried out the riskassessment for the coating shop for the 2001report. He identified potential risks in terms ofseverity and frequency. He estimated the risksfrom looking at the hazard and its past historyrather than from guidance. He would also havereviewed the planned maintenance folders. Aspart of the risk assessment relating to electricityand gas, Mr Masterton noted “Propane GasPipes” as a potential risk. He recorded the“potential harm” resulting from the risk asbeing “leakage and explosion,” the “existingmeasures” to deal with it as being “regularinspection,” and the “new actions” to dealwith it as being “good practice and review.”The frequency potential was marked as 2 outof a possible 6, indicating it as a “possible”occurrence, whilst the severity potential wasmarked as 6 out of a possible 6, indicating thatthe result could be “death (several)”.The propane gas pipes referred to in this riskassessment were the pipes in the immediateareas surrounding the LPG oven, which couldbe affected by a naked flame. Mr Mastertontested these pipes by using washing up liquidand water and spraying it on the joints to seeif there was a leak. Mr Masterton carried outthese tests a few times before the tragedy. Thetests were carried out on all the pipe work inthe vicinity of the oven.81

PART 6The risk assessment carried out in2002On 18 February 2002, Stewart McColl sent amemo to a number of ICL employees, includingWilliam Masterton, indicating that ICL Tech’sinsurers required a risk assessment to be carriedout and requesting that this be carried outby the end of February 2002. In response,Mr Masterton prepared a handwritten riskassessment. He noted that “gas appliances andpipework” gave rise to a risk of “gas leaks.”He proposed regular checks and servicing ofequipment on a regular basis. This assessmentdid not include any reference to frequency orseverity potential. Again the pipework assesseddid not include the buried pipework betweenthe tank and the building. Mr Masterton saidthat this was because the “underground pipeswere never in the equation.” The scoring in therisk assessments would have been discussed bythe risk management team.During the course of the criminal proceedingsagainst ICL, the solicitors acting for thedefence took a witness statement from MrMasterton. He was shown a letter from MrIves of HSE dated 8 September 1988. This,I think, was the letter making a number ofrecommendations concerning the siting ofthe tank and recommending that part of theunderground pipework should be excavatedand examined. Mr Masterton had never seenthis before. He expressed anger on seeing it, ashe knew nothing about its contents in relation tothe underground pipes. He was dismayed thatthe ICL management had failed to inform himabout it. However, he could not say whether,if he had had this information, he would haveincluded it in any of the risk assessments that hehad carried out.As a result of an HSE visit on 11 August 2003,Stewart McColl wrote to Annette Leppla, anHSE inspector, on 15 August 2003, enclosingvarious documents, including a copy of the2001 risk assessments in respect of ICL Tech.It included the risk relating to propane gaspipes and noted the frequency potential as a“possible” occurrence and the severity potentialas indicating that several deaths could result if itdid occur. The assessment did not include anyreference to the hazards of the buried LPG gaspipes. In Mr Masterton’s opinion this was themost accurate risk assessment and to the best ofhis knowledge was the last risk assessment done.The effect of the risk assessmentscarried out by ICLThe assessments carried out on behalf of ICLTech related primarily to known occupationalrisks. The gas inside the factory was identifiedas a hazard but the possibility of a leak of gasfrom the exterior underground pipes was notconsidered.There is no record of anyone on behalf of anycompany within the ICL group carrying out anyrisk assessment in relation to the buried LPG pipe.It is plain that the fact that the existence of theunderground pipe was overlooked by all ofthose who were involved in the risk assessmentexercise produced a major failure in safetypractice. I find it difficult to understand why thathappened. The underlying lesson is, I think,that the senior management at GroveparkMills relied on their suppliers and, to a lesserextent, HSE for advice on LPG safety and inconsequence had only the most diminishedawareness and understanding of the risks thatattended their installation and of the extent oftheir own responsibilities.82

THE ICL REPORTProfessional risk assessmentFollowing a visit from HSE on 2 February andreceipt of a letter dated 7 February 2000which enclosed an Improvement Noticerequiring a COSHH assessment to be carriedout by 30 April to assess the risks to employeesfrom hazardous substances used in relationto coating processes,ICL Tech approacheda safety consultant, Alistair McCourt, forassistance.Mr McCourt attended at Grovepark Mills on16 or 17 February 2000. After his visit, heinformed Mr Marshall that he was going tobring in a firm of occupational hygienists whospecialised in COSHH, dust in the atmosphereand noise. Mr McCourt returned with Mr GerryMooney from Associated Health Services andagreed to provide ICL Tech with a quotation forservices relating to health and safety with MrMooney providing a quotation for occupationalhealth services.The quotation provided by Mr McCourt on 25February 2000 was for a consultancy packageproviding a tailor-made Safety ManagementSystem, health and safety advice, identificationof the name of the consultants to be engaged,scheduled visits every six months, updating ofthe firm’s system, and a reduced day rate foradditional work. The quotation was based ona three year consultancy contract at a fixedprice of £2,200 plus VAT per annum. Otherservices would be charged at the day rateof £275 plus VAT plus expenses includingrisk assessments, site inspections, accidentinvestigations, and auditing. LPG was identifiedin the context of compressed gases in respectof the use of cylinders for the fork lift trucks andthe heating on the manufacturing floor. Thebulk tank was not identified. ICL Tech’s thenmanaging director, Peter Marshall decided thatMr McCourt’s quotation did not represent valuefor money since Mr McCourt was tendering forservices that were already in place and werenot in issue with HSE.Mr McCourt said that if he had been instructedto carry out a risk assessment encompassingthe LPG installation at that time, he wouldhave thought that the supplier of the bulk tankwould have been responsible for it and thatthere would have been a written scheme ofexamination which would have included thepipework. He would not have included theunderground pipework in any risk assessment.InsurersIt appears that in the years 1994-2004,excluding motor insurance claims, there werefive minor claims for employer’s liability. TheInsurers noted that the group had a lowaccident rate.On 6 July 1993, ICL Plastics’ then insurers,London & Edinburgh Insurance, sent inspectorsto examine the site at Grovepark Mills. TheICL representatives consulted were MargaretBrownlie, described as accounts and officemanager, and William Masterton.As a result of the visit, a report entitled LossControl Engineer’s report, was prepared andsent to Margaret Brownlie by J M Britton, SeniorLoss Control Engineer. The focus of the reportwas the activities of ICL Tech. No mention wasmade of the underground pipework. The reportreferred to the relevant legislation making itapparent that the Management of Health andSafety at Work Regulations 1992 applied tothe company. Comment was also made onthe outside storage areas containing propane83

PART 6cylinders and static propane (LPG) tanks. Aguide to written schemes of examination basedon the Pressure Systems and Transportable GasContainers Regulations 1989 was appendedto the report. A covering letter dated 23 July1993 was sent by John A Johnson, GroupLoss Control Manager, along with the reportto Margaret Brownlie stating that if she shouldrequire any additional information, she shouldcontact the authors of the report. It appears thatshe did not take this offer any further.On 28 June 2002, Margaret Brownliewrote on behalf of ICL Plastics to Marsh Ltd,ICL’s insurance brokers, and enclosed riskassessments for ICL companies including ICLTech. None of the risks identified related to theburied pipework. The assessment identified therisk relating to gas leaks as being a possibleoccurrence but it differed from the assessmentcarried out in October 2001 in that it identifiedthe severity potential for gas leaks as being only2 out of 6, that is to say a potential for minorinjuries only. This change in the risk assessmentremains unexplained.84

THE ICL REPORTChapter 14 – The approach to LPGsafety at Grovepark MillsThe part played by the companiesICL Plastics had limited involvement in healthand safety in relation to the operationalmanagement of the individual companies.Subsidiaries had responsibility for their ownworkforce and health and safety policy. TheICL Plastics’ personnel department kept itselfinformed of changes in employment legislationand disseminated that information through to thesubsidiary companies. It also ensured that newemployees of the subsidiaries were aware oftheir own health and safety obligations undertheir employment contracts.The subsidiaries referred health and safetymatters to the holding company only if therewas a major policy question, or if some majorexpenditure was proposed.Colin Foard was responsible for Stockline’shealth and safety. Margaret Brownlie wasresponsible for health and safety at ICL Plastics’offices.The responsible officer for health and safety atICL Tech was its managing director. Frank Stottheld that responsibility until his resignation in1998. Thereafter responsibility lay with PeterMarshall until 2000 and then with StewartMcColl.There was a health and safety managementteam consisting of Stewart McColl, PeterFerguson, Ian Mavers, Nicholas Downie andBill Masterton. The company had in place aHealth and Safety Policy Statement.Within ICL Tech individual departments hadresponsibility to develop and enforce practicesthat were consistent with ICL Tech’s overallhealth and safety regime. Individuals withineach department were responsible for ensuringthat staff adhered to health and safety rules andprocedures.When COSHH regulations came in, COSHHregisters were introduced and maintained. Datasheets were available for workers to reviewindicating the nature of the product in use andthe recommended precautions.The part played by employees anddirectorsCampbell DownieIn his evidence to the Inquiry, Mr Downie saidthat after the executive directors were appointedto the subsidiary companies, his role was onlyto provide financial and strategic guidance tothe group. He became semi-retired in the mid1980s and was a non-executive director andchairman at the date of the explosion.Whatever Campbell Downie’s formal positionmay have been, I think it unlikely that in practicehis role was as hands-off as he implied. Thefinancial management of the companieswas tightly monitored. The directors of thevarious ICL companies regularly consultedMr Downie in relation to any decisions thatwere financially significant. While Mr Downiedid not regard himself as having the ultimatecontrol and responsibility for the operatingdecisions for ICL Plastics, ICL Tech or any ofthe other subsidiaries, his control over financialmatters was such that he exerted considerableinfluence, directly or indirectly, and whetherconsciously or not, over those decisions.In the period 1982 to 1988, internal exchangesof memos between Campbell Downie and MrStott regarding HSE concerns about the LPG85

PART 6installation indicate how closely Campbell Downiewas involved in day to day management at thattime. There was even one memo in which MrDownie’s approval was sought for the installationof a row of pegs in a cloakroom.In the period 1982 to 1998, Mr Stott asmanaging Director of ICL Tech was responsiblefor health and safety in the factory. Heeffectively continued with this responsibility untilMr McColl took over in 2000. It is apparentfrom the evidence that he pursued a policy ofnon-co-operation with HSE on safety questionsaffecting the tank installation. At times heactively misled the inspectorate and respondeddisingenuously to HSE’s concerns about the bulktank. Mr Frank Stott died before the explosion.In February 1982 HSE submittedrecommendations for improvements to the bulktank storage site. These included the installationof a drench system. Frank Stott telephoned HSEafter their visit on 3 December 1982 and saidthat all of the recommendations, except for thedrench system, had been complied with. Hesaid that the drench system had been deliveredand was to be installed during the Christmasshutdown period. On 20 December 1982 hewrote confirming this. That representation cannothave been true. It was an attempt to play fortime. HSE then recorded on 29 December1982 that no further action was required. Inthe event the drench system was not installed,because the water tank required to service itwas thought to be too heavy for the roof of thebuilding. No other water supply was available.In November 1985, safety questions about thetank arose again. On 18 December 1985, HSEwrote to Mr Stott requesting ICL Plastics to let HSEknow whether all the requirements of February1982 had been met and to set out the actionproposed to be taken. A check visit was to bemade in May 1986. On 13 January 1986, MrStott, as managing director of ICL Tech, but notICL Plastics, to whom HSE had addressed theirletter, replied to HSE. He reported that they wouldagain clear the area but that they had not founda practical solution for spraying the tank. HSErecorded on the file that Mr Stott had writtenindicating that the items brought to his attentionhad received or were receiving attention.The question of a drench system arose againin April 1988. Following a discussion betweenthem, Mr Downie sent a memo to Mr Stottrecording that”a bund wall around the tank (with railings)was part of an early recommendation insiting the tank, but later Inspectors hadreversed that decision and the railings wereremoved. An inspector had suggestedremoval of the bund wall, but this hadnever been implemented … It now appearsthe H & S E wish to reconstruct the bundwall and it is suggested a drench system isinstalled. Originally the drench system wasnot a requirement of the Inspectorate for atank of our capacity. I resist the notion thata water drench system should be installed,indeed we have no adequate water supplyat that end of the building and the cost ofany effective system would be enormous.If you cannot agree such problems withthe Inspectorate before we dig up and resurfacethe yard gate area we will end updoing the yard job twice.I trust the matter can be resolved toeverybody’s satisfaction.”86

THE ICL REPORTMr Stott responded on 14 April 1988. He said that“They only want to repair the existing bund”and “we must try to talk them out of thedrench but this will be difficult this timearound.”By then more than two years had passed sinceMr Stott had written to HSE to inform themthat they had not found a practical solution forspraying the tank.On 18 August 1988, Frank Stott sent a furthermemo to Campbell Downie telling him of theHSE visit by Mr Ives and Mr Tyldesley, the detailsof the visit are recorded in the chapter dealingwith HSE’s involvement at Grovepark Mills. Hepointed out that the 2-tonne tank was again thefocus of attention. He said that the inspectorshad seemed highly displeased that ICL Tech hadnot complied with the request for a water drenchsystem to be installed. Mr Stott said inter alia:“I suspect we have reached the end of theroad in side stepping their requests (since1982) and I have taken the precaution ofseeking information on the cost of the twoalternatives which we may be faced with 1)The changeover of the batch oven to towngas 2) the cost of burying the appropriatesized propane tank somewhere within ourboundaries…”This memo reflects Mr Stott’s temporising andobstructive attitude towards HSE, howeverjustified ICL Tech may have been in resisting theneed for a drench system for the tank.Mr Downie replied on 23 August. He did notremonstrate with Mr Stott for his attitude towardsHSE. He said:“Thanks for your memorandum of 18August, I note you have taken theappropriate steps.I am not unduly concerned with the FactoryInspectors displeasure and believe wehave complied with historic requirements,generally adopted by other users whodo not seem to suffer our local officials’concern.In the event we must take action and Iwould appreciate first having a commentfrom Calor, as the proposed expenditurein relocating a tank below ground levelmight require us to consider other options ordiscontinue the use of propane.”Mr Ives and Mr Tyldesley thought that DrGunn’s recommendation for a fixed waterdrench system for a tank of that size wasunusual. Mr Tyldesley doubted whether a casecould have been made for it. So Mr Downiewas probably right to question the need for it.Nevertheless, Mr Downie’s memorandashowed that he too had an unenthusiasticattitude towards HSE. The documents suggestthat Mr Downie was prepared to meet HSErequirements if he could be satisfied that theywere necessary and that the benefit justifiedthe cost. Mr Downie was prepared to have theyard dug up if necessary but was reluctant tohave this done twice. Mr Downie’s reason fornot remonstrating with Mr Frank Stott’s commentregarding sidestepping HSE requests wasthat the purchase of a drench system was anoperational decision for Mr Stott. In my view heacquiesced in Mr Stott’s attitude and in doingso condoned Mr Stott’s tactics.87

PART 6Mr Downie acknowledged that the risk of theexplosion was avoidable and that the explosionshould never have occurred. He disclaimedresponsibility for it on the basis that he was notinvolved in day to day operational decisionsand that responsibility for health and safety laywith ICL Tech. In taking this line he overlookedhis own involvement as director when thepipework was installed.In the course of his evidence Campbell Downiemade the following statement:‘This tragedy has been devastating. Ithas affected all of us personally. In theimmediate aftermath of the explosion, myconcern was for all the employees anddirectors, including my son Nick whowas buried for about 5 hours and wasalso severely injured. I just had to say tomyself try not to go to bits and try not tolet everyone down. I have tried to supporteverybody since the tragedy. I have triedto keep the companies going. I have comeout of semi-retirement to do this.’He went on:“That is a matter of the utmost regret foran event which, in hindsight, would seemavoidable and that if it were possible atsome time in the future whatever to have aforgiveness for an event that should neverhave happened, then that would be mywish.”Frank StottIn a letter to HSE dated 25 January 1989, MrStott responded to Mr Tyldesley’s requirementsfor the siting of the tank. He said:“I can now confirm that we are in fact incontrol of the land outwith our main factorygate and that we have already movedthe car parking facility to the far side ofthe gate, which would be in excess of 20metres from the proposed site of the tank.“There is no reason why we should notremove bricks from the wall and we will infact put up a “No Parking“ sign to preventother people from using this area as aparking spot. If this proves ineffective wewill find some other form of preventative inthis matter.“I trust that the above information will allowyou to accept the Calor proposals, whichwe will implement with Calor as soon aspossible.”The bricks were never removed from the wall atthe base of the tank to provide ventilation. MrStott’s representation that ICL Tech had controlover the land outside its gates was untrue. Theland outside the gates was open to the public.The issues surrounding the drench systemand the car parking had nothing to do withthe explosion; but they display Mr Stott’sattitude to safety and his apparent lack ofcomprehension of the thinking behind the HSErecommendations.Mr Stott was also recorded by HSE on 1September 1988 as having represented thathe was transferring the LPG oven to mains gas.The HSE inspector concerned treated this withscepticism. This representation was untrue. ICLTech was considering converting to natural gasif the tank problems could not be resolved, butno decision had been made.88

THE ICL REPORTFrank Stott’s attitude to HSE was uncandid andobstructive. If he had been receptive to HSE’sconcerns, he might have considered carefullythe thinking behind the recommendation that thepipe should be excavated and inspected.In the result, ICL Tech, through Mr Stott,effectively obstructed inspectors of the HSE inthe discharge of their functions.Mr Stott made a favourable impression on MrMcNab when he visited the site on 9 January1992.That was a diagnostic inspection in which MrMcNab concentrated on safety managementand sought to have Mr Stott manage healthand safety better rather than rely on the HSEinspections, but it was also a check visitfollowing up Mr Tyldesley’s recommendations. Idiscuss that aspect of the visit elsewhere.Stewart McCollStewart McColl was responsible for undertakingand implementing risk assessments atGrovepark Mills. He was therefore closelyinvolved in health and safety in all threecompanies. In October 2000, Stewart McCollfollowed Peter Marshall as managing director ofICL Tech. He perished in the explosion. He tookover responsibility for health and safety in ICLTech from Mr Frank Stott. He had a health andsafety management team consisting of himself,Peter Ferguson, Ian Mavers, Nicholas Downieand William Masterton. From the evidence ofemployees and former employees and from theHSE records of his period of responsibility, Iam satisfied that he had a genuine commitmentto health and safety and was scrupulous inhis attention to safety matters. When he wasmanaging director, health and safety was anitem at weekly management meetings andcommunications from HSE were posted for allemployees to see. Mr McColl was intolerant ofhealth and safety infringements. If an employeearrived without correct equipment, he was senthome. On the day of the explosion Mr McCollhad taken an employee to task for a breach ofsafety.Apology by the ICL companiesIn the course of the closing submissions for theICL companies, senior counsel tendered thefollowing apology:“Everyone involved in both ICL companiesfeels profound sadness and regret. Whathappened on 11 May 2004 has blightedso many lives. Detailed written submissionson behalf of ICL have been lodged inrespect of phase one and I do not attemptto rehearse these again but suffice it tosay that both ICL companies accept thatin respect of the events leading up toMay 2004 they fell short of the standardsrequired by the provisions of the Healthand Safety at Work Act. While othersmay have played their part in the mistakesthat led to the underground pipe beingessentially ignored, both companies andthe individuals responsible for overseeingthe health and safety of the employeesdo not seek to escape responsibility fortheir own shortcomings. It has been saidbefore and should be said again that bothcompanies apologise and express deepremorse for those who have been affectedby the tragedy.”89

PART 6The part played by HSEHSE’s approachGeoffrey Podger, Chief Executive of HSE, saidthat it was matter of regret that HSE’s owninterventions were not more successful. Heaccepted that HSE supervision of the site hadbeen deficient in several respects.Mr Podger described HSE as essentiallyconducting a sampling regime under theHSWA, part of which is the promotion of goodpractice and part of which is the enforcement ofsafety in individual cases. HSE could help withadvice and with monitoring, but at all times itwas the duty holder who was responsible andwho had the ability to undertake what neededto be done. Mr Podger confirmed that it was hisunderstanding that, on at least four occasions,HSE had not followed up recommendations forcheck visits until much later than planned. Heaccepted that Mr Tyldesley’s recommendationto excavate the pipe, if acted upon, wouldhave revealed the unprotected state of thepipe and would have given an opportunity forremedial action. That opportunity had beencompletely missed.HSE knew of the risks of corrosion and ofleakage of LPG into underground voids from atlatest November 1980 when the internal HSEfield circular FIC 286/43 was issued. Thatcircular applied to underground pipes carryingliquid under pressure, but it noted that thestandards could be applied with advantage topipes carrying vapour.The inspection system operated by HSE reliedon following inspections, on adequate recordkeepingof previous visits and on inspectors’own observations and assessments. It is selfevidentthat there were failures in this system atthe Grovepark Mills. There was an identifiablefailure to follow up on previous inspections.There was an inadequate appreciation by HSEat general inspector level of the risk presentedby ageing underground LPG pipework ofunknown composition. HSE’s advice to itsgeneral inspectors was focused on the risksof a BLEVE and on the conditions that mightcontribute to it.HSE’s visitsHSE inspectors visited the site several timesbetween April 1970 and the late 1980s. Thepresence of the LPG bulk tank was first notedin 1975. Thereafter the inspectors, with oneexception, were preoccupied with the riskthat the contents of the tank might ignite. Theprotection of the tank was seen as an urgentpriority.Dr Gunn, an HSE specialist fire and explosionexpert, visited the site on 21 January 1982 toadvise on the hazards arising from the siting ofthe tank. It was not within the technical scope ofhis visit to consider the underground pipeworkor the route of the pipe when it entered thebuilding. There was nothing in the visiblepipework to cause him to consider such matters.Dr Gunn was aware of the risks associated withburied LPG pipework and with the collection ofleaked LPG in voids, trenches, basements andother underground areas. He was familiar withHSE internal circular FIC 286/43. He knew thatthe LPG tank and the pipework were over tenyears old, but since consideration of the buriedpipework was beyond the scope of his visit,he made no recommendation concerning it. Atthe inquiry, Dr Gunn accepted that if he hadrealised that the pipework went into a void, hewould have considered the implications of this.90

THE ICL REPORTHe said that he had no reason to do so sinceall that he saw was the pipe going off from thetank and through a wall.The check visit scheduled for May 1982 tocheck on Dr Gunn’s recommendations did nottake place until December 1982. It was obviousthen that the recommendations had not beenimplemented in full.In 1988, Mr Tyldesley was asked to make aspecialist inspection and to report.Mr Tyldesley knew of HSE internal circular FIC286/43. He visited the premises with Mr JohnIves on 9 August 1988. Their principal concernswere again related to the siting of the tank;but Mr Tyldesley identified the existence of theburied LPG pipework. The critical stages thatensued are as follows.The Ives-Coville agreementStage 1Mr Tyldesley inspected the external LPGinstallation above ground and the pipe withinthe basement. He prepared a report dated22 August 1988 for Mr Ives. He noted that DrGunn’s recommended improvements had beenimplemented only to a limited degree and that itwas “a still unsatisfactory installation”. He madetwelve recommendations. Recommendation 11was as follows:“Part of the underground pipework carryingvapour into the building should be excavated.The state of the pipework and any corrosionprotective coating should be examined by acompetent person, and any recommendationsmade as a result of this inspection should becarried out. A pressure test of the pipeworkshould also be carried out.”Mr Tyldesley deserves great credit for beingthe only person in this history who was alert tothe risk arising from the unknown condition ofthe buried pipework. His recommendation 11was critical. Had it been carried out, it wouldhave shown that the pipe was unprotected. Inall likelihood the pipe would have shown signsof corrosion, having been buried in aggressivesoils for almost twenty years. Mr Tyldesleywas perceptive in seeing that the undergroundpipework was as much a source of hazard asthe siting of the tank.Mr Tyldesley knew that the entry of LPGpipework into an unventilated void was amatter of concern but he did not comment onthat feature of the installation at the site. Hedid not recommend removal or re-routing ofthe pipework in the basement. I infer that hethought that, though not ideal, the layout did notbreach HS(G)34.In the events that followed the opportunitywas missed to ascertain the condition of thepipework and to take action to avoid the riskthat it created.Stage 2After a further visit to the ICL premises, Mr Ivessent a letter to ICL Tech that set out all of MrTyldesley’s recommendations verbatim.Stage 3Mr Stott copied Mr Ives’ letter to Calor. On 4January 1989 Maurice Coville of Calor wroteto Mr Ives on behalf of ICL Tech. In relationto recommendation 11 he made the followingcounter-proposal:“With regard to paragraph 11 of yourletter, the condition of the attendant vapour91

PART 6off-take pipe would be ascertained, duringvessel-exchange, by examination of the“riser-pipe” at the vessel and by a pressureteston the pipeline”.Mr Ives passed Mr Colville’s reply to MrTyldesley for his views. Mr Tyldesley said thatthe counter-proposal to recommendation 11was “acceptable”. But in relation to the sitingof the tank, he said that unless ICL Tech couldgain control of the land outside the premises,he would support enforcement action and thathe hoped that this would now take place.This comment earned him the heavy-handedresponse from Mr Ives that I have quotedpreviously.Mr Tyldesley said that his understanding ofCalor’s response was that they were going todig down a short way to ascertain the conditionof the pipework. He said that examining thepipework above ground would tell no oneanything that could not already be seen. Calorhave suggested to me that there is no evidencethat a limited excavation around the riser pipewas not actually carried out and that at thattime the pipe may not have been corroded.Had a limited excavation been carried out,on the evidence available to the Inquiry, thiswould have shown that there was no protectionapplied to the pipe below ground level. Inmy view, the fact that industry practice, basedon published guidance, was to pressure testto check the integrity of the undergroundpipework is no answer to the underlying riskthat Mr Tyldesley had identified. In my view,Mr Tyldesley should not have accepted thecounter-proposal without having it spelledout that Calor’s “examination” would involveexcavation. Mr Tyldesley’s acceptance of thecounter-proposal with nothing further said wasthe critical event in terms of HSE’s involvement.It brought to an end the possibility of HSE’sinsisting on there being a proper examinationof the buried pipework. HSE consider thatthere were opportunities for ICL, Calor andJohnston Oils to have intervened in the followingfifteen years. Mr Tyldesley has said that heregarded the contents of Calor’s letter to bean explanation of what they would do ratherthan a counter-proposal, and that it was implicitin the proposal to examine the riser that thiswould involve a degree of excavation. In hisview, this being the case, acceptance of theCalor proposal should have led to a properexamination of the buried pipework.At the end of his evidence, and of his ownaccord, Mr Tyldesley made the followingsincere and moving expression of his regrets:“Last September after the prosecutionwas complete but before this Inquiry wasannounced, I put on my website somecomments about ICL. These include anapology. I was, and still am, sorry that thisdisaster wasn’t averted. Towards the end ofthe year Brechin Tindall Oates, who actedat the time for HSE staff, told me to removethis web page. Somewhat reluctantly I did.During May, when my statement to thisInquiry was being prepared with the helpof Pinsent Masons, I wanted again tofind a way of saying sorry. We exploredvarious forms of words but could not findany that did not either imply, howeverobliquely, that anyone else might haveanything to say sorry for or appear totake on my own shoulders responsibilityfor matters over which I did not feel 100%responsible. So the paragraphs were left92

THE ICL REPORTout. It seems that once the legal processesstart, the word “sorry” becomes very difficultto say. Despite that, I just want the familiesto know where my sympathies lie.”Stage 4Mr Ives replied to Calor repeating MrTyldesley’s view on the counter-proposal torecommendation 11. He did not questionMr Tyldesley’s acceptance of the counterproposal.He relied on Mr Tyldesley as theexpert and had no reason to challenge hisadvice. As a general inspector, he may nothave been conscious of the reasoning on whichrecommendation 11 was based.At the date of the Inquiry, Mr Ives had norecollection of any specific HSE guidancerelating to such dangers, but was aware ofconcerns about underground pipelines. Hesaid he had relied on the specialist adviceof Mr Tyldesley. It is unfortunate that, despitehis officious insistence that any decision onenforcement action was his to take, he failed toquestion why Mr Tyldesley no longer stood byhis recommendation 11.Stage 5On 17 January 1990, Mr Coville advised MrIves that the work on the recommendationshad not yet been carried out and that it wasnow proposed that the single 2-tonne LPG tankshould be replaced with two smaller 1-tonnetanks. This was agreed to by Mr Ives as fulfillingMr Tyldesley’s recommendations. Mr Ives notedthat a check visit should be carried out inMarch 1990. This visit did not take place. Thetwo tanks were not installed until June 1991.During that period no initiatives were taken byCalor, ICL or HSE to assess the condition of theunderground pipework. It is likely that when the2-tank arrangement was eventually installed,a pressure test was carried out; but there is noevidence that Calor inspected the riser pipe.It is now obvious that there was no properfollow-up on the requirements of the Ives-Covilleagreement. If the condition of the undergroundpipework had been properly ascertainedin 1989, it is likely that the lack of corrosionprotection and the existence and the extent ofcorrosion would have been identified.In January 1992, Mr McNab made the longoverdue check visit to follow up the Ives-Covilleagreement. The only relevant record of this visitis Mr McNab’s handwritten note that “LPGseems to meet 1990 agreement”. Mr McNabwas clearly mistaken. Although the tanks hadbeen exchanged, the agreement had not beenfully implemented. Mr McNab was unable toexplain how he missed the non removal of thebricks in the wall to increase the ventilation.There is nothing on the file to indicate thathe asked whether the riser pipe had beenexamined on the exchange of tanks and, if so,what was found. This was a further opportunityfor the integrity of the underground pipe to beconsidered. It was missed.Follow-up visitsOn several occasions follow-up visits that werenoted to take place on HSE Reports on Visitsforms were not carried out. The repeatedfailures of inspectors to take notice of the buriedLPG pipework on such visits or to insist upona sufficient investigation represented missedopportunities for its continuing corrosion to bedetected. Ultimately it fractured.93

PART 6ConclusionLooking over this part of the history, I concludethat while HSE’s inspection regime is a riskbasedsampling regime aimed at promotinggood practice and dealing with failures andsafety concerns, if need be by enforcementaction against the relevant duty holders, theactions of HSE’s general inspectors overall werecharacterised by an inadequate appreciation ofthe risks associated with buried LPG pipeworkand unventilated voids; and by a failureproperly to carry out check visits.Can it ever be justifiable for HSE to resile fromits own requirements?HSE represents the public interest. It must assessits requirements by reference to safety criteria andto the tests of reasonableness and proportionality.Its requirements must be uninfluenced by anycommercial considerations that may affect thejudgment of the owners of the site.If in response to a prohibition notice or a noticeto do work, HSE receives a counter-proposalon behalf of the site owner that could be aseffective as that which HSE proposes, it is theduty of HSE to consider that response on itsmerits. If it is persuaded that the counter-proposalis sound and effective, it may justifiably modify itsown position accordingly. That is a realistic andresponsible approach to decision-making by apublic regulatory body in such circumstances.But what it must not do is to resile from its ownconsidered position for fear that the site ownermay contest the notice and perhaps do sosuccessfully. If HSE remains conscientiouslyconvinced that its proposed solution is the rightone, it is its duty to defend that position, even ifthat means litigation. Mr Podger has confirmedthis to be HSE’s position.It is clear from Mr Ives’ evidence about theCalor counter-proposal that his decision toaccept it was influenced, in part at least, by hisfear of the consequences if he should reject it.It was well-known to the Inspectorate that Calorhad a history of challenging HSE enforcementnotices. In my opinion, Mr Ives’ reasoning foraccepting the counter proposal ought not tohave been influenced to any extent at all bysuch a consideration.Calor consider themselves to have a constructiverelationship with HSE and reject any suggestionthat they intimidate HSE when they occasionallyseek to assist their customers to resolve anypotential enforcement notice issue. I myself makeno such suggestion.Replacement of FIC 286/43 with HS(G)34FIC 286/43, was a document internal to HSE foruse by general inspectors but also available tospecialist inspectors. It applied to liquid carryingpipes but noted the standards could be appliedwith advantage to vapour carrying pipes. Inthe period 1984 to 1988 HSE’s guidance onLPG was revised. In July 1987, HS(G)34 cameinto force. It replaced Guidance Note CS5 andHS(G)15 and revoked FIC 286/43(REV). HS(G)34 was a booklet on the bulk storage of LPGat fixed installations. It was on sale to the public.Its target audience was users, suppliers and fieldinspectors. It was drafted by Dr Fullam.HS(G)34 was less specific than the approach thathad been taken in FIC 286/43 and FIC 286/43(REV). As in FIC 286/43, the section relevant tounderground pipework in HS(G)34 did not applyto vapour pipes. Unlike FIC 286/43 and FIC286/43(REV), HS(G)34 did not suggest that thestandards might with advantage be applied tounderground vapour pipelines.94

THE ICL REPORTParagraph 188 of HS(G)34 stated that:“Underground piping carrying liquid whichis laid in a backfilled trench should beexamined for corrosion, or tested in such away as to establish continuing integrity, atleast once every ten years.”In providing that integrity should be tested at leastonce in every ten years, it was more specificthan FIC 286/43 (REV); but it was less specificin its failure to specify what form of testing mightbe used to establish continuing integrity, in theabsence of an examination for corrosion.Dr Fullam agreed that that HS(G)34 was the“vaguest of them all” in comparison with FIC286/43 and FIC 286/43 (REV). He said:“….it reflects the general move towards arisk-based approach not just in terms of LPGbut in fact all engineering standards weremoving towards a risk-based approachwhere you didn’t give such specific detailbut you allowed a competent person to usetheir judgement based on their engineeringknowledge. That was the general trendreally in the engineering profession.”He also said that at the time when he wroteHS(G)34:“I had an agreement with UKLPG’spredecessor that Code of Practice 22would contain more detail about vapourpipelines and so I put in the absoluteminimum basic requirement that you had toprotect the thing from corrosion.”Code of Practice 22 in the event did not comeinto force until 1990. In Dr Fullam’s view it wasdirected more towards construction and materialthan inspection and maintenance. The Codeprovides inter alia that “pipework should only beburied when unavoidable. The pipeline routeshall be permanently marked or recorded. It mustbe adequately protected against corrosion andmechanical damage”. It further says that, “Unlessotherwise provided with the means to assess thecondition of buried metallic pipework, suitableprovision shall be made to facilitate periodic leaktesting” and adds, “Steel pipe conveying liquidlaid in a backfilled trench should be examinedfor corrosion, or tested in such a way as toestablish its continuing integrity, at least onceevery 10 years. See Code of Practice No 1, Part3”. This reflected the relevant terms of HS(G)34.Section 6.1 provided further detail about therequired protection for vapour phase pipeworkwhich I need not quote.HS(G)34 appears to have caused a doubtamong inspectors as to whether paragraph188 required excavation of the pipework. DrFullam explained in his statement:“Mr Tyldesley identified that the only way ofknowing about the continuing integrity of thepipe is to understand its physical state as wellas to carry out a pressure test. A pressure testprovides assurance that, over the period ofthe test, the pipe is not leaking but providesno information on the capacity of the pipe tocontinue to contain the hazardous substance.HS(G)34 at section 188 makes reference tothe ‘continuing integrity’ of the undergroundpipework which is not demonstrated by apressure test alone.”Dr Fullam appears to have regardedinspection as implicit in the term “continuingintegrity”.95

PART 6When he was referred to the Ives-Covilleagreement, Dr Fullam expressed the followingview.“If in fact those intentions [Mr Colville’s] didnot include excavation of the undergroundsection of the riser, and simply examination ofthe riser pipe above ground and the pressuretest, in my opinion that did not comply withthe then published guidance HS(G)34.”Calor’s view during the hearings was that forthe purposes of HS(G)34, a survey for leakagenot including excavation was sufficient forvapour carrying pipework.HSE appears to accept that the interpretationof HS(G)34 was not clear-cut. Dr Fullamacknowledged that since the ICL explosionOC/286/105 has been published to provideclarity. This guidance concerns“the ongoing integrity of buried, metallicpipework, used for conveying LPG as avapour or liquid.”The standard to be achieved is clearly set out:“Buried metallic pipes of poor or unknowncondition are re-routed above ground andprotected against mechanical damage,where it is reasonably practical to do so.Where it is not reasonably practicable tore-route above ground, then either –– the buried metallic pipework shouldbe replaced by buried polyethylenepipework or a proprietary pipeworksystem which should be installedin accordance with manufacturer’sinstructions; or– the buried metallic pipework (andits corrosion protection) should beexamined and assessed to confirmits condition as acceptable followingwhich it should be subject to ascheme of inspection, examinationand maintenance to ensure itscontinued integrity.”OC/286/105 is quite specific on the subjectof enforcement. It provides for the service of anImprovement Notice where there is evidenceof buried, metallic LPG pipework in poor orunknown condition or where there is no strategyfor inspection, examination or maintenance; andfor the service of a Prohibition Notice wherethere is clear evidence of corrosion.Why was the problem missed by HSE?The dangers of corrosion to buried pipeworkwere known to the HSE for many years, aswas the danger arising from LPG pipeworkin unventilated voids. Why then did everyinspector who visited Grovepark Mills before1988 fail to notice the existence of the buriedLPG pipework? The reason is, I think, that thenational statistics for fires and explosions didnot suggest that leaks in LPG pipework werea major safety issue. That was certainly theposition of Mr Ives. He saw the critical issueas being the safety and integrity of the tankinstallation, which he saw to be vulnerable,especially in what he supposed to be an areaof criminality. It was this concentration on thetank and the fear of a BLEVE that caused theseinspectors to take their eye off the pipework.Dissemination of information within HSEThe report relating to an LPG explosion inan underground firing range in Daventry in96

THE ICL REPORTDecember 1987 dated 13 January 1988 wasnot disseminated widely within HSE. It hadnot been seen by Mr Ives when he acceptedCalor’s counter-proposals. Mr Tyldesley hadnot seen it, but he was aware of the hazardsattaching to buried metallic pipework.Mr Tyldesley said that the report of the Daventryexplosion would have been entered in acomputer database called marcode whichwas not used by the specialists. The circulationof the report was restricted to a few specialistinspectors. It appeared to have been sent tothe Public Utilities Group, but the circulation listshowed that it had not been sent to the Fireand Explosion Specialist Group at the Bootleheadquarters; so there was no obvious routeby which it could have reached the fire andexplosion specialists in HSE.Dr Fullam did not know of the Daventryreport until after the ICL explosion. When itwas circulated, HS(G)34 had been alreadypublished. Since it was an isolated incident,where the cause of failure was an obviouslack of corrosion protection, it would not haveprompted him to revise HS(G)34. He agreedthat in view of the responsibilities that he heldat that time, the failure within HSE to bring thatreport to his attention represented a systemicfailure. The failure to circulate the Daventryreport as a high priority represented a missedopportunity to make inspectors better informedand more immediately aware of the hazards ofburied metallic pipework and more alert to thedangers that it might represent.It appears that there are more ways currently inwhich information can be shared within HSE,but there still does not appear to be a systemin place to ensure that important reports, suchas the Daventry report, are disseminated morewidely and in particular to the relevant officials.Process safety specialist inspectors are membersof an electronic community of interest andpractice. They exchange information. Thereis an annual process safety conference.There is a Fire and Liquefied FlammableGases knowledge hub and a Process SafetyCorporate Topic Group which itself has regularmeetings with UKLPG. Incidents reported underRIDDOR meeting the criteria for investigationare placed on the inspection database COIN.There are also regular meetings with utilitycompanies. The Health and Safety Laboratoryhas been commissioned by the ProcessSafety Corporate Topic Group to considerhow further information can be gathered fromexisting databases of process safety incidents.The outcome of this review is not known bythe Inquiry. I hope that a more reliable andcoherent system will be developed than thatwhich operated when the Daventry incidenttook place.HSE informed the Inquiry that it does notcurrently have a formal, specific system formonitoring adverse safety trends across thecommercial and industrial LPG sectors or sites.97

PART 6The part played by Calor andJohnston OilsCalorICL relied on Calor for advice and expertise.Calor had the knowledge to alert all of theircustomers including ICL to the inevitability ofcorrosion in metallic pipework. Calor also knewof the hazard represented by unventilated voidsin premises where there was an LPG supply.There is no indication that Calor alerted ICL tothese risks at any time. Calor have said that ICLdid not consult them regularly. They have furtherindicated that they do not consider it to beinevitable that underground metallic pipeworkwill corrode if it is properly protected when laidand subsequently maintained effectively by itsowner. Evidence received by the Inquiry fromthe former Calor employee who undertookCalor’s extensive research programme intothis subject has been that, even where pipeswere appropriately protected by Denso tape,corrosion has been found. Calor have madea number of representations to the Inquiryconcerning the extent of its legal duties inrespect of the premises into which it delivers.These are matters that remain the preserve ofthe proper courts and I propose to express noviews on them.Calor invited me to make a finding in fact thatMr Coville’s counter-proposal to Mr Tyldesely’sRecommendation 11 went beyond the stepsrecommended in the applicable guidance, andthat at that time there had been no reportedproblems with the pipework.Calor also invited me to find that Mr Tyldesleyhad not referred in his recommendations to thefact that the pipework entered an unventilatedvoid in the basement. Mr Tyldesley was clearthat he was required to make a judgment callon what was the minimum requirement to meetthe standard of sections 2 and 3 of the Healthand Safety at Work Act and that guidelinesnever gave answers to all the questions. Hedisagreed with counsel for Calor that theguidance at paragraph 188 of HS(G)34,which recommended that underground pipingcarrying liquid in a back filled trench should beexamined for corrosion or tested to establishcontinuing integrity every ten years, prescribeda standard applicable only to pipes carryingliquid. HS(G)34 was for guidance only andhe considered that pressure testing every tenyears without some greater certainty was notsatisfactory as a standard.Calor referred Mr Tyldesley to LPG ITA Codeof Practice in particular to paragraph 6.2.1(a) which related to pipework carrying vapourbelow 5 bar, as was the case at ICL, whichrecommended surveying for leakage at afrequency dictated by the risks associatedwith its location, pressure of operation andaggressiveness of its environment, and (b)which recommended that above 5 bar, “wherepracticable”, this survey might be a repeat ofthe pressure test carried out upon installation.Calor’s view was that the application ofthe pressure test suggested by Mr Covillerepresented a higher standard than thatenvisaged by the then guidance.Mr Tyldesley was clear that adherence to thewritten word of guidance was not sufficientwithout consideration of wider factorsinvolved. In his view, guidance was just that.It had no legal effect. He was required touse his professional judgement as to whatwas necessary, taking into account all thecircumstances known to him. He considered that98

THE ICL REPORTparagraph 6.2.1 (a) required a judgement calldepending on the location, operation, pressureand aggressiveness of the environment. I agreewith that approach.Dr Fullam was clear that in his view Calor’scounter-proposal, if it did not involve excavationbelow ground level, was not satisfactory andwould not have complied with HS(G)34.In my view, for so long as Calor contractuallyaccepted no responsibility for pipeworkbeyond the vapour off-take valve, it was atleast a tenable position for them to say thatthe buried pipework was a matter for the useralone. But they could not maintain that positionwhen they agreed to advise and representICL in its negotiations with HSE. Mr Tyldesley’srecommendation 11 confronted Calor withthe question of the integrity of the pipe. Calorknew that it had been in situ since 1969. Theyhad not been involved in its installation. Theyknew nothing about it. The risks of corrosionin underground metallic pipes were by thenwell known and well understood. Thesecircumstances suggested that at the very leastthe condition of the pipe should be investigated,whatever the status of the various guidancedocuments and whatever their meaning. IfCalor considered that a solution falling short ofexcavation would suffice, they should, I think,have described it more precisely and givenreasons why they thought that that solution wassatisfactory. Mr Coville’s counter-proposal wasnot entirely clear in either respect. However, Iaccept immediately that it was for Mr Ives, asthe responsible officer of the regulatory body,and Mr Tyldesley, whom he consulted on thepoint, to reject the counter-proposal, if that wastheir view of it.Calor have since maintained that examinationof the riser referred to in the counter-proposalwould have also involved excavation of thesoil around the riser. There is no evidence thatthis was done. If it had been done, it wouldhave shown that there was no protection to thepipework below ground beyond galvanisation.Calor consider that the real issue is whetheror not the pipework was corroded. My ownview is that the real issue was to establish whatthe condition of the pipe was at that time. Theonly reliable way of doing so was to excavateit. If the pipe had been excavated, in wholeor in part, it would have been apparent that ithad no protection against corrosion other thangalvanisation. An informed judgement couldthen have been made as to the risk that thecondition of the pipe created and would createin the future.Johnston OilsJohnston Oils were responsible for supplyingLPG to the site from 1998. Johnston Oilsconsidered that they would be responsible forthe pipes only up to the first stage regulator.When they took over from Calor, they didnot carry out any physical examination ofthe service pipework nor did they proposeany steps by which that might be done. Theycarried out an appropriate pressure test whentheir first tank was installed, and when itsreplacement took place. In doing so, JohnstonOils were following the industry standard.Johnston Oils proceeded on an assumption thatthe integrity of the pipework was sufficientlyvouched by the pressure test.99

PART 6Uncertainties affecting commercialand industrial users of LPG in theyears preceding the explosionComplexities as between contracts for supplyThe terms of the LPG suppliers’ contracts variedas to the extent of the respective responsibilitiesof supplier and customer. It appears that ICLwere not fully aware of their responsibility forthe continuing integrity of the undergroundpipework.Calor consider that there was no reason whyICL should not have been fully aware of theirresponsibilities for the continuing integrity of theunderground metallic pipework. They refer tothe booklets and guidance notes for customersto which I refer elsewhere in this report. I donot consider these to have been adequate toalert a customer to the particular risks inherentin ageing buried metallic pipework and in theexistence of a void in the pipe run.I am satisfied that no one in senior managementin the ICL group had a clear idea as to wherethe supplier’s responsibilities ended and thecustomer’s began.Level of understanding of LPG and reliance onthe expertise of suppliersThe implications of buried ageing, corrodingmetallic pipes and their potential leakage werenot understood by anyone on the ICL premises.There was little to no understanding of thenature and the properties of LPG. There wasno understanding of the vulnerability of buriedmetallic pipework.Both suppliers confined themselves to theirresponsibility for the integrity of the tank, save forcarrying out pressure tests on connection to thecustomer’s pipework. To carry out these pressuretests, they must have used the shut-off valve in thebasement area or in the coating shop, since therewas no external isolation valve. Those carrying outthe pressure tests would have had the opportunityto identify that the external riser pipe entered thebuilding below ground and that the pipeworkwent through the basement. The undesirabilityof these circumstances was long establishedwithin the industry. Both suppliers at the ICLpremises were well placed to alert and advise thecustomer. There was no evidence that either did.Calor consider their information leaflets, Healthand Safety Information for Bulk Calor GasUsers and Guidance Notes for CommercialCustomers relating to the pressure systemsregulations provided such information. Thefirst referred to the carrying out of a visualexamination of an LPG system and the useof operational tests at least once every fiveyears. The revised version of 1995 contains thecomment that “the useful and safe working lifeof the distribution system, including pipework,regulators and valves will vary with a number offactors such as conditions of duty, environment,standard of maintenance”.In my view, there is nothing in these documentsto draw a reader’s attention to the issuesinherent in the ageing metallic pipework or tothe existence of a void. There is no mentionof the characteristic behaviour of LPG vapouron an escape nor of its propensity to track theeasiest route and accumulate at the lowest levelavailable to it. Guidance Notes for CommercialCustomers related to Pressure Systems andTransportable Gas Containers Regulationswhich came into force July 1994. Theseregulations required owners of pressure systemsto know the operating pressures of their systems100

THE ICL REPORTand to know that the systems were safe at thosepressures. They were aimed at preventing therisk of injury from unintentional release of storedenergy from a system containing “relevant fluid”,including LPG systems operating above 0.5 bar.A written scheme of examination was requiredto cover pipework if a) its mechanical integritycould be significantly reduced in service, forexample, by corrosion, erosion or fatigue;and b) the failure and the sudden release ofstored energy would give rise to danger. Theseregulations were succeeded by the PressureSystems Safety Regulations 2000 (“PSSR”).These regulations concerned a sudden releaseof stored energy causing a danger to people.I do not regard these as having any specialrelevance to this case.The Calor welcome pack was also cited asproviding relevant information. The versionproduced to the Inquiry contained a sectioncalled “Looking after pipework”. This makes itclear that the pipework from the outlet of thefirst stage regulator is the responsibility of thecustomer. It makes a request that the customershould ensure the above ground pipework isadequately protected and is capable of beinginspected, and that care is taken when diggingaround the vicinity of underground pipework.I do not consider that this document wasadequate to alert a reader to the specific riskswith which this Inquiry has been concerned.Johnson Oils acknowledge that they did notidentify that the external riser pipe enteredbelow ground; but they consider that they hadno responsibility to inspect their customer’spipework beyond the first stage regulator.Complexity of legislation and guidanceIn what is essentially a self-regulating industrythe suppliers are well placed to advisecustomers as to the standards and regulationsthat apply to LPG installations.The regulations applicable to constituentelements of an LPG installation are not tobe found in any one source. They applypiecemeal. They generally apply more widelythan to LPG alone.The complexities of the applicable regulationsare such that the ordinary user is bound to needhelp in understanding them.The industry has acknowledged that there isa need to improve its communications with itscustomers and assist them with information thebetter to understand their responsibilities.Confusion as to which company HSE andothers were dealing with at any one time.There were degrees of confusion as toresponsibility for the safety of the installation atthe site.ICL Plastics was the original customer of Calorand was responsible for the installation of thesystem. Delivery orders for the replacement tankrecorded ICL Tech as the customer. ICL Plasticspaid for the LPG and re-charged to ICL Tech.When Johnston Oils took on the supply, the bulktank Agreement was with ICL Plastics. JohnstonOils invoiced ICL Plastics for the tank and ICLTech for the supply of LPG.On the incorporation of ICL Technical Plastics,the responsibility for the fixed plant andequipment was transferred from ICL Plastics toICL Technical Plastics. There was no transfer101

PART 6of the title to the site. ICL Plastics remained theheritable proprietor of the land in which the LPGpipework was buried.HSE addressed a number of letters to ICLPlastics although the premises were occupied asa factory by ICL Tech. The managing directorsof ICL Tech responded on ICL Tech letterheads.ICL Tech used the LPG in the industrialprocesses. ICL Plastics had no day to dayinvolvement in them.Throughout the period from their incorporationto the explosion, ICL Tech occupied thatpart of the premises in which the LPG ovenwas situated. They were the company thatused the buried pipework and carried outrisk assessments in relation to the plant andequipment in their part of the premises. At nostage did ICL Tech even consider the integrityof the buried pipework or the existence of thevoid, or the implications if LPG should escapefrom the underground pipework.Nor did ICL Plastics. It is not for this Inquiry tomake judgments as to the law regarding theirrespective legal responsibilities. Those arematters for the courts. It is enough for me to saythat the uncertainties within the ICL Group as tothe responsibilities of the constituent companieswere prejudicial to safety.The companies do not dispute that there mayhave been confusion regarding their respectivelegal responsibilities. They have stressed tome that there was no deliberate intention toconfuse, cloud issues, obstruct or mislead anyperson.The Local AuthorityThroughout the period from 1969 until 2004responsibility for the building legislation and theplanning legislation lay with the relevant localauthority, namely Glasgow City Council, andits statutory predecessors the Corporation of theCity of Glasgow (until 1975) and the City ofGlasgow District Council (until 1996).In relation to the Building (Scotland) Acts1959 and 1970, it is my view that there wasno inadequacy in the building itself, nor inthe use of that building for the industrial andadministrative purposes carried out by the ICLcompanies, nor in the manner in which thatbuilding was modified or altered, at any rateafter 1969. In the case of building control,there was no requirement to take into accountthe existence of any LPG installation whenproposed alterations to the building were beingconsidered.Strathclyde Fire ServiceStrathclyde Fire Brigade records show thatStrathclyde Fire Brigade carried out a routinefire safety inspection of the ICL Plastics premiseson 5 December 1989 in consequence of whicha notice was issued requiring an upgrade of thefire precautions.Paul McClintock, currently the GroupCommander, Operations and Development, forNorth and South Ayrshire Area of StrathclydeFire and Rescue, recalled that he attended theICL premises in 1993 or 1994 when workingas a fire prevention officer based at YorkhillFire Station, Glasgow. He was a memberof a Project Team which was responsible forreviewing, updating and amending existingfire certificates for various premises. The reviewwas being conducted under the terms and102

THE ICL REPORTrequirements of the Fire Precautions Act 1971.It involved visits and inspections of premises,notifications to owners and occupiers ofnecessary requirements for fire safety procedures,amendments to fire certificate documentation andthe creation of computer assisted design buildingplans (known as CAD plans).On 4 October 1993, Mr McClintock issuedICL Plastics with a form FPA4(i) a noticespecifying alterations that had to be made tothe premises The alterations schedule referredto the alarm system, signs and notices, and firefighting equipment. These requirements werelow key. On a scale of 1-10 with 10 beinga major concern, Mr McClintock rated therequirements for ICL Plastics at 2. ICL Plasticshad until 4 January 1994 to comply withthese requirements. On 9 December 1993,Strathclyde Fire Brigade received a letterfrom ICL Tech confirming that the outstandingrequirements were complete.On 20 December 1993, Mr McClintockrecorded that an Amended Fire Certificate wasbeing prepared. Although it was not specificallyrecorded in the case notes, Mr McClintockwas of the opinion that he would have visitedthe premises on 5 January 1994 to deliver theamended certificate. He would have issued itonly after touring the premises to ensure that allalterations had been carried out. The amendedcertificate indicated that the premises werein single occupation and did not include thebasement.A CAD plan was appended to the amendedcertificate. It showed neither the basementnor the stairwell that ran from the groundfloor down to it. The appendix page in thecertificate, which included an entry for eachfloor level, has no reference to the basement.Mr McClintock did not recall there beinga basement. Normally an area such as abasement would be omitted from the relevantplans only if it was unused and permanentlysealed off. In these situations the basementwould have been considered to be outwith thescope of the fire certificate or not in use. Thisshould have been clearly recorded.According to Strathclyde Fire Brigade’sOperational Technical Note A6, a planshould have indicated the existence of abasement and the basement access. One ofthe purposes of a record was to assist crewsto locate access points. A basement stairaccess was an essential feature to show on aplan. Had the fire service been aware that thebasement was in use for accessible storage, itwould have been included in the fire certificateand two means of escape would have beenrequired.On 3 August 2001, Strathclyde Fire Brigadecarried out a routine fire safety inspection of thepremises and considered the fire precautionssatisfactory at that time.Strathclyde Fire Brigade also maintained arecord under the provisions of the Fire ServicesAct 1947. The record included a plan of theground floor. Nine familiarisation visits wererecorded by fire crews who attended at thepremises between 1991 and 2003. Three ofthose visits were recorded as a ‘re-inspection’.A re-inspection was a check of the accuracy ofthe records held and the purpose of a visit wasto assist with fire crew familiarity.I am satisfied that none of these events had anybearing on the occurrence of the explosion.103

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THE ICL REPORTPart 7105

PART 7Chapter 15 – What caused the disasterThe initiating event on 11 May 2004The seat of the explosion was in the section ofthe basement into which the LPG pipe enteredthe premises. Kenneth Murray died there ofinjuries consistent with his having been at thepoint of the explosion. He was the only personwho could have brought about that ignition,but precisely how that occurred remainsunknown. A spark may have been caused bythe operation of an unprotected light switch.Some but not all of the wiring had beenspark-protected. A rusted and badly damagedcigarette lighter was found in the rubble. It maybe that Kenneth Murray lit a cigarette with it. MrMurray was unfortunately in the wrong placeat the wrong time. He was an innocent victimof circumstances. I have already described thedetailed circumstances leading to the escapeand accumulation of LPG in the basement andto the explosion and collapse of the building.The causes of the explosion, and the lessons tobe drawn, are now fairly clear. As is always thecase, hindsight highlights missed opportunitiesto identify the risk and to take action to avoid it.My recommendations are based on the lessonsto be learned.This Inquiry is not about ascribing blame orfault. Those are matters for the courts. Thepurpose of the Inquiry is to establish the factsand to make appropriate recommendationsfor the safety of LPG sites. I am encouragedby the comment of senior counsel for thoseinjured survivors and bereaved families whowere represented by Thompsons. In his closingstatement he said of his clients:We have been instructed to advise theInquiry that they do feel that the truth ofwhat happened has come out”.The explosion itself was not the direct cause ofdeath, save in one case. Most of the deceasedwere working on the second floor of thebuilding. It was the collapse of the building thatcaused their deaths.The building did not suffer a “disproportionatecollapse.” With an explosion of such severity,the almost complete collapse of the buildingwas reasonably to be expected. Leaving asidethe existence of the void, it cannot be said thatany inadequacy or deficiency in the originalconstruction of the building, or in its subsequentalteration and maintenance, contributed to theexplosion or to the severity of its consequences.There was no significant pre-event damage tothe building and no significant deterioration of itby age or use. The construction, alteration andmaintenance of the building made it reasonablyfit for the purposes for which it was being used.It collapsed progressively as a result of thepowerful overpressure that acted upon criticalelements of the structure.The immediate cause of the explosion was theescape of LPG from the substantially corrodedunderground pipework at the cracked rightangledbend close to the southern wall of thebuilding, the tracking of the escaped gas intothe basement of the building at the west end,the accumulation of the gas in the basement toa point where it constituted an explosive mixturein air, and the ignition of that mixture.“Although the evidence was frequentlyupsetting to them, they were able to gain aclear insight into the cause of the disaster.106

THE ICL REPORTThe history of the pipeTo explain that immediate cause, it is necessaryto examine the history of the installation,management and maintenance of theunderground pipe over a period of about 35years from the introduction of LPG to the site.The fracture of the pipe occurred because nooneinvolved in the installation of the pipe andthe subsequent raising of the yard appreciatedthe risks that were inherent in buried metallicpipework. The pipe was not adequatelyprotected against corrosion in the first place.The raising of the yard added to the stress on it.HSE carried out inspections of the site over aperiod of about thirty years. Only one of theseinspections alerted HSE to the existence andcondition of the buried pipework.On that occasion HSE recommended that thepipe should be excavated. Calor respondedto HSE on behalf of ICL Tech. HSE acceptedCalor’s counter-proposal without questioningwhether it would achieve the objective ofthe recommendation. Whether or not Calor’sproposal to examine the riser on exchangeof tanks is to be construed as involving anexamination of the underground pipe, andwhether it was reasonable for HSE to supposeat that time that it did, need not be decidedby this Inquiry. What matters is that therecommendation was not followed through.The pipe was not excavated. Thereafter no onethought to ascertain the condition of the pipe.In due course the condition of the pipe wasnot considered in any of the risk assessmentscarried out by ICL Tech. Its existence wascompletely missed.The key factors having a bearing onthe event(1) Inadequacies in the 1969 works for thelaying of the pipework under the yard andits entry into what was then an open area,partially below ground level, within thefactory premises.The underground steel pipework had beengalvanised, but it had no other corrosionprotection. With one exception close to thetank, the fittings were ungalvanised and hadno corrosion protection at all. By 1969 it wasknown that wrapping galvanised pipes inDenso tape provided added protection fromcorrosion.The pipe track was filled with a range of soiltypes classified as having “aggressive” to “veryaggressive” corrosive qualities. The soils weremixed with rubble in-fill that contained largepieces of concrete that bore directly onto thepipe.As installed, the pipe rose vertically to about0.45 metres above ground before enteringthe building horizontally through a brickedupwindow by way of a right angled bend.Where the pipe passed through the bricked-upwindow, it was neither sleeved nor sealed. Thelack of sleeving left the pipe unprotected fromthe brickwork and any building movements.When the pipe was later buried, the absence ofsealant provided an easy tracking route, but notnecessarily the only one, for any escaping LPG.The underside of the right angled bend wassignificantly corroded. It had a crack of about71% of its circumference. The failure of the bendcaused a significant leak close to the entry pointof the pipe into the basement.107

PART 7Under the terms of the contract with Calor,ICL Plastics, under the managing directorshipof Campbell Downie, were responsible forthe installation of the underground pipeworkbetween the tank and the LPG ovens.Calor’s letter of 29 May 1969 noted:‘…..should our quotation be acceptable toyou, the galvanised iron pipe, pipe fittings,et cetera, required to connect from the twoovens to the bulk propane supply should becarried out by your own labour force.”and the notes to the quotation specified that“it would be the customer’s responsibility toexcavate and subsequently infill a suitabletrench to accommodate the high pressurepipeline from the Bulk Storage Vessel to themain building.”According to a Calor witness, it was likely thatif the customer had indicated that he intendedto arrange for the laying of the pipework, Calorwould have provided a specification and arecommended method of working. No evidenceof any such specification or working methodhas been found. There is no evidence that anyspecialized technical advice was either sought orgiven in relation to the laying of the pipework.Campbell Downie’s brother-in-law, FrankSemple, supervised the installation of theunderground pipework. It appears that heengaged a subcontractor whose identity isunknown. On 17 December 1969 ICL Plasticswrote to Calor confirming that “our installationconforms to the necessary precautions for tankinstallations”. Whatever those precautions were,they were not met.Full galvanisation and Denso wrapping wouldhave provided some protection against thecorrosive effects of the surrounding soil andextended the safe life of the undergroundpipework and its fittings; but neither would haveprotected them from corrosion indefinitely.After the pipework was installed, no record waskept of the condition in which it was buried. ICLPlastics failed to keep its condition under review.(2) The raising of the level of the yard in early1973This was the next critical event. ICL Plasticsappear to have left it to the builders to decidehow to carry out the work. It appears thatthe builders carried out the work without anytechnical advice. Without the specification orthe plans submitted with the application forthe building warrant, I cannot say whether thebuilders were aware of the entry of the pipeinto the building.The yard was raised by using rubble andsoil infill and then surfaced with concrete.This buried the LPG pipe where it enteredthe building. The soil and rubble had acorrosive effect on the now buried riser andthe ungalvanised right-angled pipe bend. Therisk of corrosion is greater close to a buildingbecause of the higher moisture content of thesoil in that area, generally from the run-off ofrain.The weight of the soil and rubble and theconcrete slab resting directly on top of the riserpipe put additional stress on the right-angledbend where it turned to pass through thebricked-up window. This particular source ofstress is consistent with the position of the crackin the pipe. Although the loading on the pipe108

THE ICL REPORTwas one of the factors that led to the criticalevent, the right-angled bend, with the remainingpipework, was bound to fail at some point inconsequence of corrosion. This is shown by thesmall perforation found in the pipe about a thirdof the distance from the tank.My conclusion is that it is unlikely that thosewho raised the level of the yard consideredwhat effect that would have on the pipeworkor whether it should be protected in any way.Their failure to protect the pipe or to seal theentry point at the building demonstrates howlittle they knew of the properties of LPG or ofthe vulnerability of buried metal pipework andfittings to corrosion.Since there was no sealing around thepipework, the burial of the pipework under thenew level of the yard provided a means bywhich LPG leaking from the pipe could trackinto the building and accumulate there.Tracer gas tests made after the explosion showedthat there was a leakage path below the pipeentry point. I cannot determine the exact pathby which the LPG tracked into the building. LPGtracks the easiest route and can permeate throughsubterranean structures. One cannot assumethat if the entry point been sealed it would haveprevented the LPG from passing into the building.A suggestion was submitted to the Inquiry that theLPG may have welled up and then, by reasonof the building alterations, accumulated in thebasement by way of the stairwell. Whatever theexact means of ingress, what matters is that theLPG escaped from an underground corrodedpipe, cracked in consequence of externalcorrosion and a weight bearing load at a pointdirectly outside the unsealed entry of the pipe tothe building and accumulated in the basement.(3) The laying of the steel chequer-plate floorover the open pit area at the west end ofthe building in 1982.In 1982 Campbell Downie instructed JGNReid Brothers Limited (Reid) to supply and installthe steel floor over the open pit. Reid built afreestanding mezzanine structure consisting ofsteel chequer-plate flooring supported on lateralsteel beams, in turn supported on steel columnsfooted on concrete plinths. This extended theexisting suspended concrete ground floor toform the despatch area. The ground floorinternally was above the external ground level.A wall divided the closed-over pit from theremainder of the original basement area. Nomechanical ventilation was installed.There is no evidence that any of thoseconcerned in these works thought about theLPG pipe in the basement or about the potentialconsequences if there should be a leakage andaccumulation of LPG within the void.Even before the steel floor was laid, thebasement had no mechanical ventilation. Suchnatural ventilation as there was would beinadequate to disperse an accumulation of LPG.While the construction of the steel floor mayhave reduced any natural ventilation, it did notcreate an unventilated void. The void alreadyexisted and LPG was capable of collecting atthe bottom of it. It was possible that the LPGcould have reached a critical explosive mix,even without the presence of the steel floor.The real significance of the laying of the steelfloor was that the LPG pipework, where itentered the building, could no longer be seenor accessed except in the basement. The layingof the floor also made it less likely that a leak ofLPG would be detected by smell.109

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THE ICL REPORTPart 8111

PART 8Chapter 16 – The responses of HSEand of the industry in the aftermath ofthe disasterHSEPost explosion guidanceAfter the explosion HSE gave a relatively lowpriority to the planning of a metallic pipeworkreplacement strategy. HSE considered thatan explosion of this kind was a relativelylow probability event, that it had to prioritiseits resources and that it should develop areplacement strategy in collaboration with theindustry.Discipline Information Notice (DIN) NoCD5/059 “Developing an inspection strategy toensure the ongoing external integrity of buried,metallic, LPG pipework” (November 2004)This internal technical note drafted by PennyTaylor was issued in November 2004 toprocess safety and mechanical engineeringspecialist inspectors. The background note to itrecords that“HSE knows of several cases of externallycorroded buried, metallic, LPG pipework.Corroded pipework may lead to LPGreleases that can accumulate, igniteand explode. Several cases of externalcorrosion of buried pipework, one of whichled to building collapse and personalinjury, have been reported to the HSE. ThisDIN is to promote awareness and providea timely reminder of the safety precautionsapplicable to metallic underground pipescarrying LPG as a vapour or liquid”.This notice sets out the comparison withnatural gas and explains the Advantica servicereplacement policy for natural gas lines. It thenprovides a short summary of the applicablelegislation and review of the guidance. Italso details an inspection strategy for buriedpipework stating that“the only really effective inspection methodcurrently available is to excavate and visuallyinspect the sleeve or coating for defects andif possible the external surface of the pipe.For this reason metallic pipework should onlybe buried when it is unavoidable.”It highlights the limitations of pressure testingsince it will not indicate the exact location of aleak nor the condition of the pipework. It alsohighlights difficulties in the use of gas detectingdevices. It recommends that an inspectionstrategy should be developed by a suitablycompetent person and sets out the factors to betaken into account in preparing such a strategy.The notice contains a warning that “it is notconsidered good practice to excavate a livepipe, i.e. containing LPG.”Checking LPG Pipework Leaflet (March 2006)This leaflet was produced in March 2006 anddistributed to LPG users. It clearly explains thatthe user is responsible for its LPG pipework. Italso sets out in plain English questions that theuser should consider when checking the natureand condition of LPG pipework. If in doubt, theuser is advised to contact the HSE infoline. Fewusers have done so.Shuna Powell Report “Industry practice regardingthe integrity of buried metal LPG pipework”PE/05/08R 2006 (29 November 2006)This Report follows on a survey, commissionedby HSE, of about 500 companies with limitedknowledge of their LPG and associated buriedpipework. In the course of the survey 29companies were visited.The findings of the Report showed that therewas a serious lack of comprehension amongstusers about the dangers of underground metallic112

THE ICL REPORTLPG pipes and about the levels of maintenancerequired, and generally poor knowledge of therelevant regulatory framework.Those users that took part in the surveywere provided with a copy of the DisciplineInformation Notice (DIN) No CD5/059 of2004 to which I have referred. It is not clearfrom the Report what action, if any, HSE tookwhere the state of the pipework was unknown.OC/286/105 “The ongoing integrity ofburied, metallic LPG pipework – inspection andenforcement considerations” (April 2008)This Operational Circular was directed andcirculated to all operational inspectors in FieldOperations Directorate (FOD) and HazardousInstallations Directorate (HID) and related to a“matter of potential major concern, namely theongoing integrity of buried, metallic pipework,used for conveying LPG as a vapour or liquid.”Matters of “potential major concern” aredefined in OC 18/12 as being “those thathave a realistic potential to cause either multiplefatalities or multiple cases of acute or chronicill-health”. This circular advises inspectors onmatters to be considered and on the actionto be taken during visits to commercial andindustrial sites where LPG is used. It specifies thesources of technical advice and support.It advises that if buried metallic LPG pipework isnot protected against corrosion, or if the statusof the pipework or its protection is unknown,prompt action should be taken. The standard tobe achieved is as follows:“Buried metallic pipes of poor or unknowncondition are re-routed above ground andprotected against mechanical damage,where it is reasonably practical to do so.Where it is not reasonably practicable tore-route above ground, theneither –– the buried metallic pipework shouldbe replaced by buried polyethylenepipework or a proprietary pipeworksystem which should be installedin accordance with manufacturer’sinstructions; or– the buried metallic pipework (andits corrosion protection) should beexamined and assessed to confirmits condition as acceptable followingwhich it should be subject to ascheme of inspection, examinationand maintenance to ensure itscontinued integrity”The expectation is that, for initial enforcement,where there is evidence of buried, metallicLPG pipework in poor or unknown conditionor where there is no strategy for inspection,examination or maintenance, an ImprovementNotice should be served. Where there is clearevidence of corrosion, a Prohibition Notice isappropriate. HSE inspectors have issued fourenforcement notices related to underground LPGpipework since the date of the ICL explosion.HSE involvement in Calor’s risk-based strategyfor the replacement of buried, metallic, LPGpipework (“replacement strategy”)I shall describe the Calor replacement strategylater in this chapter.HSE first became involved in the Calor strategyin 2007 when Dr Fullam invited UKLPG toconsider underground pipework in domesticpremises. HSE was concerned that users didnot realise that they owned their pipeworkand were required to maintain it. As a result113

PART 8of the ICL explosion and an LPG explosionin November 2006 at a house at Glenspin,South Lanarkshire, caused by a leak from anunderground pipe, HSE’s concern was the riskof gas entering a building and being ignited.HSE, UKLPG and members of the industryagreed to develop jointly a risk-basedapproach to the identification and replacementof pipework most at risk of corrosion.The factors to be considered in developingthe matrix were the soil type, the materialsused in the pipework, the location of the pipein relation to the building, whether the entrypoint of the pipe into the building was belowground, and whether the pipe was sleeved. Atthat time Calor had been conducting researchsince 2006, which indicated that corrosion waslikely to be greater in sandy soils than in claysoils.HSL researchAll parties hoped to use a model developedby Transco and Advantica (the Advanticamodel) that I shall describe in more detail later.This modelled the likelihood of the ingress ofgas into buildings from natural gas pipes. IfHSE and UKLPG could use this model, or anadjusted version of it, the work to developan action plan to replace LPG pipework thatwas at risk could proceed more quickly. InDecember 2007 HSL, through Dr Fullam,agreed to fund and undertake additional workto assess whether the Advantica model couldbe used for this purpose.At the end of the oral hearings of the InquiryDr Fullam said that, although it was not yetcomplete, the HSL research suggested that, withsome modification, the Advantica model couldbe applied to industrial/commercial pipework.He said that he expected that a prioritised listof replacements would be in place betweenEaster and summer 2009 and that a plan ofaction would be agreed in the latter part of2009. He said that the question of resourceswould have to be considered in parallel withthe development of a plan.MiscellaneousHSE has improved operational instructionsfor HSE and LA staff. In April 2005, it issuedrevised operational procedures. The COINcomputer system now provides the standardsand support systems to manage follow upvisits to premises. HSE will introduce a newcompetence-related training programme forregulatory and specialist inspectors in 2009.CalorReplacement strategy – The research programmesAdvantica research into buried pipeworkAdvantica has conducted extensive researchinto the failure mechanisms of underground gasmains. It has developed a mains and servicereplacement model used in the United Kingdomnatural gas industry for metallic mains. HSE hasendorsed its methodology.Calor research into buried LPG pipeworkThe Calor research into buried LPG pipeworkwas commissioned after the explosion atGlenspin. During the investigation into theincident it became apparent that one of thepossible causes was corrosion of the servicepipework. Mr Gary Tomlin reported this toa meeting of the Calor Safety Health andEnvironment Business Management Team.He was then authorised to conduct researchinto ageing metallic underground LPGpipework.114

THE ICL REPORTCalor’s research was carried out betweenNovember 2006 and February 2008. Itsmain purpose was to further understandingof the mechanism of corrosion of LPG servicepipework; of the factors that affect corrosionand the migration of escaping gas; and of thepotential for explosions.Calor conducted a database survey anddetermined the number and location of theircommercial customers. Calor believe that theyhave about 8000 commercial customers whoseinstallations predate 1993, and therefore theymay have metallic pipework as a part or wholeof the system.The first part of the research was carried outthrough inspection and, where appropriate,excavation at 500 domestic premises in England,Scotland and Wales where the LPG vessel wasinstalled before 1993. Calor also visited domestic,industrial and commercial sites where, after areport to Calor’s emergency service, a Calorengineer had confirmed that a gas escape hadoccurred from service pipework.Calor also inspected their LPG distributionnetworks. They conducted leakage surveys onseveral hundred installations and had specialistcontractors carry out certain excavations.The research was focused on the material ofthe pipework, its condition, its routing, and itsoperating pressure, the corrosion mechanisms,the migration of gas and the means of detectingescapes.With the information gained from this research,Mr Tomlin developed Calor’s pipeworkinspection strategy and their risk-basedreplacement programme.Calor procedure for inspection and replacementCalor-owned pipeworkIn 2006 Calor introduced an internalprocedure for the inspection and replacementof pipework that they own; for example,pipework installed on metered estates. Theyhave begun a programme of work to surveysuch pipework annually and to replace it wherenecessary. Where metallic pipework does notrequire immediate replacement, Calor carryout a risk assessment and prioritise it for futurereplacement.Customer-owned pipeworkIn relation to customer-owned pipework atindustrial and commercial installations, Calorare working with UKLPG, other suppliers andthe HSE to identify, by means of the risk-basedstrategy, those installations that are at greatestrisk.Calor have shared the information gained fromthis research with HSE and with the industrythrough UKLPG. The HSE, through HSL, isundertaking practical experiments in order tovalidate Calor’s findings on the phenomenonof LPG migration. If HSE’s findings are inagreement with Calor’s, a risk-based modelwill be adopted by HSE to identify thoseinstallations that are in high risk areas. Theconsequence will be a prioritised programmeof replacement of underground pipes based onrisk rather than on continuing inspection.“Checking LPG Pipework” leafletAfter the ICL explosion, Dr Terry Ritter andMr Gary Tomlin collaborated with HSE in thedevelopment of its Checking LPG Pipeworkleaflet. Calor distributed this leaflet to all theirindustrial and commercial customers. They alsoset up a dedicated helpline and website.115

PART 8After that a reminder letter was sent to customers.For those with installations from before 1992,the letter highlighted the fact that their buriedpipework might be metallic and would requireinspection and replacement. Calor offered toassist customers with such work.Technical Memorandum No 84/ UKLPG UserInformation Sheet No 15Calor assisted LPGA and HSE in thedevelopment of LPGA Technical MemorandumNo. 84 (TM84) “Inspection and Maintenanceof LPG Pipe Work at Commercial and IndustrialPremises”. This is now available from thewebsites of UKLPG and Calor as UKLPG UserInformation Sheet No 15.Johnston Oils LtdInitial site survey at tank exchangeIn 2005 when Johnston Oils became aware ofthe cause of the ICL explosion, they carried outa site survey at every tank exchange to establishif the installation had steel risers.Where the standard and design of aninstallation is unknown, Johnston Oils’ currentpolicy is to carry out a site survey and a riskassessment of the pipework. If there is evidenceof buried steel pipework, Johnston Oils suggestremedial action. The appropriate remedialaction could be to replace it. If the customeris not prepared to accept Johnston Oils’recommendation for remedial action, the tankexchange will not take place.Site survey of all installations supplied byJohnston Oils (commercial and domestic)Johnston Oils are now undertaking a site survey,separate from the UKLPG survey to which theyhave also contributed, of all installations, bothcommercial and domestic, to which it supplies.They intend, on completion of the survey, toshare the results with all their customers. Thissurvey is also separate from the procedure thatthey now enforce at tank exchange. JohnstonOils are therefore systematically examiningevery installation to which they supply gas. Theywere about halfway through this programme inOctober 2008. They expect to complete it byJuly/August 2009.Assistance to usersJohnston Oils respond to requests for technicalinformation and advice from SMEs by carryingout a site visit which may include a riskassessment. They make an accurate record ofthe bulk vessel and all pipework at the time ofinstallation, or at a tank exchange and after allannual inspections.Their policy is to liaise with their customerswhen an agreement is entered into andregularly throughout the contract. They issuethe HSE leaflet Checking LPG Pipework to theircustomers.UKLPG and LPGAChecking LPG Pipework leafletIn 2005-2006 the LPGA worked with HSEand other parties to produce the HSE leafletChecking LPG Pipework to which I havereferred. In 2006 about 65,000 copies ofit were distributed by LPG suppliers to theircommercial and industrial customers. Telephoneenquiries to the HSE Information line and tothe LPG suppliers were lower than expected.Several LPG suppliers have repeated thisexercise.Desktop exerciseLPG suppliers carried out a desktop exercise in2007 to estimate the proportion of domestic bulk116

THE ICL REPORTinstallations that could present a high to mediumrisk. The estimate was based on the age ofthe installation, the pipework material and thepressure under which the system operated.In early 2008 survey documentation wasdistributed to all LPG suppliers to help them toidentify which of their domestic bulk installationsmight be at higher risk. The survey material isnow being interpreted by LPG suppliers.Draft safety cardAt the same time UKLPG provided a draft gassafety card to all LPG suppliers for distributionto users or for incorporation in their ownpublications. The card reminds the customerof the actions to be taken in an emergency,raises CO2 awareness and stresses the need toemploy CORGI-registered installers.Technical Memorandum 84/UKLPG userinformation sheet 15LPGA Technical Memorandum No 84, nowUKLPG User Information Sheet No 15, Inspectionand Maintenance of LPG Pipework at Commercialand Industrial Premises, was published on theUKLPG website in March 2007.It outlines the need for pipework owners toinspect LPG pipework and maintain it in asafe condition. It advises that an inspectionstrategy should be drawn up based on a riskassessment of the system. It describes the factorsto be considered in the risk assessment, suchas the phase of the LPG, the location of thepipework, the routing of the pipework and itspoint of entry into the building. It deals with thesubsequent risk categories and gives examplesof risk strategies that may be applied. It doesnot highlight other factors that have since beenfound to be relevant, such as soil type andsurface cover. At its conference in April 2008UKLPG held a seminar on the subject.Codes of PracticeUKLPG Codes of Practice (CoPs) are reviewedroutinely every three years. The most recentrevision is to Code of Practice 1, Part 1 (January2009).UKLPG has redrafted CoP 22 to take accountof revised guidance regarding checkingunderground pipework. The redraft is currentlyout for consultation.The proposed revisals will reinforce therecommendations that pipework should alwaysenter premises above ground level; thatpipework should not be installed in unventilatedspaces; that all systems should incorporate anemergency control valve; that buried pipeworkshould not be metallic, and that buriedpipework should be subject to risk assessmentand an inspection and maintenance strategy.UKLPG had a meeting with the IGEM,along with Calor and Advantica, to discusssimplification of the codes of practice thatapply to LPG pipework in all uses, includingUKLPG CoP 22, IGEM UP/1, TD3 and TD4.The objective is to remove duplications and toremove all doubt as to the extent to which thevarious Codes apply.Involvement in Advantica/Calor modelWorking closely with HSE, the LPG industryhas been reviewing LPG installations in orderto produce a “risk matrix” by which thoseresponsible for underground service pipeworkcan understand the risks associated with it andidentify the timescale by which they shouldreplace it.117

PART 8Shell Gas Limited (SGL)SGL has been working along with othermembers of the UKLPG and the HSE on thedevelopment of the Checking LPG Pipeworkleaflet. During 2006 and 2007 it too sentcopies to all its industrial and commercialcustomers. At the same time SGL supported thedevelopment of User Information Sheet 15 withother suppliers and with HSE. Its managementhas consulted with its engineers and commercialstaff on the problem of raising awareness ofthese documents among its users.In 2007, SGL undertook a desktop exercise todetermine how many customers in the domesticmarket sector might have pipework at risk asa result of the material used and the operatingpressure.In July 2008, SGL as part of Shell’s globalSafety Day campaign, briefed all staff on thequestion of pipework integrity. It appears thatthis was primarily aimed at domestic customers.SGL is a participant in the development ofthe Advantica risk-based approach to steelpipework replacement.118

THE ICL REPORTPart 9119

PART 9Chapter 17 – LPG safety:an overview[1] IntroductionIn this part of the Report I shall examine ingeneral terms the weaknesses of the regulatoryregime that this disaster has exposed and setout the general principles on which, in my view,a proper safety regime should be based.Suppliers and UsersThe contractual arrangementsIn this part of my Report, I use the terms “user”and “supplier” in a non-technical sense; that isto say I do not use these expressions as theyare defined in the GSIUR 1998. By user I meanthe party who uses the LPG in its appliances,whether for manufacturing, heating or otherpurposes. By supplier I mean the retailer whofills the user’s tank.In most cases, the supply of LPG is a matterbetween supplier and user alone. In suchcases the LPG supplier normally owns thetank and provides the tank as part of theoverall supply contract. The extent to which thesupplier owns the associated pipework varies.I deal with this problem at a later stage in myrecommendations. There are however industrialsites where the LPG user owns the tank and istherefore able to buy LPG from any one of arange of suppliers at the best available price.In most of the discussion that follows I shall speakof the straightforward situation where there is asingle supplier and single user and I shall confinemy discussion and recommendations to the caseof an LPG supply to commercial and industrialpremises. My understanding is that in LPGinstallations at domestic premises, with which thisInquiry is not concerned, it is common for thesupplier to own the tank and the pipework asfar as the second stage regulator, although thispractice is by no means uniform.In the ensuing discussion therefore I shall notdeal specifically with the exceptional caseswhere there is an LPG supply to meteredestates, with multiple users and a managinglandlord or system operator. In such cases eitherthe supplier or the managing landlord or systemoperator assumes responsibility for the LPGpipework in order to avoid the confusion thatwould result if responsibility were to be spreadamong the individual users.There is also the exceptional case of liquidfilling installations, such as auto gas fork lifttruck filling installations where the normalarrangement is that the supplier retainsownership of all safety-critical items such aspumps, dispenser, filling gun and non-metallichoses.The user side of the industryOne of the most notable features of the industryis the variety and diversity of the users. Althoughalmost every major supplier has among itscustomers one or more major users, the majorityof the users are small to medium sized enterprises,almost all of whom would regard LPG as simplyanother utility of which to make use in the courseof their business. This diversity has considerableimplications for safety. It points to the need for atighter and clearer safety regime.In terms of the COMAH Regulations, top tiersites, having an inventory of more than 200tonnes of LPG, must prepare a Safety Reportdemonstrating that a Major Accident PreventionPolicy (MAPP) has been properly implemented,that adequate safety and reliability have beenincorporated into the design, operation andmaintenance of the facility, that emergencyplans are being prepared and that sufficientinformation has been given to the competent120

THE ICL REPORTauthorities to make decisions (COMAHRegulations Schedule 3: cf A Guide to theControl of Major Accident Hazards Regulations1999, HSE books, L111, 1999). For lowertier sites, having an inventory of more than50 tonnes of LPG, the COMAH Regulationsrequire the preparation of a MAPP to provide astatement of senior management’s commitmentto providing an organisation that can achievea high standard of major hazard control(COMAH Regulations, Schedule 2).The preparation of MAPPs and safety reportsare demanding tasks requiring an effortcommensurate with the hazard potential ofthe site. However, the great majority of LPGusers are not subject to these requirements and,such is their diversity, the achievement of asatisfactory standard of safety may be difficultto secure. Such users are subject to healthand safety duties under MHSWR, PUWER,DSEAR and PSSR. Their obligation to preparea risk assessment is much less demanding thanthe obligations incumbent on the operators ofCOMAH sites; but, as this case has shown,even a small LPG site can suffer a majordisaster.The uncertain extent of communicationbetween supplier and userIt has clearly emerged from the Inquiry that atpresent the degree of communication betweensupplier and user may vary considerably. Muchdepends on the size and technical resources ofthe supplier and on the degree of commitmentto safety on the part of the user. In my opinion,the effective flow of information and advice fromsupplier to user cannot be allowed to remainon this uncertain basis. In the following chapterI make certain proposals with a view to havingthis put on a more formal and rigorous basis.The view of the industryAlthough only two suppliers were coreparticipants, I am satisfied that the view of theindustry on any relevant topic, where there issuch a view, has been reflected in the evidencecontributed by UKLPG. Where there appearsto be no industry view, or where there aredifferences in view within the industry, I havementioned that specifically in discussing myrecommendations.The contribution of Mr Sylvester-EvansIt is a pleasure to acknowledge the help thatMr Rod Sylvester-Evans has given to the Inquiry.His evidence has provided me with a valuableindication of the direction in which the industryshould travel in its pursuit of the unattainableideal of absolute safety.Mr Sylvester-Evans’ conclusions have beengenerally accepted by the core participants.His recommendations, subject to minor mattersof detail, seem to me to make good senseand to provide a pragmatic solution. Theyhave the considerable merit that they canbe implemented within the existing statutoryframework. Although my own recommendationsdo not coincide with his, I base them largely onMr Sylvester-Evans’ template and, in so doing,acknowledge my considerable debt to him forhis clear-sighted view of the issues.[2] My preferred approachThe need for a coherent responseThe effort that went into the retrieval of evidencefrom the site of the disaster and the expertisethat was enlisted to discover the causes of thedisaster will be largely in vain if this Inquirydoes not lead to a coherent programme ofaction that will minimise the risk of a recurrenceof such an event. Much of the talk at this Inquiry121

PART 9was to the effect that my recommendationsshould ensure that a disaster of this kind willnever happen again. Ensuring that such adisaster does not happen again is beyondthe reasonable expectations of any set ofrecommendations, however well considered;but the aim must be to minimise the risk so faras can be done. This requires a concerted andlogical programme of action.Some basic principlesI make all of the recommendations that follow inChapter 10 with the fundamental objective ofensuring that every LPG installation is safely andproperly installed, safely and properly managedby the user and safely and properly overseenby the regulatory bodies having responsibilitiesin respect of it.In the achievement of that fundamentalobjective, there are certain subsidiary principles.In my opinion, pre-eminent among these isthe principle that, whatever may be the dutiesand responsibilities of regulatory bodies andof suppliers, the primary responsibility for LPGsafety lies, from first to last, with the party whocreates the risk. That means, in effect, the siteuser. It is the user who brings onto the land ahighly volatile and dangerous gas. No amountof responsibility for safety on the part of anythird party can ever be said to absolve the userfrom that primary responsibility. This principlehas considerable relevance in the presentcase. I have little doubt that ICL’s unenthusiasticapproach to LPG safety, at any rate in MrFrank Stott’s time, was allied to the idea thatsafety measures were to be taken only at theprompting of HSE. That is a fundamentallyfallacious attitude that should have no part inany modern safety regime.General conclusionThe Inquiry has left me in no doubt that thepresent safety regime is inadequate. Thequestion then is what approach should be takento improving it. My general conclusion is thatprogress in this field should, wherever possible,proceed on a basis agreed between HSE andthe industry, which means in effect UKLPG,and that a heavy-handed regulatory approachis to be avoided except where it is essential.However, a consultative approach and a cooperativespirit will be pointless if progress is notmade with an appropriate sense of urgency.More specifically, my approach proceeds on theview that the regulatory authorities, and HSE inparticular, should start from a proper knowledgeand understanding of LPG risks; should achievea standard of inspection and enforcement thatis appropriate to the seriousness of these risks;should be consistent in their approaches toenforcement; and should have clearly definedlines of demarcation between their respectivespheres of competence.Lastly, my recommendations proceed on thebasis that there should be no barriers to thefullest possible sharing of all health and safetyknowledge relating to LPG between theregulatory authorities, the suppliers and the users.I have tried throughout my recommendations tomake proposals that are practical and readilycapable of implementation without unreasonablecost. Nevertheless, I recognise that in relationto my proposed metallic pipework replacementprogramme, the cost implications may wellbe significant. Having regard to the potentialrisks that now exist, I do not consider that onthis aspect of my recommendations cost canconstitute a reasonable ground of objection.122

THE ICL REPORTTable - Comparison of Gas Incidents with some Everyday RisksCause of DeathAnnual Risk ofDeathAnnual riskper Million(approx)RefSourceMen aged 65 to 74CancerInjury & PoisoningAll accidental causesAll forms of road accidentsFire and flameFatalities to workersHomicideAll Gas incidents (domestic)Gas incidents – CO poisoningGas incidents – fire & explosionStruck by lightning1 in 511 in 3871 in 3,1371 in 4,0641 in 16,8001 in 125,0001 in 125,0001 in 166,7001 in 2,210,0001 in 2,840,0001 in 10,000,0001 in 18,700,00027,8002,600318246608860.450.350.100.053123334546667Table References: -1. Annual Abstract of Statistics (2001) – Health Statistics Quarterly – Summer 20012. Annual Abstract of Statistics (2001) – England & Wales - 19993. Annual Abstract of Statistics (2001) – UK -19994. Annual Abstract of Statistics (2001) – England & Wales – 1991-20005. HSC Health & Safety Statistics 2002/03 to 2006/07, based on an average fatality rate of0.8 per 100,000 workers per year.6. From HSE – Gas Safety Statistics – 1997/98 to 2006/07 (Domestic related, averaged overthe UK population and includes natural gas and LPG)7. Office of National Statistics (2001) – England & Wales 1995 to 1999.Putting LPG safety in contextNotwithstanding its naturally hazardousqualities, the use of LPG in industrial,commercial and domestic installations is,in general, safe. One cannot assert theproposition with any greater certainty thanthat since the only available data are derivedfrom “piped” gas supplies, an expressionthat comprehends both natural gas and LPG,and does not disaggregate gas incidents inindustrial and commercial installations fromthose in domestic installations.The risk table gives the opportunity for acomparison of gas incidents with a variety ofeveryday risks. The table categorises three setsof data in relation to three categories of gasincidents, namely all gas incidents (domestic);gas incidents – CO poisoning; and gasincidents – fire and explosion. The table showsthat, in general, the risk of gas explosions issmall in relation to all but one of the othereveryday risks described in the table.123

PART 9This table adequately establishes theunlikelihood of the occurrence of an LPGexplosion in terms of statistical probability. Butthe worrying question, of course, is not howlikely it is that an LPG explosion will occur, butwhat may happen if it does.[3] Weaknesses in the present systemThis Inquiry has highlighted, in stark form, thefollowing nine aspects of the present LPGregime that give rise to significant risks.The problem of metallic pipeworkIt has become clear from this Inquiry that theHSE and the suppliers have only the mostuncertain estimates of the scale of the problemof metallic underground pipework.The clear and overriding hazard which thisdisaster has highlighted is that there is, to anextent that is yet to be exactly determined, aconsiderable amount of underground metallicLPG pipework whose state of integrity isunknown. Since the use of polyethylenepipework has been standard practice for overtwenty years, it is likely that existing metallicpipework has been subject to a long periodof corrosive attack. None of this pipework issubject to any systematic regime of inspectionand maintenance; nor subject to systematicdata recording. As matters now stand, thereis every possibility that a similar disaster couldoccur again.Responsibilities of user and supplierTwo main problems arise from the relationshipof the user and the supplier. The first is that thereis no uniformity of practice in the demarcationof responsibility for LPG installations betweenthem. Most suppliers seem to acceptresponsibility up to the first stage regulator,but at least one of the major suppliers, Calor,accepts responsibility only up to the vapouroff-take valve.The second problem is that since the supplierdisclaims responsibility for the pipework beyondthe point stipulated in the supply agreement,and since the industry considers that the supplierhas no obligation to inspect the user’s pipeworkbefore supplying to it, there is no safeguard toprevent a user whose installation is dangerousfrom accessing supplies of LPG.Lack of systematic record keeping of allinstallationsThis inquiry has demonstrated that one of themajor weaknesses in the current regime is thatno user is obliged to keep comprehensiverecords of all matters relevant to the safetyof it; for example, design drawings, plans,maintenance records and the like.The problem of awareness of riskThere are also weaknesses in the appreciationand prevention of LPG risks. The problem showsitself in several ways. For the bulk LPG user, theLPG supply is only ancillary to the user’s mainpurpose and effort, and is not at the forefrontof the user’s attention. There may also be atendency for the safety of buried pipeworkto be overlooked. The problem of a lack ofawareness of LPG hazards may be moreacute in the case of small and medium sizedenterprises.As a result of this failure in awareness of risk,it is possible for pipework for this hazardousproduct to be designed and laid by personswho have no particular expertise in LPG safetyand only a meagre appreciation of the risks. Asthis Inquiry has shown, it is possible for changes124

THE ICL REPORTto be made to the physical surroundings ofan LPG installation, like the raising of the yardand the creation of the basement void in thiscase, without there being any consideration ofthe implications for LPG safety. This Inquiry hasalso shown that the user of an LPG installationmay entirely overlook the safety considerationsaffecting buried pipework and that a formalrisk assessment may be carried out by persons,however conscientious and well-intentioned,who lack a proper awareness of the risks thatburied pipework creates.It follows from these possibilities that a lackof awareness of the safety considerationsmay also indicate a lack of knowledge of thepotential consequences of an escape of LPGand in particular the potential consequences ofan explosion. Such lack of awareness of riskleads inevitably to failures in the managementof risk and in the taking of measures tomitigate it; to failures in the proper response tosafety incidents, and to failures in educationand training of staff in the appreciation andmanagement of risk.These problems have been highlighted sincethe occurrence of the disaster in the HSL reportIndustry Practice Regarding the Integrity ofBuried Metal LPG Pipework (PE/05/08R: 29November 2006). From a sample of 58 LPGsites that had buried metal pipework, HSL foundthat documentation and records relating to theburied pipework system were rare; that generallythe understanding of the levels of maintenancerequired for it was poor; that some sites hadnever conducted an inspection of it, had noidea where to obtain information, and had notconsidered any risk assessment relating to it; andthat on other sites that had procedures in place,these procedures did not extend to preventativeand maintenance programmes. Of thecompanies that felt that they had a maintenanceprogramme in place, many of the programmeswere unlikely to be sufficient to assess theintegrity of the pipework. Few companies hadknowledge of what was done by sub-contractorsbrought in to maintain it. Before the visit by HSL,many companies believed that the responsibilityfor the maintenance of it lay with the tankprovider and/or the LPG supplier. HSL alsofound that the majority of the users visited did notknow where to find information relating to theinspection and maintenance of such pipeworkand that some felt that if the PSSR did not applyto them, then they did not have to check theintegrity of the buried metal pipework at all.In its recent Operational Circular The OngoingIntegrity of Buried Metallic LPG Pipework –Inspection and Enforcement Considerations(OC286/105, version 1, updated to 12 May2008), HSE give priority to alerting its owninspectors “to a matter of potential majorconcern, namely the ongoing integrity of buried,metallic pipework, used for conveying LPG asvapour or a liquid.”Since the HSL study on which its 2006Report (supra) is based also found that thequality of ventilation at some LPG sites wasquestionable, even when the users believedthat the area was ventilated, there is everyreason to conclude that some LPG users havean inadequate understanding and appreciationof LPG hazards. That fact alone is cause forserious concern. While there is such a lack ofappreciation, it is little wonder that managementweaknesses are reflected in a failure toappreciate the existence of hazard, let aloneto deal with it by effective programmes ofmonitoring and maintenance.125

PART 9My findings in fact demonstrate that each ofthe events that contributed to the causation ofthe disaster resulted from a wholly inadequateunderstanding of the nature of LPG risks and awholly inadequate appreciation of the natureand extent of the hazards and risks associatedwith the installation, together with a safetyculture in which LPG risk was not given anyproper degree of priority.Inadequacies of the risk assessment systemAs this case vividly illustrates, compliance withthe risk assessment provisions of MHSWR andDSEAR gives only a limited assurance of thesafety of an installation. It is possible for whatmay look like a full risk assessment to miss asignificant risk, as happened at GroveparkMills.Unregulated entry to the LPG market placeAnyone who can find a source of LPG canenter the market as an LPG supplier and isunder no obligation to join UKLPG or to abideby its codes of practice. In an industry thatdeals with such a hazardous product, suchpossibilities are not, in my view, conducive tosafety.Demarcation of responsibilities of HSE andlocal authoritiesThe Inquiry has brought to light a lack of clarity,which I did not expect, as to the respectiveprovinces of HSE and local authorities inrelation to safety standards in industrial andcommercial premises in which there is an LPGsupply.In terms of the Health and Safety (EnforcingAuthority) Regulations 1998 HSE is, in general,the enforcement authority for industrial premises,hospitals, educational establishments andconstruction sites, whereas the local authorityenvironmental health departments are theenforcement authorities for other premises suchas retail sites and offices.There is a complication relating to responsibilityfor inspection and enforcement of the structuralsafety of buildings. It appears that in relationto the safety of the building, from the point ofview of structure and layout, the responsibilitiesof HSE and the buildings authority mayon occasions overlap. The respectiveresponsibilities of HSE and local authorities inrelation to the structural safety of buildings canbe ascertained from a careful reading of thelegislation and the relevant regulations andcirculars; but only with difficulty.In this case, the demarcation of responsibilitybetween HSE and the local authority buildingcontrol departments is prescribed in the HSEOperational Circular OC404/21 (StructuralSafety: Action by Inspectors Including Liaisonwith Local Authorities, 31 January 1991) andHELA Local Authority Circular No 82/2 (RevdMay 2000, review date May 2005).For new buildings and for the initiation ofremedial action for structural instability,responsibility lies with the local authoritybuilding control department. In accordance withsection 1(3) of the HSWA, HSE enforcementofficers “should address the structural safety ofexisting buildings.” This expression is also usedin HELA LAC 82/2 (supra); but in the earlierHSE Operational Circular OC404/21 it is saidthat “HSE inspectors are more often concernedwith safe systems of work than with structuralsafety of existing buildings, although HSWAsection 1(3) explains that risks to safety andhealth includes risks attributable to the condition126

THE ICL REPORTof the work premises therefore inspectors have arole to play on which guidance is given below.”The guidance referred to in OC404/21 (supra)is to the effect that where, in any HSE-enforcedpremises, the building or structure is inaccessibleto the general public, it may be appropriatefor matters of structural danger to be handledby HSE. The OC says “Where the stability ofa building is put at risk by the work activity inthat building, then the inspector should enforceunder HSWA section 3 or probably section 2as appropriate. The local authority should beinformed of action taken in this respect.” Theguidance in LAC 82/2 is broadly to the sameeffect but it refers to the inspector as being the“enforcement officer” and that may be either anHSE or a local authority inspector. LAC82/2also refers to the MHSWR and the Construction(Health, Safety and Welfare) Regulations.At Grovepark Mills, HSE had regulatoryoversight and responsibility for enforcingquestions of building safety as they related tothe workplace.Regulatory weaknessesIt appears that in this case and, I think, moregenerally, there has been a failure by HSE toinstitute a prioritised system of inspection ofolder LPG installations having buried pipework;an insufficient training of inspectors in LPGhazards and risks, and a failure to ensure theeffective follow-up of inspections that haveshown up risks on an LPG site.Lack of communicationThe final area of weakness that I have identifiedis in the lack of effective communication tousers of the risks inherent in LPG installations,and particularly in buried pipework, andin LPG escapes; a lack of effective sharingof knowledge of risks between users andsuppliers; and a lack of prompt and effectivenotification of LPG incidents, and of the lessonsto be learned from them, to users and suppliers.[4] The urgency of the matterIn my opinion, there is no time to lose. I havealready described the HSE response tothe tragedy. The corrosion of the pipe wasidentified at an early stage in the investigationof the explosion. Five years later, HSE has notproduced a coherent action plan to deal withunderground metallic pipework and the riskof a recurrence. HSE’s reaction to the tragedyhas been based on an assessment, made fromcertain data on gas explosions, that the risk ofa recurrence is remote. That assessment hasunderlain its stiffly bureaucratic response to thetragedy and its apparent lack of any sense ofurgency. When asked what priority HSE hadattached to producing an action plan MrsSandra Caldwell said:“We did give it priority but I would wantto put it into context, that there wereother aspects of our work that also had apriority…but if you actually look at the trackrecord for LPG, the probability is a lowprobability.So, yes, we have applied priority. We aretaking work forward, but we would havehad other areas of priority as well outsideLPG that we would balance this work with.….if you look back, there were probablytimes that we may have been able tospeed this up but equally we were workingin partnership with others who also hadtimetable pressures as well.”127

PART 9I am sure that HSE’s response has beeninformed by a genuine appreciation of theneed for a programme of action; but I think thatits approach in the aftermath of the disaster hasbeen misguided in three respects.The first and most fundamental is that althoughthe available evidence suggests that the overallprobability of an LPG explosion is low, thereal worry in this case is as to the degree ofprobability of leakage arising from a failure inburied metallic pipework. That is an avoidable riskthat arises from the inevitable process of corrosion.The assessment of it is entirely dependent onknowledge of the age of the pipework, the extent,if any, to which it is protected and the physicalsurroundings of the pipework, including the soilconditions and the likelihood of impact damage.Where any of these factors is unknown, it followsthat the extent of the risk is unknown, too.The second difficulty in HSE’s approach is thatits own work in this field has not advanced ourknowledge of the number of LPG installations inthe United Kingdom with underground metallicpipework. So the scale of the problem has yetto be assessed.The third difficulty is that since the assumedlow-probability event of an explosion may,in any individual case, have catastrophicconsequences, a sense of urgency would bean appropriate response to the serious issue ofpublic confidence that this disaster has raisedand would be a sensitive response to the depthof feeling on the subject in the west of Scotland.[5] Basic principles of a modernsafety regimeIn my opinion, it is essential that reform in thisarea should be practical and practicable;should avoid the imposition of unnecessaryburdens on the regulatory body and on theindustry; should be readily understood by allwho have an interest in LPG installations; andshould be capable of flexible adaptation in thelight of experience and advances in scientificknowledge.The urgent priorities for action are that thereshould be a complete awareness among allwho are involved with LPG installations of thehazards and risks that are inherent in ageinginstallations and in particular in those that haveunderground metallic pipework. It is essential toestablish a uniform regime that can be appliedto all installations within the wide range ofsites and users. It is also essential that usersshould be educated in the risks and in theirresponsibilities and should know where theresponsibilities of supplier and user begin andend.It is also vital that action of this kind shouldextend to an examination of the buildings intowhich LPG has been introduced.I therefore propose that there should be a clearand concerted action plan and that it should beimplemented promptly and in a co-ordinatedway.[6] The proposed action planFor reasons that I shall give in detail, I considerthat there should be an action plan for all bulkLPG installations in commercial and industrialpremises in the United Kingdom and that theplan should be carried out in four phases.The first and most urgent priority is to identifythose sites where there is underground metallicpipework between tank and appliance andthereafter to replace all such vapour phase128

THE ICL REPORTpipework, on a systematic and prioritised basis,with polyethylene.Along with this there should be an earlyinspection of all buildings that have an LPGsupply in order to identify any hazardousfeatures that arise from the design and layoutof the building or are inherent in the layout orthe condition of the service and installationpipework.The next phase, which I think should runconcurrently with the pipework replacementprogramme, is to establish a permanent anduniform safety regime governing the installation,maintenance, monitoring and replacement ofall LPG systems, including the establishmentof a uniform rule for the demarcation of theresponsibility for any installation betweensupplier and user. This should proceed on theprinciple of life-cycle integrity, that is to saythe principle that the integrity of the systemfor safe operation should be understoodand safeguarded at every stage in the lifeof the system from initial design to ultimatedecommissioning.Next, there should be continuing and planneddevelopment of the safety regime, particularly inrelation to the use of polyethylene pipes.Lastly, there should be a permanent system bywhich safety questions will be reviewed anddealt with on an industry-wide basis, by whichadvances in the knowledge and understandingof safety questions will be communicatedeffectively within HSE and from HSE andUKLPG to suppliers and users alike and bywhich the areas of regulatory responsibilitybetween HSE and local authorities will beclarified.129

PART 9Chapter 18 – The action planPhase 1 – the urgent programmeof pipework replacement andalterations to buildingsAn urgent programme of replacement ofburied metallic pipeworkTerms of referenceThe action plan that I propose in this chapterrelates only to buried metallic pipework carryingLPG in vapour-phase. Much of what I saywould apply to such pipework carrying LPGin liquid form. That however is covered by aseparate safety regime and consideration of itis, in my opinion, outwith my terms of reference.Is replacement essential?It is a basic truth that all underground metallicpipework, even if it is protected, will inevitablycorrode. Protection of the pipe, before it isburied, by means of taping, galvanising andthe like is not a sufficient solution. Even if themeans of protection are applied with completeefficiency, such a measure merely postpones theinevitable day when the pipe will fail. Relatedto this problem is the fact that in any given casethe present condition of an underground metallicpipe that has been protected in this way cannotbe accurately assessed without excavation andexamination. Metallic pipework, even nonferrouspipework such as the copper sectionsthat are used in some installations, has only alimited life. Protective measures, therefore, evenif applied effectively, merely defer the risk.Where the pipework has been given some formof protection, such as a protective sleeve, awrapping of Denso tape or a coating of somekind, it is reckless to assume that the protectionhas been carefully and effectively applied.There is, for example, a right and a wrong wayto wrap a pipe with Denso tape. Furthermore,conditions on the site may make it difficult forprotective measures to be applied effectively. Incases of this kind, even when the date of burialof the pipe is known, it cannot be assumed thatthe anti-corrosion protection will be effective forthe normally to be expected period.The Inquiry has considered various options tomonitor or to protect buried pipework.Pressure testing of underground pipework willidentify if there are any existing leaks in the system,but will achieve little else. A satisfactory pressuretest says nothing about the condition of the pipeother than the fact that at the moment of the test itis not leaking. That is no safeguard. That, I think,was the mistake made when the Ives/Covillecompromise was reached in this case.Of the options short of replacement that havebeen considered at the Inquiry, cathodicprotection is the likeliest. It is of little value innew piping systems when the better option ofpolyethylene is available. Cathodic protectionof an existing system is not, in my view, adesirable option. It necessitates the partialexcavation of the pipe. Since it is in theexcavation that the bulk of the cost of suchan operation is incurred, it seems pointless toexcavate in order to apply cathodic protectionwhen excavation gives the better opportunity ofreplacement. Moreover, since the use of suchpipework has been obsolete for twenty fiveyears or more, the cathodic protection wouldprobably be applied to pipework that wasalready degraded. A further consideration isthat in the common configuration where there isburied polyethylene pipework with steel risers,cathodic protection would have to be appliedseparately to each riser, which would doublethe cost. I conclude therefore that the proposed130

THE ICL REPORTaction programme should be based upona commitment to the complete replacementof all underground metallic pipework withpolyethylene, and to nothing less than that.The responsibility for this work should rest on theLPG user and should be mandatory.This will be a major undertaking that will requirecommitment and co-operation on the part ofusers, suppliers, UKLPG and HSE.Identifying the scale of the problemThe first priority, in my view, is to identify thesites where underground pipework is knownto be, or may be, metallic, whether protectedor not. It is only with that knowledge that therecan be a prioritised programme of replacement.For this purpose, the primary duty of inspectionand, if need be, replacement, must rest on thesite owner.Where inspection short of excavation failsto establish the nature of the undergroundpipework and where the date of installation iseither unknown or is a date at which the use ofmetallic pipework would have been a possibility,it would be irresponsible, in my opinion, tomake any optimistic assumption as to the currentcondition of the pipework. If the pipeworkis metallic and is unprotected, it may surviveintact for 30 years; but in any individual casethat period can be much less. The quality ofworkmanship in the installation, the soil conditionsand impact damage are all reasons why thesafe working lifetime of an unprotected metallicpipe may be considerably less than 30 years.On the other hand if the metallic pipework hasbeen protected, one cannot be confident that theprotection was effectively applied or, even if itwas, that it continues to be effective.I conclude therefore that if it is known that theunderground pipework is metallic, the only safecourse is to replace it with polyethylene. If thereis no reliable information as to the nature andcondition of the pipework, the only safe optionis to excavate it and, if it is found to be metallic,to replace it with polyethylene.A prioritised programmeMy conclusion is that complete replacement ofunderground metallic vapour phase pipeworkwith polyethylene is the right solution; but areplacement programme has to be practicable.The immediate replacement of all undergroundmetallic pipework is unrealistic.A realistic replacement strategy must be toidentify the highest risk cases and deal withthem as a matter of extreme urgency andto have a rolling programme of prioritisedreplacement in all other installations, some ofwhich may have to be advanced in priority asthe programme progresses. This is a practicableoption only if there is a reliable means ofidentifying and measuring the risk.It cannot be said that at the moment there is afully developed risk assessment model capableof immediate implementation. However, there isgood reason for the optimistic view that such amodel will be available in the near future. In anearlier chapter I have referred to the researchprogramme instituted by Mr Tomlin under theauspices of Calor. In my opinion, Mr Tomlin’sis a sensible programme that may reasonablybe expected to provide a workable basis fora reliable risk assessment model. In essence,this is a simple risk ranking method based on anumber of factors affecting the corrosive powerof the particular soil type in which the pipe isembedded.131

PART 9For the high risk sites, the priority is immediateand urgent. In relation to those sites that areof a lower priority, I recommend that, on thelines of HSE’s own internal guidance in OC286/105, the site owner should adopt aninspection and maintenance strategy for buriedmetallic LPG pipework to monitor its conditionpending replacement.The problem of steel risersSince it became standard practice to usepolyethylene for buried pipework, and in viewof the vulnerability of polyethylene to impactdamage, it has been common practice to installsteel risers. This however has raised a problem,because the riser near to the building goesthrough soil of a higher than normal moisturecontent and is therefore in the area of greatestsusceptibility to corrosion.It is essential, in my view, that the pipeworkreplacement programme should extend tothe substitution of polyethylene for steel risers.That will raise two considerations; namely thevulnerability of polyethylene to impact damageand its tendency to degrade in ultra violet light.For these reasons, when polyethylene risers aresubstituted for existing steel risers, they shouldbe protected with a glass reinforced plasticsleeve.This recommendation raises a serious practicalproblem. I have received convincing evidence thatany replacement programme will be hindered bythe shortage of competent personnel. The problemis to draw up a prioritised programme for thereplacement of risers that will be practicable andof the greatest effectiveness.I have come to the conclusion that it wouldnot be sensible for me to attempt to laydown a hard and fast order of priorities orto attempt to assign a timetable for the workthat is required. At one extreme there will berisers that are known to have been in situfor a matter of decades. At the other, therewill be risers that are known to have beeninstalled in recent years. In recent installation,wherever it can be said that the integrity ofthe risers is satisfactory for the time being, andthat it can be treated as a low priority case,it will be reasonable to defer replacementand to institute a managed inspection schemein the meantime. What matters is that theprogramme of riser replacement, whatever itsphasing, must be treated as an integral partof the overall replacement programme andpursued with a sense of urgency. As work onthe replacement programme progresses, furtherknowledge will be gained. It is likely thereforethat the assessment of priorities, overall and onindividual sites, will be reviewed and amended.I therefore recommend that HSE, in consultationwith UKLPG, should set the order of prioritiesand keep it under review as experience of thework grows.An urgent review of safety of buildingsInspectionOne of the causes of this disaster was that whenthe alterations were made to the basement andto the yard, the safety considerations that thosealterations raised were overlooked. There may bemany premises with LPG installations that werenot built to current standards where the designitself or some subsequent alteration may havecreated LPG hazards. I therefore recommend that,in conjunction with the survey of the undergroundpipework, the premises themselves should beinspected in order to identify any conditions thatcreate the risk that leaking LPG may migrate andaccumulate in unventilated spaces.132

THE ICL REPORTModification of existing installationsIn relation to existing buildings, the keyconsiderations are whether the pipe entry isabove or below ground, whether pipe entriesbelow ground are sealed and whether thepipework is routed through unventilated spaces.Unventilated voids - interim measuresThe existing LPGA guidance (CoP 22:2002,s 2.2.6), which proscribes the installation ofpipework in unventilated voids, does not applyto existing installations. This points to the needfor a systematic programme of inspection of allbuildings that have an existing supply.If LPG pipework in such buildings is found tobe passing through an unventilated void, thepriority should be to have it re-routed. Wherethat is not possible within a reasonable timeand at reasonable cost, and only in that case,the pipework should be sleeved continuouslythrough the void with a sleeve ventilated to asafe place. This is the recommendation of IGEMin relation to new installations where pipework isto be run through an unventilated void (cf IGEM/UP/2, 2008, ss 7.22.3 and 10.4). My ownview, in the light of this disaster, is that in all newinstallations such pipework should be forbidden.Putting pipework entries above groundThe vulnerability of an underground pipe entrypoint to the migration of leaked LPG fromburied pipework was a major and ultimatelydisastrous weakness in the installation atGrovepark Mills. The recommendations of thecurrent LPGA Code of Practice relate primarilyto new installations but are intended to applyalso to modifications and alterations to existinginstallations (LPGA CoP 22:2002, s 1.2). Thecurrent IGEM guidance on the point appliesto new installations only, but is subject to therecommendation that existing installations shouldbe modified to meet the new standard (IGEM /UP/2, 2008, s 1.4).The existing LPGA guidance (CoP 22:2000,s 2.1.3) rather cautiously recommends that“wherever possible” service pipe entries tobuildings should be above ground and that anECV should be installed as near as is reasonablypracticable to the point of entry. For industrialand commercial buildings the Code of Practicerefers to IGEM/UP/2, which, while advisingthat it is preferable to use above-ground entries,recommends that if pipework has to enter or exitfrom below floor level it should do so through acontinuous gas-tight sleeve (ibid, s 9.2-9.3).In the light of this Inquiry I consider that theserecommendations do not go far enough. Inmy opinion, it is only in the most exceptionalcases that such arrangements should even becontemplated. The normal rule should be thatall existing installations should be modified,if necessary, to bring the pipework into thebuilding above ground level and with an ECVfitted near to the entry point. The advantagesof that are obvious, particularly in an improvedsafety regime based in part on routineinspections.Sealing pipe entry pointsThe amateurish way in which the pipework wasled into the building at Grovepark Mills througha hole knocked in the brickwork and withoutany attempt to seal the gap was a major defectin the original installation. It is essential that atthe entry point through an external wall LPGpipework should be sleeved and that the sleeveshould in turn be sealed to the structure. Thisarrangement should ensure that gas cannotpass between the pipe and the sleeve or133

PART 9between the sleeved pipe and the wall, butshould allow normal movement of the pipe.These requirements are to be found in both theLPGA Code of Practice (s 2.2.6) and the IGEMguidance (s 7.3.2). In my view, they should bemandatory in all existing installations.If the pipe entry is below ground, it should bere-routed above ground and fitted with an ECV.Likewise, pipework passing through unventilatedspaces should be re-routed or appropriateventilation should be installed.These requirements will cause expense andinconvenience to users; but it was considerationsof expense and inconvenience that underlaythe misguided approach of the late Mr Stott.In my view it is only if it can be shown that theremedial measures that I propose are impossiblethat any other option should be considered. Inthat event, a safety case should be preparedand should be subject to verification byan approved competent person (ACP) inaccordance with my later recommendations,the test being whether any other solution can beshown to achieve an equivalent level of safety.PHASE 2 – CREATING A NEW SAFETYREGIMEIntroductionThe immediate priorities that I have identified areonly an aspect of the wider question of puttingLPG safety on a new footing. That questioninvolves the creation of a system directedto ensuring life-cycle integrity of every LPGinstallation.In the following part of this chapter I shalldiscuss a proposed new safety regime fromthe standpoints of the user, the supplier and theregulatory authorities. These are the foundationson which a new and long-term safety regimeshould be built. Thereafter I shall put forwardthe principles on which a permanent and moremethodical system of communication betweenall parties affected by LPG safety should bedevised.The user’s role in safetyThe responsibility of the userAll of the many questions surrounding aproposed safety regime were consideredat the Inquiry largely in the context of theresponsibilities of HSE and of the suppliers. Thatrepresents a seriously incomplete view of theproblem.For the purposes of this report, I am notconcerned to explore the legal principlesregulating the civil liabilities of the owner,the occupier and the user. I proceed on thebasis that the user has a legal interest in thesite, whether as owner or as tenant, or hassome lesser entitlement to occupation of thesite, perhaps by way of a licence from anassociated company in a group. On that basis,it is sufficient to say that, whatever the scopeand extent of the civil liabilities of all the partieshaving legal interests in the site, the primaryresponsibility for the safety of the LPG pipeworkshould rest with the user of the installation. Itis he who brings a hazardous substance ontothe site. It is he who has the means at hand toinspect and maintain the pipework. The usercannot, in my view, rely on the oversight of HSEor on the expertise of the supplier to absolvehim of that responsibility.I make this seemingly obvious point becausethe evidence shows that, until a late stage in the134

THE ICL REPORThistory, the ICL companies at Grovepark Millsneglected properly to consider the hazards thatwere associated with the LPG installation, orwere content not to give safety an appropriatedegree of priority, so long as they were underno pressure on that subject from HSE or fromtheir suppliers.I think that it should be made clear to allusers of LPG that inspection of LPG sites byHSE, cannot relieve them of their own directresponsibilities for the safety of their installations.The Installation RecordThe “interface” problemThere may be a multiplicity of legal interestsinvolved in any LPG installation. In the normalcase ownership of the installation is dividedbetween user and supplier; but the position isless straightforward where the user’s interestin the site is less than that of ownership orwhere there is a metered supply to multipleusers controlled by a landlord or a supplyof a similar kind that is managed on behalfof multiple users. In my view, it should bean elementary principle that the number of“interfaces” between responsible parties shouldbe minimised in the interests of safety. Goodpractice requires that all parties should knowthe extent of their ownership or other legalinterest in the installation and the nature andextent of their legal rights and duties; and thatthese matters should be set out in a readilyaccessible source, an “Installation Record,” bymeans of diagrams, plans and appropriatedocumentation.These principles have added point where thereis a handover from one supplier to another orwhere contractors are engaged to carry outany work on the installation itself or any workthat may affect its integrity. The present HSEleaflet Checking LPG Pipework – Industrial andCommercial User Responsibilities (C70, March2006) is a timely contribution to the task ofeducating users to understand the extent of theirresponsibilities. I consider that my proposal forthe institution of Installation Records would bean essential step in this process.The functions of an Installation RecordOne of the reasons why this tragedy occurredwas that the pipe was out of sight and out ofmind. Johnston Oils, who happened to be thelast supplier to the site, carried out the tankexchange in a thoroughly professional way;but then linked the tank installation to a systemof pipework about which they knew little ornothing. They saw that part of the installation asbeing the customer’s responsibility.Since there was no readily available recordof the history of the installation, one canunderstand why the underground pipework wasnot seen as a matter for concern by either Caloror Johnston Oils, and was completely missed inthe ICL risk assessments.I therefore regard it as essential that every LPGinstallation should have its own comprehensiveInstallation Record. The Installation Recordwould provide safety features that were whollylacking in this case. It would be a clearand complete source of data regarding theinstallation and its history to which all interestedparties could refer. It would provide for aprocess of continuous assessment of the safetyof any individual installation. Its existence wouldraise awareness of safety considerations on thepart of users and suppliers. In short, it wouldhelp to promote a suitable safety culture. Itwould also be a compendious source book135

PART 9demonstrating that the installation complied withall relevant statutory requirements and providefor a better appreciation of safety questions asthey arose. In this way, it would assist HSE in itsinspection and enforcement functions.Contents of the Installation RecordThe contents of the Record should include, in myview, the following:(a) a concise account of the history of theinstallation from its introduction to thesite setting out all modifications andadaptations to it, and all tank exchanges;(b) detailed drawings of the installation fromtank to appliance, with a full technicalspecification including a note of all workingpressures, materials used and the like;(c) details of the safe operating envelope forthe LPG system;(d) a summary of the engineering safeguardsdesigned to prevent safety incidents;(e) a complete record of all inspections andreports of inspections;(f) a complete record of all maintenancecarried out to any part of the system;(g) a set of layout drawings of those partsof the site in which the installation wassituated;(h) a set of drawings of those parts of thebuilding from the entry point to the LPGappliance and of those parts adjacentto the installation that could have safetyimplications for the installation itself or couldbe affected by an incident involving theinstallation;(i) a concise statement of the legalresponsibilities of the various interests on siteunder the Health and Safety at Work Actand subordinate regulations;(j) a concise identification of the partieshaving legal interests in the site; that isto say, the owners of the site or of partsof it; the occupiers of the site or parts ofit, whether under lease or licence; andthe customer who is contracted with thesupplier, if that customer is neither an ownernor occupier;(k) a statement of the legal responsibilitiesof those parties having an interest in theinstallation itself, namely the user and thesupplier;(l) a notice identifying the enforcing authorityfor safety on the site;(m) a risk assessment covering the design andoperation of the installation complying withMHSWR and DSEAR;(n) instructions for a response to anyemergency that may arise; and(o) a current and valid verification certificatein accordance with one of my laterrecommendations.I further recommend that guidance on thedetailed contents of an Installation Record anda suitable template should be developed byHSE in consultation with UKLPG. HSE andUKLPG could prepare a suitable statement ofrecommended practice regarding ownership,demarcation of responsibility and consequentlegal duties.Responsibility for keeping the Installation RecordI recommend that the preparation, maintenanceand safe custody of the Installation Recordshould be the direct responsibility of the user.One of the core participants, Mrs Ferguson,suggested that if there were to be such aRecord, there should in every case be a namedperson having responsibility for custody of it.That, in my view, is a sound proposal and Iadopt it.136

THE ICL REPORTA verification schemeExisting guidanceThe LPGA CoP No 1, Part 3:2006 and theTechnical Memorandum (TM) No 84 dealwith the vital question of effective inspectionof LPG pipework. TM No 84 recommendsthat employers, by which is meant, I assume,the user or, during tank filling, inspectionor maintenance, the supplier, should havea strategy for the periodic inspection andtesting of all pipework and that the findingsof the inspection should be reviewed by acompetent person who should make suitablerecommendations for any changes to thestrategy that may be necessary (sections 2 and5).The HSE Leaflet “Checking LPG Pipework”(ref 16) is to similar effect. It recommends thatthe party responsible for the pipework shouldensure that a competent person draws upan inspection and maintenance strategy ifone does not exist. Where metallic pipeworkis buried, HSE’s guidance to its inspectorssuggests as an appropriate level of competencythat of the Institute of Corrosion, PipelinesCoating Inspector, Level 2.The outline of a formal verification schemeIt is not enough that an Installation Recordshould indicate the condition of the installation.It is essential, in my view, that there should beindependent scrutiny of every installation bya competent third party at regular intervalsthroughout its life. The existing guidance to whichI have referred should in my view be developedinto a formal verification scheme by meansof which the integrity of every LPG installationwould be periodically assessed by an approvedcompetent person (ACP). A verification schemewould, I think, have averted this disaster.I propose therefore that every installation shouldbe subject to mandatory periodic verificationby an ACP whose duty it would be to verify theintegrity of the installation and to certify whetheror not the installation itself, the safety regimeapplying on site and any mitigation measures inplace at the site were satisfactory. The presenceof plans within the Installation Record wouldalert such an ACP to possible hazards createdby the design of the building.Under such a scheme a verification certificatecould be granted or refused outright; or itcould be withheld pending the completion ofany remedial work that the ACP might require.The granting of a certificate would be acondition precedent to the continued use of theinstallation.The details of such a scheme, and the intervalsat which verification would be necessary,should be a matter for discussion between HSEand UKLPG.The choice of an ACPIf such a scheme were to be introduced, animportant question of policy would arise as tothe choice of an ACP. It was suggested at theInquiry that there might be good reason whythe LPG supplier could act as the ACP if it wereto be suitably accredited. I do not accept thatsuggestion. It is important that scrutiny of thiskind should be independent both in substanceand in appearance.The response of the industry and HSEI have taken account of the concerns ofCalor and UKLPG on this aspect of the case.Calor’s position is, in brief, that verification isunnecessary if there is an installation recordin existence and if GSIUR is extended to137

PART 9industrial premises. UKLPG makes the point thatconsiderable time and effort would be involvedin the monitoring of a formal competencyscheme and that such a scheme would add toexisting skills shortages. More fundamentally,UKLPG suggest that a verification schemewould externalise the accountability and theresponsibilities that ought to remain with theduty holder. On balance, UKLPG considers thatthe available resources would best be directedto the pipework replacement programme, theintroduction of the installation record and theextension of GSIUR to industrial premises.HSE has no objection to a verification scheme,provided that it does not divert resources from aprioritised pipework replacement programme.Notwithstanding the views of Calor andUKLPG, I consider that a verification schemewould have a useful and distinctive part to playin a new safety regime. It would be a means ofenforced periodic scrutiny and a valuable wayof promoting a safety culture.There was general agreement that if averification scheme is to be introduced, it shouldbe developed jointly by UKLPG and HSE. Isupport the view of HSE that in that event HSEshould take the lead role. That, I think, wouldcorrectly reflect HSE’s statutory role and wouldbe particularly appropriate if the accreditationelement in the scheme were to involve CAPITA,the successor of CORGI.SanctionsUnder a verification scheme of this kind it wouldbe appropriate that wherever a verificationcertificate was not in force, it should beunlawful for the user to use the installation or toobtain any further supply of LPG to it.Mr Sylvester-Evans invited the Inquiry to considerwhether such use or the obtaining of a supplyin such circumstances should be a criminaloffence.It seems to me that there is little point in averification scheme if there is no effectivesanction against the LPG user who continues touse an installation for which a valid verificationcertificate is not in force.Having regard to the risks involved in theuse of a system that is ex hypothesi unsafe,I do not regard the imposition of a criminalsanction on the user in such a case as beingdisproportionate. On the contrary, it would be apowerful incentive to safety.The role and responsibilities of the supplierThe tankNotwithstanding the primary responsibility ofthe user, the practice of the industry is, in mostcases, that the supplier retains ownership ofand responsibility for the tank. Although themerits of that practice have not been debatedat the Inquiry, no party has suggested that thepractice should change. The practice seemsto me to be conducive to safety. It ensures asafe and efficient standard of installation, asystematic and effective system of monitoringand inspection, and the safe and competentreconditioning of tanks at tank handovers orat other appropriate intervals. In view of thepotential for an explosion or a BLEVE if the tankcontents were to leak and ignite, and in viewof the paramount importance of maintaining theintegrity of the tank, it is desirable that in suchcases the supplier should accept responsibilityfor the tank and for some part of the tankpipework up to a defined stage.138

THE ICL REPORTThe responsibility of the supplier for theinstallation should be regulated contractually inevery case; but, for reasons that I shall discuss,I am opposed to any idea that the suppliershould be made responsible for pipeworkbeyond that defined stage.While it is in the interests of safety that thesupplier should accept responsibility for the tank,I can see no reason why the supplier shouldhave to accept any responsibility for the systeminto which he supplies his product and I can seecogent reasons why he should not. The suppliermay have no first-hand knowledge of the historyof the installation on the site; he has no controlover the site and no right of access to it andmay not be in a position to carry out inspectionsat a frequency and to an extent that the properexercise of such a responsibility would require. Ifthe supplier were to have such a responsibility,he might be open to claims by the customer if,for example, his inspection or maintenance ofthe installation were to disrupt production. Therewould also be serious insurance implications.In my view, there is every reason why legislativeand regulatory policy should rest on the simpleproposition that any such installation shouldat all times be the overall responsibility of theperson who uses it.Where should the supplier’s responsibility end?One extreme option is that the supplier shouldaccept responsibility, if not even outrightownership, of the service pipework up to andincluding the Emergency Control Value (ECV).This option has the superficial attraction that itwould align the position in LPG installations withthe well-recognised arrangement in the supplyof natural gas. It also has the attraction that theLPG supplier would, in general, be thought tobe more competent in ensuring the integrity andsafety of the pipework. It would also provide aclear line of demarcation.Despite these seeming advantages, I reject thisoption. In my opinion, it would be wrong inprinciple that the owner or occupier of the siteshould be relieved of the direct responsibilitythat flows from the use of pipework that is parssoli; or that the supplier should have to acceptresponsibility for pipework to which he has noright of access, and which he has no right toalter, adapt or excavate without the permissionof the user and the owner or occupier of thesite, if that should be a different person.There would also be, in my view, a material riskthat where the supplier prescribed changes tothe service pipework in the interests of safety,the user might switch suppliers rather than incurthe expense that such changes might entail.On the whole matter I am convinced that thesupplier’s responsibility should be restricted tothat of responsibility for the tank and for thepipework associated with the tank itself. Thatreflects the status quo in almost every case. Itfocuses the attention of the supplier onto thetank and filling area. It avoids complicationsat tank exchanges. It gives the supplierresponsibility for equipment over which he cancontractually retain ownership and exercise acontractual right of access.This option, however, has the consequence thata greater burden of responsibility is devolvedupon the user, or owner or occupier of theland, and with it a responsibility to adopt morerigorous safety practices than were to be seenat Grovepark Mills.139

PART 9The question then is at what point theresponsibility of the supplier should end. TheInquiry has shown that in practice there are onlytwo options; namely that the responsibility of thesupplier should extend only to the Vapour OffTake Valve (VOTV) or that it should extend to theFirst Stage Regulator (FSR).Both arrangements are to be found in currentpractice. That fact alone is a cause for concern,particularly when there is a change of supplierand a consequent change in the contractualarrangements on that question.The first option is insisted on by Calor in itsconditions of contract. Since the vapour off-takevalve is invariably part of the tank assemblage,this option has the attraction that it is clear-cutand incapable of ambiguity or misinterpretation.The second option is adopted by Johnston Oilsand is the predominant practice in the industry.It has the disadvantage that in many installationsthe first-stage regulator is sited some distancefrom the tank, which increases the extent of thesupplier’s responsibility.Whichever option is to be preferred, it is vital,in my opinion, that only one option should bepermitted and that that option should be enforcedrigorously throughout the industry. Where thereis a change of supplier and the new supplier’scontract conditions on this point differ from thoseof his predecessor, the scope for misunderstandingcreates a serious safety hazard.My own view is that the uniform rule throughoutthe industry should be that the supplier’s liabilityextends up to the first-stage regulator. Despitethe simplicity and clarity of the Calor approach,I think that it is best to adopt the solution thatreflects the prevailing practice in the industry. Ialso favour this solution because in cases wherethe first-stage regulator is at a distance fromthe tank, it is undesirable that the customer, orthe person in control or ownership of the site,should be responsible for the intervening lengthof pipe which at that point is carrying LPG attank pressure.Enforcing the uniform demarcation ofresponsibilityThe next question is how best to securea uniform extent of responsibility. Myrecommendation is that a provision specifyingthat the supplier is responsible up to the firststageregulator should be mandatory in everysupply contract. I also recommend that thedemarcation of responsibility should be spelledout in clear terms in the Installation Record.Finally, I recommend that, to fortify the statementof responsibility, the pipework on either side ofthe first-stage regulator should be colour codedfor the avoidance of doubt.Making risk assessments effectiveThe user, as employer, is obliged by DSEARto make a suitable and sufficient assessmentof the risks to his employees which arise fromdangerous substances at the workplace. Amongthese are the risks of fire and explosion. Thesame obligation rests on the supplier when hisemployees are at the site, for example duringtank filling.The assessment must also cover the scale ofthe likely effects of a fire or an explosion.This therefore requires the user to assess thelikely effects of an explosion on the structureof buildings. The risk assessment must be sitespecific. Generic assessments can be a usefulstarting point but it is essential to consider site140

THE ICL REPORTspecific risks. The user and the supplier areobliged under DSEAR (reg 11) to co-ordinate therisk assessments of their respective equipment.This obligation represents an important meansof communication between supplier anduser and is conducive to the making of aneffective risk assessment overall. Both the userand the supplier, as employers, have a duty(DSEAR, reg 5(3)) to review and up-date therisk assessment periodically, or at the time of asignificant change to the installation, such as atank exchange.This case has demonstrated the weakness of therisk assessment process. The regulations merelyoblige the employer to carry out an assessment.They do not provide any safeguard that willensure that the assessment is properly carriedout by a competent person; or that it is subjectto any form of independent expert audit. I donot doubt that the risk assessments at GroveparkMills were carried out conscientiously, but thiscase demonstrates that formal compliance withMHSWR and DSEAR gives no assurance ofsafety.This is a public inquiry and not a law reformproject. I do not feel that it is appropriate that fromthe evidence of one case I should extrapolateany general principles for the amendment of theexisting regulations. However, I recommend thatthe Ministers should consider whether the existingregulations on risk assessment could be mademore effective, perhaps by the addition of someform of independent safety audit.The industryA registration schemeIn view of the hazardous nature of LPG, the risksinvolved in the transportation and delivery of itand the responsibilities of suppliers in relationto LPG installations, I think that it is entirelyreasonable that all suppliers of bulk LPG in theUnited Kingdom should be accredited andpublicly identified. At present, entry to the retailLPG market is open to anyone who can sourcea wholesale supply of the product. Competitionpolicy may point to the wisdom of that; but fromthe point of view of public safety, it cannot bea wise policy to allow unrestricted entry to anindustry in which the consequences of a failurein safety can be so catastrophic.In my opinion, the importance of the safetyconsiderations necessitates that there shouldbe a registration scheme for all bulk suppliersof LPG; that registration should be in the formof accreditation based on the achievement ofcertain minimum standards and that registrationshould be a condition precedent to the supplyof LPG to any user on any terms.I should make clear that in making this proposalI do not envisage the establishment of a formallicensing scheme.Calor and Johnston Oils support this proposal;but opinion within UKLPG is divided. MrShuttleworth of UKLPG expressed concern thata registration scheme, if introduced, shouldnot be unduly onerous on the supplier andshould not act as a deterrent to the entry ofnew suppliers in the market. In my view, neitherobjection is cogent.In my view, a registration scheme is a necessaryelement in the safety strategy that I propose. Itwill enable HSE to set what it considers to beappropriate standards for entry to the market. Itwould be for HSE in consultation with UKLPGto decide what the standards for accreditationshould be.141

PART 9A uniform contractual provision as to theextent of the supplier’s responsibility for servicepipeworkI have already given my reasons for concludingthat the responsibility of the supplier shouldend at the first stage regulator. To ensure thatthat position is applied uniformly throughout theindustry, every supplier should be obliged toinclude a provision to that effect in its terms andconditions.Supply to unverified installationsI also propose that unless a verificationcertificate is in force for the installation, it shouldbe unlawful to supply LPG to it.I have already commented on the idea of therebeing criminal liability for the unlawful use ofan installation for which there is no verificationcertificate in force. It would seem logical thatthere should be a complementary liability onthe part of the supplier who supplies to such aninstallation.UKLPG was resistant to the idea that thereshould be a criminal liability on the part of thesupplier in such a case. It regarded that ideaas being inconsistent with the principle that thefundamental responsibility for the safety of theinstallation from the service pipework downstreamshould rest with the user. UKLPG also figures thecase where a supplier doubted the safety ofthe system but the user nevertheless had a validcertificate. It considered that the other proposedrecommendations that I have now acceptedwould provide a regime where the respectiveresponsibilities of user and supplier were clearlydefined and that it was the responsibility of HSEto ensure compliance with the regime. UKLPGconsidered that a criminal sanction on the supplierin such circumstances would be disproportionate.I do not regard the idea of a criminal sanctionagainst the supplier as being disproportionate.Where the obligation would be on the user toobtain a valid verification certificate, the supplierwould have only the lenient obligation of requiringthe user to produce the certificate before thesupplier made the supply. Not to do so would,in my view, be irresponsible. The sanction in thiscase would be a considerable deterrent to therogue supplier in such circumstances. In the casefigured by UKLPG, the production of a validcertificate would absolve the supplier of anycriminal liability; but if the supplier neverthelessdoubted the safety of the system, it would remainthe duty of the supplier to withhold the supply.The supplier’s own recordI also recommend that, in addition to theInstallation Record that should be maintained onsite, each LPG supplier should be required tomaintain a formal record relating to each site towhich it supplies LPG. This record should includethe supplier’s current asset register, specifyingthe individual items of equipment of whichthe supplier contractually retains ownership;incorporating the provisions of the InstallationRecord as to the respective responsibilities ofthe supplier and the user; and noting the criticalsafety features, inspections records and riskassessments for all such equipment. The suppliershould be under an obligation to furnish a copyof the relevant section to each user.PHASE 3 – THE CONTINUINGDEVELOPMENT OF THE SAFETY REGIMEA continuing programme of monitoring ofburied polyethylene pipeworkPhase 1 of my proposed action plan has thepurpose of having all buried metallic vapour142

THE ICL REPORTphase pipework replaced by polyethylenepipework at the earliest practicable date.That of course will lead into a further safetyquestion affecting the polyethylene pipework.It too is subject to long-term decay and, to agreater extent than metallic pipework, to impactdamage. The safe life of a polyethylene pipeis thought to be about 50 years; but sincesuch pipework has been in use only sincethe early 1980s that remains to be proved. Itis essential therefore that the mistakes of thepast are not repeated in relation to buriedpolyethylene pipework. There therefore has tobe a programme of continuing research intothe safety of polyethylene pipework and acompulsory requirement on users systematicallyto check the integrity of such pipework withintheir sites.Should the UKLPG Codes of Practice beapproved?Thanks to the efforts of UKLPG and itspredecessor, the industry is guided by Codes ofPractice that are familiar to HSE and of whichit has no criticism. In stage 2 of the Inquiry, thequestion was raised whether the status of theseCodes should be elevated to that of ApprovedCodes. Some participants considered that thatwould ensure a better standard of compliancewith the Codes by suppliers and users alike.I do not regard this as being an issue ofany great significance. In my view, it is thesubstance rather than the form of the Codes thatmatters. If UKLPG and HSE were to agree thatthere was a useful purpose to be served by theelevation of the status of these Codes, it wouldbe open to HSE to do so. That is a matter thatcan be left to those bodies to decide. I makeno recommendation on the point.PHASE 4 – ESTABLISHING EFFECTIVECOMMUNICATIONS AND CLARIFYINGRESPONSIBILITIESImproved communicationCommunication of knowledgeI see it as essential that there should be promptand effective communication between allinterested parties of all technical developmentsin matters of LPG safety, and of all LPGincidents and the lessons to be learned fromthem. Such communication would have ensuredthat the Daventry incident, to which I havereferred, and the lessons to be learned fromit, would have been publicised throughoutthe industry promptly and effectively. On thatoccasion, the occurrence of the incident wasnot even properly communicated within HSEitself. A suitable communication system shouldbe established by HSE in consultation withUKLPG.Communication within HSEOn the evidence before the Inquiry, I thinkthat HSE has learned the necessary lessonsfrom its own previous failures to communicateknowledge effectively within its ownorganisation.Communication of adviceThe record of UKLPG in the promotion of goodpractice is impressive. I recommend that HSEshould, in consultation with UKLPG, preparepractical advice for LPG users regarding thefulfilment of their statutory duties, particularlyunder DSEAR. We may be confident thatUKLPG will continue to give such advice to itsmembers and to make such advice available tosuppliers who are not members of UKLPG.143

PART 9Communication between HSE and UKLPGI have no reason to think that the relationsbetween HSE and UKLPG are in any wayunsatisfactory. But it is important, I think, thatin matters of safety there should be the fullestpossible sharing of knowledge between thesebodies based on a relationship of trust andmutual confidence. The ideal is that there shouldbe complete sharing of knowledge relating toLPG incidents. HSE has access to knowledge ofsuch incidents arising from the data collected ondangerous occurrences under the Reporting ofInjuries, Diseases and Dangerous OccurrencesRegulations 1995 (RIDDOR) and from its owninspections of LPG sites; but UKLPG mayalso have knowledge from its members ofincidents and potential incidents not reportableunder RIDDOR from which there are lessonsto be learned. It would be regrettable if suchknowledge were not to be shared through fearof the consequences, through an unwillingnessto admit fault or through a mistaken concern forcommercial sensitivity.Communication from supplier to userThere is general agreement that the supplier inevery case should assist the user with practicalguidance on LPG safety matters of whichthe user, and particularly the small user andthe new user, may be unaware; and that thesupplier should be obliged to provide the userwith details of its asset register, critical safetyfeatures, examinations, inspections and riskassessments for its equipment on the user’s site.A users’ forumThere was a division of opinion at the Inquiryas to the value of establishing a users’ forumunder the auspices of HSE and/or UKLPG. Sucha forum could provide a means for the sharingof knowledge and ideas in the field of LPGsafety. While I accept that such a forum wouldcontribute to effective communication, I am notpersuaded that there is any urgent need forit. I think that the better course is to implementthose recommendations that are urgent, to putin place the introduction of Installation Records,verification, accreditation and so on and in thelight of the modern updated regime that will thenexist, to leave the desirability of such a forum tobe considered in the new context of LPG safety.A safety regime for the regulatory authoritiesResponsibilities for inspection and enforcementI have commented on the lack of clarity as tothe responsibilities of HSE and local authoritiesin the enforcement of safety of buildings. In myopinion, it is essential that the respective rolesand responsibilities of these bodies in relationto LPG risks should be clearly identified in everycase and should be set out expressly in theInstallation Record.It is my hope that if Installation Records wereto be introduced, any proposed change in thelayout or construction of a building to whichLPG was supplied or was to be introducedwould be carefully considered for its safetyimplications.While it is obvious that there should be a cleardefinition of responsibility for regulatory oversightfor each commercial and industrial LPG site, it isalso clear that there should be a clearly definedresponsibility for reviewing the safety of thebuilding into which the supply is made.What the responsibilities of HSE and thelocal authorities should be, and whether it isdesirable that there should be two regulatorybodies in this field, are wider issues. Sincethe local authority did not take part in theInquiry and since a major investigation into144

THE ICL REPORTthe desirability of there being two regulatoryauthorities in relation to the structural safety ofbuildings into which LPG is supplied wouldstray beyond my precise terms of reference, Ido not consider that it would be appropriatefor me to make any recommendations on thatsubject, even if I were in a position to do so. Itis sufficient for the purposes of my own termsof reference that I should comment that thereseems to be an area of uncertainty that shouldbe clarified in early course.In the meantime it is important that HSEshould publish more detailed guidance on theassessment of the structural safety of buildingsinto which LPG is supplied.145

146PART 9

THE ICL REPORTAppendices147

AppendicesAppendix 1 – List of core participantsCalor Gas LimitedHealth and Safety ExecutiveICL Plastics LimitedJohnston Oils LimitedMembers of bereaved families and injured survivors as represented by Thompsons SolicitorsMrs Anne FergussonMrs Sheena O’BrienMrs Joyce RussellMrs Louise Smith148

THE ICL REPORTAppendix 2 – List of witnesses beforethe InquiryStage 1Gordon Bell 2 July 2008 Read out ICL employee on site at the time of the disasterDavid Andrews 2 July 2008 Read out ICL employee on site at the time of the disasterJames McGoldrick 2 July 2008 Read out ICL employee on site at the time of the disasterJames Baxter 2 July 2008 Read out ICL employee on site at the time of the disasterIan Mavers 2 July 2008 Read out ICL employee on site at the time of the disasterJames Smith 2 July 2008 Read out ICL employee not on site at the time of the disasterAndrew Galloway 2 July 2008 Read out Non-ICL employee on site at the time of the disasterLynn Cameron 2 July 2008 Read out Eye witness to the explosionJacqueline Brown 2 July 2008 Read out Eye witness to the explosionAnne Marie Donnelly 2 July 2008 Read out Eye witness to the explosionGeorge Leyden 2 July 2008 Read out Eye witness to the explosionJames Moir 2 July 2008 Read out Eye witness to the explosionWilliam McDonagh 2 July 2008 Called Rescue and arrangements for investigationJames Porteous 2 July 2008 Called Rescue and arrangements for investigationWilliam Brodie 3 July 2008 Read out Employee of Calor GasKeith Young 3 July 2008 Called Employee of Calor GasMaurice Coville 3 July 2008 Called Employee of Calor GasAlexander Clezy 3 July 2008 Read out Employee of Calor GasHenry Betts 3 July 2008 Called Employee of Calor GasWilliam Delaney 4 July 2008 Called Employee of Calor GasKenneth Platt 4 July 2008 Read out Employee of Calor GasThomas Dudgeon 4 July 2008 Called Employee of Johnston Oils Ltd (J Gas)Alan Elliot 4 July 2008 Called Employee of Johnston Oils Ltd (J Gas)David Inglis 8 July 2008 Called Employee of Johnston Oils Ltd (J Gas)Sue Johnston 8 July 2008 Called Evidence relating to HSE visitsAlistair Gunn 8 July 2008 Called Evidence relating to HSE visitsAlexander Keddie 8 July 2008 Called Evidence relating to HSE visitsJohn Ives 9 July 2008 Called Evidence relating to HSE visitsAlan Tyldesley 9 July 2008 Called Evidence relating to HSE visitsAlan Tyldesley 10 July 2008 Called Evidence relating to HSE visitsAlistair McNab 10 July 2008 Called Evidence relating to HSE visits149

AppendicesStage 1 continuedAlistair McNab 11 July 2008 Called Evidence relating to HSE visitsJohn Powell 11 July 2008 Called Evidence relating to HSE visitsCameron Adam 11 July 2008 Taken as read Evidence relating to HSE visitsAnnette Leppla 11 July 2008 Taken as read Evidence relating to HSE visitsMichelle Gillies 11 July 2008 Taken as read Evidence relating to HSE visitsMichael Wilcock 11 July 2008 Taken as read Evidence relating to HSE visitsDonald Sloan 11 July 2008 Taken as read Evidence relating to HSE visitsBryan Cousland 11 July 2008 Called Evidence relating to HSE visitsIan Bowie 11 July 2008 Called Evidence relating to HSE visitsAlastair McCourt 15 July 2008 Called Non- ICL person (Safety Consultant)James Kincaid 15 July 2008 Read out Non- ICL person (Gas Engineer)Paul McClintock 15 July 2008 Called Non- ICL person (Fire Officer)Steven Smith 15 July 2008 Taken as read Non- ICL person (Fire Officer)Stuart Murie 15 July 2008 Called Non- ICL person (Group Manager Building Control andSupport Services)John Turner 15 July 2008 Read out ICL Director/employeeSheena O’Brien 15 July 2008 Read out ICL employeeNicholas Downie 15 July 2008 Called ICL Director/employeeWilliam Masterton 15 July 2008 Read out ICL employeeTracey Downie 16 July 2008 Read out ICL employeeCampbell Downie 16 July 2008 Called ICL Director/employeeCampbell Downie 17 July 2008 Called ICL Director/employeeLorna Downie 17 July 2008 Called ICL Director/employeeColin Foard 17 July 2008 Called ICL Director/employeePeter Marshall 17 July 2008 Called ICL Director/employeeLynda McColl 17 July 2008 Called ICL employeeGeorge McLean 17 July 2008 Taken as read Investigation and explanation of the cause of the disasterJean McGoldrick 17 July 2008 Taken as read Investigation and explanation of the cause of the disasterAndrew Stott 22 July 2008 Called ICL employeeFrancis Mellor 22 July 2008 Taken as read Investigation and explanation of the cause of the disasterStuart Hawksworth 22 July 2008 Called Investigation and explanation of the cause of the disaster150

THE ICL REPORTStage 2Stephen Brown 21 October 2008 Called Technical Adviser, OfgemGary Tomlin 22 October 2008 Called Senior Consultant, Advantica, formerly TechnicalSupport Manager, Calor Gas LtdHenry Betts 23 October 2008 Called General Manager, Autogas Ltd, formerly CentralOperations Manager, Calor Gas LtdTerrence Ritter 23 October 2008 Taken as read Calor lead contact with HSE and Calorrepresentative on the UKLPG BoardAllan Elliot 24 October 2008 Called Director, Johnston Oils LtdRob Shuttleworth 24 October 2008 Called Chief Executive, UKLPGJeffrey Watson 24 October 2008 Taken as read Technical Manager, UKLPGBrian Neale 24 October 2008 Called Independent consultant (chartered engineer),formerly Principal Specialist Inspector, HSERoger King 4 November 2008 Called Expert in chemical engineering and corrosionscienceHenry Betts 4 November 2008 Called General Manager, Autogas Ltd formerly CentralOperations Manager, Calor Gas LtdDr Brian Fullam 4 November 2008 Called Head of Process Safety Topic Group, HSEPhilip Papard 5 November 2008 Taken as read Principal Inspector of Health and Safety within theHSE Safety UnitAlistair McNab 5 November 2008 Taken as read Head of Operations for the Field OperationsDirectorate (FOD) in Scotland (HSE)Sandra Caldwell 5 November 2008 Called Deputy Chief Executive of HSE/DirectorGeoffrey Podger 6 November 2008 Called Chief Executive, HSERod Sylvester-Evans7 November 2008 Called Independent Consultant151

AppendicesAppendix 3 – Chronology of legislation,regulations, codes of practice and guidance(Note: Some of the early FI/HSE guidance was for internal use only and not for general distributionto LPG suppliers and users.)DateFirst published in 1940(9 Revisions)December 1959NFPA Code 58American National Fire ProtectionAssociation Code 58IGECommunication No 563Recommendations for the laying ofsteel gas service pipesNotes- Referred to in a number of early UK LPG related codes- Aimed at mains gas- Deal with the service pipe from the gas main to theconsumer’s control- highlighted the hazard of corrosion to steel service pipes- which was addressed by wrapping pipework- Supplements BS COP 331.101- Wording revised in IGE/TD/4 (1973)1959 Building (Scotland) Act - Enabled the setting of building regulations1961 Factories Act 1961 - Applied to certain safety, health and welfare matters inpremises which fell within the definition of ‘factory’- Contained provisions for the enforcements of legalrequirements and imposed penalties for contraventions- Dealt with precautions required when working on pipeworkand installations carrying flammable materials including LPGbut did not deal with their design or maintenance- No provision for maintenance or design of work equipment ingeneral other than for guards and fencing1961 LPGITC COPCode of Practice for Installationof bulk LPG storage at consumers’premises1963 LPGITC COPInstallation of bulk LPG storage atconsumers’ premisesRevised Edition- Sets minimum standards for bulk LPG installations atconsumers’ premises- Covers tanks, pipework and fittings up to the inlet of the firststage regulator- Does not cover corrosion protection of pipelines, periodicinspection of pipelines or routing of pipelines and point ofentry to the building- Outlines minimum separation distances- All materials must be resistant to the action of LPG gasesunder service conditions- Reprinted yearly until 1968 (with the exception of 1965 and1967) with a revision in 1963- Revised in 19691963 NFPAAmerican National Fire ProtectionAssociation COP Numbers 58 and591964 Fire Protection Association (FPA)Booklet No 39Storage and handling of LiquefiedPetroleum Gases- Describes minimum standards of safety thought to benecessary for bulk storage of LPG- Identified the hazard of corrosion to pipework and riskassociated with basements where escaping gas couldaccumulate- Reproduces the tank separation distances given in the LPGITCCOP152

THE ICL REPORT1965 HMFI SHW 30Safety, Health and Welfare BookletMinistry of Labour; HMFINew Series No 30The Bulk Storage of Liquid PetroleumGas at Factories- Identifies that the major potential hazard from storage of LPGwas that of fire and explosion which could be reduced to“acceptable proportions”, provided that the plant was suitablydesigned and adequate safety measures adopted- Gives general guidance to ‘would-be’ users of LP gas on theproblems with storage- Made reference to NFPA Codes 58, 59, and LPGITC Codeof Practice- Renamed HSW 30 in 19731967 IP/9Institute of PetroleumModel Code of Safe Practice part9: Liquid Petroleum gasAlso published as the IGE/SR/61967 FIC 286/1 – Fire and explosiondisaster hazards- Provides a general guide to safe storage, handling andtransport of LPG- Required that the location of all pipes and valves be known,and that those responsible for the operation and handling ofLPG should be aware of the guidance- It also requires that piping should be protected againstphysical damage and corrosion- Includes training- Reiterated much of the LPGITC guidance 1969- Superseded by IP9 Volume 1 (1987)- The note draws attention to a wide range of major fire andexplosion hazards from dusts, chemicals, gasses, highlyflammable liquids and LPG- The note describes two factors which may increase thedisaster potential: the process maybe housed in an unsuitablebuilding and the scale of the plant maybe larger thancustomary in the partMay 1968FIC 286/7 – Notification of fire andexplosion disaster hazards to theChemical Branch- Reported back on a series of sample inspectionsJuly 1968December 1968IGE/SR/6 BookletInstitute of Gas Engineers SafetyRecommendationsAlso published as IP/9 in 1967 (seeabove)FIC 286/8 – Fire and explosionhazards: Causes of outstanding riskRequired that:- location of pipes and valves be known- those responsible for the operation and handling of LPGshould be aware of the guidance- Piping should be protected against physical damage andcorrosion- Reiterated much of the LPGITC guidance 1969Instructions to district inspectors regarding reporting outstandingrisks to Chemical Branch1969 DATE OF INSTALLATION OF LPG PIPEWORK & TANK AT ICL PLASTICS1969 LPGITC 8 Code of PracticeMaintenance of Fixed Bulk LPGvessels at Consumers’ Premises- Includes inspection and re-test details- In 1974 is combined into COP 1April 1969LPGITC 1 Code of Practice:Installation and maintenance of bulkLPG storage at consumers’ premises- Revision of LPGITC COP 1961- Sets standards rather than minimum standards- Discussed corrosion protection of underground vessels- Covers pipework and fittings up to the first stage regulator- Only required the pipework to be resistant to the actions of LPG- Contains minimum separation distances- Excludes inspection and re-test details for which the reader isreferred to LPGITC 8 – Maintenance of Fixed Bulk LPG vesselsat Consumers Premises, 1969- Revised in November 19741970 Building (Scotland) Act 1970 - Enabled the setting of building standards1971 Fire Precautions Act 1971 - Provides for the protection of persons from fire risks153

Appendices1971 Home OfficeCOP for Storage of LPG at FixedInstallations1972 HFLR 1972Highly Flammable Liquids andLiquefied Petroleum GasesRegulations 1972- General guide to safe practice in storing and handling LPG atfixed storage installations where tanks are filled on site- Contains minimum separation distances as LPGITC COP April1969- 1977 Reprint- and later reissued as HSE Guidance Note CS5- Implemented under the FA 1961 and referred largely to highlyflammable liquids but they also included commercial butane,propane and their mixtures- Regulation 7 dealt specifically with LPG- Required LPG tanks and containers to be suitably marked andwhere practicable stored/located in the open air- LPG had to be stored in pipe-lines and pumps or otherappliances forming part of a totally enclosed pipe-line system- Repealed by DSEAR 20021972 Town and Country Planning(Scotland) Act1973 ICL PLASTICS’ YARD RAISED1973 HSW 30Health and Safety at WorkThe Storage of Liquefied PetroleumGas at FactoriesDepartment of Employment- Renamed from and same material as Safety, Health andWelfare Booklet, New Series 30 (1965)- Amended in 1975November 1973IGE/TD/4Recommendations on transmissionand distribution practice; IGE/TD/4Laying of steel and ductile iron gasservice pipesCommunication No. 879- Revision of IGE Communication No 563- Many recommendations from IGE Communication No. 563remained the same but some changes were made to thewording of relevant sections- Second Edition in 19811974 FIC 286/20 – Storage of liquefiedpetroleum gas at distribution depots1974 HSWA 1974Health & Safety at Work Etc Act1974- Records the results of a series of inspections in 1973 targetedat distribution depots storing and filling LPG cylinders- Primary purpose is the securing of the health, safety andwelfare of persons at work, whatever the nature of the workor of the premises on which it is carried out1974 AEGLPTSD/2EInstallation & inspection of small bulkLPG fixed storage tanks up to 5m 3capacity- Based on practices in operation in major European countries- Applicable to domestic, commercial, agricultural and industrialusages of LPG and to all tanks or groups of tanks up to 5m 3- Sets separation distances which are less than those specifiedin LPGITA 11974 LPGITA bookletIntroduction to LPG- Describes the essential properties of LPG, their major uses andprecautions necessary for safe application- It is intended as an introduction for technical and sales staffinvolved in its handling or sale, for students and for users ofthe fuel.154

THE ICL REPORTNovember 1974 LPGITA Code of Practice 1:Installation and maintenance ofbulk LPG storage at consumers’premises- Revision of 1969 LPGITC 1 Code of Practice- Combines COP 8- Buried pipelines first addressed by LPGITA- Guidance covers the distribution system up to the consumingequipment.- Sets minimum standards for the frequency of inspection andtesting to be adopted- Deals with corrosion protection of underground pipework fromsoil conditions- Includes aspects of maintenance, inspections and testing ofboth pipework and vessels- Buried pipelines should be surveyed for leakage at afrequency dictated by the risks- States that all fittings not specifically covered should bechecked at intervals not exceeding one year- Revised in 19781975 HSW 30 (Amended) - Amended from 1973 version- In April 1981 is published with minor amendments asHS(G)151976 Fire Certificates (Special Premises)Regulations 19761977 Health and Safety (EnforcingAuthority) Regulations 1977(SI 1977/746)1977 HSEGuidance notes for the Storage ofLPG at Fixed Installations4 th Impression with amendments- Provide that a fire certificate issued by HSE shall be requiredin respect of premises of the kind specified in Schedule 1 tothe Regulations- Made local authorities responsible for enforcement for certainactivities but not for ‘factories’- Revoked in 1989- Reprint from COP for the Storage of LPG at fixed installations(1973)March 1978 LPGA Code of Practice Part 1Installation and Maintenance of BulkLPG Storage at Consumers’ Premises- Revision of 1974 Code of Practice Part 1- Revised and replaced by 4 part Code in 19911979 IP Model Code of Safe PracticePart 13: Pressure Piping SystemsExamination1 st Edition- Provides a guide to safe practices in the in-serviceexamination and testing of piping systems in the petroleumand chemical industries, and consists primarily of scheduledexaminations by Competent Persons- Second Edition published in 1993October 1980November 1980FIC 286/42 LPG accidents anddangerous occurrencesFIC 286/43 – Underground pipesconveying LPG- Provided information on the number (81) and type of LPGrelated accidents and reported Dangerous Occurrenceswhich occurred in the previous two years- Described recommendations concerning the installation,commissioning and inspection of underground pipesconveying LPG primarily in liquid form although similarstandards could be applied with advantage to pipesconveying LPG vapour1980 BS5958: Part 1 - Code of practicefor control of undesirable staticelectricity. General considerations- Metal piping should be electrically continuous so that theresistance to earth of the installation does not exceed 10 6ohms.- Replaced by BS 5958 (1991)- Replaced by PD CLC/TR 50404:2003 “Electrostatics: Code ofPractice for the avoidance of hazards due to static electricityApril 1981HS(G)15Health and Safety Series bookletThe Storage of LP at Factories- The object and scope remain the same as HSW30.155

Appendices1981 Chemical Sheet 4Cylinders and similar containers(HSE)1981 FIC 286/61 – Fire and explosionincidents in 1979- Covers the keeping of cylinders and small bulk tanks- When due for review in 1997 it was decided to produce oneset of guidance with input from the LP Gas Industry and HSE- Summarised accidents and dangerous occurrencesinvolving the use of oil, natural gas, or LPG as a fuel in fixedinstallations, surface coating using flammable liquids and theoperation of solvent evaporating ovensMay 1981June 1981August 1981CS5The Storage of LPG at FixedInstallationsGuidance Note Chemical Series 5(HSE)FIM 1981/34 Underground plasticpipes for use with low pressure LPGUnderground pipes carrying LPG,Minutes of meeting held in ChapelStreet on 04.08.81- This was based on the HSE Guidence Notes 1977 andthe earlier Home Office COP “Storage of LPG at fixedinstallations 1971”- Required the installation to be maintained to an acceptablestandard with the objective of maintaining the safe operatinglimits- Develops the level of maintenance required- Reprint with minor amendments of the Home Office COP- Provides a general guide to safe practice in storing andhandling LPG at fixed storage installations where tanks arefilled on site- Highlighted that plastic pipe, particularly polyethylene, issometimes used for underground low pressure gaseous LPGand that no objection should be raised to its use at pressuresbelow 2 bar- New standards for HSE agreedDecember 1981 IGE/TD/4 Edition 2Gas ServicesCommunication No. 1180- Revision from 1973- Apply to services intending to operate at pressures notexceeding 7 bar gauge- Apply to pipe diameters up to and including 50mm nominalbore for steel pipes and 63 mm outside diameter forpolyethylene pipes.- 3 rd Edition in 19941982 LPG TANK EXCHANGED BY CALORFebruary 1982FISM 8/1982/2 Underground pipesconveying LPG- Noted that the use of concrete lined trenches backfilled withsand for underground pipes conveying LPG is still beingdiscussed within HSE and with industry1982 AEGLPTSD/6EInstallation of underground pipeworkfor LPG vapour systems up to 4 barsworking pressure1982 AEGLPLPG installations on vessels- The recommendations cover the minimum requirementsfor the selection and use of materials and components forunderground LPG vapour pipework systems up to a workingpressure of 4 bar- These recommendations apply to pleasure craft, cargo shipsand fishing boatsOctober 1982March 1983September 1983FIC 286/68 – Small LiquefiedPetroleum Gas cylinder filling plantsLPGITATechnical Memorandum Part 11FIC 286/43 Rev – Undergroundsteel pipes conveying LPG as aliquid- Information to inspectors regarding small LPG cylinder fillingplants- Recommendation for the use of polyethylene pipework forburied LPG vapour systems up to 4 bar working pressure- Covered installation, backfilling and pressure testing ofpolyethylene pipework but did not include advice oninspection- Replaced FIC 286/43 issued in November 1980- Described a survey of establishments carried out by inspectorsin 1982156

THE ICL REPORT1984 CIMAH 1984Control of Industrial Major HazardsRegulations 1984- Replaced by COMAH 1999May 1985HELALocal Authority Circular (LAC)Technical Underground steel pipesconveying LPG as a liquid- Content is a direct reproduction of FIC 286/43 RevOctober 1986 LPGITA Code of Practice 1 Part 3Installation and maintenance of bulkLPG storage consumers’ premises– Part 3 - Periodic inspection andtesting- LPG supplier must ensure that LPG users are aware of theimportance of carrying out a scheme of inspection- Risk based approach- A leakage survey should be carried out at least every 10years for installations operating at 5 bar or above- States that the system should have been designed andinstalled in accordance with LPGITA Code of Practice Parts1 or 2- Revised in 2000February 1987 IP/9 Volume 1Institute of Petroleum1987 HSE Guidance Note CS 11(Chemical Sheet 11)The Storage and Use of LPG atMetered Estates1987 HSG34The storage of LPG at fixedinstallations- Supersedes IP/9 1967- Covers refrigerated LPG and large pressure storage atrefineries, bulk distribution plants and large industrial consumerpremises where such pressure storage is greater than 135m 3- States that Volume 2 IP9 was intended to cover pressurestorage at industrial commercial and domestic premise butHSE has no record of this being published- Due for review in 1997 but was decided to produce one setof guidance with input from the LP Gas Industry and HSE- Updates and supersedes Health and Safety series bookletHSG15 and HSE Guidance Note CS5.- Required the installation to be maintained to an acceptablestandard with the objective of maintaining the safetyoperating limits and emphasis to be placed on featuresaffecting the integrity of the installation- In reference to underground pipework it deals only with pipescarrying liquid- Withdrawn in 2000 after being superseded by LPGAguidance (starting with LPGA COP 1 Part 1, 1998)1988 IVES/TYLDESLEY/COVILLE ‘COMPROMISE’May 1988LPGITA Code of Practice 1: Design,installation and maintenance of bulkLPG storage fixed installations;part 2 – small bulk installations fordomestic purposes- Covers domestic premises- Should be used in conjunction with Code 1 Part 1, Code 1Part 3 and Code 22- States that pressure shall be controlled in at least 2 stages- Notes that Code 22 is ‘in preparation’1989 PSTGC 1989Pressure Systems and TransportableContainers Regulations 1989February 1990 LPGA COP 22LPG Piping – System Design andInstallation1991 TD Minute 2B/INF/2/91LPGITA COP 22:LPG Piping Systems – Design andInstallation- Revoked and re-enacted by PSSR 2000- Came into force apart from certain Regulations (e.g. ontransportable gas containers) on 1 July 1990.- Guidance for those involved in the design and installation ofLPG pipework systems; to give guidance on the selection ofmaterials, the design, installation and testing of pipework forLPG liquid and vapour- Revised in 1996- The minute introduces the LPGITA COP 22157

AppendicesApril 1991 OC 286/98LPGITA COP 22Design and InstallationOctober 1991 Lpga Code of Practice 1Design, Installation andMaintenance of Bulk LPG Storageat Fixed Installations: Part 1 Designand Installation1992 PUWER 1992Provision and Use of WorkEquipment Regulations 19921992 MHSWR 1992Management of Health and Safetyat Work Regulations 1992- Issued to Agricultural, Factory and quarries Inspectors andFCG specialist inspectors- It is almost a direct reproduction of TD Minute 2B/INF/2/91- Revision of 1978 COP 1- Now a 4 Part Code- Include vessels over 150 litres and the associated equipmentup to but not including the consuming equipment- Revised in July 1998- Implemented the parts of the European Use of WorkEquipment Directive that applied to general work equipment- Contained the requirement to maintain work equipment, thedefinition of work equipment would include items using LPG,but where pipework was part of the installation/building, itwas not covered- Came into force as part of a package of six sets ofRegulations to implement a number of EC Directives dealingwith the health and safety of workers- MHSWR was the GB implementation, together with theexisting HSWA of the Framework Directive (89/391/EEC) thathad the objective of setting up general duties under whichmore specific Directives would sit- The key duties were that of carrying out a risk assessment andsetting up health and safety arrangements under an effectivemanagement system- The aim was for all hazards to be identified, their riskassessed and those risks to be adequately managed1992 Approved Code Of Practice (ACOP)and Guidance; Management ofhealth and safety at work- Describes the key duties of MHSWR 1992 including thatof carrying out a risk assessment and setting up health andsafety arrangements under an effective management system- The aim was for all hazards to be identified, their riskassessed and those risks to be adequately managed1992 Planning (Hazardous Substances)Regulations1993 Town and Country Planning(Hazardous Substances (Scotland))Regulations 1993- With the Town and Country Planning (Hazardous Substances(Scotland)) Regulations 1993 implement the land use planningrequirements of the European Union Seveso II Directive- The regulations require sites with hazardous substancespresent above certain thresholds to seek consent from thelocal planning authority- With the Planning (Hazardous Substances) Regulations 1992implement the land use planning requirements of the EuropeanUnion Seveso II Directive- The regulations require sites with hazardous substancespresent above certain thresholds to seek consent from thelocal planning authorityMarch 1993September 1994IP13 2 nd EditionInstitute of Petroleum Model Codeof Safe Practice part 13: PressurePiping Systems ExaminationIGE/UP/2 ProcedureGas Installation Pipework, boosters& compressors on industrial andcommercial premisesCommunication No. 1598- Supersedes first edition published in 1979- Provides a guide to safe practices in the in-serviceexamination and testing of piping systems in the petroleumand chemical industries, and consists primarily of scheduledexaminations by Competent Persons- Guidance on the installation of gas pipework and certainancillary equipment on industrial and commercial premises- Covers similar subject matter to former British Gas plcpublications IM/16 and IM/15- Scope includes installation pipework designed to convey 3 rdfamily gases in the gaseous state, for a design pressure notexceeding 2 bar- IGE/UP/2 is referred to in the subsequent edition of LPGACOP 22 issued in June 2002158

THE ICL REPORTNovember 1994 IGE/TD/4 Edition 3Gas ServicesCommunication No.1562- Extends the scope to reflect the predominant use ofpolyethylene pipe and the increasing use of LPG- For LPG the recommendations apply to services suppliedfrom bulk storage vessel installations where the service pipeconnects the first stage regulator to the emergency controlvalve.December 1994LPGA Code of Practice 1: Design,installation and maintenance of bulkLPG storage fixed installations;part 2 – small bulk installations fordomestic and similar purposes- Major revision in 2000 and an amendment in 20031995 THSD MinuteTHSD/A3/T/2/94Pipelines for conveying LPG liquidand vapourNovember 1995 OC 286/104Pipelines for conveying LPG Liquidand Vapour- Provides information primarily on the design, installationand testing of liquid and vapour pipelines within industrialbuildings and premises- Gave general guidance on the design, installation and testingof LPG pipelines and was based on THSD Minute THSD/A3/T/2/94.- The OC did not consider ongoing maintenance or inspectionof pipework1995 RIDDOR Reporting of Injuries,Diseases and DangerousOccurrences RegulationsFebruary 1996 LPGA COP 22LPG Piping – System Design andInstallation- Revision of 1990 COP 22- Revised in 20021996 Pipelines Safety Regulations - PSR regulates third party conveyance of a fluid through apipeline from a primary source to a tertiary userDecember 1997 LPGA: LPG Technical Fundamentals - Notes that LPG does not affect metals but many non-metallicsubstances are chemically attacked by LPG1997 FPWR 1997Fire Precautions (Workplace)Regulations 1997- Require employers to address general fire precautionsconcerning fire fighting, fire detection, and escape routesand to cooperate and coordinate on these matters with otheremployers on their site- It does not deal with process fire safety and so does notcover the siting and maintenance of gas and LPG pipeworkand equipment1997 Town and Country Planning(Scotland) Act1998 CHANGE FROM CALOR GAS SUPPLY TO JOHNSTON OILS LTD SUPPLY1998 GSIUR 1998Gas Safety (Installation and Use)Regulations 19981998 HSC Approved Code of Practice:Design Construction and Installationof Gas Service Pipes: PipelineSafety Regulations 1996- Cover requirements for the safe installation and maintenanceof gas appliances etc- Applies to domestic, retail and commercial premises but, savefor regulations 37, 38 and 41 and subject to regulation 3(8),does not apply generally to ‘factories’ within the meaning ofthe Factories Act 1961- Applies to all service pipe installations with a maximumoperating pressure of up to 7 barg which connect to a naturalgas distribution main159

Appendices1998 PUWER 1998Provision and Use of WorkEquipment Regulations 19981998 OM 1998/114 Guidance onstorage of LPG- Amends PUWER 1992 and implements a 1995 amendmentto the European Use of Work Equipment Directive- Main changes concern mobile plant and power presses- Work equipment extended to include ‘installations’- Employers were required to ensure work equipment exposedto conditions causing dangerous deterioration is inspected atsuitable intervals- Applies to all work equipment this means that any items of apressure system not covered by PSSR are covered by PUWER- Issued by Safety Unit to explain some changes in the formatof guidance for LPGJuly 1998 LPGA COP 1Bulk LPG Storage at FixedInstallations:Part 1 Design, Installation andOperation of Vessels Located aboveGround- Revision of October 1991 COP 1- First version to have a foreword by the Advisory Committee onDangerous Substances (ACDS)- Aimed at those involved in the safe practice of storing andhandling of LPG in bulk at fixed installations- Supersedes the 1991 edition of COP1 Part 1 for aboveground vessels and HS(G)34- Revised in February 20041998 PUWER 1998 ACOP and Guidance- Safe Use of Work Equipment L221998 (3 rd Edition) GS4Safety in Pressure TestingHSE Guidance Note1998 Health and Safety (EnforcingAuthority Regulations)- Requires that if a risk assessment made under the MHSWRidentifies a significant risk from the installation or use or workequipment then a suitable inspection should take place- Provides guidance for pressure testing- Sets out the allocation of enforcement responsibilities betweenthe HSE and local authoritiesJanuary 1999 LPGA COP 1: Part 1 - Amendment to 1998 version1999 Pressure Equipment Regulations1999- Deals with the supply of pressure equipment1999 COMAH 1999 - Replaced CIMAH 1984- Implemented the Seveso II Directive- Main aim is to prevent and mitigate the effects of those majoraccidents involving dangerous substances which can causeserious damage to people or the environmentDecember 1999TM62LPG AssociationTechnical memorandum 62: Gassoundness testing of LPG servicepipework, installation pipework andappliances- Withdrawn after the publication of BS 5482 Part 1 in 2005- Includes small commercial installations and pipework andappliances with a total internal volume of 0.02 m3 or less1999 Management of Health and Safetyat Work Regulations 1999- Consolidates changes made since MHSWR 1992October 1999CHIS4 ‘Use of LPG in small bulktanks’HSE Chemical Information Sheet 4- After the withdrawal of HS(G)34 there was a need for freeHSE guidance to be produced for small-scale users of LPG inbulk tanks- covers the hazards of LPG, precautions, and actions in theevent of a fire or leak- Highlights the fact that LPG vapour is heavier than air and willcollect in drains, gullies and cellars- Deals with the need to ensure there are adequatearrangements for inspection and maintenance of the tank andits equipment but states this is normally arranged by the LPGsupplier160

THE ICL REPORTOctober 1999December 1999CHIS5 ‘Small scale use of LPG incylinders’HSE Chemical Information Sheet 5ACOP and guidance forManagement of health and safetyat work Regulations; L21Second Edition- Not applicable to the ICL Installation- Consolidates some changes made by amendments and tomake clear the implementation of the Directive in some areas,in particular, the way and need to reduce unacceptable risks- Gives extensive information on how to carry out riskassessments, risk reduction and the management of healthand safetyJanuary 2000LPGA Code of Practice 1: Design,installation and maintenance of bulkLPG storage fixed installations;part 2 – small bulk installationsfor domestic and similar purposes(Revision)- Revision of 1994 COP 1 Part 2- Deals solely with vapour take-off, above ground, buried ormounded installations of 150-4500 litres water capacitywhere the LPG is stored under pressure at ambienttemperatures in single fixed vessels2000 LPGA Code of Practice 1: Bulkstorage fixed installations; Part 3 –Examination & InspectionFebruary 2000 PSSR 2000Pressure Systems Safety Regulations2000- Revision of the 1986 COP 1 Part 3- Gives guidance for items that have to be included in thewritten scheme of examination (WSE) of bulk LPG vesselshaving a capacity of 150 litres or more and those itemsto be included in the WSE of distribution systems up to theconsuming equipment operating at pressures in excess of 0.5barg- Reiterates the periodic inspection of underground pipes below5 bar as requiring survey for leakage by pressure testing, gasdetection etc- Assumed that the system had been designed and installed inaccordance with COP 1 parts 1, 2 and 4- Revised September 2006- Revoked and re-enacted PSTGC (1989)- Applies to all pressure systems with a ‘relevant fluid’- Requires a Written Scheme of Examination to be drawn up bya competent personApril 2000 OM2000/113 - Explains that the PSSR 2000 Regulations revoke and re-enactwith minor changes the PSTGC 19892000 PSSR 2000, ACOPSafety of Pressure Systems L1222000 HELA LAC 66/8Pressure Systems Safety Regulations2000 Issues of Interpretation- Described the changes between PSTGC 1989 and PSSR2000- Changes were mainly connected with the introductionCarriage of Dangerous Goods legislations that had revoked7 of the regulations and the introduction of the PressureEquipment Regulations 1999- Gives a basic interpretation of terms used in PSSR such ascompetent person, relevant fluid etc2000 HELA LAC 52/15 (rev May 2000) - Makes enforcement officers aware of the existence of aflexible pipe which may have a use on autogas forecourtswhere buried pipe is used between the LPG vessel and thedispenser2000 Building Regulations - These regulations apply to England and Wales under theBuilding Act 19842001 NFPA 58American National Fire ProtectionAssociation Code 58 – update of1963 version- Applies to the operation of LPG containers, piping andassociated equipment when delivering LPG to a building foruse as a fuel gas- Includes discussion on protecting buried pipework from trafficloading and corrosion- Requires that owners or operators of LPG bulk or industrialsystems shall prepare and implement procedures to maintainthe ongoing mechanical integrity of the LPG systems161

Appendices2002 Amendments to Workplace (Health.Safety and Welfare) Regulations- Regulation 4A concerning the stability of buildings wasintroduced by way of an amendment in SI 2174/2002;Health and Safety (Miscellaneous Provisions) Regulations2002June 2002 LPGA COP 22 - Revision of 1996 COP 22- Does not contain a foreword from HSE’s ACDS because itscontents are outside the scope of previous HSE guidance2002 OC 284/7DSEAR 2002SI 2002/2776- Produced by FOC SU to announce DSEAR and describe therequirements of the legislation and the inspection/enforcementapproach2002 COSHH Control of substanceshazardous to health2002 HSE INDG370 Leaflet: Fire andExplosion: How Safe is yourworkplace?- Provides further guidance on DSEARJanuary 2003May 2003May 2003May 2003May 2003LPGA Code of Practice 1: Design,installation and maintenance of bulkLPG storage fixed installations;part 2 – small bulk installationsfor domestic and similar purposes(revision 2)DSEARDangerous substances andexplosive atmospheres L138DSEARStorage of dangerous substancesL135DSEARControl and m mitigation measuresL136DSEARSafe maintenance, repair andcleaning procedure L137- Revision of 2000 COP 1 Part 2ACOPACOPACOPACOPFebruary 2004 LPGA COP 1 Part 1 Revised - Revision of July 1998 COP 1- More detailed in its application to existing installations11 May 2004 DATE OF EXPLOSIONJuly 2004 HELA LAC 65/54a - Concerned the investigations into two incidents that occurredat petrol filling stations with LPG installations that identifiedserious weaknesses in the installation of some LPG pipeworkand in the sealing of underground ductsSeptember 2004 HSE HID Short Life Circular - Sent to HSE Inspectors regarding the LPGA Codes of Practiceand ALARPNovember 2004HSE Discipline Information NoteCD5/059: Developing an inspectionstrategy to ensure the ongoingintegrity of buried metallic pipework- Internal technical note to process safety and mechanicalengineering specialist inspectors. It included furtherinformation on buried metal pipework2005 Building (Scotland) Act 2005 - This Act repeals the Building (Scotland) Acts of 1959 and19702005 Building (Scotland) Regulations2005- Under the Building (Scotland) Act 2005 aim to ensure thesafety of people in and around buildings, whether domesticor commercial.162

THE ICL REPORT2005 Fire (Scotland) Act - The onus is on the owner or occupier of premises to preparea written fire assessment, focussing on the use of the building,its construction and the potential for a fire.2005 Regulatory Reform (Fire Safety)Order 2005- Deals with fire safety in non domestic premisesApril 2005 HSE OM 2000/113 - Guidance to HSE inspectors regarding PSSR 2000June 2005COMAH (Amendment) Regulations2005- Broadens the scope of COMAH- Reflects changes in Seveso IIDecember 2005 BS 5482 Part 1:Domestic butane- and propane-gasburninginstallations- Withdrew TM62 1999March 2006June 2006September 2006HSE Leaflet: ‘Checking LPGpipework’HSE INDG163 Leaflet: Five steps torisk assessmentLPGA Code of Practice 1: Bulkstorage fixed installations; Part 3 –Examination & Inspection- This HSE leaflet was sent to all LPG users through the LPGsuppliers- Provides employers with advice regarding risk assessments- Produced in 1998, revised in 2002 and reissued in 2006- Revised 2000 version- Included an expanded section on what an inspection regimeshould considerMarch 2007 Technical Memorandum 84:Inspection and maintenance ofLPG pipework at commercial andindustrial premisesJanuary 2008 User Information Sheet 015:Inspection and maintenance ofLPG pipework at commercial andindustrial premises- It outlines the need for pipework owners to insepct andmaintain LPG pipework in order to ensure its continued safeoperation- This is a reprint of Technical Memorandum 84 by UKLPG- There are no differences from Technical Memorandum 84April 2008OC 286/105 The ongoing integrityof buried, metallic LPG pipework– inspection and enforcementconsiderations- This is a follow on from DIN CD5/059- Aimed at all inspectorsSeptember 2008 Draft UKLPG Code of Practice 22 - Redrafted to take account of revised guidance in relation tounderground metallic LPG pipework- Still in draft formJanuary 2009 UKLPG Code of Practice 1: Part 1 - Revision from 2004 edition163

AppendicesAppendix 4 – The history of theInquiryThe Inquiry: Terms of ReferenceOn 1 October 2007 the Lord Advocate,the Rt Hon Eilish Angiolini QC, and the thenSecretary of State for Work and Pensions, theRt Hon Peter Hain MP, announced that a jointpublic inquiry under the Inquiries Act 2005 (the2005 Act) would be held in Scotland into thecircumstances of the disaster. The Inquiry wasto be a joint inquiry since health and safetymatters were not within the competence of theScottish Ministers. The Inquiry might howeverconsider matters relating to Scotland that werenot reserved.This was the first inquiry in Scotland, and thefirst joint inquiry, to be held under the 2005Act, and the second to be held since inception.On 5 December 2007 it was announced thatI was to be the Chairman of the Inquiry andthat the Inquiry’s Terms of Reference, as agreedbetween Scottish Ministers and the Secretary ofState for Work and Pensions, were to be:• To inquire into the circumstances leadingup to the incident on 11 May 2004 atthe premises occupied by the ICL groupof companies, Grovepark Mills, Maryhill,Glasgow• To consider the safety and related issuesarising from such an inquiry, including theregulation of the activities at Grovepark Mills• To make recommendations in the light of thelessons identified from the causation andcircumstances leading up to the incident• To report as soon as practicable.By Instrument of Appointment, dated 15 and17 January 2008 the Secretary of State forWork and Pensions and the Cabinet Secretaryfor Justice on behalf of the Scottish Ministersestablished the Inquiry with a setting up date of21 January 2008 and formally appointed meas its Chairman. The Instrument of Appointmentspecified that the Inquiry would be subject tothe Inquiries (Scotland) Rules 2007 (the 2007Rules) made under section 32(3) of the 2005Act. These rules were laid on 13 December2007 and came into force on 19 January2008.Mr Roy Martin QC and Mr Kenny McBrearty,Advocate, were appointed as counsel to theInquiry.On 21 January 2008, Ms Jillian Glass, of HMTreasury Solicitor’s Department, GovernmentLegal Services, was appointed as Solicitor tothe Inquiry.Setting up the InquiryWhen she announced the Inquiry the LordAdvocate said that she intended that it wouldopen on Tuesday 8 April 2008. On 7December 2007 the Procurator Fiscal wrote tothe bereaved families and injured survivors tothis effect.In the event, it became apparent that theessential preparatory work would necessitatea later start to the hearings. The Solicitor tothe Inquiry at once began to establish theInquiry Secretariat; appoint staff; procureoffice premises; secure a suitable venue forpublic hearings; prepare budgets and establishfinancial and accounting relationships withthe Scottish Ministers; register under the DataProtection Act 1998; draft procedures andprotocols for the purposes of the 2007 Rulesand the 2005 Act; establish a website, obtainthe release and use of the evidence for thecriminal case from the Crown Office andobtain further evidence relevant to the remit,164

THE ICL REPORTand procure technical support for the recordingof Inquiry documentation and its electronicpresentation in public hearings together withtranscription of evidence for daily posting on thewebsite during the public hearings.PremisesOfficesAn office was leased on 18 February 2008from Edinburgh Council at Lothian Chambersand was occupied in the week of 3 March2008. The proximity of the office to the Courtof Session gave ready access between theInquiry Team, the Chairman and counsel.VenueAn extensive search for a venue in Glasgow forthe Inquiry hearings had begun in November2007. Several available venues had to beruled out on grounds of cost, unavailability,accessibility or security. Glasgow High Courtand Glasgow Sheriff Court were discountedsince both facilities were under considerablepressure from the volume of their normalbusiness.The Community Central Hall at Maryhill isowned by a community development charitythat provides facilities and services includingcare for the elderly, youth projects, trainingprogrammes and opportunities for the benefitand well being of the community. It waschosen as the venue in February because of itsfacilities and its accessibility to the communitymost closely affected by the disaster. Thenecessary refurbishment of the Hall has left alasting benefit to the local community. In thedays immediately after the explosion the Hallprovided support to the rescue services andrefuge for families and friends. A memorialservice was subsequently held there. It continuesto provide a meeting place for some of thoseaffected by the disaster. A further public inquiryhas since been held there. This has extendedthe benefit of the expenditure incurred by thisInquiry.On 4 April 2008 it was announced that theCommunity Central Hall would be the venuefor the Inquiry. Relatives and survivors weredivided in their views as to the choice of venue.I greatly regret that this caused upset to some.Obtaining and review of evidenceThe underground pipe that failed had beeninstalled 35 years before the explosion. Theevidence about its installation was sparse.I intended that the Inquiry would be openand transparent. Accordingly, the Inquiryteam notified those providing documents andinformation that such evidence was likely tobecome public at some stage of the Inquiry.I gave an assurance that I would use anyevidence provided to me only for the purposesof fulfilling my remit.I invited anyone who held relevant evidence tosupply it to the Inquiry and to inform the InquirySolicitor of any reason why it should be treatedas confidential. It would then be possible for meto consider in each case whether a restrictionnotice under section 19 of the 2005 Act wouldbe appropriate.Criminal evidenceThe Crown held the evidence gathered for thecriminal prosecution. On 21 December 2007the Procurator Fiscal supplied copies of theCrown productions and core police statementsto counsel to the Inquiry.165

AppendicesIn January 2008 the Inquiry Solicitor, juniorcounsel to the Inquiry and the ProcuratorFiscal met to discuss the scope of the criminalinvestigation, the nature of the information heldby Crown Office and any legal constraintsthat might affect the use of the evidence by theInquiry. During March and April, the Crowngave the Inquiry Team access to its productionsand statements, including a further 923 policestatements.This material greatly assisted the Inquiry.The Inquiry did not examine any personalmedical records. The Crown did not provideinvestigation information that was not producedin evidence.In late April and early May 2008, as amatter of courtesy, Crown Office wrote tothe witnesses from whom the Inquiry wishedto seek assistance, enclosing copies of theirprecognitions. It informed the witnesses that theInquiry would be approaching them directly.The Inquiry Team sent draft statements andwhere relevant further questions to the witnessesconcerned incorporating relevant informationfrom the Crown statements and precognitionstogether with copies of any documentationreferred to in the drafts. The team asked eachwitness to answer any questions and to confirmor amend the draft statement. Any amendedstatements were returned to the witnesses forsignature.On 2 May sixty two draft Inquiry statementswere sent out to witnesses with a request thatthey be returned no later than 12 May 2008. Iam indebted to the witnesses, and the lawyersassisting them, for their co-operation. It enabledthe Inquiry to disclose these statements to thecore participants before the public hearings andto adhere to the start date of 2 July.Material recovered in the course ofthe criminal investigation but notavailable for review for relevance bythe InquiryAmong the productions were numerousdocuments recovered from the site. Some hadbeen recovered directly. Others had beenretrieved from the debris that was removed fromthe site. All of the rubble and the remains ofthe building had been removed by skip undercontrolled conditions to another secure site. Forseveral weeks thereafter police officers siftedthe debris. They retrieved 1276 one-tonne bagsof documents. Papers relating to the building,and to LPG and Health and Safety matters,but not considered to be of evidential value,were kept in about 40 boxes. They werereviewed by the Procurator Fiscal and by theICL companies’ lawyers.The Inquiry Team requested access to theseboxes. The Procurator Fiscal then learned thatthey were no longer available. They had beenstored in a container that vandals had set onfire.Other evidence obtainedThe Inquiry Team’s investigations producedfurther relevant information which was publishedon the website.Extensive questionnaires were submitted toCalor Gas, Johnson Oils, UKLPG and HSE afterStage 1. This exercise provided a volume ofuseful information for Stage 2.166

THE ICL REPORTThe Inquiry’s own electronic databasereferences were substituted for the CrownOffice production references for the purposesof the hearings. The Crown Office retained theoriginals of the productions.Disclosure to core participantsOn 1 May 2008 the Crown provided theproductions to the Inquiry electronically.This enabled the Inquiry to disclose themelectronically to the core participants.The Crown confirmed that all productions couldbe made available to the core participantsregardless of their relevance to the terms ofreference. Of the core participants, previouslyonly ICL had had access to all productions inthe criminal case. The Inquiry Team identifiedthe documents relevant to the terms of reference.These were disclosed as the Inquiry bundle.The remaining productions not considered to berelevant were disclosed to core participants in aseparate electronic disk.During the Inquiry further material was added tothe Inquiry bundle.Inquiry Bundle – Stage 1On 16 May 2008, following receipt of signedconfidentiality undertakings, the Inquiry bundlewas disclosed to core participants. It consistedof 3 disks.Disk 1 was subdivided into 3 sections –Guidance, Expert and Other. “Guidance”consisted of legislation, codes of practiceand guidance notes. “Expert” consisted ofvarious expert reports. “Other” consisted ofmiscellaneous documentation relevant to theInquiry. This disk was re-issued on 19 June2008. A finalised version was issued on 24June 2008. On 7 August, after Stage 1, Disk 1was re-issued to core participants’ recognisedlegal representatives together with thedocuments added and statements used duringStage 1.Disk 2 contained Crown productions that Iconsidered not to be relevant to the Inquiry. Itwas left to each recognised legal representativeto decide whether to review this material. Noparticipant relied on any of it. Other materialssuch as police production reports and alarge number of photographs were yet to bereviewed for relevance and were excluded. On19 June 2008 the final version of this disk wasissued to core participants.Disk 3 contained the finalised Inquiry statementsfor Stage 1. On 4 June 2008 this disk was reissuedto core participants with fully referencedstatements and a provisional list of witnesses.On 23 June 2008 the finalised disk was issuedalong with the final list of witnesses for Stage 1.Four core participants represented themselves atthe Inquiry. During June they were given accessto the Inquiry bundle by members of the InquiryTeam.Inquiry Bundle – Stage 2On 14 October 2008, the Inquiry teamdisclosed an updated version of Disk 1 to thecore participants. All documents added to itwere marked as “added for Phase 2”. On17 October, the team disclosed a further 24documents as part of the Inquiry bundle. On 29October, the team disclosed a few additionaldocuments and the referenced statements to thecore participants.167

AppendicesOther reports and documentsOn 27 June 2008, the Inquiry issued a HSEDVD showing the smoke test carried out on theICL pipework and a police DVD showing therecovery of evidence. As the recognised legalrepresentative for a number of the bereavedfamilies and survivors, Mr McGuire was askedto advise the Inquiry in writing if any of themthought that these might cause distress. TheInquiry received no correspondence on thismatter from Mr McGuire.Undertakings as to confidentialityOn 16 May I released the Inquiry diskshaving received professional undertakings asto confidentiality from the recognised legalrepresentatives of the core participants. Theseundertakings were to apply to the disks and toall further documents and information providedin the course of the Inquiry.The undertakings specified that hard copies ofdocuments were to be made only for specificpurposes and were to be retained within thefirm, with no disclosure to be made to any thirdparty; that the recognised legal representativeswere permitted to give their clients accessto the documents in their offices, subject tospecific exceptions; and that all documents andinformation supplied in the course of the Inquirywere to be destroyed within a month of thedelivery of my Report to Ministers.Members of the Inquiry Team gave those coreparticipants who represented themselves theopportunity to read this material.Core participants also provided undertakings.Breach of professional undertakingby Mr Patrick McGuireIn the course of the second week of the publichearings it came to my attention that MrPatrick McGuire, of Thompsons had brokenhis personal professional undertaking to meby having given hard copies of statements tocertain of his clients in advance of their beingpublished on the Inquiry website. It appearsthat Mr McGuire gave these copies to thosecore participants who had been clients ofThompsons before the Inquiry but not to any ofthose who had been represented earlier by twoother firms of solicitors.Mr McGuire wrote to the Solicitor to the Inquiryand expressed his sincere and unreservedapologies. He accepted that he had brokenhis personal professional undertaking. Hesaid that he had misread it and had failedto notice that access could only be given athis firm’s premises. He said that his breachof the undertaking had not been deliberate.He said that he had arranged for the returnof the statements from those to whom he hadsent copies and that he deeply regretted theincident.In the event it appears that Mr McGuire’sbreach of his undertaking did not seriouslyprejudice the conduct of the Inquiry.First Preliminary HearingOn 5 February 2008 I announced that the firstpreliminary hearing would take place on 25February.The Inquiry website went live on Friday 22February.168

THE ICL REPORTAt the first preliminary hearing I said that Iwould conduct the Inquiry in two stages. Thefirst would deal with the factual circumstancesleading to the explosion and safety and relatedmatters, including regulatory issues arisingfrom that examination. The second wouldconsider the lessons to be learned and therecommendations to be made.I invited those who wished to be coreparticipants to apply to me in writing. I drewattention to the provisions under which I couldrequire two or more core participants to have asingle legal representative where their interestsin the outcome of the Inquiry were similar,where the facts on which they were likely torely were similar and where it was fair andproper for them to be jointly represented. I alsomade clear that it was not necessary for a coreparticipant to be legally represented.I indicated that, at the conclusion of eachstage of the Inquiry, I would receive notes ofthe core participants’ proposed findings in fact,and of suggested lessons to be learned, andany proposed recommendations and closingsubmissions.I invited any interested person to submitrepresentations on any matter that might fallwithin the terms of reference.I intended to receive all relevant informationin written form within a timetable. Where oralevidence was to be given, I required thatcore participants who wished to examine anywitness should apply in writing specifying thetopics that they wished to raise.On 4 March 2008 the Inquiry Solicitorwrote to the bereaved families and survivorsrepeating my concern that they should haveevery opportunity to express their views andconcerns. She enclosed a note explaining therequirements for an application to be a coreparticipant.Second Preliminary HearingOn 8 April 2008, at the second preliminaryhearing, I gave my decision as to theparties who were to be admitted as coreparticipants. The list of core participants is setout in Appendix 1. In relation to next of kinI admitted a single representative, being thesurviving spouse, where applicable, or theeldest child, failing which either parent. I invitedrepresentations with regard to any particularcircumstances. I rejected applications frominsurers. Individual HSE inspectors reservedtheir position. I decided that the question asto whether any core participant should beadmitted to all or part of the Inquiry should bekept under review.I invited interested persons to submit concisestatements of case by 16 May setting out theissues that they wished me to consider, havingregard to my terms of reference, and thoseaspects of the circumstances leading up tothe explosion that they wished the Inquiry toinvestigate. I also invited core participants tonotify me of the topics on which they wishedto participate, the matters that they soughtto establish on each and their view of therelevance of those matters to my terms ofreference.I wished to maintain a flexible approach and toproceed on a full disclosure of the positions ofthose interested from the outset.169

AppendicesOn 22 April 2008 there was a meetingbetween the Inquiry Solicitor, the legalrepresentatives of the core participants and theunrepresented core participants to discuss thearrangements for the Inquiry.On 2 May 2008, I published the InquiryProcedures document on the Inquiry website.On the same date I published the InquiryProtocol setting out the procedures to befollowed in respect of applications for legalrepresentation.On 16 May 2008, I issued my determinationas to the test as to financial resources forthe purposes of public funding. I made anadvance allowance for reading time to enableThompsons and their counsel to read thematerial. This was not utilised.On 10 June 2008, I issued my decision on theapplications for funding for legal representationat public expense by those core participantswho were next of kin or were injured survivors.The deadline for applications to questionwitnesses in Stage 1 was 16 June. In the eventthe group represented by Thompsons did notsubmit applications until 1 July. As their role wasnot pivotal to the outcome of the Inquiry, thisdelay did not unduly disrupt it.First application for funding at publicexpenseBy letter dated 22 February 2008, Thompsons,on behalf of themselves and Levy and McRae,Solicitors (Levy and McRae), notified me thatthey collectively represented all of the injuredvictims and the families of the deceased. Theymentioned that another firm, Austin Lafferty andCompany (Austin Lafferty), represented someof the victims, but that they would be dealingwith the matter on their own. Thompsons saidthat they proposed to instruct one set of counselconsisting of a leader and two juniors. Theyapplied for an award of legal costs. They setout an estimate of 400 hours preparation workby solicitors at £200 per hour with a chargeof £500 per day for each firm to attend at theInquiry. They estimated that 40 days wouldbe required for preparation by counsel at ratesof £250 per hour for leading counsel and£175 per hour for junior counsel. Counsel’sfees would amount to, in all, £7,000 per dayduring the hearings. The letter recorded that itwould be necessary to obtain expert evidencefor the families and victims, that this wouldinvolve further work and expenditure estimatedat £15,000 plus additional solicitor’s time, andthat the inquiry hearings would last for severalmonths.I made it clear at the preliminary hearing on 25February 2008 that until I made my decision onthe applications for core participant status, noquestion of funding could arise. On 8 April, Igranted core participant status to the next of kinof those who died and to the injured survivors.Funding at public expenseThe legislation recognises that the length andcost of public inquiries depends to an extent onthe amount of publicly funded representationand on the role that legal representatives arepermitted to play in the proceedings. In 1990the then Attorney General said that “In general,the Government accept the need to pay outof public finds the reasonable costs of anynecessary party to the Inquiry who would beprejudiced in seeking representation were hein any doubt about funds becoming available.170

THE ICL REPORTThe Government do not accept that the costsof substantial bodies should be met from publicfunds unless there are special circumstances.”The power of a Chairman to make an awardof public funding is restricted by statute topayments of compensation for loss of time,expenses properly incurred in attendance atthe Inquiry, and to fees for legal representationwhere a person is providing evidence, or is aperson who, in the opinion of the Chairman,has a particular interest in the proceedings oroutcome of the Inquiry that justifies such anaward.A Chairman must act with fairness and withregard to section 17 of the 2005 Act and mustavoid any unnecessary costs, whether to publicfunds, witnesses or others. He is also requiredto comply with any Determination issued byMinisters under section 40.On 21 February 2008, the Ministers exercisedtheir powers under section 40 and issueda Notice of Determination prescribingqualifications and conditions on my powerto award amounts in respect of legalrepresentation and setting a maximum on thefees to be allowed.The Determination related to the payment oflegal expenses from public funds. It providedinter alia that payment could be made only incircumstances where the Chairman consideredit to be fair, reasonable and proportionateand that any award must be subject to thecondition that payment would be made onlyfor work evidenced as having been done ina cost effective and efficient manner, whereunnecessary duplication had been avoidedand the best use of funds had been made. Anyaward had to specify the nature and scope ofwork to be carried out. As an Inquiry under the2005 Act is inquisitorial in nature, no paymentwas permitted for work of an investigativenature or in relation to the obtaining of expertreports without express permission givenin advance. The Determination prescribedmaximum hourly rates and the maximum numberof hours for which solicitors could charge.Retrospective awards were forbidden.Scottish Ministers and the Secretary for Statefor Work and Pensions also determined therate of remuneration for counsel to the Inquiry inaccordance with section 39 of the 2005 Act.In making any award the Rules require theChairman to take into account the financialresources of an applicant and the publicinterest. I therefore had to decide what wouldbe the legitimate, proportionate and fair tests toapply in allowing funding at public expense.After the first preliminary hearing I receivedapplications to be core participants from,among others, bereaved family members andinjured survivors. Taking into consideration allthe circumstances, including expectations thathad been raised in the period before the settingup date, I admitted them as individual coreparticipants. Those who represented themselveswere given help by the Inquiry Team. MrsFerguson and Mrs Smith, who attended on everyday of the Inquiry, greatly impressed me withtheir approach. Their questions were particularlyhelpful. I invited others who had been injuredor bereaved, and who did not wish to be coreparticipants, to submit questions in writing.One of the primary considerations underlyingthe 2005 Act and the 2007 Rules is the171

Appendicesavoidance of multiple representations ofpersons who have had an identity of interest.There is also the important consideration ofcost. I therefore invited the three legal firmsrepresenting a number of the bereaved familiesand injured survivors to reach an agreement ona single joint representation.When that was agreed, they could apply forpublic funding for legal expenses. Levy andMcRae indicated that the legal aid tests wouldnot be acceptable. A number of the familieswere said to object to any suggestion as tomeans testing.In the course of consideration of this MPs,MSPs and others involved themselves directlyin this issue. Patricia Ferguson MSP, AnnMcKechin MP, the STUC and representativesof the bereaved families sought a meeting withKenny MacAskill MSP, Cabinet Secretary forJustice, to discuss a number of concerns theyhad in relation to the running of the Inquiry. Themeeting took place on 14 May 2008.At that meeting I understand concern wasexpressed that the bereaved families andsurvivors might be expected to pay for legalrepresentation if they were unable to satisfy atest for financial assistance. It was asserted bythose concerned that Ministers had assuredthem that the Government would meet theirlegal costs in full. I was unaware of any suchassurances which, in my opinion, would havebeen outwith their gift.There was also a concern expressed by thefamilies that if they had to make a financialcontribution towards legal representation, thecontribution would somehow be paid to theGovernment. On 4 June 2008 the Ministerfor Justice and the Secretary of State for Workand Pensions jointly wrote to me confirmingthat the question of legal representation of coreparticipants at public expense was a matter forthe Inquiry Chairman and that this had beenmade clear by the Cabinet Secretary for Justiceat the meeting on 14 May. The Ministers alsoconfirmed that their respective departments hada budget in place jointly to fund the Inquiryand that there was no desire on the part of theScottish and UK Governments to require anycontribution from the families towards the costsof the Inquiry.On 16 May I issued a determination setting outthe criteria that I intended to adopt in applyingRule 18 of the 2007 Rules. Rule 18 requiresthe Chairman to take into account the financialresources of an applicant together with thepublic interest when considering making anaward pursuant to an application under section40 of the Act.I had previously invited core participantsto make representations to me as to theappropriate criteria for the Rule 18 requirement.I received no representations on the matter,other than the oral comment to the Inquiry teamfrom a representative for some of the bereavedfamilies that the test for legal aid would not beappropriate.At least one of the next of kin was concernedthat he might be disqualified from being a coreparticipant because his income was slightlyover the threshold set in my determinationof 16 May. I made it clear that none of thenext of kin was at risk of being excluded asa core participant. It was open to all or anyof the next of kin to represent themselves ifan award should not be made, or to pay for172

THE ICL REPORTrepresentation on their own behalf. I repeatedmy opinion that it was not necessary for a coreparticipant to be legally represented. I alsomade it clear that where a core participant’sincome exceeded the threshold, I was willing toreceive representations and to consider whetherto make an award in the circumstances of thecase. In the event, no core participant wasexcluded from participating in the Inquiry onfinancial grounds.In my determination of 16 May, I directedthat those core participants who were nextof kin or were injured survivors were to havesingle legal representation. Thompsons hadinformed the Inquiry by a letter dated 2May that “agreement” had been reached.Thereafter I confirmed Mr Patrick McGuireto be the grouping’s single recognised legalrepresentative.The funding permitted under the award wasinitially for consideration of the evidencecontained in Inquiry bundle, makingapplications for any questions, and attendingoral hearings so far as necessary properly torepresent their clients’ interests. Funding wasthen granted for specific items of work.The only other funding at public expense wasfor some small incidental costs of less than£1000 in all.Statements of caseThe statements of case were published on theInquiry website.Interested persons submitting statementsincluded IOSH, Prospect (a Trade Union),STUC, Mrs Ann McKechin MP on behalf of MrConnelly, Mr Connelly, Strathclyde University,Families against Corporate Killers, Mr AlistairMcNab (an HSE Inspector), and the FireBrigades Union. On 9 June 2008 I publishedmy response to the initial statements of case.The issues raised in statements of casesubmitted by interested persons were as follows.IOSHThe Scottish Health and Safety system and itsapplication at ICL; compliance with Health andSafety and Fire Regulations; and training of ICLstaff in OSH matters.ProspectGuidance to HSE inspectors on dangersof leaks from underground LPG pipework;communication of incidents to HSE fieldinspectors; and financial pressures on HSE.STUCThe extension of the rights of trade unionappointed health and safety representatives toinspect workplaces and employers where tradeunions are not recognised.Ann McKechin MPThe handling of Mr Connelly’s complaints byICL and HSEMr ConnellyThe attitude of ICL management to health andsafety issues; exposure of staff to hazardoussubstances; lack of personal protectionclothing and equipment for staff; and poorcommunication of health and safety issues tostaff within ICL.Strathclyde UniversityHostility of ICL management to trade unionism;oppressive approach within ICL to employer/173

Appendicesemployee relations; exposure of employees tohazardous substances; deficiencies in healthand safety training, instruction supervisionand communication systems within ICL ; anddeficiencies in oversight of ICL by HSE.Families Against Corporate KillingFinancial benefit to ICL companies arising fromthe explosion; and HSE funding.Mr McNabA number of issues including actions by ICL andCalor, the matter of multiplicity of LPG guidanceand the dissemination of information to HSEinspectors regarding similar incidents involvingLPG.Fire Brigade UnionThe role played by Fire Safety InspectingOfficers; similarity with previous incident; andcurrent regulatory framework.Stage 1 hearings - 2 to 22 July 2008Some witness statements that did not give riseto further questioning were read into the Inquiryrecord. Some witnesses were given the optionto attend in person to read their own statementor to have their statement read on their behalf.Some were called to give oral evidence,four of whom were excused on health orcompassionate grounds. Their statements wereread into the record. Questions for witnesseswho did not attend were put to them in writing.Their answers were circulated and published.Throughout the Inquiry I maintained an openinvitation to injured survivors and bereavedfamilies to submit questions in writing to anywitness.The topics addressed in Stage 1 were asfollows:1. The identity of those who died and thosewho were injured;2. The circumstances leading up to theincident;3. The history of the ICL Group and theoccupation and use of Grovepark Mills;4. The history of the buildings at GroveparkMills and the processes carried out there;5. The history and use of the LPG installationat Grovepark Mills;6. The history of the regulation and inspectionof the LPG installation;7. The cause of the explosion.The list of the witnesses Stage 1 is set out atAppendix 2.The LiveNote© technology enabled a verbatimtranscription of the evidence to be displayedin real time on the core participants’ laptops.The transcripts were published on the Inquirywebsite shortly after the morning and afternoonsessions.The Inquiry documents were displayed onmonitors by electronic document presentationequipment. The proceedings, includingdocument presentation, were transmitted insound and vision to a dedicated media suiteand to two separate rooms set aside for thefamily members and survivors.At the end of Stage 1, I requested the coreparticipants to submit to me by 15 August2008, their proposed findings-in-fact, anda note of the evidence on which each wasbased. I waived this requirement in respect ofthose core participants who were without legalrepresentation.174

THE ICL REPORTI also requested core participants to submitto me by 15 August, a note of any proposedlessons to be learned from the facts establishedin Stage 1. I invited core participants tosuggest what measures could have preventedthis tragedy and what inspection or oversightregime would be appropriate to ensure the safeand proper installation and maintenance of LPGpipes on small commercial premises.I invited any other interested persons to makesimilar submissions. I received submissions fromProspect and Mr Tyldesley.Stage 2 PreparationsIn August, I commissioned a report from MrRod Sylvester-Evans which considered possibleimprovements to the current LPG regime,particularly as it related to LPG pipeworkat small industrial and commercial bulk usersites. I invited core participants to submit theirproposed recommendations and their responsesto Mr Sylvester-Evans’ report by 26 September2008.Notice to Core Participants- 8 September 2008This notice, amongst other things, set atimetable for the submission of proposedrecommendations by core participants andany further representations that they wished tosubmit, and for the circulation of submissions.On 10 October 2008, I issued a determinationindicating my proposals for procedure in Stage2, together with a provisional list of witnesses.Stage 2 hearings - 21-24 October2008 and 4-7 NovemberThe purpose of Stage 2 was to consider whatrecommendations might be made to Ministersin the light of the lessons learned from thedisaster.The relevant material included the expert reportson the disaster. The focus of Stage 2 was onthe regime of installation, maintenance andmonitoring of LPG pipework. This includedconsideration of statutory and other guidanceavailable to occupiers, the users and gassuppliers; and the position of HSE and the LPGindustry.Calor Gas Limited assisted the Inquiry greatlyby providing a small demonstration tank toillustrate the constituent elements of an LPGinstallation.In Stage 2, I heard evidence from witnessesfrom HSE on the recommendations proposedby Mr Sylvester-Evans. At the end of Stage 2,I asked Mr Sylvester-Evans to present modifiedconclusions and recommendations in the lightof the evidence and submissions from coreparticipants.On 24 October 2008, I asked coreparticipants to make closing submissions on 13November. I also invited interested persons tosubmit written representations by 12 November.I received written representations fromUKLPG, Mr Tyldesley, Stirling and StrathclydeUniversities, the Institute of Gas Engineers andManagers (IGEM) and Shell Gas Limited.On 13 November 2008, I heard closingstatements from the core participants andconcluded the hearing.Consultation with LPG usersBy the end of the Inquiry hearings, I hadheard from directors and employees of the ICLcompanies, representatives of the gas industry,175

AppendicesLPG suppliers, regulators, bereaved familiesand survivors. I invited the CBI and UKLPG toidentify for my benefit a range of small- andmedium-sized LPG users who might wish tocomment on the suggested recommendations.I received comments from:• Bernard Matthews Farms• Countrywide Farmers plc• British Holiday and Home Parks Association• Trevelgue Holiday Park• Greenfield EngineeringThe responses broadly supported Mr RodSylvester-Evans’ approach. They highlightedthe need to secure pipework integrityand ownership, greater awareness andmanagement of LPG hazards and risks, andimproved communications between regulators,suppliers and users. They expressed concernsabout the merits of a verification schemeand the risks of damage to buried pipes ifthey should be excavated for the purpose ofinspection.I am grateful to those LPG users who submittedtheir views.Other interested personsMr Ronald Jamieson submitted his ownobservations as an interested person with abackground in building design and construction.Mr Jamieson had certain views on some of theevidence led in Stage 1. His comments relatedto the cause of the explosion, the date andnature of the construction of the building, thegeological conditions and the point of entry ofLPG into the building. The Inquiry Solicitor metMr Jamieson in October and December 2008and June 2009 to clarify certain points thatarose from the material that he had provided.Mr Jamieson stressed that his submissions werefor the information of the Inquiry and were notintended for wider circulation or publication.He agreed that the notes of these meetingswould suffice to record the understanding that hewished the Inquiry to take from the papers thathe had submitted. The notes of these meetingsare on the Inquiry website.Mr Arthur Cardwell contacted the Inquiry to drawmy attention to a device that he had inventedto detect a drop in gas flow and pressure andthereby indicate the possibility of a leak. Theinformation before the Inquiry indicated that anescape of LPG from a corroded pipe would notnecessarily cause a sufficient drop in pressure totrigger Mr Cardwell’s device. Since LPG is used atlow pressures, and since corroded pipes are oftenplugged by corrosion or soil, the escape of gasmay be slow but continuous, and in consequencedifficult to detect.The ICL/Stockline Disaster: Anindependent report on workingconditions prior to the explosion,2007In August 2007, before my own Inquiry was setup, a multi-disciplinary team of academics fromthe Universities of Strathclyde, Stirling, York andLiverpool published a report entitled The ICL/Stockline Disaster: An independent report onworking conditions prior to the explosion. I readthis report before I began my Inquiry. The termsof reference of the research team that prepared it,and its working methods, were different from mine.The principal aims of the team, and of its report,were stated as being:• To understand as fully as possible thecircumstances and context within whichthe disaster occurred. These include the176

THE ICL REPORTcompany, its regulation, structure andfinancing, its work practices, employmentrelations, built environment and health andsafety practices.• To ensure that the experiences of thoseworkers and ex-workers, who wanted theirvoices to be heard, were fully documented.Workers’ experiences can be a vital sourceof knowledge in the prevention of futuredisasters. Workers’ silence has all too oftenled to a lack of justice: legal, social andeconomic.• To build up a picture of what workinglife was like inside the factory.To considerthe role played by inspection, regulationand enforcement agencies that directlyand indirectly determine the policiesand practices of companies such as ICLStockline.The evidential base from which the team drewits conclusions consisted of interviews withseven present and former employees of ICL andStockline. The evidence of six of these is quotedanonymously. The research team used “actionresearch” methods involving “risk mapping” and“body mapping” exercises by which, accordingto the report (p 3), “workers provided unrivalledevidence of working conditions, potentialhazards and symptoms of ill-health.” The reportcovers matters such as the alleged managementstyle of the Downie family, the alleged hostilityof management towards trade unionism, and anallegedly oppressive management approach toemployer/employee relations and to the fixing ofpay and conditions. It alleges that managementgave priority to cost minimisation and reducedworkers’ holiday entitlements; exposedemployees to hazardous substances, includingasbestos; gave them ineffective protection fromdust and fumes, routinely disregarded health andsafety legislation and statutory regulations andseriously breached COSHH Regulations. Thereport also alleges that there was an incidenceof respiratory complaints among employeesand that there were deficiencies in health andsafety training, instruction, supervision andcommunication systems.The report also deals with the question of thehigher rates of fatal and major industrial injuriesin Scotland in comparison with those in theUnited Kingdom overall and with the allegedinadequacy of HSE’s resources. It accuses HSEof certain shortcomings in enforcement generallyand at Grovepark Mills in particular. It alsodeals in passing with alleged shortcomings inthe system of small company auditing.The research team’s investigations appear tohave been carried out with the co-operationof the ICL/Stockline Support Group, whosesolicitors were one of the firms instructingcounsel for the families and survivors in theInquiry. I should record that counsel for thefamilies and survivors did not rely on any partof this report. None of the core participantsapplied for it to be lodged as a production andnone referred to it at any stage in the Inquiry.The report is available at www.hazards.org/icldisaster/icl_stockline_report.pdf.177

AppendicesAppendix 5 – The ICL Inquiry TeamJillian GlassTrevor LodgeKathryn McCartneySolicitor to the InquirySecretary to the InquiryDeputy Solicitor to the InquiryLinda Craik Office Manager (until September 2008)Katy MackenzieMeryl SkeneAdministratorLegal assistantCOUNSEL TO THE INQUIRYRoy Martin QCKenny McBrearty, Advocate178

THE ICL REPORTAppendix 6 – Definitions andglossaryDEFINITIONSbara Absolute pressure measured in bar (1bar = 14.5 psi)barg Gauge pressure measured in bar (where0 barg = 1 bara)Hazard The potential for harm arising from anintrinsic property or disposition of something tocause detriment.Installation Pipework downstream of theemergency controlPipework valve to the gas appliance or plantLPG supplier Used in this report to describethe LPG company supplying the bulk tankLPG user Used in this report to describe theparty who uses LPG in its process, plant orappliancesService Pipework Pipe for supplying gas tothe premises from a gas storage vessel, beingany pipe between the gas storage vessel andthe outlet of the emergency controlRisk The chance or likelihood that someoneor something will be adversely affected in astipulated way by the hazard.GLOSSARYACDS Advisory Committee on DangerousSubstancesACoP Approved Code of PracticeACP Approved Competent PersonAEGLP European LPG AssociationALARP As low a risk as reasonably practicableALGED Association for Liquid Gas Equipmentand Distributors (now part of UKLPG)BLEVE Boiling Liquid Expanding VapourExplosionCOIN Computer Operated InformationCOMAH Control of Major Accident HazardsCoP Code of PracticeCOSHH Control of Substances Hazardous toHealthDIN Discipline Information NoticeDSEAR Dangerous Substances & ExplosiveAtmospheres RegulationsECV Emergency Control ValveFIC Factory Inspectorate CircularFISM Factory Inspectorate Specialist MinuteFOD Field Operations Directorate, HSEFPA Fire Protection AssociationFSR First Stage RegulatorGSIUR Gas Safety (Installation and Use)Regulations179

AppendicesHELA Health and Safety Executive/LocalAuthority Enforcement Liaison CommitteeHID Hazardous Installations Directorate, HSEHMFI Her Majesty’s Factory InspectorateHSE Health and Safety ExecutiveHSL Health and Safety LaboratoryHSWA Health and Safety at Work etc ActICP Independent Competent PersonIGE Institution of Gas Engineers (now IGEM)IGEM Institution of Gas Engineers andManagersIOSH Institute of Occupational Safety andHealthLA Local AuthorityLPG Liquefied Petroleum GasLPGA LPG Association (now UKLPG)LPGITA LPG Industry Technical AssociationLPGITC LPG Industry Technical CommitteeMAH Major Accident HazardMAPP Major Accident Prevention PolicyMHSWR Management of Health & Safety atWork RegulationsNAWR Noise at Work RegulationsOC Operational CircularOM Operational MinuteOSH Occupational Safety and HealthPER Pressure Equipment RegulationsPSSR Pressure Systems Safety RegulationsPUWER Provision and Use of Work EquipmentRIDDOR Reporting of Injuries, Diseases andDangerous Occurrences RegulationsRSP Relevant Statutory ProvisionsSME Small or Medium-Sized EnterpriseTHSD Technology and Health ServicesDivision, HSE (now Directorate of Science andTechnology)TM Technical MemorandumVOTV Vapour Offtake ValveWHSWR Workplace (Health, Safety andWelfare) RegulationsWSE Written Scheme of ExaminationPrinted in the UK for The Stationery Office Limitedon behalf of the Controller of Her Majesty’s Stationery OfficeID6151493 07/09Printed on Paper containing 75% recycled fibre content minimum.180

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