Management failures blamed for Buncefield disaster

The report into the explosion and five-day fire at the Buncefield oil storage depot in December 2005 – Britain's most expensive industrial disaster – tells, for the first time, the full story of the HSE and Environment Agency's investigation. Drawing on material held back until the criminal prosecution was completed and the appeals processes exhausted, 'The Buncefield explosion: Why did it happen?' identifies several failings. First and foremost, it cites systems for managing the filling of industrial tanks of petrol that were both deficient and not fully implemented. Secondly, it concludes that an increase in the volume of fuel passing through the site put unsustainable pressure on those responsible for managing its receipt and storage – a task they lacked information about anyway and struggled to monitor. That pressure was made worse by a lack of necessary engineering support and associated expertise on the plant. Thirdly, a culture had developed where keeping operations going was more important than safe processes, says the HSE, "which did not get the attention, resources or priority status they required". And fourthly, inadequate arrangements were in place for containment of fuel and fire-water to protect the environment – and hence the consequential extensive damage. Gordon MacDonald, chairman of the COMAH (Control of Major Accident Hazards) Competent Authority Strategic Management Group, which published the report, says: "Major industrial incidents are thankfully rare. This report will help make them even less frequent by sharing some key insights and lessons with the wider high hazard industries." And he continues: "Companies that work in a high hazardous industry need to have strong safety systems in place, underpinned by the right safety culture. Buncefield is a stark reminder of the potential result of a poor attitude towards safety." Meanwhile, IOSH hazardous industries group chair Rob Fair believes that, since Buncefield, there has been a change in the way health and safety is run. "Buncefield was a terrible wake up call that may have been needed for some companies and organisations," says Fair. "At the very least it prompted many to reflect upon and review their existing processes and arrangements, so they could ensure that they were not caught out with a similar catastrophe." And he adds: "This report sums up some of the main issues from Buncefield, spelling out some of the key safety messages we must continue to take forward for wider use in the hazardous industries. But it shouldn't take a Buncefield type event to force us to take stock of what we are doing and where we can learn from others." In July 2010, five companies were fined a total of £9.5million for their part in the catastrophe. "The local community was devastated and the environmental impact of the disaster is still evident today. With estimated total costs exceeding £1billion, this remains Britain's most costly industrial disaster," comments MacDonald. The 36-page report highlights several process safety management principles, the importance of which were underlined by the failings at Buncefield. First, there should be a clear understanding of major accident risks and the safety critical equipment and systems designed to control them. Second, there should be systems and a culture to detect signals of failure in safety critical equipment, and to respond to them quickly and effectively. Thirdly, time and resources for process safety should be made available. Fourthly, once all of these are in place, effective auditing systems are needed to test the quality of management systems and ensure they being used. And finally, at the core of managing a major hazard business should be clear and positive process safety leadership with board-level involvement and competence to ensure that major hazard risks are properly managed.