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    HSE SAFETY BULLETINS

    Sharing information on incidents and accidents for learning

    It is now possible to subscribe to HSE Safety Bulletins. The bulletins comprise Safety Alerts and Safety Notices:

    Safety Alerts – for major faults that would result in a serious or fatal injury and where immediate remedial action is required and;

    Safety Notices – issued to facilitate a change in procedure or it requires an action to be undertaken to improve the level of protection or instruction in a potentially dangerous situation. It must be acted upon within a reasonable time, if a time period is not stated. It is not as immediate as a safety alert.

     

    Speech by Judith Hackitt at Safety Alert Workshop

    I am very pleased to have the opportunity to speak at this workshop and I am particularly pleased to see the mix we have here today participating – people from Trades Unions, Professional Bodies, Employers and other regulators as well as HSE colleagues. I believe this to be a very important topic and by “this” I mean not just the subject of safety alerts themselves but the broader topic of ensuring that we all play our key roles in disseminating important information and learning. This is how we can help to avoid the lessons from incidents and accidents being learned the hard way many times over in different industry sectors and at different times.

    I’d like to start by positioning this activity in the context of HSE’s new-ish strategy for Health and Safety in Great Britain in the 21st century. The collective mission, which everyone has strongly endorsed and, which drives the new strategy is “the prevention of death, injury and ill health to those at work and those affected by work activities”. Some of the most important ways in which we can prevent harm to people at work is to ensure that lessons are learned from incidents, that they are learned as widely as possible and in a timely manner – and that they are not forgotten or allowed to fade with time. I believe that it is all of the facets of learning and promulgating lessons which you are her today to discuss.

    Just as with every other element of HSE’s new strategy, I and the rest of HSE are very much aware that we are part of a much bigger system and these are not things that we can or should try to achieve on our own. We need your help and your leadership. There are parts of this activity which some of you will be better able to deliver than HSE. In fact there are some aspects of learning these lessons which have to be taken forward by others and that is why today’s discussion about respective roles and responsibilities is so important.

    I want to illustrate my point by relaying to you a story I told in a recent speech I made to a group of engineers and people from industry in Aberdeen.

    Some of you may have heard me say before that I belong to the generation whose attitudes to safety and process safety in particular were formed in the 1970s by events which included the explosion at Flixborough in 1974. If you are not from that generation, or if your memory is not as good as it used to be, let me just remind you of a few details of what happened at Flixborough. On a Saturday afternoon in June 1974 there was a large explosion at the Nypro site in the North East of England. 28 workers were killed in the explosion and a further 36 suffered injuries. The number of casualties would have been many more if this incident had occurred on a weekday rather than a Saturday. There were a further 53 reported injuries to members of the public in the neighbourhood and there was considerable damage to offsite property.

    In March, prior to the explosion it had been discovered that there was a vertical crack in the fifth of a series of reactors in the process and the crack was leaking cyclohexane. After shutting down to investigate the problem the decision was taken to remove the leaking reactor and install a bypass connecting reactors 4 and 6. On the afternoon of 1st of June that bypass system ruptured resulting in the large vapour cloud of cyclohexane which exploded. All 18 people in the control room were killed when windows shattered and the roof collapsed. Fires burned onsite for over 10 days.

    So what were some of the important lessons to come out of Flixborough and to be applied more broadly?

    A plant modification had been made without full assessment of the potential consequences. Only limited calculations had been undertaken to engineer the changes and no drawings had been produced.

    No one had considered the potential for a major disaster to happen as a result of the change that had been made.

    No thought had been given to the locations of personnel in the event of a major incident occurring.

    I took up my first job as an engineer in industry less than 2 years after Flixborough happened and I know that Flixborough had been a huge wake-up call throughout major hazards industries. Hazop and Hazan training was required for every engineer. Change management processes were rigorous. Every effort was made to minimise the number of personnel located close to major hazard facilities.

    So now let’s move forward in time a little over 10 years to 1988. I’ve already said that this story relates to a speech I gave in Aberdeen and in 1988 the world’s worst disaster occurred in the offshore industry. Piper Alpha was a large fixed platform located around 200km NE of Aberdeen. It was originally installed for the production of crude oil and was later converted for gas production. Because the platform was originally designed for crude oil production the location of key operations and the siting of firewalls were built to a set of design criteria which were compromised when the platform converted to gas production. Of the 226 people on the platform at the time of the incident 165 died along with 2 rescue workers on a standby vessel. The Cullen inquiry into the disaster concluded that the initial cause of the explosion and subsequent fireball had been a condensate leak which was the result of maintenance work being carried out simultaneously on a pump and related safety valve. Maintenance and safety procedures were deemed inadequate as were the arrangements for refuge and evacuation of personnel.

    I’m hoping that at this point some of you are already making the links and seeing some of the similarities between these events and the more recent investigations which have taken place into the explosion at BP’s Texas City refinery and closer to home at Buncefield in 2005.

    I have chosen to retell this story here today because it illustrates some of the broader principles I want all of you to think about in relation to learning lessons across all industry sectors:

    Lessons learned in one industry sector can have much broader application – failure to properly isolate equipment before maintenance work continues to cause horrific injuries and fatalities to workers across all sectors – from agriculture, to printing, electricity generation. We must ensure that safety alerts do not take a narrow a view of applicability – this is clearly an area where HSE will need help and support from others to spread messages as widely as possible.

    We also need to bring to people’s attention the fact that similar accidents keep repeating themselves – this means none of us can ever become complacent and believe that a problem is fixed, or, that because we have communicated an important message once, or even twice, that it has been learned by everyone and fully embedded in procedures forever.

    The issue of ensuring that lessons do not fade with time goes way beyond the process of safety alerts. Here again there are significant opportunities for others in Trades Unions and professional organisations to help us with the processes that will improve the sustainability of learning for the long term and ensure that corporate memory fade does not cause learning to diminish in future generations of workers and managers and professionals.

    HSE believes that by initiating this new and updated web-based process of safety alerts we have started a renewed effort to share key learning and messages. I also think that it demonstrates that we too in HSE have learned some important lessons about how to communicate and what we can communicate in what timeframe. The Major Incident Investigation Board which was set up immediately after the Buncefield explosion has set new standards and expectations in terms of timely information for others to act upon. I believe it is very significant that this process produced several interim reports as well as a final report and that all of them appeared before any prosecution has taken place. The HSE Board were keen to see HSE use this learning to re-examine our communication in relation to all incidents and newly identified risks, not just to incidents of the size of Buncefield.

    It would be unrealistic if we were not to recognise that there will be times of course, when impending enforcement action may inhibit what can be said and when about incidents which happen and learning which arises from that, but I believe this is the start of a renewed commitment from HSE to consider that balance with even more rigour and to ensure that information is shared as soon as possible when there is the potential for others to benefit from learning things quickly. Our commitment is that we will make a balanced judgment on what information should be released and when and will act in order to prevent further harm as a priority over preserving evidence for the purposes of legal proceedings.

    My hope is that this seminar today will be the start of a renewed process of communication which will build on much of the good practice which is already in place. But we must also recognise that there are important roles for others to play to make this renewed process successful:

    HSE will not by any means be the only people who discover significant risks to which others need to be alerted. Sadly if we are the ones who are aware of them then there is a good chance that this is because an incident or a failure has already occurred. By far the best alerts are those that warn others of a risk and how to address it – before anyone is hurt or killed. That means that we need the engagement of industry specialists and managers and professional bodies in this process.

    I understand that this, just as much as within HSE, is territory where legal experts say we must act with caution; there are other potential legal implications for companies in sharing information relating to “failures” or shortcomings in systems which they have uncovered. But I am equally convinced that these legal concerns are solvable and can be overcome – and I believe that it is part of your role and your contribution to developing this new and improved system of sharing of information to tackle this issue. I know for sure that I would not want to find myself or my company in a position where we were aware of a problem but had not communicated it to others – only to learn later that others had been harmed by the same problem in another organisation. Given the emphasis that many companies place on Corporate Social Responsibility these days I find it hard to accept that there is true commitment to CSR of potential legal concerns stand in the way of sharing knowledge that could save someone’s life and prevent harm and suffering. There is a real balance to be struck here between legal prudence and what is morally indefensible.

    My main purpose in coming here today is to encourage you to take this important work forward. There may be significant challenges to be overcome as we take this forward but that is what they are – challenges to be overcome not obstacles which stop us doing what we all know it is right and proper to do for everyone’s benefit. I hope that we will all look back on this seminar as the point at which we embarked upon a journey to deliver a new and highly effective means of communicating important safety information throughout the world of work and business. This must not be a one off event but the launch pad for you all to work together to play your respective and supportive roles to deliver an effective solution.

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