BUNCEFIELD MAJOR INCIDENT INVESTIGATION

InitialReporttotheHealthandSafetyCommissionand theEnvironmentAgencyoftheinvestigationintothe explosionsandfiresattheBuncefieldoilstorageand transferdepot,HemelHempstead,on11December2005

BuncefieldMajorIncidentInvestigationBoard

BUNCEFIELD MAJOR INCIDENT INVESTIGATION

InitialReporttotheHealthandSafetyCommissionand theEnvironmentAgencyoftheinvestigationintothe explosionsandfiresattheBuncefieldoilstorageand transferdepot,HemelHempstead,on11December2005
BuncefieldMajorIncidentInvestigationBoard

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Contents

Executivesummary Introduction 1
5
iv

Part1SummaryoftheincidentandsubsequentInvestigation OverviewofBuncefieldoperations 5
Timelineofkeyevents 7
EmergencyresponsetotheBuncefieldincident 10
TheInvestigation 11
Part2IssuesofconcernarisingfromtheInvestigationtodate Designandoperationofstoragesites 18
Emergencyresponsetoincidents 21
Advicetoplanningauthorities 23

18

Annexes
1 Termsofreferenceandprogress 24
2 MembersoftheindependentBoard 27
3 PlanninghistoryofBuncefieldsiteandneighbouringdevelopments 4 UKpetroleumrefinery,pipelineandstoragesystem 35
5 IncidentsthathavesimilaritieswiththeBuncefieldincident 37
6 Fireandexplosionhazardsfrompetrol 39
7 ProductcompositionatBuncefield 44
8 Regulatoryframeworkforhighhazardsites 46
9 Regulationofperfluorooctanesulphonates(PFOS) 49
10 Legalconsiderations 51
Glossary 54
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28

Furtherinformation

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Executivesummary

ThetermsofreferenceoftheInvestigationdirectedbytheHealthandSafety CommissionintotheexplosionsandfiresattheBuncefieldoilstorageandtransfer depot,HemelHempstead,on11December2005requireaninitialreporttobe producedfortheHealthandSafetyCommissionandtheEnvironmentAgency whenthemainfactsoftheincidenthavebeenestablished. TheindependentBoardsetuptosupervisetheInvestigationhaspreviously publishedthreeProgressReportssubmittedtotheBoardbytheInvestigation Manager.TheInitialReportpresentstheBoardsviewthatenoughofthefacts havebeenestablished,asdescribedintheProgressReports,tosetoutwith reasonableconfidencethesequenceofeventsleadingtotheincidenton 11December.ThisalsoallowstheBoardtoidentifyseveralissuesofconcernfor theeffectiveregulationoffuelstoragesitessuchasBuncefield.

Summaryoftheincidentandsubsequentinvestigation
TheInitialReportsummarisesandupdatesmaterialfromtheProgressReportson thenatureofoperationsatBuncefield,thetimelineofkeyevents,theemergency responseandtheprogressoftheInvestigation.Evidenceshowsthatthemain explosionprobablyresultedfromtheignitionofavapourcloudemanatingfrom Tank912inBundAintheHertfordshireOilStorageLimitedWestsite,mostlikely resultingfromanoverfillofunleadedpetrol.Theprobablemechanismforthe creationofthevapourcloudisdescribed,thoughuncertaintyremainsaboutwhy theexplosionwassoviolent. MainfindingssincethepublicationoftheThird ProgressReportrelatetothe functioningofthesystemsusedtoshutdownfueldeliverywhenatankisfull;the likelycompositionofthefuelreleasedfromTank912;andtheongoingmonitoring oftheenvironmentalimpactoftheincident,particularlyinrelationto groundwatercontamination.Inthislastregard,theincidenthasnowbeendeclared a MajorAccidenttotheEnvironment(MATTE).TheInvestigationcontinues.

IssuesofconcernarisingfromtheInvestigationtodate
ThoughknowledgeoftheBuncefieldincidentisstillincomplete,enoughisknown fortheBoardtodrawbroadconclusionsabouttheneedforactioninthreeareas:

Designandoperationofstoragesites. Emergencyresponsetoincidents. Advicetoplanningauthorities.

Designandoperationofstoragesites TheBuncefieldincidentinvolvedfailuresofthemeansprovidedtocontainfueland waterusedinfirefighting(knownasfirewater)atthreelevels:primary, secondaryandtertiary.Theparamountneedistoensuretheintegrityofthe primarymeansofcontainment,ietomakesurethatfueldoesnotescapefromthe vesselsinwhichitisnormallycontained.Furtherprecautionsneedtobe consideredtopreventthishappeningand,shoulditstilloccur,toinhibitthe formationofaflammablevapour.

1

Thisdoesnothoweverlessentheneedforeffectivesecondaryandtertiary containment(bundsanddrains,mainly)thatpreventpollutantsfromescapingthe siteandcontaminatingtheenvironmentshouldprimarycontainmentbelost. Emergencyresponsetoincidents Overall,theresponsetotheincidentwasveryimpressive.Theincidenthas highlightedtheneedtohaveeffectiveemergencyarrangements,bothonandoff site,intheeventofamajorincidentofthiskind.LessonsfromBuncefieldprovide a veryimportantopportunitytobringaboutimprovementsinemergency preparednessofresiliencegroupsthroughoutBritain,andfurtherafield.Thereare a numberofreviewsintotheeffectivenessoftheemergencyresponsetoBuncefield beingcarriedoutbytheagenciesconcerned,andtheBoardintendstoreturnto thisimportantareainthefuture. Advicetoplanningauthorities TheBuncefieldincidentposesfundamentalquestionsaboutresidentialand commercialdevelopmentsaroundsiteslikeBuncefield.Continuinguncertaintyin thisareacreatesseriousproblemsforlocalcommunities,particularlythosedirectly affectedbytheBuncefieldincident.Thisisacomplexissuerequiringabalanceto bemadebetweentherisksandbenefitsofdevelopment.TheBoardintendsto addresstheseissuesindetailoncethepreliminaryconclusionsofHSEscurrent reviewofitsadvicetoplanningauthoritiesareknown. A measuredapproachisjustifiedsincethelikelihoodofasimilarexplosion remainslow,andshouldbemadelowerstillbyaprogrammeofactionsdesigned toincreasethereliabilityofprimarycontainment.Inourview,theimportanceof reachingconclusionsthatareconsidered,costedandsustainablegreatlyoutweighs anybenefitthatmightbederivedfromcomingtosummaryjudgements.

Introduction

1 Thisreportistheinitialreportrequiredbythetermsofreferenceofthe InvestigationintotheexplosionsandfiresattheBuncefieldoilstorageandtransfer depot,HemelHempstead,Hertfordshireon11December2005.1 TheInvestigation wasdirectedbytheHealthandSafetyCommission(HSC)usingitspowersunder section14(2)(a)oftheHealthandSafetyatWorketcAct1974. 2 TheInvestigationisbeingcarriedoutjointlybytheHealthandSafety Executive(HSE)andtheEnvironmentAgency.HSCappointedanindependent InvestigationBoard,chairedbyLordNewtonofBraintree,tosupervisethis investigation.2 ThisreporthasbeenpreparedbytheInvestigationBoard,basedon informationarisingfromthecontinuingHSE/EnvironmentAgencyInvestigation. ThroughouttheInvestigation,theBoardhasbeensuppliedwithProgressReports fromtheInvestigationManager,TafPowell,whichtheBoardhaspublished.3 3 ThisreportdoesnotrepeatallthematerialcontainedintheProgressReports, whichshouldbereadforafullerunderstandingoftheInvestigationuptoMay 2006.Part1summarises,andupdateswherenecessary,keypointsofthe InvestigationforcompletenessandtoaidinunderstandingtheInvestigation BoardsinitialconclusionssetoutinPart2.TheBoardhasincludedsignificant newfindingsfromtheInvestigationthathaveemergedsincethepublicationofthe ThirdProgressReporton9May.Othernewmaterialiscontainedintheannexes tothisreport. 4 TheInvestigationtermsofreferencerequireaninitialreporttobesubmittedto HSCandtheEnvironmentAgencyassoonasthemainfactsoftheincidenthave beenestablished.TheInvestigationisstillcontinuing.Nevertheless,the InvestigationBoard considersthat,withpublicationoftheThirdProgressReport inMay,enoughfactshavebeenestablishedtosetoutwithreasonableconfidence thesequenceofeventsleadingtotheincidenton11December.Inparticular, enoughisknownfortheBoardtobeabletoidentifyseveralissuesofconcernfor theeffectiveregulationoffuelstoragesitessuchasBuncefield.Aswellasthemain factsoftheincident,theBoardhasincludedinPart2ofthisreportitsemerging thoughtsaboutfutureactiontoaddresstheseissuesofconcern. 5 TheInvestigationBoardplanstogivefurtherconsiderationtotheseissues.

2 3

ThefulltermsofreferencearereproducedinAnnex1.Termofreference6requiresan initialreport. TheMembersoftheInvestigationBoardarelistedinAnnex2. DetailsofthethreepublishedProgressReportsarecontainedinFurtherinformation.

Part1 Summaryofthe incidentandsubsequent investigation

6 ThissectionsummarisesinformationcontainedinthethreeProgressReportsto theBoardpublishedbetweenFebruaryandMay2006.Fulldetailscanbefoundin thereports,whichareavailableontheInvestigationwebsite.4 Wherenecessary, thisinformationhasbeenupdatedinthisreportandsupplementedbynewfindings fromtheInvestigation.Othernewinformationiscontainedintheannexes, referencedasappropriateinthetextbelow.

OverviewofBuncefieldoperations
7 TheBuncefieldoilstorageandtransferdepotisalargetankfarmoccupiedby threecompanies.Theseare:HertfordshireOilStorageLimited,ajointventure betweenTotalUKLimitedandChevronLimited;UnitedKingdomOilPipelines LimitedandWestLondonPipelineandStorageLimited,whosesiteisoperatedby BritishPipelineAgencyLimited;andBritishPetroleumOilUKLimited.5 Eachsite isclassifiedasatoptiersiteundertheControlofMajorAccidentHazards (COMAH)Regulations1999.6 8 Figure1showsthelayoutoftheBuncefielddepotanditssurroundings.The Buncefielddepotformspartofanationalpetroleumrefinery,pipelineandstorage system,describedinAnnex4.FuelproductsweresuppliedtoBuncefieldbythree pipelinesystems:

10pipeline(FinaLine)fromLindseyOilRefineryonHumberside,terminating intheHertfordshireOilStorageLimitedWestsite; 10 pipelinefromMerseysidetoBuncefield(M/Bpipeline),terminatinginthe BritishPipelineAgencyLimitedoperatedCherryTreeFarmsite; 14 pipelinefromThames(Coryton)toKingsbury,Warwickshire,withaspur linetoBuncefield(T/Kpipeline),terminatingintheBritishPipelineAgency Limitedoperatedmainsite.

9 Thethreepipelinesalltransportedfuelproductsindiscretebatches,separated byaninterfaceorbufferofmixedproduct.Attheterminal,theoperators monitoredthearrivalofthevariousgradesoffuelandseparatedthemoutinto dedicatedtanksbyfueltype.Theinterfaceofmixedfuelwasdivertedtospecial smalltankstobereinjectedintothemainlargestoragetanks,ifthefuel specificationallowed,ortransportedbacktotherefineryasslopsforrerefining.

5 6

DetailsofthethreepublishedProgressReportsarecontainedinFurtherinformation. Thesereportshavenotbeenrevisedtotakeaccountofmorerecentfindings. TexacoLimitedbecameChevronLimitedon3July2006. Theregulatoryframeworkforhighhazardsites,includingthemainrequirementsof COMAH,issummarisedinAnnex8.

Figure1 PreincidentlayoutofBuncefield depotandimmediatesurroundings 6

10 Theseparatedproductsleftthedepoteitherbyroadtankeror,inthecaseofthe majorityofaviationfuel,viatwodedicatedpipelinesfromtheBritishPipeline AgencyLimitedmainsiteintotheWestLondonPipelinesystem,whichsupplies HeathrowandGatwickAirports.TankersoperatingfromBuncefieldwereof44or 18tonnescapacityandwereincreasinglyoperatedbyspecialisedtransportoperators.

Timelineofkeyevents
10December2005 Around 19.00, Tank912inBundAattheHertfordshireOilStorageLimited WestsitestartedreceivingunleadedmotorfuelfromtheT/Kpipeline,pumping atabout550m3/hour(flowratesarevariablewithinlimits). 11December2005 Atapproximately midnight(00.00) theterminalwasclosedtotankersanda stockcheckofproductswascarriedout.Whenthiswascompletedataround 01.30, noabnormalitieswerereported.Fromapproximately03.00, thelevel gaugeforTank912recordedanunchangedreading.However,fillingofTank 912continuedatarateofaround550m3/hour.

Calculationsshowthatataround05.20 Tank912wouldhavebeencompletely fullandstartingtooverflow.Evidencesuggeststhattheprotectionsystem whichshouldhaveshutoffthesupplyofpetroltothetanktoprevent overfillingdidnotoperate.Fromthistimeonwards,continuedpumpingcaused fueltocascadedownthesideofthetankandthroughtheair,leadingtothe rapidformationofarichfuel/airmixturethatcollectedinBundA. At05.38vapourfromtheescapingfuelisfirstvisibleinCCTVfootagefroma cameralookingdownthewesternedgeofBundA,flowingoutofthenorth westcornerofBundAtowardsthewest.7 At05.46 thevapourcloudhadthickenedtoadepthofabout2mandwas flowingoutofBundAinalldirections. By05.50 thevapourcloudhadstartedflowingoffsitenearthejunctionofCherry TreeLaneandBuncefieldLane,followingthegroundtopography.Itspreadwest intoNorthgateHouseandFujicarparksandtowardsCatherineHouse. Between05.50 and06.00 thepumpingratedowntheT/Kpipelineto HertfordshireOilStorageLimitedWest,andonwardstoTank912,gradually rosetoaround890m3/hour. By06.01 thevapourcloudextendedtothewestalmostasfarasBoundaryWay inthegapsbetweenthe3Com,NorthgateandFujibuildings;tothenorthwestit extendedasfarasthenearestcornerofCatherineHouse.Itprobablyextendedto thenorthoftheHertfordshireOilStorageLimitedsiteasfarasTank12,operated by BritishPipelinesAgencyLimited,andprobablyextendedsouthacrosspartof theHertfordshireOilStorageLimitedsite,butnotasfarasthetankerfilling gantry.TotheeastitreachedtheBritishPipelineAgencyLimitedsite. At06.01thefirstexplosionoccurred,followedbyfurtherexplosionsanda largefirethatengulfedover20largestoragetanks.Themainexplosionevent appearstohavebeencentredonthecarparksbetweentheHertfordshireOil StorageLimitedWestsiteandtheFujiandNorthgatebuildings.

TimingsdeducedfromCCTVfootagehavebeencorrectedforanyinaccuratesettingof theCCTVtimers.

At06.08 anemergencyservicesmajorincidentwasdeclaredandoperational commandandcontrolwassetupneartheincidentsitewithinminutes. At 09.00 StrategicCoordinatingGroup(Goldcommand)convenedforthe firsttime. Anextensiveplumeofsmokefromtheburningfueldispersedoversouthern Englandandbeyond.8 Theplumecouldbeseenfrommanykilometresaway, andwasalsoclearlyidentifiedinsatelliteimages.

12December2005 Noon. Peakofthefire.25Hertfordshirepumpswereonsitewith20support vehiclesand180firefighters.

Therewassomelossofsecondarycontainment,asthebundswereunableto fullycontaintheescapedfuelandwaterusedinfirefighting(knownasfire water),whichovertopped(iespilledoverthetopof)thebundwalls.

14December2005 HSEassumedcontroloftheInvestigationfromHertfordshireConstabulary.

Damagetobundscausedbytheintenseheatofthefirecausedsignificantloss ofsecondarycontainmentontheHertfordshireOilStorageLimitedWestand BritishPipelineAgencyLimitedsites.Therewasalsoextensivelossoftertiary containmentatthesiteboundariesandlargeamountsofcontaminatedliquids escapedoffsite.Thefireservicerecoveredasmuchofthecontaminatedrunoff aspossible,butwasunabletopreventcontaminationofgroundwaterand surfacewater.

15December2005 FirealloutdeclaredbytheFireService.

786000litresoffoamconcentrateand68millionlitresofwater(53million cleanand15millionrecycled)wereusedoveralltocontaintheincident duringtheperiodoffirefightingoperations. StrategicCoordinatingGroup(Goldcommand)convenedforthelasttime.

16December2005 Theonsiteinvestigationstarted(thepreliminaryplanningandinformation gatheringhadcommencedearlier).HSEissuednoticestosecurethesite,to ensureboththatevidencewasleftundisturbedandthatcleanupoperations wereconductedsafely.Keypartsofthesiteremainedtoodangerousfor investigatorstoaccessforweeksormonths. 18December2005 HertfordshireOilStorageLimitedstartedsurveyingroadsandbuildingsonthe site.

MonitoringbytheMeteorologicalOfficeshowedthatthevisibleplumewasmainly blackcarbon(soot).Fulldetailsoftheplumeandrelatedairqualitymonitoring arrangementsaregivenintheDepartmentfortheEnvironment,FoodandRural AffairsInitialreviewoftheairqualityaspectsoftheBuncefieldoildepotexplosion, availableatwww.defra.gov.uk/environment/airquality/buncefield/index.htm.

20December2005 HSCformallydirectedHSEandtheEnvironmentAgencytoinvestigatethe incidentandtomakeaspecialreport.HSEappointedTafPowell,Directorof HSEsOffshoreDivision,tobetheInvestigationManager.HSCalso announcedtheappointmentofanindependentBoardtosupervisethe Investigation.

ThecontrolroomontheHertfordshireOilStorageLimitedWestsitewas sufficientlystructurallysoundtoallowentryforgatheringrecordsandother evidence.

23December2005 TheInvestigationteam,withassistancefromHertfordshireConstabularyand HertfordshireFireandRescueService,recoveredcomputersfromdamaged officesandplacedtheminsafestorage. 5 January2006 HertfordshireFireandRescueServicehandedcontrolofthesiteovertothe Investigationteam.HertfordshireConstabularyandHertfordshireFireand RescueServicecontinuedtogiveinvaluablesupporttotheInvestigationteam thatwasworkingtogatherandsecureevidence. 12January2006 HSCappointedLordNewtonofBraintreetochairtheindependentBoard. February2006 Allfirewaterhadbeenremovedfromsiteandstored,pendingsafedisposal. Theareaaroundtheloadinggantryhadbeenmadesafeforaccessandtankers, whichwerepresentatthetimeoftheincident,wereremoved.

InvestigatingpersonnelgainedaccesstoBundAforthefirsttime. Internalroadwayswereclearedandlimitedworkstartedonremovingdebris fromBundA.Samplingoffuelinpipeworkwascarriedoutpriortosafe disposal.Asfuelresiduesstillremainedininterconnectingpipeworkand damagedtanks,monitoringforflammablevapourwasroutinelycarriedout.

EmergencyresponsetotheBuncefieldincident
11 Thecoordinationandmanagementframeworkatanyincidentidentifiesthree levelsofinterlinkedleadershipandcoordination.9 Theyare:

Strategic Gold Tactical Silver Operational Bronze

12 Theemergencyservices(primarilytheFireandRescueServiceandthepolice) ledtheinitialresponsetotheincidentanditsimmediateaftermath.Representation ofallagenciesdeployedtoresolvetheBuncefieldincidentwasestablishedthrough a meetingprocessknownastheStrategicCoordinatingGroup,alsoknownas Goldcommand.ThisincludedtheEnvironmentAgencyasaCategory1responder undertheCivilContingenciesAct2004.10 TheStrategicCoordinatingGroup madedecisionstoensurethattheimplementationofstrategicaimswasdelivered bythetactical(Silver)andoperational(Bronze)commands. 13 TheStrategicCoordinatingGrouphaditsfirstmultiagencymeetingat09.00 on11DecemberatHertfordshirePoliceHeadquarters,chairedbythePolice StrategicCoordinatingGroupCommander.Adecisionwasmadeatthismeeting toevacuatethosewithdamagedhomesandworkplaces,andtotelleveryoneinthe immediatevicinitytosheltergoin,stayin,tunein. 14 TheStrategicCoordinatingGroupremainedinplaceuntil18:30onThursday 15December. Disposaloffirewater 15 Thecontaminatedfirewaterwasremovedfromthesiteduringthefirstthree weeksfollowingthefire,althoughanunknownquantitycontaminatedthesurface watersandgroundwater.Followingtheevent,furthercontaminatedwaterresulting fromrainfallorcleaningoperationswasremovedfromthesitebytankerand storedalongwiththefirewaterinanumberoflocationsaroundthecountry. 16 Thefirewaterremainsintemporarystorage,anditisimportantforthismatter toberesolved.TheBoardunderstandsthatthedecontaminationoffirewateron suchanunprecedentedscalemayrequiretheuseofseveralprocessestorenderthe watersuitableforitsreturntotheenvironment.Theoilcompaniesaredeveloping optionstoachievethis,whichwillbeassessedbytheEnvironmentAgencyto ensurethattheyhavetheminimumimpactpossibleontheenvironment. 17 On21June2006,theEnvironmentAgencywasinformedthatsome800000 litresofthiscontaminatedwaterhadbeenreleasedinadvertentlyfromstorageinto a sewagetreatmentplantandthereafterintotheRiverColne,atributaryofthe RiverThames.TheEnvironmentAgencylaunchedaninvestigationwiththe assistanceofThamesWaterUtilitiesLimited,whooperatethestoragefacilityand associatedsewagetreatmentworks.Thisinvestigationhasyettobeconcluded.

10

10

UKResilience.Managementandcoordinationoflocaloperations, availableat www.ukresilience.info/ccact/errpdfs/err_chap_04.pdf. OtherCategory1respondersincludedtheHealthProtectionAgency(HPA)andthe StrategicHealthAuthority.TheEnvironmentAgencysrolewastominimisetherisksof environmentaldamage.HSEisaCategory2responder,soduringtheearlyphaseofthe incidentstoodreadytoprovideadviceandexpertiseonrequest.

TheInvestigation
18 ProgressReports13detailfourkeyaspectsoftheInvestigation,briefly summarisedbelow:

Lossoffuelcontainment. Formationofthevapourcloud. Theexplosions. Environmentalmonitoring.

Lossoffuelcontainment 19 ThefirstProgressReportindicatedthattheexplosionprobablyresultedfrom ignitionofavapourcloudemanatingfromthevicinityofBundAinthe HertfordshireOilStorageLimitedWestsite.TheInvestigationManagerwas sufficientlyconfidentintheinvestigationfindingstostateintheThirdProgress Reportthattheinitiallossofcontainmentwhichcreatedthevapourcloudoccurred fromTank912inBundA,mostlikelyresultingfromanoverfillofunleadedpetrol. 20 Tounderstandhowthefuelescaped,theInvestigationexaminedhowTank912 anditsinstrumentationandcontrolsystemsfunctionedatthetime.This examinationsuggestedfurtherlinesofinquiry,involvingaspectsoftheautomatic tankgaugingsystem,andthehighlevelalarmsystem.Investigatorswantedto ascertainhowthegaugingsystemperformedandwhyautomaticshutdownof delivery didnottakeplaceasintendedwhenthetanksultimatehighlevel(iethe specifiedmaximumcapacity)wasreached. 21 The ThirdProgressReportdetailedfindingsaboutinstrumentationandcontrol systemsonTank912.Theseincludetheproductmonitoringsystemsbothforleveland temperature,andtheultimatehighlevelswitch,whichwaspart of the system to prevent overfillingofthetank.AstheThirdProgressReportexplained,fromaboutthreehours before theincident,thelevelgaugeremainedstatic,althoughthetankcontinuedtofill. 22 Theultimatehighlevelswitchshould,iftriggered,causeanalarmtosound andshutdownthesupplyoffueltothetank.SincepublicationoftheThird ProgressReport,mostoftheultimatehighlevelswitchfromTank912hasbeen recovered,alongwithotherpartsoftheinstrumentationsystemsonthisandother tanks,forexamination. 23 Furtherinvestigationintothedesignoftheultimatehighlevelswitchindicated thatthepositionofatestleverorplatefittedtotheswitchiscriticaltoensure continuedeffectiveoperation.WhiletherelevanceofthisfeaturetotheBuncefield incidenthasstilltobedetermined,oneoftheissuesthathasarisenfromthese enquiriesrelatestotherelianceonthistypeofswitchatmanysimilarinstallations throughouttheUKandworldwide. 24 TheCompetentAuthorityhastakenactiontobringthisissuetotheurgent attentionofoperatorsofsimilarsitesintheUKthroughaSafetyAlert.11 TheAlert appliestoaparticularkindofswitchusedinultimatehighlevelalarmsystems. ImprovementNoticeshavealsobeenissued,requiringthesupplierstocontactusersor installersoftheseswitchestoalertthemtothisissueandproviderevisedinstructions andlabellingonthesafeuse,setting,cleaningandmaintenanceoftheswitches.The Boardnotesthecontinuingcooperationofthesuppliersinthatprocess.

11

SiteslikeBuncefieldareregulatedbyaCompetentAuthority,asdetailedinAnnex8. ThefulltextoftheSafetyAlertcanbefoundonHSEswebsiteat www.hse.gov.uk/comah/alerts/sa0106.htm.

11

Formationofthevapourcloud 25 TheThirdProgressReportdescribedextensivetestsundertakentomodelthe behaviouroffuelescapingfromTank912duringoverfilling.Tank912wasfitted withadeflectorplate,installedtodirectwaterfromsprinklersonthetankstopto itssidestoprovidecoolingintheeventoffire.Thetestsdemonstratedthatthe deflectorplatechannelledsomeoftheescapedfuelontothetankwall,buttherest ranoverthetopoftheplate,fragmentingintodropletsthatcascadedthroughthe air.Mostofthefuelrunningdownthewallhitawindgirder(astructuralstiffening ring)anddetachedfromthetankwall,creatingasecondcascadeofdroplets. 26 Theseconditionswouldpromotetheevaporationofthelightercomponentsof petrol,egbutanes,pentanesandhexanes.Thefreefallofdropletsleadsto entrainmentofairandmixingbetweentheairandfuelvapour,andtheformation ofarichfuel/airmixture.Coolingofthesurroundingair,alreadysaturatedwith watervapourbytheevaporation,wouldcausesomeofthewatercontentto precipitateasanicemist,whichisconsistentwiththecloudofmistvisibleon

Figure2 Thepatternof fueldispersion(for illustrationonly) 12

Nottoscale

CCTV.Thefuel/airmixtureanditsaccompanyingicemistwereheavierthanair and sowereinitiallycontainedwithinthebund.Asthevolumeofthemixture grewfromthecontinuingoverfillingofthetank,itflowedoutofthebund, dispersingandflowingoffsite.Furthermixingwiththeairwouldhavereducedthe vapourconcentrationtothepointwheresignificantvolumesofthemixturecould supportanexplosion.12 27 SincepublicationoftheThirdProgressReport,furtherworktosimulatethe overflowofliquidfromthefullheightofTank912hasconfirmedthepatternof fueldispersalandvaporisationshowninFigure2. Theexplosions 28 TheThirdProgressReportdescribedanumberofpotentialignitionsourcesof themainexplosionthatoccurredat06.01on11December.Theprimecandidate appearstobeanexplosionwithintheemergencygeneratorcabinonthesouthside oftheNorthgatebuilding;thisisconsistentwiththesiteofthemainexplosion event.However,furtherstudyoftheCCTVevidenceshowsasuddenillumination oftheeastfaceoftheFujibuilding,consistentwithanexplosionoraflashfireat thelocationofthepumphousetotheeastofthelagoonontheHertfordshireOil StorageLimitedWestsite.Thisilluminationwasrecordedbyacamerabeforeit wasdestroyedbytheoverpressure,suggestingthatthisexplosionorflashfire occurredbeforethemainexplosionat06.01.Thepumphouseisthesubjectof continuingforensicinvestigation. 29 Muchuncertaintyremainsaboutwhytheexplosionwassoviolent,generating overpressuresofamagnitudemuchgreaterthancurrentunderstandingofvapour cloudexplosionswouldpredict.Forexample,amethodincurrentusewould predictoverpressuresof2050millibar(mbar)intheopenareasoftheNorthgate andFujicarparks.Thecurrentbestestimatesoftheoverpressuresthatactually occurredintheseareasareof7001000mbar,leadingtoextensivedamageto adjacentbuildings.Annex6describesthemechanicsoffire andexplosionhazards fromfuelssuchaspetrol,ascurrentlyunderstood. 30 Continuingworkrelevanttogainingabetterunderstandingoftheexplosion hasincludedextensivesamplingtoidentifythecompositionofthereleasedfuels,as wellastoverifytheproductdistributionthroughoutthedepot.Itshowsthatthe releasedfuelprobablyhadabutanecontentof10%andconsequentlywouldhave hadahighvapourpressure,ieitwouldbecapableofevaporatingrapidlyto produceaflammablevapour.Thetotalbutanecontentisspecifiedinthestandard, anddependsonwhethertheproductiswinterorsummergrade.Forwintergrade petrolthevapourpressurelimitsaredefinedas70100kiloPascals(kPa)andfor summertheyarereducedto4570kPa.SeeAnnex7forfurtherinformationabout standardsandfuelcomposition. 31 Furtherresearchisneededtotrytodiscovertheactualmechanismfor generatingtheunexpectedlyhighoverpressuresseenatBuncefield.TheBoard referstothisagaininparagraph76,andinrelationtotermsofreference1and5 inAnnex1. 32 ThenumberandseverityofinjuriesatBuncefieldwaslowcomparedtosome othermajorincidentsinvolvingexplosions,andtherewerenofatalities.Annex6 providesmoreinformationaboutexplosionoverpressures,andincludestables whichshowthelevelsofdamageorinjurythatwouldnormallybeexpectedto resultfromdifferentoverpressures.
12

Theexplosivepropertiesofpetrol,includingthesignificanceofvapourconcentrations,
areexplainedinAnnex6.

13

Environmentalmonitoring Airquality 33 Aninitialreportontheresultsoftheairqualitymonitoringandtheimpactof theplumeonhumanhealthandvegetationwaspublishedbytheDepartmentfor theEnvironment,Food,andRuralAffairs(DEFRA)inMay2006.13 Overall,the reportconcludedthereareunlikelytohavebeenwidespreadairqualityimpactsat groundlevelduetopollutantsemittedfromtheBuncefieldfires.Itwentontosay thatoverallitwasconcludedthatthefireatBuncefieldOilDepotdidnotresultin substantialpollutionofsoilandgrassesandthatpollutantlevelswere,ingeneral, unexceptionalandtypicalofUKurbanenvironments. 34 Theprevailingmeteorologicalconditionsatthetimeoftheincidentandthe highbuoyancyofthesmokeplumefromthefireresultedinmostoftheplume materialreachingahighaltitudeintheatmosphere.Itthendispersedoverawide areawithminimalmixingdowntogroundlevel. Landinvestigations 35 TrialpitswereexcavatedstartinginFebruaryonandsurroundingthesiteto assesstheimpactonland.Theinitialfindingsindicatethatthesurfacelayeris contaminatedwithfuelandfirefightingproducts. 36 TheextentanddegreeofthecontaminationofthelandwithintheBuncefield depotiscontinuingtobeestablished.Manytrialpitshavebeenexcavatedto investigatethesoilbeneaththeconcretehardstandingandunderthebasesofthe bunds.AllofthisinformationwillinformthecontinuingInvestigationandallow theEnvironmentAgencytoassesstheoilcompaniesproposedremediationofthe contaminationwhenthatisformallysubmittedtotheCompetentAuthority. Surfacewaterandgroundwatermonitoring 37 Extensivesurfacewatermonitoringimmediatelyfollowingtheincidentwas carriedoutatanumberoflocations,asdetailedintheSecondProgressReport. Monitoringwillcontinuefortheforeseeablefutureattheselocationstodetermine anylongtermeffectsontheaquaticenvironment. 38 TheEnvironmentAgencystartedtomonitorthegroundwaterunderand aroundtheBuncefieldsitesoonaftertheincident.Thismonitoringhasshownthat thereiscontaminationofthegroundwaterbyfirefightingproducts,fuels,and fuelrelatedproducts.ThishasbeenreportedinthepreviousProgressReportsand ontheEnvironmentAgencywebsite. 39 Followingthedetectionofcontamination,theEnvironmentAgencyreviewed thesamplinglocationsfortheexistinggroundwatermonitoringnetwork(detailsof whichwerereportedintheSecondProgressReport)andconcludedthatfurther monitoringboreholeswererequiredatspecifiedlocations.Someofthenew boreholesarealreadyinstalled.

13

14

Thisreportpresentsandsummarisestheairqualitymeasurementsmadeduringthe Buncefieldincident,andincludesresultsobtainedfromtargetedlocalmonitoring, measurementsfromlongtermmonitoringnetworks,themodellingundertakenbythe MeteorologicalOffice,andemissionsestimatesofthepollutantsfromthefire. SeeFurtherinformationforfurtherdetails.

40 Thenewmonitoringboreholeswillensurethattheextentofpollutionis understood.Also,theincreasedgroundwatermonitoringnetworkwillimprovethe understandingofflowandcontaminanttransportwithinthechalkaquifer. 41 Inadditiontotheextensivesamplingthatiscurrentlyunderway,theEnvironment Agencyisdevelopingagroundwaterconceptualmodeltoassistinunderstandingthe movementofpollutantswithinthegroundwaterandaquifersothatitmayassessthe likelyextentofcontamination.Thismodelisaconceptualrepresentationofthe environment(inthiscaseanaquifer)andtheinteractionswithinit. 42 Alloftheabovewillaidtheassessmentoftheimpactofthecontaminationon theenvironmentandtohumanhealth.Itwillalsoassistindeterminingthebest solutionsforthecleanupofthegroundwaterandtheaquifer. Perfluorooctanesulphonates(PFOS) 43 Perfluorooctanesulphonatesareagroupofchemicals,collectivelyidentified asPFOS,whichhavebeenshowntobehazardous(persistent,bioaccumulative andtoxic).PFOSchemicalshavebeenusedinadiverserangeofapplications, includingasanadditivetoaidthespreadingpropertiesoffirefightingfoam. PFOSdoesnotappeartodegradeinthenaturalenvironment.Duetothis stability,ithasnowbecomewidespreadbothinhumansandintheenvironment. Annex9describestheenvironmentalhazardspresentedbyPFOSandthecurrent approachtoitsregulation. 44 PFOSwasnotroutinelymonitoredandanalysedinanysurfacewateror groundwaterintheUKpriortotheBuncefieldincident.Samplingandanalysisfor PFOSarenotstraightforwardanduntilveryrecentlytherehasbeennorecognised recommendedlimitforPFOSlevelsingroundwaterordrinkingwateragainst whichtoassessanyresults. 45 PFOSwaspresentinsomeofthefoamusedtocombattheBuncefieldfire.At thestartoftheBuncefieldincident,PFOSinthefirewaterwasrecognisedasan importantpotentialcontaminantforland,surfacewaterandgroundwater.The EnvironmentAgencyandothershavesampledgroundwaterandsurfacewater extensivelyforPFOSandothercontaminantsbothonandoffsitefromsoonafter theexplosion.TheBoardnotesthatitistheresponsibilityofthelocalwater companytomonitorthequalityofdrinkingwater(asopposedtogroundwaterand rivers),andthattheDrinkingWaterInspectorate(DWI)regulatestheactivitiesof watercompaniesinrelationtodrinkingwaterquality. Resultsofmonitoring 46 PFOSwasdetectedintheRiversVerandColneinthedaysimmediately followingtheincident,however,theselevelsdroppedbelowthelowestthreshold detectablebytheEnvironmentAgencyafterashortperiod.Ongoingtestingstill showssporadicdetectionofPFOSintherivers.Nodirectimpacthasbeendetected eitheratthetimeorintheinterveningmonthsonfishorotheraquaticspeciesin thesewaters.Onlylongtermmonitoringwillidentifyiftherehasbeenalasting environmentalconsequenceofthepresenceofPFOSanditsassociatedfluorinated compounds. 47 Resultstodate(sixmonthssincetheincident)ofgroundwatermonitoringhave shownthepresenceoffuels,fuelrelatedproductsandresiduesfromthefire fightingfoamsingroundwateratanumberoflocations,buttheyaremost prevalentunderandclosetothesite.
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48 AlthoughPFOSabovethelevelofthreemicrogrammesperlitre(whichisthe advisorylevelsetbytheDWIforPFOSindrinkingwater)hasbeendetectedin environmentalmonitoringsamples,theselevelshavenotbeendetectedinsamples of drinkingwater. 49 Itcouldbemanymonthsbeforethefullextentofthecontaminationofthe groundwaterisknown.TheEnvironmentAgencyisworkingwithDWIandthe localwatersupplycompaniestoensurethattheyarefullyawareofsampling results,andareabletoactappropriatelytosafeguardpublicwatersupplies. Furthermonitoring 50 InviewoftheapparentwidespreadoccurrenceoftracequantitiesofPFOS aroundtheHemelHempsteadarea,someapparentlyunconnectedwithBuncefield, theEnvironmentAgencyisconductingatargetednationalgroundwatersampling exercisetoinvestigatethewiderprevalenceofPFOSandrelatedcompoundsin groundwater. 51 TheinitialmonitoringprogrammeisbeingcarriedoutintheperiodAprilto July2006.GroundwaterisbeingsampledatselectedsitesontheEnvironment Agencysnationalgroundwatermonitoringnetwork.Arangeofsiteshavebeen selectedinrural,urbanandindustrialareas.Somesitesarewherefirefighting foamsmayhavebeenused,egfirestations,airbasesetc,whileothersarewhere suchuseisnotsuspected.Approximately150siteswillbesampledasapartofthis programme. 52 Ifperfluorosurfactantcompoundsaredetectedingroundwater,repeatsampling willbecarriedouttoverifytheinitialresultsandtoinvestigatepersistence.If widespreaddetectionoccurs,theprogrammewillbeextendedbeyondJulyand,if necessary,selectedcompoundsaddedtotheroutinemonitoringprogramme.A similarsamplingexerciseisplannedforsurfacewaterstotakeplaceoverthe periodJulytoDecember2006. NotificationtotheEuropeanCommission 53 TheCompetentAuthority(atBuncefield,jointlyHSEandtheEnvironment Agency)isrequiredunderregulation21(1)and(2)oftheCOMAHRegulationsto informtheEuropeanCommissionofanymajoroccurrenceonaCOMAHsite. HSE,onbehalfoftheCompetentAuthority,issuedashortreporton10March 2006forinclusionontheMajorAccidentReportingSystem.Asfurther informationofinternationalsignificancebecomesknown,theCompetent AuthoritywillalsopassthisontotheEuropeanCommissionandhencethe internationalcommunity. 54 DEFRAhasestablishedthresholdcriteriadefiningaMajorAccidentToThe Environment(MATTE),basedonSchedule7(part1)oftheCOMAHRegulations. TheEnvironmentAgency,usingthesecriteria,hasdeterminedthattheBuncefield incidentisaMATTE,andtheCompetentAuthorityhasrecentlyreportedthisto theEuropeanCommission.Thisdeterminationisbasedontheresultsof EnvironmentAgencymonitoringofgroundwaterbeneathandinthevicinityofthe Buncefieldsite,whichhasbeenshowntobecontaminatedwithfuelsandfire fightingfoambyproducts.Thisareaofcontaminationisdeemedtoextendover theonehectarethresholddescribedintheRegulations.Thereportingofthis MATTEtotheEuropeanCommissionhasnoimpactonthecontinuedmonitoring andremediationprogrammethatisalreadytakingplace.

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ThecontinuingInvestigation 55 WorkcontinuesontheInvestigationtoensurethatallreasonablelinesof enquiryarefollowed.Evidencecontinuestobegatheredfromdifferentsources. Theemerginginformationcontributestoagreaterunderstandingoftheunderlying rootcauses,andwillallowtheInvestigationteamtorefineitsenquiriesfurtherand tobringintofocuselementssuchaswidermanagementsystemsandorganisational factors. 56 Almostalltheplantandequipmentrequiredforforensicexaminationhasbeen recoveredfromtheBuncefieldsite,whichwillallowtheoperatorstodemolish buildings,tanksandbunds.However,furtherinvestigationworkwillbecarried outontheintegrityofthefloorsofthebundstogetherwithenvironmental monitoringofthegroundunderneath,inparticularwheretankswerelocated. 57 TheInvestigationhasalsoconsideredpreviousincidentswhichmayhave similaritiestotheeventsatBuncefield.ThesearesummarisedinAnnex5.Workis inhandtoidentifyotherincidentsthatmayberelevant.

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Part2 Issuesofconcern arisingfromtheInvestigation todate

58 KnowledgeoftheBuncefieldincidentisstillincomplete,butenoughisknown todrawsomebroadconclusionsaboutactionswhichmightbetakentoimprove health,safetyandenvironmentalprotectionatornearoilstoragesites,including areaswherefurtherworkisneeded.TheBoarddoesnotintendtomakeany commentatthisstageonpossiblelegalproceedings.Theinitialobservationsset outhereconcernbroaderissues.TheBoardwillcontinuetoensurethat informationismadepubliclyavailable,eitherthroughitsownreportsorviathe CompetentAuthority,whereitisnecessarytoensurecontinuedsafety,whilealso attemptingtopreservetheintegrityofanyfuturecriminalproceedingsthatmight bebroughtbytherelevantenforcingauthorities. 59 TheBoardsobservationsandconclusionsatthisstagefallintothreeareas, whichareconsideredfurtherbelow:

Designandoperationofstoragesites. Emergencyresponsetoincidents. Advicetoplanningauthorities.

60 Webelievethese,togetherwithourexaminationofHSEsandtheEnvironment AgencysrolesinregulatingtheactivitiesontheBuncefieldsite,willformthe broadscopeofourfurtherwork.

Designandoperationofstoragesites
61 TheBuncefieldincidentinvolvedfailuresofprimary,secondaryandtertiary meanstocontainfuelandassociatedfirewaters.

Primary meansarethetanks,pipesandvesselsthatholdliquids,andthe devicesfittedtothemtoallowthemtobesafelyoperated. Secondary meansareenclosedareasaroundstoragevessels(oftencalled bunds),createdusuallybyconcreteorearthwalls.Theirpurposeistohold anyescapingliquidsandanywaterorchemicalsusedinfirefighting. Tertiarymeansarethingssuchasdrainsdesignedtolimitthepassageof chemicalsoffsite,raisedkerbstopreventliquidsthathavebreachedthe bundsfromescapingintothegeneralareaaroundthesite,etc.

62 TheBoardhasalreadyseensufficientinformationfromtheInvestigationtobe abletoexpressanobvious,butnonethelessimportantopinionthatsafety,health andenvironmentalprotectionareofparamountimportanceatsiteslikeBuncefield. Wewouldexpectthispointtobeuppermostinthemindoftheindustrychaired taskgrouprecentlyconvenedbyHSEtopursueimprovementstosafetyand environmentalprotectionatfueldepots.

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63 Theoccurrenceofamassivefuelvapourexplosionconfirmstheoverriding needtoensuretheintegrityoftheprimarymeansofcontainment;inotherwords, tomakesurethatliquiddoesnotescapefromthevesselsinwhichitisnormally meanttobeconfined. 64 SafetyandplanningassumptionsatfueldepotslikeBuncefieldhaveuntilnow beenbaseduponfiresinpoolsofescapedliquid,heldincheckbybundswhilethe emergencyservicesestablishcontrol.Theformationofahugevapourcloudfrom tankstoragewasnotconsideredasufficientlycrediblescenarioforlanduse planningpurposes.14 OneparticularlessonfromtheBuncefieldincidentis thereforethatsuchacloudcanformwhileahighlyflammableliquidsuchas unleadedpetrolisescapingfromprimarycontainmentinastoragetank,and wherethepathofescapeinvolvescascading,fragmentinganddispersingthe liquidfromheight(egfromtheventsinthetopofatankthatisbeingoverfilled). 65 TheInvestigationhasdemonstratedthatovertoppingatankwithhighly flammablefuelismorelikelytoproduceapotentiallyexplosivemixturethan poolingfromalowerlevelescape,suchasmayresultfromatankfailure.The Investigationhasalsoshownthatthedesignofthetankitselfmayhave contributedtothevapourformationatBuncefield.Thissuggeststhatdesignand constructionoftanksandpipeworkthatcouldbefavourabletotheformationof flammablevapoursshouldbediscouraged. 66 Secondaryandtertiarymeansofcontainmentarevitalforenvironmental protection.However,thesecondarycontainmentprovidedbybundsaround tanksisoflesservaluewherethereisrapidformationofvapourthatwillfairly quicklyoverflowthebundwall.Tertiarycontainmentalsohaslittleeffectagainst a cloudofvapour,asitisintendedtointerceptandholdliquidflowingalongthe ground.ItistheBoardsviewthattheineffectivenessofcustomarymeansof secondaryandtertiarycontainmentagainstmigrationoflargevolumesofvapour reemphasisesthatthemosturgentfocusofattentionshouldbeonpreventing lossofprimary containmentand,shouldthatoccur,inhibitingrapidlargescale vaporisationandanysubsequentdangerousmigrationofaflammablevapour. 67 TheInvestigationalsorevealedthatthefirepumphousethatprovidedthemeans todistributecoolingwaterforthewholeBuncefieldsitewasimmediatelyadjacentto, anddownhillfrom,BundA.Asdescribedinparagraph28,recentCCTVanalysis hasidentifiedthispumphouseasalikelysourceofoneoftheearlyignitionsofthe flammablevapour.Thelossofthepumphouse,probablyfromaninternalexplosion ofvapourthathadenteredfromthesurroundingcloud,immediatelyrendered inoperativethefirefightingprovisionsforthesite.Itisforeseeablethatflammable vapourinanenclosurecould,ifignited,causedamagewithinthatenclosure.The riskofflammablevapourreachingfirepumpsincreasesthecloserthepumpsareto tankscontainingvolatileflammableliquids.Theindustrychairedtaskgroupmay wanttoreviewwhethercurrentguidancerelatedtothesitingand/ormeansof protectionofemergencyresponsefacilitiesissuitableatsitessuchasBuncefield. 68 FollowingpublicationoftheInvestigationManagers first ProgressReport in February2006,theCompetentAuthority(HSEwiththeEnvironmentAgencyinEngland andWales,andwiththeScottishEnvironment ProtectionAgencyinScotland)begana programmeofsiteinspectionstoensureoperatorsreviewedkeydesignandoperational aspectsoftheirsites,aprocesssupportedbythefindingsofsubsequentProgressReports.

14

AtBuncefield,theformationofaflammablevapourcloudatthetankerloadinggantry, asopposedtothetankstorageareas,wasconsideredbytheCompetentAuthorityand siteoperators,butthelevelofoffsitehazardthiswouldposewasjudgedtobelower thanalargepoolfireoriginatingfromthetankstoragearea.

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69 ThepreliminaryfindingsoftheCompetentAuthorityprogrammewere publishedon13June2006.15 As a resultoftheprogramme,threeImprovement Noticeshavebeenserved.TheBoardwelcomesthisinitiativeandlooksforwardto thepublicationofthedetailedfindingsoftheCompetentAuthorityprogrammeof inspectionthisautumn.TheBoardnotestheindustryseffortsinworkingwiththe CompetentAuthoritytoreviewthefindingsfromboththeInvestigationandthe SafetyAlertreview,andtomakerecommendationstothejointindustry/regulator taskgroupregardingactionneededtoimproveriskcontrol.Inparticular,the Boardnotesthatpartofthisworkwillbetoreviewandrevisepublishedguidance onhandlingflammableliquidsatstoragesitesbymid2007,andexpectsthiswork tobepursuedwithvigour. 70 Thatguidanceshouldbetheculminationandrecordofasubstantialeffortby theindustry,workingwiththeregulators,andbegunatonce,todevelopand implementbettermethodsforhandlingflammableliquidsatstoragesites, particularlywherevolatilefuelsarehandled,withtheprincipalaimofsafely confiningtheminthevesselsintendedforthatpurpose.BymethodstheBoard meanstheplant,equipment,managementsystems,operationalproceduresand workingpracticesprovidedtoachievesafeoperationandtheongoingverification byoperators,supportedbytheCompetentAuthority,thatallthesecontrolmeasures areeffective. 71 Insummary,theInvestigationhasrevealedanumberofmattersconcerningthe designandoperationofsitessuchasBuncefieldwhereimprovementsto maintainingprimary containmentmustbeconsideredbytheindustry,working closelywiththeCompetentAuthority.Thesemattersinclude:

theelectronicmonitoringoftanksandpipework,andassociatedalarmsthat warnofabnormalconditions; thedetectionofflammablevapoursintheimmediatevicinityoftanksand pipework; theresponsetothedetectionofabnormalconditions,suchasautomatic closureoftankinletvalvesandincomingpipelinevalves; theextenttowhichtheexteriorconstructionoftanks(egtanktopdesign) inhibits,orcontributesto,flammablevapourformation; thesitingand/ormeansofprotectionofemergencyresponsefacilities;and therecordingofmonitoring,detectionandalarmsystemsandtheiravailability (egoffsite)forperiodicreviewoftheeffectivenessofthecontrolmeasuresby theoperatorandtheCompetentAuthority,aswellasinrootcauseanalysis shouldtherebeanincident.

72 Whereaneedforadditionalsystemsisidentified,HSCandtheCompetent Authorityshouldsatisfythemselvesthatcurrentlegalrequirementsarerobust enough,andsupportedwithsufficientresources,toensurethatthesesystemsare providedandmaintainedateveryfuelstoragesitewheretherisksrequirethem, withoutrelyinguponvoluntarycompliance.Ithasnotbeenestablishedwhether changesinthelaworintheresourcesavailabletotheCompetentAuthorityare requiredtoachievethisend.TheBoardis,however,clearthattheseverityofthe Buncefieldincidentmakesacompellingcaseforanysuchchangestobemadeasa matterofveryhighlegislativepriority,shouldtheneedbeidentified.

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15

ThefullreportisavailableonHSEswebsiteatwww.hse.gov.uk/comah.

73 Aswellasensuringtheeffectivenessofprimarycontainment,theindustry, workingwiththeCompetentAuthority,shouldembarkonareviewofthe purpose,specifications,capacity,constructionandmaintenanceofsecondaryand tertiarycontainment,andinparticularthebundsaroundtanks.Thisworkshould leadtorevisedguidance,eitheraspartofthatreferredtoinparagraphs69and70, orproducedseparatelybutonatleastasrapidatimescale.Again,thenecessary standardsshouldbecapableofbeinginsisteduponbylaw. 74 TheBoardisclearthatitwillwishtoofferfurtheradvicewhenthe Investigationisfurtheradvanced.Thismightdealwith,forinstance,thehuman andorganisationalfactorsthatcontributetothesafeoperationofamajorhazard sitesuchasafuelstoragedepot.Suchfactorsinclude,forexample,job organisation,managementoforganisationalchange,monitoringandsupervision, trainingandcontrolroomlayout. 75 Inthelongerterm,itmayprovenecessarytoconsideradditionalstandardsfor theoveralllayoutofstoragesites. 76 Thesystemfordeliveringfuelsafelyaroundthecountrydependsongood communicationsbetweenthoseresponsiblefordeliveryandthoseresponsiblefor receivingthedeliveredbatches,toensuresitesreceivingfuelareabletoaccept deliveriessafely.Theadequacyofexistingsafetyarrangements,including communications,mayalsoneedtobereviewed.TheBoardexpectstoreturnto theseandothermattersinduecourse. 77 Furtherworkisneededtoresearchtheactualmechanismforgeneratingthe unexpectedlyhighexplosionoverpressuresseenatBuncefield.Thisisamatterof keeninternationalinterest,andparticipationfromabroadrangeofexperts,as wellastheindustry,isessentialtoensurethetransparencyandcredibilityofany researchprogramme.TheBoardwillconsiderfurtherrecommendationsaboutthe natureandscopeofsuchwork.

Emergencyresponsetoincidents
78 Improvingthearrangementstopreventfiresandexplosionsinnowaylessens theneedtohaveeffectiveemergencyarrangementsintheeventofanincident.This coversbothplanningforemergenciesandtheeffectivenessoftheresponse. OperatorsoftoptierCOMAHsitesarerequiredbylawtoprepareadequate emergencyplanstodealwiththeonsiteconsequencesofpossibleincidents,and theymustalsoprovidelocalauthoritieswithinformationtoenablethemto prepareemergencyplanstodealwiththeoffsiteconsequences.Theadequacyof theseplansdepends,amongotherthings,onafullappreciationofthepotentialfor majoraccidents.Inthelightoftheemergingfindings:

Operatorsofoilstoragedepotsshouldreviewtheironsiteemergencyplans andtheadequacyofinformationtheysupplytolocalauthoritiestoensure theytakefullaccountofthepotentialforavapourcloudexplosion,aswellas fires.FromtheforthwithactionstakenbydepotoperatorsandtheCompetent AuthorityinresponsetotheCompetentAuthoritysSafetyAlertof 21 February2006,responsibleoperatorsshouldhavealreadyundertakensuch reviews.TheCompetentAuthoritymustensurethatthisisthecaseandwork withtheindustrytoensurethatalllearningisfullyshared.

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Thepublichealthimplicationsofpotentialvapourcloudexplosionsmustbe consideredinbothonsiteandoffsiteemergencyplans.Thoughthepublic healthimpactofBuncefieldappearstohavebeenminimal,thismaynot necessarilyhavebeenthecaseunderdifferentconditions.16 Aswithonsiteprotectivesystems,HSCandtheCompetentAuthoritybodies shouldsatisfythemselvesthatlegalrequirementsarerobustenoughtoensure anynecessarychangestoemergencyplansaredulymade.

79 Severalseparatereviewsarelookingattheeffectivenessoftheemergency responsetoBuncefield.Theemergencyservices,particularlythefireandpolice services,respondedimpressivelyandonamassivescalethatwasalmostcertainly unprecedentedinmoderntimes.Inevitablytherearelessonstobelearnedfrom suchanexceptionalevent.Thisisparticularlyimportantgiventhenewnessofthe local,regionalandnationalresiliencearrangementstestedatBuncefield.TheBoard intendstoreturntothistopicwhenmoreinformationisavailablefromthose reviews.MeanwhiletheBoardhasthefollowingobservations:

GiventhehugecostoftheBuncefieldincident,itisessentialnottomissanyof thelessonsithasprovidedforemergencyresponse.Liketheresponseitself,this isamultiagencytaskthatrequiresaclearlead.ItwillbepartoftheBoards ongoingworktoestablishaclearpictureoftheleadprovidedbycentral Governmentforfirstresponders. ThepublichealthimpactsofBuncefieldappeartohavebeenminimal. Nevertheless,theincidenthasrevealedtheimportanceofprompt,usefuladvice toearlyresponderssuchastheFireandRescueServices,andtothepublic. Theremayalsobescopetoimprovethecoordinationofsamplingand monitoringactivities,particularlyintheearlystagesofmajorincidents.The BoardwelcomestheestablishmentofaHealthProtectionAgencyledworking groupaimingtoestablishframeworksandagreedworkingpracticesforany future postincidentenvironmentalsampling,andawaitswithinterestthe resultsofthiswork.TheBoardalsowelcomesthestepsbeingtakenbythe HealthProtectionAgencytodrawtotheattentionofregionalresilienceforain BritaintheimmediatelessonsofBuncefieldfortheprovisionofhealth protectionadviceduringamajorincident. Thelocalresidentialandbusinesscommunitieshaveintereststobeconsidered, egthemaintenanceofemploymentandsupportineffectingarapidreturnto socialnormality.Thisappearstobebotharegionaland,onthescaleof Buncefield,anationalissue.ItisnotcleartotheBoardhowfaremergency planningarrangementshavetakenaccountofthisaspectinthepast.The SecretaryofStateforCommunitiesandLocalGovernment,throughthe GovernmentOfficefortheEastofEngland,recentlyestablishedataskforceto investigateoptionsforGovernmentsupporttobusinessesandlocaleconomies intheperiodfollowinganexceptionaldisaster.Thisinitiativeisverywelcome andtheBoardhopesswiftprogresswillbemadeinthiswork.

16

22

ThelowimpactonpublichealthoftheBuncefieldincidentisaninitialconclusionof theHealthProtectionAgency.TheirreviewofthehealtheffectsoftheBuncefieldfireis availableatwww.hpa.org.uk/explosions/hemel.htm.

Advicetoplanningauthorities
80 OneofthestarkestissuesraisedbytheBuncefieldexplosionisthelocationof siteswithsuchmajorhazardpotentialalongsideneighbouringcommercialand residentialdevelopment.Thesituationposesthefundamentalplanningquestion thatallpartieshavetoaddressquitesimply,whattodoaboutsuchdevelopment. 81 TheBoardisacutelyawareoftheproblemsthatplanninguncertaintiescausefor localcommunities,particularlythosedirectlyaffectedbytheBuncefieldincident. DecisionsaboutrebuildingbusinessesneartheBuncefielddepotcrucialtothe livelihoodofthosewhoworkinthosebusinessesandtothelocaleconomyingeneral hingeondecisionsaboutrebuildingthewholeofthearea,includingthedepotitself. 82 Akeyelementofthelanduseplanningprocessfordevelopmentsaround BuncefieldandmanysimilarsitesistheadviceHSEprovidestoplanningauthorities. TheBoard,initsstatementof9MayonpublishingtheThirdProgressReport, indicateditsviewthatenoughinformationhademergedatthatstagetoenableHSE toreviewasamatterofurgencythebasisandstandardoftheadviceitprovides.The BoardnotesthatHSEhasactedonthatchallengeandexpectstoproducesome preliminaryconclusionsintheautumnofthisyear. 83 TheBoardrecognisesthatthisisacomplexissueforwhichtherearenosimple solutions.Thereisaneedtobalancetherisksandbenefitsofdevelopment a judgementmadenoeasierbytechnicalandscientificuncertainties.Thisis illustratedbythefactthatHSEs adviceonthissitewasbasedonarepresentative worstcrediblescenarioofamajorliquidfuelpoolfire.Avapourcloudexplosion wasinitiallyconsidered,butarisingfromtankerloadingoperationsandnottank storage.Apoolfirewasassessedaspresentingthegreateroffsitehazard.The Buncefieldincidentbringsintoquestiontheassessmentpolicyformanyoil/fuel depotsites,andthezonesettingmethodwhichitinforms. 84 TheBoardintendstoaddresstheseissuesinmoredetail,butnotbeforeseeing thepreliminaryconclusionsofHSEsreview.Ameasuredapproachisjustifiedsince thelikelihoodofasimilarexplosionremainslow,andshouldbemadelowerstill byaprogrammeofactionsdesignedtoincreasethereliabilityofprimary containment.Inourview,theimportanceofreachingconclusionsthatare considered,costed,andsustainablegreatlyoutweighsanybenefitthatmightbe derivedfromcomingtosummaryjudgements. 85 WewillbeinterestedtoknowHSEsviewsonthedesirabilityandfeasibilityof anapproachtoadviseondevelopmentsaroundsiteslikeBuncefieldbasedmoreon considerationofrisk.Undersuchanapproach,thelikelihoodofmajorincidents, takingintoaccountallthemeasuresinplaceagainstthem,wouldplayamore explicitpartthanhithertoindeterminingplanningadvice. 86 TheBoardhasalsonotedtheincrementaldevelopmentaroundBuncefield(and presumablyothersites).17 Giventhatmostplanningadvicecurrentlyfocuseson specificdevelopmentssubjecttoplanningapproval,thiscouldmeanthatinthe future,moreattentionshouldbepaidtothetotalpopulationatriskfromamajor hazardsite.TheBoardwelcomestheMinisterialStatementlaidintheHouseof Commonson15May,whichreferredtocrossGovernmentworkonthisissue currentlybeingcoordinatedbytheCabinetOffice,andtowhichHSEismaking animportantcontribution,andlooksforwardtotheconsultationwith stakeholdersexpectedlaterthisyear.

17

Thehistoryofdevelopmentwithina3kmradiusoftheBuncefielddepotsitebetween 1966and2005isshowninFigure5,Annex3.

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Annex1

Termsofreferenceandprogress
ThisannexsetsouttheeighttermsofreferencefortheInvestigationandexplains theprogressthatisbeingmadetowardsaccomplishmentofeachofthem.

1 Toensurethethoroughinvestigationoftheincident,thefactorsleadingup toit,itsimpactbothonandoffsite,andtoestablishitscausationincluding rootcauses TheBoardhaspublishedthreeProgressReportsfromtheInvestigationManager. Thesehaverevealedthemainfactsoftheincident,buthavenotspeculatedonwhy controlofthefuelwaslost.Theexplosionmechanism,iethemeansbywhich unexpectedlyhighoverpressuresweregenerated,issubjecttosignificantfurther investigation.Thismayrequirewiderexpertconsultationandresearch. Thecriminalinvestigationispursuingallreasonablelinesofinquiryintothefacts andcausesoftheincidenttoenabletheCompetentAuthority(HSEandthe EnvironmentAgency)totakeaviewonlegalproceedings.

2 Toidentifyandtransmitwithoutdelaytodutyholdersandother appropriaterecipientsanyinformationrequiringimmediateactiontofurther safetyand/orenvironmentalprotectioninrelationtostorageanddistribution ofhydrocarbonfuels TheCompetentAuthorityissuedaSafetyAlert toaround1100COMAHduty holderson21February2006.Specialattentionwaspaidto108fueldepotowners storingCOMAHquantitiesoffuelinGreatBritain,seekingareviewof arrangementsfordetectinganddealingwithconditionsaffectingcontainmentof fuel.MostdutyholdersrespondedtothealertbytheEasterdeadline.Meanwhile, theCompetentAuthorityvisitedall108depotstofollowupthealert.Aninterim reportwaspublishedon13Juneandisavailableat www.hse.gov.uk/comah/alert.htm. TheEnvironmentAgencyissuedfurtheradvicetoitsinspectorstoinvestigate secondary(bunding)andtertiary(drainsandbarriers)containmentatdepotsin EnglandandWalesinresponsetotheSecondProgressReport.TheEnvironment Agencyisexpectedtopublishareportinthesummer.TheEnvironmentAgency alsocontinuestomonitortheeffectsofBuncefieldonthesurroundingenvironment andtoissueupdatesonitswebsite,www.environmentagency.gov.uk.Theinitiative isbeinghandledseparatelyforScotlandbytheScottishEnvironmentProtection Agency,withjointinspectionsundertakenwithHSEcoveringprimary,secondary andtertiarycontainment,andmanagementsystems.However,itisintendedthat anoverallviewofthesituationinBritainwillbeavailablethissummer. On16JuneinvestigatorsservedtwoImprovementNoticesonthemanufacturersof thehighlevelalarmswitchinstalledonTank912,havingidentifiedapotential problematothersitesrelatedtothesettingoftheswitchfornormaloperations followingtesting.ThiswasfollowedupbyaSafetyAlertfromHSEon4July alertingoperatorsrelyingonsuchswitchesofthepotentialproblem.
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TheChairmanoftheBuncefieldBoardwrotetotheChiefExecutiveoftheHealth ProtectionAgencyon3Julyenquiringintoprogresswithinformingregionalresilience groupsofearlylessonslearnedfromBuncefield,focusingonpublichealthissuesinthe immediateaftermathofamajorairborneincident.

3 ToexaminetheHealthandSafetyExecutivesandtheEnvironmentAgencys roleinregulatingtheactivitiesonthissiteundertheCOMAHRegulations, consideringrelevantpolicyguidanceandinterventionactivity Workisprogressingsteadilyonbothpartsofthereview,concerningrespectively HSEsandtheEnvironmentAgencyspriorregulatoryactivitiesatBuncefield.The fullfindingsofthereviewwillbeincorporatedintotheBoardsfinalreport(see termofreference8).Anyimmediateimportantlessonsfromtheexaminationofthe CompetentAuthorityspriorrolewillbeincorporatedintothelessonslearned programmeundertermofreference5.

4 Toworkcloselywithallrelevantstakeholders,bothtokeeptheminformed ofprogresswiththeInvestigationandtocontributerelevantexpertisetoother inquiriesthatmaybeestablished TheongoingimpactonresidentsandbusinessesoftheBuncefieldincidenthasbeen reportedinallthreeProgressReports.TheBoardhasmaintainedanactiveinterest inreleasingasmuchnewinformationaspossibletothecommunityandits representatives,suchasthelocalMPMikePenning,toassistinunderstandingthe eventsof11December2005,andtomaintainpublicconfidencethatprogressis beingmadewiththeInvestigation.Residentsandbusinesseshaveshown remarkableresilienceingreatadversity.DacorumBoroughCouncilinparticular, butalsoStAlbansandHertfordshireCouncils,haveperformedextremely effectivelyinverydifficultcircumstances,andhavesupportedtheBoardinits engagementwithresidentsandbusinesses,ashasMikePenningMP. TheBoardhasalsokeptkeyGovernmentstakeholdersinformedofthe Investigationsprogress,andhasmaintaineditsinterestindevelopmentsthathave takenplacesinceBuncefieldtohelpmanagetheaftermathandsupportareturnto normalityforresidentsandbusinesses. TheBoardhasengagedwithallthepublicsectoragenciesinvolvedinthe emergencyresponsetoBuncefieldandhasmetwithanumberofthekeyagencies, particularlytheCategory1(Gold)responders.Thisisnotanissueinwhichthe Boardhasprimaryresponsibilitybut,asreportedinthisInitialReport,theBoard isgivingfurtherconsiderationtoemergencyresponseandemergencypreparedness issues,andwillsaymoreonthislater. TheBuncefieldMajorIncidentInvestigationmadepresentationstotwomulti agencydebriefingsessionson21and28Junetoinformregionalresiliencegroups aroundBritainoftheresponsetotheBuncefieldincident.

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5 Tomakerecommendationsforfutureactiontoensuretheeffective managementandregulationofmajoraccidentriskatCOMAHsites.This shouldincludeconsiderationofoffsiteaswellasonsiterisksandconsider preventionofincidents,preparationsforresponsetoincidents,andmitigation oftheireffects HSE,theEnvironmentAgencyandtheHealthProtectionAgencyarecontributing tothisworktoassisttheBoardtomakesensible,practicalandaffordable recommendationsforimprovementsinthelightoftheBuncefieldincident. Keyworkstreamsareinenvironmentalprotection;landuseplanning;fireand explosionmechanisms;controlandinstrumentation;humanandorganisational factors;health;emergencyresponseandpreparedness;andregulatoryimpact. HSEhasconvenedanindustrychairedtaskgroupthatincludestheEnvironment AgencyandtheScottishEnvironmentProtectionAgency,toconsiderdesignand operationissues.TheBoardisconsideringhowtomakesuitablearrangementsfor furtherresearchandmodellingofexplosionmechanismsinflammablevapour clouds.HSEhasbegunworkonchangestolanduseplanningadviceandis workingcloselywithaCabinetOfficeledteamonapplyingnewknowledgeof riskstosocietyintheplanningsystem.TheHealthProtectionAgencyisconsulting keyagenciestoimprovepublichealthadviceandsupportduringsignificant pollutionevents.

6 ToproduceaninitialreportfortheHealthandSafetyCommissionandthe EnvironmentAgencyassoonasthemainfactshavebeenestablished.Subject tolegalconsiderations,thisreportwillbemadepublic Thiselementisdischargedbythepublicationofthisreport.

7 ToensurethattherelevantnotificationsaremadetotheEuropean Commission A reportfromtheEnvironmentAgencyandHSEwasmadetotheEuropean Commissionon10March.Subsequently,theEnvironmentAgencydeclared BuncefieldaMajorAccidentToTheEnvironment(MATTE),andtheCompetent AuthorityhasrecentlyreportedthistotheEuropeanCommission.

8 Tomakethefinalreportpublic Thetimingforthepublicationofthefinalreportremainsuncertainandisof courselinkedtoprogressonthemaintermsofreferenceandtoanydecisionon anycriminalproceedingsthatmightbeconsidered.Thepossibilitiesincludea furtherinterimreportorreports;decisionsmustnecessarilydependonthetiming ofdevelopmentsandconsiderationofthepublicinterest.

26

Annex2

MembersoftheindependentBoard
TheRt.Hon.LordNewtonofBraintree hasbeenalifepeersince1997after spending23yearsasaConservativeMemberofParliamentforBraintree,Essex. From1982to1988heheldministerialpositionsattheDepartmentofHealthand SocialSecurity.In1988hejoinedtheCabinetasChancelloroftheDuchyof LancasterandMinisterattheDTI.HethenheldthepostofSecretaryofStatefor SocialSecurityfrom1989to1992whenhewasappointedLeaderoftheHouseof Commons,whichhehelduntil1997.In2002hechairedtheCommitteethat reviewedtheoperationoftheAntiTerrorism,CrimeandSecurityAct2001. ProfessorDougalDrysdale isoneoftheleadinginternationalauthoritiesinFire SafetyEngineering.HewastheChairmanoftheInternationalAssociationofFire SafetyScienceuntilSeptember2005andiscurrentlytheeditoroftheleading scientificjournalinthefield,FireSafetyJournal.Hiswiderangeofresearch interestsincludestheignitioncharacteristicsofcombustiblematerials,flamespread andvariousaspectsoffiredynamics.HeisaFellowoftheRoyalSocietyof EdinburghandaFellowofboththeInstitutionofFireEngineersandtheSocietyof FireProtectionEngineers. DrPeterBaxter isaConsultantPhysicianinOccupationalandEnvironmental MedicineatCambridgeUniversityandAddenbrookes Hospital,Cambridge.Inthe pasthehasadvisedtheGovernmentontheimpactsonpublichealthrelatingtoair qualitystandards,majorchemicalincidents,naturaldisastersandclimatechange. TafPowell isDirectorofHSEsOffshoreDivision.HegraduatedinGeologyand ChemistryfromNottinghamUniversity.Hisoilfieldcareerhasbeensplitbetween workingintheUKandabroadinoffshore explorationanddevelopmentand regulationofthesectorinlicensing,welloperations,policyandsafetyregulation. In1991hejoinedHSEsOffshoreDivisionfromBPandstartedworktodevelop thenewoffshoreregulatoryframework,oneofLordCullensrecommendations followinghisinquiryintothePiperAlphadisaster.AsHSEsOperationsManager, basedinAberdeen,hethenledinspectionteamsandwellengineeringspecialists responsibleforenforcingthenewregulationsuntil2000whenhetookuphis currentrole. DrPaulLeinster isDirectorofOperationsattheEnvironmentAgency.Upuntil March2004hewastheDirectorofEnvironmentalProtection,havingjoinedthe Agencyin1998.PriortothishewastheDirectorofEnvironmentalServiceswith SmithKlineBeecham.PreviousemployersalsoincludeBPInternational,Schering AgrochemicalsandtheconsultancyfirmThomsonMTSwherehewasManaging Director.PaulhasadegreeinChemistry,aPhDinEnvironmentalEngineering fromImperialCollegeandanMBAfromtheCranfieldSchoolofManagement. Paulhasworkedfor30yearsinthehealthandsafetyandenvironmentalfield. DavidAshton isDirectorofHSEsFieldOperationsNorthWestandHeadquarters Division.HejoinedHSEin1977asaninspectorinthewestofScotlandwherehedealt withawiderangeofmanufacturingandserviceindustries,includingconstruction, engineeringandthehealthservices.In1986hejoinedFieldOperationsHQtodeal withmachinery safety. HethenheldthepostofPrincipalInspectorofmanufacturingin Prestonfortwoyears,beforebeingappointedasamanagementsystemsauditorto examineoffshoresafetycasesinthenewlyformedOffshoreDivision.In1993he becameHeadofHSEs AccidentPreventionAdvisory Unit,lookingatthemanagement ofhealthandsafetyinorganisations.Between1998and2003DavidwasHSEs DirectorofPersonnel,beforebeingappointedtohiscurrentposition.
27

Annex 3

PlanninghistoryofBuncefieldsiteandneighbouringdevelopments
1 Planningpermissionwasgrantedin1966toShellMexandBPLimited,Regent OilCoLimited,MobilOilCoLimited,andPetrofina(GB)Limitedtodevelop91 acresoflandatBuncefieldfortheconstructionofastorageanddistributiondepot forpetroleumproducts.StAlbansRuralDistrictCouncilinitiallyrefusedthe applicationonthegroundsthatitwasaninappropriatedevelopmentintheGreen Beltandwouldhaveadetrimentaleffectontheamenityofthelocality.Onappeal, theMinisterofHousingandLocalGovernmentgrantedpermissionsubjecttoa numberofconditionsrelatingtodesignofthesite,treeplantingandrestrictionson thesizeofofficepremises. 2 Atthetimethattheterminalwasbuiltin1968,thesitewaswellscreenedby hedgesandtrees,buttherewereaboutninedwellingsontheperipheryofthesite tothenorthwhoseamenitieswereaffectedbythesite,andafarmtothesouth. Oneoftheninedwellingstothenorthwasconvertedin2000tocreatefive separateproperties.Since1968therehasbeengeneralencroachmentand developmentofadjacentland.ThiscanbeseenonthemapinFigure5.The majorityofthisbuildingdevelopmenttookplaceduringtheperiodfromthemid 1960stotheearly1980s,comprisingtheconstructionorredevelopmentof residentialpropertiesandanumberofschoolsandindustrialpremisestothewest ofthesite,allofwhichfellwithina3kmradiusasshownonthemap.Between 1990and2006,afewadditionalindustrialpremiseswerebuiltaroundthesite. 3 DacorumBoroughCouncilistheprincipalplanningauthorityforthesite,but a smallsectiontothenorthofCherryTreeLanefallstoStAlbansDistrictCouncil. 4 Thelocalplanningauthoritydecideswhetherdevelopmentscangoahead.But arrangementshaveexistedsince1972forlocalplanningauthoritiestoobtain consulteeadvicefromHSEanditspredecessorsaboutthesafetyimplicationsfor developmentsfromrisksassociatedwithmajorhazards.Between1991and2005, 28applicationswerepassedtoHSEforadvicerelatingtoavarietyofcommercial orresidentialdevelopmentsaroundtheBuncefieldsite.HSEadvisedagainstfour oftheseproposalsandadvisedthatsevenotherscouldbeallowedsubjectto certainconditions.Asfarasisknown,thelocalauthorityfollowedHSEsadvice inthesecases. 5 InadditiontothesespecificdevelopmentsonwhichHSEwasastatutory consultee,HSEisfromtimetotimeconsultedonothermatters.Forexample,HSE wasconsultedonfourlocalstructureplanrevisions. 6 Thecomplexbeganoperationsin1968afterapipelinewasconstructedtolink twoShellrefineriesatStanlowatEllesmerePortinCheshireandShellHavenon theThamesEstuaryatStanfordleHopeinThurrock.Thedepotoperated originallyunderlicencegivenunderthePetroleum(Consolidation)Acts1928and 1936.ThePlanning(HazardousSubstances)Act1990andsubsequentstatutory provisions,thePlanning(HazardousSubstances)Regulations1992(PHS Regulations)andlaterthePlanning(ControlofMajorAccidentHazards) Regulations1999introducednewproceduresforconsenttobesoughtfromthe hazardoussubstancesauthoritytostorehazardoussubstances.

28

7 Theconsentidentifiesthehazardoussubstancesandtheirlocationonsiteand definescertainconditionsofusesuchasmaximumsize,temperatureandpressure ofstoragevessels.Figure6containssomedetailsofconsentsobtainedforthe Buncefielddepot.TheconsentsforShellUKOilLimitedhavebeenincludedin thistableastheyhavenotbeenrevoked,althoughShellnolongeroperatesfrom thissite. HSEsroleinlanduseplanning 8 HSEsspecificroleinlanduseplanningistwofold:

UnderthePHSRegulations,thepresenceofhazardouschemicalsabove specifiedthresholdquantitiesrequiresconsentfromthelocalhazardous substancesauthority,whichisusuallyalsothelocalplanningauthority.HSEis a statutoryconsulteeonallhazardoussubstancesconsentapplications.Itsrole istoconsiderthehazardsandriskswhichwouldbepresentedbythe hazardoussubstance(s)topeopleinthevicinity,andonthebasisofthisto advisethehazardoussubstancesauthoritywhetherornotconsentshouldbe granted.Inadvisingonconsent,HSEmayspecifyconditionsthatshouldbe imposedbythehazardoussubstancesauthority,overandabovecompliance withstatutoryhealthandsafetyrequirements,tolimitriskstothepublic(eg limitingwhichsubstancescanbestoredonsite,orrequiringtankerdelivery ratherthanonsitestorage).Hazardoussubstancesauthoritiesshouldnotify HSEoftheoutcomeofallapplicationsforconsent,andwhereconsenthas beengrantedshouldsupplycopiesofthesiteplansandconditions. HSEusestheinformationcontainedinconsentapplicationstoestablisha consultationdistancearoundtheinstallation.Thisusuallycomprisesthree zonesorriskcontourareas.Theconsultationdistanceisbasedonthe maximumquantityofhazardoussubstance(s)thatthesiteisentitledtohave underitsconsent.HSEnotifiesthelocalplanningauthoritiesofall consultationdistancesintheirareas.TheGeneralDevelopmentProcedure Order1995requiresthelocalplanningauthoritytoconsultHSEaboutcertain proposeddevelopments(essentiallythosethatwouldresultinanincreasein population)withinanyconsultationdistance.HSEadvisesthelocalplanning authorityonthenatureandseverityoftheriskspresentedbytheinstallationto peopleinthesurroundingareasothatthoserisksaregivendueweightbythe localplanningauthoritywhenmakingitsdecision.Takingaccountoftherisks, HSEwilladviseagainsttheproposeddevelopmentorsimplynotethatitdoes not adviseagainstit.

9 HSEsapproachtolanduseplanningissetoutinmoredetailinAnnex2of thefirstProgressReport.Someofthisprocessisnowbeingdevolvedtocertain localplanningauthorities. 10 TheconsultationdistancerepresentsthefurthestdistanceatwhichHSEwishes tobeconsultedaboutdevelopmentsnearhazardousinstallations/majoraccident hazardpipelines.Thisdoesnotmeanthatthereisnoriskbeyondtheconsultation distance,justthatthepredictedrisksaresufficientlylowthattheyneednotbepart ofaplanningdecision. 11 Withintheconsultationdistance,HSEundertakesanassessmentofthehazards andrisksfromtheinstallationandproducesamapwiththreecontours representingdefinedlevelsofharmorriskwhichanyindividualatthatcontour wouldbesubjectto,basedoninformationrelatingtothehazardoussubstances consent.Theharmorrisktoanindividualisgreatertheclosertotheinstallation.
29

Thecontoursformthreezones,withtheoutercontourdefiningtheconsultation distancearoundmajorhazardsites.ThelocalauthorityconsultsHSEonrelevant proposeddevelopmentswithinthisconsultationdistance.

Figure3 Consultation distanceandzones

12Whenaplanningapplicationisreceived,HSEorthelocalplanningauthority firstidentifiesinwhichofthethreezonestheproposeddevelopmentislocated. Secondly,theproposeddevelopmentisclassifiedintooneoffoursensitivitylevels. Themainfactorsthatdeterminetheselevelsarethenumberofpeopleatthe development,theirsensitivity(vulnerablepopulationssuchaschildren,oldpeople) andtheintensityofthedevelopment.Withthesetwofactorsknown,asimple decisionmatrixisusedtogiveaclearAdviseAgainstorDonotAdviseAgainst responsetothelocalplanningauthority,asshownbelow:

Levelofsensitivity

Developmentin innerzone DAA AA AA AA Example Example Example Example

Developmentin middlezone DAA DAA AA AA

Developmentin outerzone DAA DAA DAA AA

1 2 3 4 Sensitivitylevel1 Sensitivitylevel2 Sensitivitylevel3 Sensitivitylevel4 Figure4 Landuse planningsensitivitylevels anddecisionmatrix

Factories Houses Vulnerablemembersofsocietyeg primaryschools,oldpeopleshomes Footballground/largehospital

DAA meansDonotAdviseAgainstthedevelopment AA meansAdviseAgainstthedevelopment

13 Morecomprehensiveguidanceontheallocationofsensitivitylevelsisgivenon thePlanningAdviceforDevelopmentsnearHazardousInstallationswebsite (www.hse.gov.uk/landuseplanning/padhi.pdf).

30

HistoryoftheconsultationdistancearoundtheBuncefieldsite 14 HSEhashadarrangementswithlocalplanningauthoritiesforconsultation arounddevelopmentsinthevicinityofmajorhazardssincetheearly1970s, althoughitwasnotuntiltheimplementationoftheNotificationofInstallations HandlingHazardousSubstancesRegulations1982(NIHHSRegulations)in1983 thatHSEfirstreceivednotificationfromShellMexandBPoftheterminalasa majorhazard.Agenericnonsitespecificconsultationdistanceof250mfromthe boundaryofthesitewassetforconsultationpurposesandtherelevantlocal planningauthoritywasnotified.Atthattimeitwascustomarytoissueageneric consultationdistancewithoutperformingasitespecificassessment.This consultationdistancewasbasedupontheassumptionthatthemainhazardwas fromthermalradiationfollowingamajorfirewithinthebund. 15 In1992thesiteexpandedandMobilandShellsentanothernotificationand applicationforconsenttostorecertainamountsofflammablematerial.The existingconsultationdistancewasmaintainedatageneric250mfromthesite boundary.Therearenorecordsofthetechnicalassessmentsthatwereperformed whenthelocalplanningauthoritysoughtadviceondevelopmentswithinthe vicinityofthesite,butearlyassessmentswerebasedthen,asnow,uponapoolfire followinglossofcontainmentofasubstantialquantityofflammableliquid. However,fortanksthatwerebundedtherewasacontinuingassumptionthatany subsequentfirewouldbewithintheconfinesofthebund. 16 In1996asitespecificreassessmentwasperformedbaseduponconsented amountsofflammablematerial,andtheconsultationdistancewasreducedfrom 250mto190m.Theoriginal250mwassetintheearlydaysofHSEgivingland useplanningadvice,toensurethatalldevelopmentsthatmightbeadvisedagainst wouldbesubjecttoconsultation.By1996,technicalpolicyandmethodologyhad beenreviewed.Inaddition,threezonemapswerenowbeingproducedsothat developmentcontroladvicecouldbegivenmorequicklyandefficiently.Thenew policyassumedthatthebundwouldnotbeabletocontainthefullcontentsofa tankfollowingasudden,catastrophicfailure.Itwasassumedthatthebund wouldbeovertoppedandtheresultingpoolfirewouldextendbeyondthe confinesofthebund. 17 InJuly2001anotherconsultationdistancewascalculatedduetoanextensive reassessmentofthehazardsfromthesitefollowingthesubmissionofabatchof newconsentapplicationsfromtheoilcompanies.Theregulationsrequiring consenttostoreflammablesubstanceswerechangedin1999toincludeadditional flammablematerials.Theconsultationdistancewasreducedfrom190mto185m. Thiswasunchangedfollowingafurtherconsentapplicationon8July2005from BP.Thepresenceoftheadditionalmaterialdidnotalterthemainbasisofthe calculationwhichassumedtheworstcaseeventwasthecatastrophicfailureofthe largesttankcontaininggasoline.Theconsultationdistancewasreducedslightly owingtoaslightchangetotheinputsinthemodelusedtoperformthe calculations.SeeFigure7forarepresentativeplanofthesiteshowingthe consultationdistancesinceJuly2001.

31

Figure5 Developmentswithin3kmoftheBuncefieldsitebetween1966and2005 32

Somedetailsofhazardoussubstancesconsentsissuedforthe Buncefieldoilstorageandtransferdepot
Operator TexacoLimited MobilOilCoLimited HertfordshireOil StorageLimited HazardousSubstancesConsentapplications 19September1983*: 10571tonnesmotorspirit 8November1983*: 17650tonnespetrol 30November1992:34020tonnesmotorspirit 18October1999:15314tonneskerosene BPOilUKLimited 18November1992:17650tonnesgasolineinnameof MobilOilCoLimited 26October1999:15080tonnesautomotivepetrolandother petroleumspirits 21October2003:15200tonnesautomotivepetroland 10522tonnespetroleumproductsclassifiedasdangerousfor theenvironment(mostlikelytobegasolineordiesel) 3 May2005:26900tonnesautomotivepetroland 10522tonnespetroleumproductsclassifiedasdangerousfor theenvironment(mostlikelytobegasolineordiesel) BritishPipeline AgencyLimited ShellUKOilLimited 26October1999:70000tonnesautomotivepetrolandother petroleumspirits 19September1983*:37397tonnesHFLsClass4and 42561tonneskeroseneandwhiteoils 30November1992:34013tonnespetroleumspiritand 39000tonnesdiesel,gasoilandkerosene 1999:33000tonnesmotorspiritand17000tonneskerosene Figure6 Hazardous substancesconsentsissued

* Note:Thefirstapplicationsforconsentwerein1992,beforethendifferentarrangementswerein place,iethesewerenotificationsunderNIHHSandconsentwasnotrequired.

33

34

Figure7 Planrepresentingthehazardoussubstancesconsentsandconsultationareaaround theBuncefielddepotsinceJuly2001(forillustrationonly)

Annex 4

UKpetroleumrefinery,pipelineandstoragesystem
Refineries 1 PetroleumproductsintheUKarepredominantlysuppliedfromninerefineries wherecrudeoilisrefinedintoliquefiedpetroleumgas(LPG),petrol,diesel, aviationfuel,gasoil,heatingoilandresidualbitumen.Fromatypicalbarrelof NorthSeacrudeoil,approximately3%becomesLPG,37%petrol,25%diesel, 20%kerosene(aviationfuel/heatingoil)and12%fueloil(forpowergeneration). Figure8showsthelocationoftherefineries.Theyaresitedonthecoastoron estuariessothattheycanreceivecrudeoilbyship.

Figure8 UKoilrefinery andpipelinenetwork 35

2 Storing,movinganddeliveringthesefuelstotheenduserareimportant elementsoftheUKeconomy.Eachyearapproximately75milliontonnesof petroleumproductsaremovedaroundtheUK. 3 AllninemainrefineriesintheUKhavesubstantialstorageforfinishedproducts comingoutoftherefinery.However,giventhelocationofrefineries,therearealso largestorageterminalsaroundthecountry,generallynearmajorconurbations. Theseterminalsaremainlysuppliedfromtherefineriesbypipeline,railandsea. Oftentheyarerunasjointventuresbetweenanumberofoilcompanies. Commercialarrangementsarecommonlynegotiatedbetweencompaniestodraw productsonexchangefromanothercompanysterminal.Thisavoidstheneedto transportproductsoverlongdistancesfromoneterminaltoanother.Figure9shows theplaceofoilstorageandtransferdepotsintheUKoildistributionsystem.

Figure9 TheUKoil distributionsystem

Petroleumpipelines 4 TheUKmainlandhasanetworkofapproximately1500milesofpetroleum pipelines.Someofthemareownedbyindividualoilcompaniesdedicatedtosupplying theirownterminals,andsomeareownedbyjointventuressuchasUnitedKingdom OilPipelinesLimited(UKOP).OthersbelongtotheGovernment.Onceinstalled, undergroundpipelinesoffersubstantialenvironmentalandsafetybenefits,notleast fromtheeliminationofroadtankerjourneysortransportationbyrailorsea. 5 Thesepipelinesareusedtotransportavarietyoffuels,includingpetrol,diesel, heatingoilandaviationfuel.Afterabatchofpredeterminedvolumeofonefuelhas beendeliveredthroughthepipeline,adifferentfuelmaybetransported.Asthefuels travelalongthepipeline,arelativelysmalldegreeofmixingwilloccuratthe interface.Asthisvolumeofmixedfuelshastobereprocessed,thepipelineoperator managestheflowratescontinuallytominimisetheseinterfacestoreducewastage. Around30milliontonnesoffuelaremovedaroundtheUKinthiswayinayear.

36

Annex5

IncidentsthathavesimilaritieswiththeBuncefieldincident
Location 1 Houston, Texas,USA Dateandtime April1962 Commentsbackground Severeleakfromagasolinetank. Almostwindlessconditions. Ignitionnearadjacenthighway. Overfillingofashipwithgasoline. Commentsexplosion Describedasablast,butno detailsareavailable. Ref
seeover

2 Baytown,Texas, USA

27January1977

Fewdetailsareavailable,butitis likelythattherewouldhavebeen congestion. Relativelyuncongestedarea.High overpressuresreported,butnot quantified.Threeminorexplosions precededthemainblast.

3 Texaco,Newark, NewJersey,USA

7 January1983 After00.00hrs

Overfillingofatankcontaining unleadedgasoline.114379m3 (80265tonnes)ofgasoline released.Slightwind,ignition source300maway. Overfillingofatankcontaining unleadedgasoline.700tonnes escaped.Lowwindspeed(2m/s).

4 NaplesHarbour, Italy

21December 1985

Relativelycongestedarea.Thetank 3 overtopped1.5hoursbefore ignition.Variousoverpressures estimatedfromdamageanalysis, buttheyareminimumvalues (eg>48kPa). Presenceofparkedpetroltankers mayhavebeensufficientto generateturbulence.High overpressuresproduced,butnot quantified. Highoverpressureproduced,but notquantified. 4

5 StHerblain, France

7 October1991 04:00hours

Leakofgasolinefromatransfer lineintoabund.Wind<1m/s.20 minutesdelay,ignitionincarpark c.50maway.Volumeof flammablecloudest.23000m3. Overfillingofatankcontaining unleadedgasoline.50000gallons (190m3, 132tonnes)released. Overfillingofagasolinetank. Fewdetails.

6 Jacksonville, Florida,USA

2 January1993 03:15hours

7 LaemChabang, Thailand

2 December1999 23:25hours

Highoverpressureproduced,but notquantified.Relativelylow congestioninthearea.

Note: Therootcauseofeachoftheaboveincidentswasthespillage(lossofcontainment) ofalargequantityofgasoline(eg>100tonnes)duetooverfillingofatank,orfailureof pipeworkinsideabund.Ineachcase,thewindspeedwasverylow,orzero,andasignificant vapourcloudwasabletoform.ThefeatureoftheBuncefieldexplosionthatappeared uniquewastheapparentlackofobstacleswhichcouldinduceturbulenceandtherebylead torapidflamepropagation,sufficienttoproducethehighoverpressuresrecorded. Accordingly,incidents2,4and5maynotberelevant.Asthelackofconfinementcannot bequantified,therelevanceoftheotherincidentsmightbesuperficial.Moreinformationis required.Workisinhandtoidentifyotherincidentsthatmayberelevant. 37

References
1 LenoirEMandDavenportJAAsurveyofVaporCloudExplosions:Second UpdateProcessSafetyProgress 199312 (1)1232 2 BouchardJKGasolineStorageTankExplosionandFire:NewarkNJ January7,1983 NationalFireProtectionAssociation(NFPA)Summary InvestigationReport(incooperationwithFederalEmergencyManagement Agency/UnitedStatesFireAdministrationandNationalBureauof Standards/CenterforFireResearch) 3 MaremontiM,RussoG,SalzanoEetalPostaccidentAnalysisofVapour CloudExplosionsInFuelStorageAreas TransIChemE 199977(B)360365 4 LechaudelJFandMouilleauYAssessmentofanaccidentalvapourcloud explosion.Acasestudy:SaintHerblain,Octoberthe7th1991,FRANCELoss PreventionandSafetyPromotionintheProcessIndustries 19951377388 5 EditedfromareportpreparedbyLtLorinLMock,TrainingDivision, JacksonvilleFireandRescueDepartmentCoveredFloaterinJacksonville: SteuartPetroleumBulkStorageTankFireIndustrialFireSafety May/June19931732 6 THAIOILFire:Awhiffofoil,thenathunderingexplosion WitnessAccounts, BangkokPost(FBKP)5December1999Page1

38

Annex6

Fireandexplosionhazardsfrompetrol
Introduction 1 Thisannexsetsoutageneralexplanationofthefireandexplosionhazards fromfuelssuchaspetrol,ascurrentlyunderstood.Itisnotlimitedtothe circumstancesoftheBuncefieldincident. Flashpoint 2 Thephysicalpropertiesofhighlyflammableliquids,suchaspetrol,aresuch thatiftheyaremishandledorreleasedtheypresentasignificantriskoffireor explosion.Inthiscontext,perhapsthemostimportantpropertyofpetrolisitshigh volatility.Atnormalambienttemperatures,thevapourreleasedbysimple evaporationfromthefuelsurfacecanreadilybeignitedasitmixeswithair.Itis classifiedlegallyasaHighlyFlammableLiquid,ieithasaflashpoint(measuredin a closedcupapparatus)below32oC. 3 Flashpointisusedtodefinethehazardassociatedwithliquidfuelsandto helpdeterminesafeworkingconditions.Theflashpointisdefinedastheminimum temperatureatwhichaliquidfuelproducessufficientvapourtoformaflammable orignitablemixturewithair.Petrolhasaflashpointofaroundminus40oC,well belownormal(ambient)temperatures,andcanbeignitedveryeasily.Itisthe vapourthatburns,releasingheat,someofwhichistransferredtothesurfaceof thefuel,thusincreasingtherateofevaporationthatsuppliestheflamewithfuel vapour. Paragraph7ofthisannexprovidesmoreinformationaboutfuelfires. 4 Notallconcentrationsoffuelvapourinairareflammable,iecapableofbeing ignitedbyasmallignitionsourcesuchasasparkoraflame.Ignitioncanonly occurifthemixtureofflammablevapourinairfallswithincertainconcentrations, knownasthelowerandupperexplosion(orflammability)limits.Forpetrol vapour,concentrationsbelow1.4%inairaretooleantoburn,whilethoseabove 7.6%aretoorich.18 Atallconcentrationsbetweenthesetwolimits,knownasthe flammablerange,themixtureswillburn,inthataflamewillpropagateawayfrom theignitionsource. 5 Theflashpointandtheflammablerangearedeterminedbystandardtestmethods.

6 Whetheranignitioncangiverisetoafire,anexplosionoracombinationof bothdependsonanumberoffactors,includingtheconditionsprevailingatthe timeandtheimmediatesurroundingsoftherelease,butparticularlyontheamount ofvapourpresentandhowitisabletomixordiffusewithair. Fires 7 Inafire,thevapourevolvedfromspiltorreleasedmaterialisignitedand continuestoburnabovethefuelsurfacewherethevapourmixeswiththe surroundingair.Thistypeofflameisknownasadiffusionflameasthefuelvapour

18

Theconcentrationofpetrolvapourinapartiallyfullpetroltankisabovetheupper explosivelimitandthereforetoorichtooburn.

39

andairmixbydiffusion,anditisthetypeofflameassociatedwithfiresinvolving liquidandsolidfuels.Heattransferredfromtheflametothefuelprovidesthe energyrequiredtomaintaintheflowoffuelvapoursthatsupporttheflame.The flamesassociatedwithaliquidpoolfirewillcompletelycoverthesurfaceandwill continuetoburnaslongasthereisfuelremaining.Theflamesofapetrolpoolfire willextinguishwhenallthepetrolisconsumed,orifaircanbeexcludedfromthe flames,orifthevapourreleasecanbepreventedorinhibited(ashappenswhenthe liquidsurfaceiscompletelycoveredwithalayeroffirefightingfoam). 8 WithlargehydrocarbonpoolfiressuchasthoseatBuncefield,theflamesare solargethatmixingoffuelvapourandairisnotefficient.Thisleadstothe formationofspecieswithintheflamethatcausethereleaseofcopiousamountsof blacksmoke.Theimmediateprecursorsofthesmokeareminutesootparticles whichradiate,producingthecharacteristicyellowcolourassociatedwithalmostall diffusionflames.Thehazardsarisingfromsuchfiresareduetoheattransferby radiationtoneighbouringsurfacesandtothehotfireproducts(richinsmokeand toxicgases)carriedaloftbybuoyancy.Pressureeffectsarenegligibleandcouldnot causestructuraldamage,butheattransfertostructuresimmersedintheflameswill causeweakeningandeventualcollapse. Explosions 9 Foranexplosioninvolvingpetrolvapourtooccur,thevapour/airmixturemust bewithinitsflammablerangewhenitencountersapotentialsourceofignition. A flamewillpropagaterapidly,spreadingsphericallyfromtheignitionsource throughouttheentireflammablemixture.Theheatreleasedasthefuelis consumedcausesthegasestoexpandasaresultoftheassociatedtemperaturerise. Ifconfined,egifthemixtureiscontainedwithinabuilding,thegasescannot expandfreelyandthepressurewillriseuntilpartsoftheconfiningstructure(such asthewindowsofabuilding)failandrelievethepressure.Thisisnormallya violenteventandmayproduceashockwavethatcancauseremotedamage. 10 Hightemperatureeffectsfromtheexplosionaretransient,buttheywillignite highlyflammableliquidsandcanignitelightweightcombustiblesolids(egtissue paper).Somecanbeleftburningaftertheexplosionhaspassed.Theflamecreated byanexplosionofpetrolvapourinairisblueorverypaleyellow,dependingon thefuel/airmixture.Itisknownasapremixedflameasthefuelvapourandairare mixedbeforeignitionoccurs.Theamountofsmokeproducedisnegligible comparedtothatproducedinafire. 11 Ingeneralterms,overpressuresarenotdevelopedifanunconfinedpetrol vapour/airmixtureisignitedbecausethegasescanexpandfreely.However,the speedatwhichtheflametravelsthroughtheflammablemixturecanvary considerably,dependingonanumberofdifferentfactors.Iftheflamespeedisvery high,someoverpressurewillbecreatedastheexpansioncannotoccurrapidly enough,despitethe(apparent)lackofconfinement.Factorsthataffectthespeed withwhichaflamewilltravelthroughaflammablemixtureinclude:

compositionofthemixture; amountofvapourandsizeoftheflammablecloud; strengthoftheignitionsource; degreeofconfinementwithintheflammablecloud(partialconfinement); turbulencecreatedwithinthemixtureastheflamefrontforcestheunburnt mixturethroughapartiallyconfinedspace.

40

12 Thetermpartialconfinementisusedtodescribeasituationinwhich obstacleslieinthepathoftheadvancingflame.Asthe(asyet)unburntmixtureis forcedpasttheseobstacles,turbulenceisproduced.Theflamewilltravelmuch morerapidlythroughaturbulentmixturethanthroughaquiescentone. 13 Theflamespeedmayvaryfromafewmetrespersecond(m/s)tosonic velocities(340m/s).Undercertainconditions,supersonicvelocitiesmaybe reached.Ifthevelocityissubsonicthepropagatingflameistermedadeflagration. Iftheflamespeedisgreaterthanthespeedofsoundtheexplosionistermeda detonation.Thefasteraflametravels,thegreatertheoverpressureproduced.A cloudofpetrolvapourintheopenwithoutanyturbulencecreatingobstructions, suchascomplexpiperacksorcongestedplant,wouldonignitionproducea deflagrationwitharelativelyslowflamespeed(eg10m/s).Suchaneventwould giverisetooverpressuresofabout0.2psi(14mbar).Foraflametoaccelerate beyondthisandcreatehigheroverpressures,someorallofthefactorsmentioned abovewouldhavetoplayapart.Aflamewouldnotacceleratetodetonation unlessitwasconfinedinalongnarrowstructuresuchasapipeline. 14 Asindicatedabove,ifaflammablemixtureisignitedwithinanitemof enclosedplantorequipment,thepressurewillbuildupuntiltheplanteitherfails orapurposebuiltventorexplosionreliefpanelopens.Storagetanks,forexample, arenormallydesignedwithaweakroofjointsothatintheeventofaninternal explosion,theexplosiveforcesareventedupwardswithouttherestofthetank failing.Withoutanyventing,andprovidedthattheitemofplantdoesnotfail,an internaldeflagrationfromhydrocarbonvapourscouldtheoreticallygivea maximumpressureriseofapproximately130psi(8.9bar). Flashfires 15 Aflashfirecanoccurifavapourrichcloudspreadsfromitsreleasepoint, undergoingsomedilutionattheinterfacebetweenthecloudandthesurrounding airsothataflammablemixture existsonlyattheinterface.Thecloudstillhasa fuelrichcore.Uponignitiontheflamefrontwillrapidlypropagatethroughthe flammableregionsofthecloudandthefuelrichregionwillburnmoreslowlyasit mixeswithair.Theflameswilleventuallybecomeestablishedasanordinary diffusionflameatthepointoforigin.Flashfiresdonotusuallygenerateany appreciableoverpressureeffects. Overpressure 16 Thepressurewavecreatedbyanexplosioncanhaveaneffectonpeople,plant orproperty,inadditiontotheharmfuleffectsfromtheburningvapour.The greatesteffectsfromthepressurewavewillbeattheclosestpointtotheexplosion. Previousworktocategorisethedamagefromblastoverpressurehasmainly consideredtheeffectsfromconventionalexplosivesandnuclearbombtests,rather thanthetypeofincidentthatoccurredatBuncefield.Explosionsareoften classifiedaccordingtotheirTNTequivalent,withanefficiencyfactorusedto compensateforthelowerefficiencyofanignitingvapourcloudinconverting chemicalenergyintoblastenergy. 17 Anotherdifferenceisthattheblastfromaconventionalexplosivehasahigh peakpressureoverashortperiodoftime,whencomparedtoahydrocarboncloud whichgeneratesalowerpeakpressurebutoflongerduration.Thelongerduration createsahigherimpulseandthereforeadifferentdamagingeffectthanthesame energyreleasefromahighexplosive.Afurtherproblemwithusingthis informationtoanalysevapourcloudexplosioneventsisthefactthatconventional explosiveshaveapointsource,whereasavapourcloudoccupiesalargevolume.
41

18 Thefollowingtablelistscommonlyaccepteddamagefiguresfromblast overpressureandcanbeusedforcomparativepurposes.However,carehastobe takeninusingthisdataasitdoesnottakeintoaccountthedurationofthe pressurewave. Commonlyaccepteddamagefiguresfromblastoverpressure Pressure (psi) 0.02 0.10 0.15 0.30 0.40 0.51.0 Pressure (millibar) 1.4 7 10 21 28 3470 Damage

Annoyingnoise,ifoflowfrequency Breakageofsmallwindowsunderstrain Typicalpressureforglassfailure Damagetosomeceilings Minorstructuraldamage Largeandsmallwindowsshattered,damageto windowframes Minordamagetohouses,2050%oftilesdisplaced Roofdamagetooilstoragetanks Housesmadeuninhabitable Asbestoscladdingshattered,fasteningsofcorrugated steelpanelsfail,tiledroofliftedanddisplaced Partialcollapseofwallsandroofsofhouses,30%of treesblowndown 90%oftreesblowndown,steelframedbuildings distortedandpulledawayfromfoundations Ruptureofoiltanks Severedisplacementofmotorvehicles Woodenutilitypolessnapped Collapseofsteelgirderframedbuildings Brickwallscompletelydemolished Completedestructionofallunreinforcedbuildings Collapseofheavymasonryorconcretebridges

0.75 0.9 1.0 1.02.0

52 63 70 70140

2.0

140

3.0

210

3.04.0 4.05.0 5.0 7.09.0 8.010 >10 70

210280 280350 350 490630 560700 >700 4900

Source:HSESpecialistInspectorReportNumber37Simplifiedcalculationsofblast inducedinjuriesanddamage

42

Commonlyacceptedfiguresfordirectharmtopeoplefromblastoverpressure Pressure (psi) 2 1.52.9 1015 1215 3034 Pressure (millibar) 138 103200 6901035 8301035 Directharmtopeople

Thresholdforeardrumrupture Peopleknockeddownorthrowntotheground 90%probabilityofeardrumrupture Thresholdoflunghaemorrhage

20682400 Near100%fatalityfromlunghaemorrhage

19 HSEusesthefollowinglevelsofoverpressureforprovidinglanduseplanning advicearoundhazardousinstallations.Thesearebasedonestimatesoffatalities withinoccupiedbuildings. Pressure (psi) 8.6 2 1 Pressure (millibar) 600 140 70 Directharmtopeople

50%fatalitiesforanormalpopulation Thresholdoffatality(15%)foranormalpopulation Thresholdoffatality(15%)foravulnerable population

43

Annex7

ProductcompositionatBuncefield
1 ExtensivesamplingofthevariouspetroleumproductsattheBuncefielddepot hasbeencarriedouttoverifytheproductdistributionthroughthesitefromthe differentsupplypipelines,andalsotoidentifythecompositionofthereleased materials.ThemajorityofthesamplesweretakenfromtheHertfordshireOil StorageLimitedsitebutsampleswerealsotakenfromthetwopipelinesfeeding unleadedpetroltothesite,theUnitedKingdomOilPipelinesLimitedT/Kpipeline andtheFinaLinepipelinefromtheLindseyrefinery. 2 Asareleaseofunleadedpetrolisconsideredtobetheinitiatingeventforthe explosionandsubsequentfire,allpetrolsampleshavebeentestedagainstthe standardBSEN228forautomotivefuels,togetherwithafullchemicalanalysisby anindependentaccreditedtesthouse.19 Samplesofotherproductshandledonsite includingdiesel,aviationfuelandgasoilhavebeensubjecttosimplelaboratory teststoconfirmtheiridentity. Productidentification 3 Thetestresultsfromthesamplestakenonsiteareconsistentwiththeproduct typeidentifiedfromthesiteplansorbythecompanyasbeingcontainedorheld withinanyparticularplantorsectionofpipework.Manyofthesamplesshowed degradationorcontaminationcausedbyheatdamagedplantoropenpipeworkas a resultoftheincident.Thisdegradationisparticularlynoticeablebythelossof themorevolatilecomponents,includingbutane,frommanyofthesamples. 4 Thelossofvolatilecomponentsfromthesampleshasmadeadirect comparisonoftheiranalyticalresultsandsubsequenttrackingofthedifferent productsourcesthroughthesiteextremelydifficult.Inadditionrepresentative samplesfromTank912aftertheincidentarenotavailableasthistankcompletely burntout,andonlyfiredamagedresiduesconsistingmainlyofwatercouldbe extractedfromthetankbottom.ThesamplesofthematerialfeedingTank912, takenbytheoperatorpriortotheincidentandretainedonsite,weredestroyed duringtheincident. Productcomposition 5 TheevidencetodateisconsistentwiththereleaseofpetrolfromTank912 whileitwasbeingfedfromtheBritishPipelineAgencyLimitedmanifold.Petrolis a blendofmanydifferenthydrocarbons,eachofwhichwillhaveanimpactonthe vapourpressure.TheBritishPipelineAgencyLimitedmanifoldfeedingTank912 wasbeingsuppliedbyaparcelofunleadedpetrolfromtheBritishPetroleumPLC oilrefineryatCoryton,Essex.Thatinturnwasmadeupfromthefeedfromfour separatetanks.Nosampleoftheparcelisavailableasthepartbatchesfromthe feedertanksarenotblendedandtestedasacompositebatchbeforebeingpumped fromsite.BritishPetroleumPLChasprovidedtheConformityCertificatesforthe individualfeedertanksshowingtheiranalysisagainsttheBritishStandard.The BritishStandardisaperformancespecificationandonlydetailsspecificlimitsfor

19

44

BSEN228:2004Automotivefuels.Unleadedpetrol.Requirementsandtestmethods. Availableonlineatwww.bsonline.bsiglobal.com.

thechemicalsleadandbenzene.Bywayofexample,thestandarddoesnot specificallylimitthecontentofbutane,whichcomprisesamixtureofbutanesand butenes,andthereforethepresenceandlevelsoftheseindividualcomponentsare not routinelydetermined.Thetotalbutanecontent,however,willaffectthevapour pressureandthisisspecifiedinthestandarddependingonwhethertheproductis marketedaswinterorsummergrade.Forwintergradepetrolthevapourpressure limitsaredefinedas70100kPaandforsummertheyarereducedto4570kPa. 6 TheConformityCertificatesshowthatthevapourpressureforthefourpart batcheswereallatorverycloseto100kPa.Thiswascorroboratedbyevidence obtainedfromtheBritishPipelineAgencyLimitedsiteaftertheincident.This correspondedtoatotalbutanecontentof10.0%.Bycontrast,othersamplesof petroltakenfromthesiteaftertheincidentandwhichhadbeendegradedby exposuretothefirewerefoundtohavelowervapourpressuresand correspondinglylowerbutanelevels.Thereforetheproductreleasedonsitewasat thetopendofthewintergradelimitforvapourpressure.Areasonableestimateof thebutanecontentofthereleasedmaterialis10%byweight.

45

Annex8

Regulatoryframeworkforhighhazardsites
1 TheregulatoryframeworkforsitessuchasBuncefield,whichpresentpotential majoraccidenthazards,comprisesrequirementsimposedonthesiteoperators underbothhealthandsafetyandenvironmentallegislation,complementedbythe requirementsofplanninglaw.Inparticular,theControlofMajorAccident HazardsRegulations1999(COMAH)apply. Healthandsafetylaw 2 Operatorsintheprocessindustriesaresubjecttotherequirementsofthe HealthandSafetyatWorketcAct1974(theHSWAct)andtheManagementof HealthandSafetyatWorkRegulations1999whichrequire,respectively,safety policiesandriskassessmentscoveringthewholerangeofhealthandsafetyrisks. ControlofMajorAccidentHazardsRegulations1999(COMAH) 3 COMAHsmainaimistopreventandmitigatetheeffectsofthosemajor accidentsinvolvingdangeroussubstances,suchaschlorine,liquefiedpetroleumgas andexplosiveswhichcancauseseriousdamage/harmtopeopleand/orthe environment.TheCOMAHRegulationstreatriskstotheenvironmentasseriously asthosetopeople.Theyapplywherethresholdquantitiesofdangeroussubstances identifiedintheRegulationsarekeptorused.Therearetwothresholds,knownas lowertierandtoptier.TherequirementsofCOMAHarefullyexplainedinThe requirementsofCOMAHarefullyexplainedinA guidetotheControlofMajor AccidentHazardsRegulations1999(COMAH).GuidanceonRegulations L111 HSEBooks1999ISBN0717616045. 4 TheCOMAHRegulationsareenforcedbyajointCompetentAuthority comprisingHSEandtheEnvironmentAgencyinEnglandandWales,andHSEand theScottishEnvironmentProtectionAgency(SEPA)inScotland.Operatorswill generallyreceiveasingleresponsefromtheCompetentAuthorityonallmattersto dowithCOMAH.TheCompetentAuthorityoperatestoaMemorandumof Understanding,whichsetsoutarrangementsforjointworking. 5 TheCOMAHRegulationsrequireoperatorsoftoptiersitestosubmitwritten safetyreportstotheCompetentAuthoritywiththepurpose,amongothers,of demonstratingthatmajoraccidenthazardshavebeenidentifiedandthatthe necessarymeasureshavebeentakenbothtopreventsuchaccidentsandtolimit anyconsequences.Operatorsoftoptiersitesmustalsoprepareadequate emergencyplanstodealwiththeonsiteconsequencesofpossiblemajoraccidents, andtoassistwithoffsitemitigation.Localauthoritiesforareascontainingtoptier sitesmustprepareadequateemergencyplanstodealwiththeoffsiteconsequences ofpossiblemajoraccidents,basedoninformationsuppliedbysiteoperators. 6 TheCOMAHRegulationsplacedutiesontheCompetentAuthoritytohavein placeasystemofinspectionsforestablishmentssubjecttotheRegulations,andto prohibittheoperationofanestablishmentifthereisevidencethatmeasurestaken forpreventionandmitigationofmajoraccidentsareseriouslydeficient.The CompetentAuthorityalsohastoexaminesafetyreportsandinformoperators abouttheconclusionsofitsexaminationswithinareasonabletimeperiod.
46

7 Theinspectionplanforaparticularestablishmentisdrawnupbyinspectors fromtheCompetentAuthoritybasedonpreviousinterventionsatthesiteandon informationgainedfromtheassessmentofthesafetyreport.Theinspection programmerequiresinputfromarangeofinspectorswithspecialistknowledgeand identifiesandprioritisesissues.Thefocusoftheprogrammeistoensurethatthekey riskcontrolmeasuresforpreventingandmitigatingmajorhazardsaremaintained. 8 TheadequacyofthisprocessanditsapplicationatBuncefieldbyHSEand EnvironmentAgencyinspectorsissubjecttoareviewundertermofreference3. Environmentallegislation 9 SomeoftheestablishmentsregulatedundertheCOMAHRegulationsarealso regulatedbytheEnvironmentAgencyandSEPA(theAgencies)underthePollution PreventionandControlAct1999(PPC)orPartIoftheEnvironmentalProtection Act1990(EPA90).TheregimeunderEPA90isgraduallybeingreplacedbythe PPCregimeandwillbefullyreplacedby2007. 10 WhilethepurposeoftheCOMAHRegulations(thepreventionofmajor accidents)differsfromthatofPPC,themeanstoachievethemarealmostidentical. Theyrequireindustrytohavegoodmanagementsystemstocontrolrisk.PPC includesaspecificdutytopreventandmitigateaccidentstotheenvironmentwhich iscomplementarytothemainCOMAHduty.TheAgenciesmanagethisoverlap betweentheirdifferentregimesfollowingtheprinciplethataccidentprevention workonCOMAHsitesisgenerallymore significantbecauseofthegreaterrisks. Supportingguidanceandstandards 11 Thelegalrequirementsaresupportedbyalargebodyofguidanceand standardsthatsetoutrecognisedgoodpracticeinthecontrolofmajoraccident hazards.Thisincludesnationalandinternationalstandards,industryguidanceand guidancepublishedbytheCompetentAuthority. Examplesofthelatterare Reducingerrorandinfluencingbehaviour HSG48(Secondedition)HSEBooks 1999ISBN0717624528andSuccessfulhealthandsafetymanagement HSG65 (Secondedition)HSEBooks1997ISBN0717612767. Landuseplanning 12 ThelanduseplanningaspectsoftheSevesoIIDirectivearegiveneffectinthe UKbythePlanning(HazardousSubstances)Regulations1992,asamendedin 1999.UndertheseRegulationsthepresenceofhazardouschemicalsabovespecified thresholdsrequiresconsentfromthehazardoussubstancesauthority,usuallythe localplanningauthority.HSEisastatutoryconsulteeonsuchoccasions.Therole ofHSEistoconsiderthehazardsandriskswhichwouldbepresentedbythe hazardoussubstancestopeopleinthevicinity,andonthebasisofthisadvisethe hazardoussubstancesauthoritywhetherornotconsentshouldbegranted.HSE willalsosupplyaconsultationdistancearoundthesite.Anyfuturedevelopments inthesezonesrequireHSEtobeconsulted. 13 Theaimofhealthandsafetyadvicerelatingtolanduseplanningistomitigate theeffectsofamajoraccidentonthepopulationinthevicinityofhazardous installations,byfollowingaconsistentandsystematicapproachinproviding adviceonapplicationsforplanningpermissionaroundsuchsites. 14 Historically,HSEhasbaseditslanduseplanningadviceonthepresumption thatsiteoperatorsareinfullcompliancewiththeHSWAct.Section2oftheAct placesadutyonanemployertoensure,sofarasisreasonablypracticable,the
47

healthandsafetyofhisemployees.Thereisacorrespondingdutyinsection3to ensure,sofarasisreasonablypracticable,thatothers(includingthepublic)arenot exposedtoriskstotheirhealthandsafety.Thesedutiesaregoalsettingand operatorsareexpectedtodeterminethemostappropriatemeanstocomplywith them,withouttheneedfordetailedapprovalfromHSE. 15 UndertheGeneralDevelopmentProcedureOrder1995,bothHSEandthe EnvironmentAgencyarestatutoryconsulteesfor:

thedevelopmentofanewmajoraccidenthazardsite;or developmentsonanexistingsitewhichcouldhavesignificantrepercussionson majoraccidenthazards;or otherdevelopmentsinthevicinityofexistingestablishments,wherethesiting ordevelopmentissuchastoincreasetheriskorconsequencesofamajor accident.

48

Annex9

Regulationofperfluorooctanesulphonates(PFOS)
1 Perfluorochemicalsareafamilyofchemicalsusedinproductsdesignedtorepel dirt,greaseandwater,includingkitchenware,carpettreatments,foodwrappers, spraysforleatherandotherclothing,paintsandcleaningproducts. 2 Agroupofthesesubstances,perfluorooctanesulphonates(collectively identifiedasPFOS),hasbeenshowntobehazardous(persistent,bioaccumulative andtoxic).PFOShasbeenusedinadiverserangeofapplications,fromfire fightingfoamadditivestouseasamistsuppressantinchromiumplating.PFOS wasalsousedincommonhouseholdantisoiltreatmentsoftenreferredtobythe tradenameScotchgard(atrademarkof3MPLC). 3 TheUKCommitteeonToxicityofChemicalsinFood,ConsumerProductsand theEnvironment(COT),anindependentscientificcommitteethatprovidesadvice totheFoodStandardsAgency,theDepartmentofHealthandotherGovernment DepartmentsandAgenciesonmattersconcerningthetoxicityofchemicalsis currentlyevaluatingPFOS,mostrecentlyinMay2006.20 4 OnthebasisofthepreliminaryCOTdiscussions,theHealthProtectionAgency advisedtheDrinkingWaterInspectorateinMarch2006that,Itappearsunlikely thatalifetimesconsumptionofdrinkingwatercontainingconcentrationsupto threemicrogrammes(ofPFOS)perlitrewouldharmhumanhealthandthat drinkingwaterconcentrationsofPFOSshouldnotexceedthreemicrogrammes perlitre.TheHealthProtectionAgencywillreviewitsadvicewhenCOThas finaliseditsassessmentofPFOS. 5 InthelightofcurrentHealthProtectionAgencyadvice,theDrinkingWater Inspectoratesview(29March2006)isthattosafeguardhumanhealth,PFOSshould notbepresentindrinkingwatersuppliesabovethreemicrogrammes/litre(g/l). 6 PFOSdoesnotappeartoundergoanydegradationinthenaturalenvironment. Duetothisextremestabilityithasnowbecomewidespreadbothinmanandthe environment.ThebiologicalpersistenceofPFOSinlivingorganismsishigh,with anestimatedeliminationhalflifeforhumansoftheorderoffourtoeightyears. 7 TheseconcernsresultedintheprincipalmanufacturerofPFOS(3M)announcing a voluntaryphaseoutofPFOSmanufacturefrom2001onwards.PFOS,however, continuestobeproducedbysomecompaniesandisusedinsomeindustrial processes,forexamplesemiconductorproductionandchromiumplating.PFOSwas usedasaningredientinsomeAFFFClassBfirefightingfoamconcentratesuntila fewyearsago.Theseconcentrateshaveashelflifeofatleasttenyearsandremaining stockswillthereforecontinuetobeavailableforuseonoilfires. 8 DEFRAconsultedonanationalactiontorestricttheuseofPFOSand substancesthatmaydegradetoPFOSinOctober2004.Thisincludedproposalsto phaseouttheuseofPFOSinfirefightingfoams.InDecember2005,theEuropean CommissionissuedaproposalforaDirectiverestrictingthemarketinganduseof PFOS.InthisdraftDirectivePFOSusedinfirefightingfoamsaswellas

20

TheCOTminutesandbackgroundworkingpaperareavailablefrom www.food.gov.uk/science/ouradvisors/toxicity/cotmeets/cot2006/334454.

49

photolithography,photographiccoats,chromiumplatingandhydraulicfluidsfor aviationwouldbeallowedtocontinue. 9 TheEnvironmentAgencyhasconductedanationalenvironmentalrisk assessmentofPFOS.21 Thisconcludedthattherewasanenvironmentalriskforall PFOSuses.Fornow,thedrivetominimisePFOSintheenvironmentanddrinking waterhastobereconciledwithitscontinueduseinsomeindustrialsectors. 10 TheriskreductionstrategyproposedbyDEFRAwouldhavephasedoutPFOS useinchromeplatingtwoyearsafterthelegislationcameintoforce,andinfire fightingfoamandmostotherapplicationsfiveyearsafterthelegislationcameinto force.ThedraftEUDirective(December2005)onPFOSdoesnotphaseoutthe useofPFOSintheseapplications.TheEUhasnowprohibitedtheUKfrom imposingunilateralrestrictionsontheuseofPFOSandanyactiontorestrictthe useofPFOSwillnowproceedatanEUlevel. TheEnvironmentAgencysapproach 11 TheEnvironmentAgencyspolicyaimistoprogressivelyreduceandultimately phaseoutthedischargeofPFOStocontrolledwaters.However,theEnvironment Agencydoesnotregulateallusersand,duetoitswidespreadpresence,itisnot feasibletopreventalldischargesofPFOSintocontrolledwaters.Whencalculating acceptableconcentrationsofPFOSinconsentedeffluentdischargestosurface watertheEnvironmentAgencywillaimtopreventdetectableemissionswhere possible.AsPFOSisaListIsubstanceundertheGroundwaterDirective,the EnvironmentAgencycannotauthoriseitsdisposaltogroundwater.

21

50

BrookeD,FootittAandNwaoguTAEnvironmentalriskevaluationreport: perfluorooctanesulphonate(PFOS)ResearchContractor:BuildingResearch EstablishmentLtd.RiskandPolicyAnalystsLtd.

Annex10

Legalconsiderations
Prosecutiondecisionmaking 1 TheBoardisawarethattheprocessofmakingenforcementdecisionsis complex.Everydutyholderandsituationisunique.Theprosecutiondecisioncan onlybeconsideredoncethecriminalinvestigationisfullycomplete,ieall reasonablelinesofenquiryhavebeenfollowed(inlinewiththeCodeofPractice issuedpursuanttotheCriminalProcedureandInvestigationsAct1996).Inthe caseofHSE,theHSCEnforcementPolicyStatementsetsouttheapproachtobe followed,inaccordancewiththeaimsoftheGovernmentsPrinciplesofGood EnforcementandrequiresHSEtoapplytheCodeforCrownProsecutors(The Code). 2 TheEnvironmentAgencyhasitsownEnforcementandProsecutionPolicy, whichalsoreliesonthoseprinciplesandcommitstheAgencytotakeaccountof theCode.Eachcaseisuniqueandwillbeconsideredonitsownmerits.Any prosecutiondecisionrequiresacarefulbalancingofindividualfactorspresentin thatparticularcaseandwillbetakenbyalawyerwhoisindependentofthe Investigation. 3 TheCodestatesthatthedecisionmaker(prosecutor)mustbefair,independent andobjective.Itistheirdutytoreviewcasesandtoensurethatthelawisproperly applied,thatallrelevantevidenceisputbeforethecourtandthatobligationsof disclosurearecompliedwith.Theprosecutorwillalsoensurethattheinvestigators haveidentifiedanymaterialthatmightunderminetheprosecutioncaseorassist thedefence,andthattheyhaveactedincompliancewiththeHumanRightsAct 1998.Themorecomplexthecircumstancesofacaseand/orthetechnicalevidence, thelongerthisprocessmaytake. Evidentialstage 4 Thereisastrictorderinwhichtheprosecutormustapplythetwostageswhich formtheFullCodeTestundertheCode.Theprosecutormustfirstconsiderthe evidentialstage.Ifthereisnottherequiredlevelofevidencethennoprosecution cangoahead,nomatterhowimportantthecaseorhowstrongthepublicinterest isinfavourofprosecution.Theprosecutormustbesatisfiedthattheevidenceis admissibletomeettheevidentialtest. 5 TopasstheevidentialstagetheApprovalOfficermustbesatisfiedthatthereis enoughevidencetoformarealisticprospectofconvictionagainsteachdefendant oneachcharge.Thisisadifferenttesttotheonethatmagistratesorjurieshaveto apply.Thisisnotsimplyacaseofpercentages.Theevidentialstageismetifthere issufficientevidencetoensurethatajuryorbenchofmagistrates,withacorrect understandingofthelaw,ismorelikelythannottoconvictthedefendantofthe allegedcharge.

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6 Theprosecutorsconsiderationswillinclude:

Isthereanyevidencewhichmightsupportordetractfromthereliabilityofan admission? Whatexplanationhasthesuspectgiven? Isthecharacterofanyofthewitnesseslikelytoweakentheirevidence? Doesthewitnesshaveamotivethatmightinfluencehisorherevidence? Isthereanyconcernovertheaccuracyorcredibilityofawitness?Ifso,whatis thebasisforthatconcern?

Publicintereststage 7 Ifthecasemeetsthestandardrequiredbytheevidentialstage,onlythencan theprosecutorconsiderwhetheraprosecutionisrequiredinthepublicinterest. Theprosecutorhastobalancethefactorsforandagainstprosecutionvery carefully.Thedecisionmustnotbeaffectedbyimproperorunduepressurefrom anysource. 8 ForHSE,theHSCEnforcementPolicyStatementsetsoutthecommonhealth andsafetypublicinterestfactors,which,ifoneormoreispresent,HSCexpects shouldleadtoaprosecution,egwhere:

deathwasaresultofthebreachoflegislation; thegravityofanallegedoffence,takentogetherwiththeseriousnessofany actualorpotentialharm,orthegeneralrecordandapproachoftheoffender, warrantsit; therehasbeenarecklessdisregardforhealthandsafetyrequirements,repeated breacheswhichgiverisetosignificantrisk,orpersistentandsignificantpoor compliance; workhasbeencarriedoutinseriousnoncompliancewithanappropriate licenceorsafetycase; a dutyholdersstandardofmanaginghealthandsafetyisfoundtobefar belowwhatisrequiredbyhealthandsafetylawandtobegivingriseto significantrisk; therehasbeenafailuretocomplywithanimprovementorprohibitionnotice, ortherehasbeenarepetitionofabreachthatwassubjecttoaformalcaution; falseinformationhasbeensuppliedwilfully,ortherehasbeenanintentto deceive,inrelationtoamatterwhichgivesrisetosignificantrisk; inspectorshavebeenintentionallyobstructedinthelawfulcourseoftheir duties.

9 Thelistisnotexhaustive.TheEnforcementPolicyStatementacknowledges thattheremaybeoccasionswherethesefactorsmaybepresentbutthatthepublic interestdoesnotrequireaprosecution.

52

10 TheEnvironmentAgencywillconsidertheenvironmentaleffectofthealleged offence,theforeseeabilityoftheoffenceorthecircumstancesleadingtoit,the intentoftheoffender,anyhistoryofoffending,theattitudeoftheoffender, whetheraprosecutionisrequiredinordertoensuredeterrence,andthepersonal circumstancesoftheoffender.Againthelistisnotexhaustive. 11 ThereisapresumptionthattheEnvironmentAgencywillprosecutewhereone ormoreofthefollowingarepresent:

Incidentsorbreachesthathavesignificantconsequencesfortheenvironment, orwhichhavethepotentialforsuchconsequences. Operationshavebeencarriedoutwithoutalicence. Therehavebeenexcessiveorpersistentbreachesofregulatoryrequirements. Therehasbeenafailuretocomplyortocomplyadequatelywithformal remedialrequirements. Therehasbeenrecklessdisregardformanagementorqualitystandards. Therehasbeenafailuretosupplyinformationwithoutreasonableexcuse,or knowinglyorrecklesslysupplyingfalseormisleadinginformation. Agencystaff havebeenobstructed. TherehasbeenanattempttoimpersonateAgencystaff.

12 TheCodeforCrownProsecutorsalsolistsotherrelevantfactorsforand againstprosecution,whichagainarenotexhaustive.Theprosecutorbalancesthe factorsforandagainstprosecution. Viewsofthevictim(s)(partofthepublicintereststage) 13 Theprosecutorwillalsotakeintoaccounttheconsequencesforthevictimof thedecisiontoprosecuteornottoprosecute,andanyviewsexpressedbythe victimorthebereaved.Whiletheprosecutorwilltakeintoaccounttheirviews, neitherenforcementauthorityisboundtofollowthoseviewswhenreachingthe finaldecisiononenforcement.

53

Glossary

ambienttemperature aquifer Thetemperatureofthesurroundingair A waterbearingstratumofporousrock,gravelorsand

barandmillibar AlthoughabarisnotameasureintheInternationalSystemof Units(SI),itisoneoftheunitsusedinmeteorologywhendescribingatmospheric pressure.TheSIunitformeasuringpressureisthepascal(Pa).Amillibarisequal to1/1000ofabar,or100pascals(ahectopascal) bioaccumulative Literally,toaccumulateinabiologicalsystem.Itiscommonly takentomeasuretheuptakeovertimeoftoxicsubstancesthatcanstayina biologicalsystem borehole A cylindricalshaftdrilledintotheground,oftenforgeological explorationorextractionofresources Bronzecommand MajorIncident Theworkingnamefortheoperationalcommandlevelduringa

bund Anenclosure designedtocontainfluidsshouldtheyescapefromthetank orvesselinsidethebund,aswellasanyadditionalmaterialsaddedtothe containerareasuchasfirefightingwaterandfoam,etc COMAH SeeControlofMajorAccidentHazardsRegulations1999

COMAHsites A sitetowhichtheControlofMajorAccidentHazards Regulations1999apply CompetentAuthority TheControlofMajorAccidentHazardsRegulations (COMAH)areenforcedbyajointCompetentAuthoritycomprisingtheHealth andSafetyExecutive(HSE)andtheEnvironmentAgencyinEnglandandWales, andHSEandtheScottishEnvironmentProtectionAgencyinScotland ControlofMajorAccidentHazardsRegulations1999 Themainaimofthese Regulationsistopreventandmitigatetheeffectsofthosemajoraccidents involvingdangeroussubstances,suchaschlorine,liquefiedpetroleumgas,and explosiveswhichcancauseseriousdamage/harmtopeopleand/orthe environment.TheRegulationstreatriskstotheenvironmentasseriouslyasthose topeople.Theyapplywherethresholdquantitiesofdangeroussubstances identifiedintheRegulationsarekeptorused.SeealsoSevesoII dutyholder Inthecontextofthisreport,anypersonororganisationholdinga legaldutyinparticularthoseplacedbytheHSWAct,theManagement Regulations,andtheCOMAHRegulations EnvironmentAgency TheEnvironmentAgencyistheleadregulatorinEngland andWaleswithresponsibilityforprotectingandenhancingtheenvironment.Itwas setupbytheEnvironmentAct1995andisanondepartmentalpublicbody, largelysponsoredbytheDepartmentforEnvironment,FoodandRuralAffairsand theNationalAssemblyforWales

54

firewater

Waterstoredforuseduring,andusedduring,firefightingoperations

foam Inthecontextofthisreport,afoamusedduringoperationstoextinguish hydrocarbonfires forthwithaction TheInvestigationtermsofreferencerequiretheInvestigation teamandBoardtoidentifyandtransmitwithoutdelaytodutyholdersandother appropriaterecipientsanyinformationrequiringimmediateactiontofurthersafety and/orenvironmentalprotectioninrelationtostorageanddistributionof hydrocarbonfuels.Thisisreferredtoasforthwithactionforboththe Investigation,theCompetentAuthority,anddutyholders Goldcommand Theworkingnameforthestrategiccommandcentreduringa MajorIncidentalsoknownastheStrategicCoordinatingGroup groundwater Allwaterbelowthewatertable,asopposedtogroundwaters, whichincludegroundwaterbutalsosubsurfacewaterabovethewatertable.The termgroundwater,whereusedinthepreviousprogressreports,shouldnormally havereadgroundwater hazard Anythingwiththepotentialtocauseharm

HealthandSafetyCommission TheHealthandSafetyCommissionisastatutory body,establishedundertheHealthandSafetyatWorketcAct1974,responsible forhealthandsafetyregulationinGreatBritain HealthandSafetyExecutive TheHealthandSafetyExecutiveisastatutorybody, establishedundertheHealthandSafetyatWorketcAct1974.Itisanenforcing authorityworkinginsupportofHSC.Localauthoritiesarealsoenforcing authoritiesundertheHealthandSafetyatWorketcAct1974 HSC HSE SeeHealthandSafetyCommission SeeHealthandSafetyExecutive

hydrocarbon Anorganicchemicalcompoundofhydrogenandcarbon.Thereare a widevarietyofhydrocarbonssuchascrudeoil(basicallyacomplexmixtureof hydrocarbons),methane,propane,butaneetc.Theyareoftenusedasfuels ImprovementNotice ImprovementNoticesareoneofarangeofmeanswhich enforcingauthoritiesusetoachievethebroadaimofdealingwithseriousrisks, securingcompliancewithhealthandsafetylawandpreventingharm.An ImprovementNoticeallowstimefortherecipienttocomply kiloPascal Pascals(Pa)aretheunitofpressureintheInternationalSystemof Units(SI).AkiloPascal(kPa)isequalto1000Pa.Althoughbararenotunits withinSI,theyaresometimesusedasunitstomeasureatmosphericpressure. 1 kPa=10bar.Seealsobarandmillibar kPa SeekiloPascal Seetier

lowertier

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MajorAccidentToTheEnvironment DEFRAhasestablishedthresholdcriteria definingaMajorAccidentToTheEnvironment(MATTE),basedonSchedule7 (part1)oftheControlofMajorAccidentHazardsRegulations1999.The EnvironmentAgency,usingthesecriteria,hasdeterminedthattheBuncefield incidentisaMATTE,andtheCompetentAuthorityhasrecentlyreportedthisto theEuropeanCommission MATTE millibar SeeMajorAccidentToTheEnvironment Seebarandmillibar

overpressure Forapressurepulse(orblastwave),thepressuredevelopedabove atmosphericpressure perfluorooctanesulphonates A groupofchemicals,collectivelyidentifiedas PFOS,whichhavebeenshowntobehazardous(persistent,bioaccumulativeand toxic).PFOSchemicalshavebeenusedinadiverserangeofapplications,including asanadditivetoaidthespreadingpropertiesoffirefightingfoam perfluorosurfactant InthecontextoftheBuncefieldincident,asurfactantisa chemicaladdedtofirefightingfoamwhichallowsthefoamtoformathinsealing filmovertheburningfuel.Perfluorosurfactantsareatypeofsurfactant PFOS Seeperfluorooctanesulphonates A fireoverapooloffueland/orwaterorotherliquids

poolfire

primarycontainment Thetanks,pipesandvesselsthatnormallyholdliquids,and thedevicesfittedtothemtoallowthemtobesafelyoperated pumphouse Inthecontextofthisreport,thestructureenclosingthepumping equipmentusedtomovewateraroundtheBuncefieldsitepriortotheincident. Itprincipallystoredwaterintendedforfirefightingoperations risk Thelikelihoodthatahazardwillcauseaspecifiedharmtosomeoneor something runoff Uncontainedliquid,eitherdepositedonsiteasrain,orinthecontextof theBuncefieldincident,fueland/orfirewaternotcontainedaspartofthe operationtocontroltheincident SafetyAlert WheretheCompetentAuthorityconsidersthatanissueposes significantrisk,itcanchoosetoissueaSafetyAlerttooperatorsofCOMAHsites informingthemoftheissueandpossiblyrequiringthemtoundertakecertain activity SCG SeeStrategicCoordinatingGroup

ScottishEnvironmentProtectionAgency Thepublicbodywhichisresponsible fortheprotectionoftheenvironmentinScotland secondarycontainment Enclosedareasaroundstoragevessels(oftencalled bunds),createdusuallybyconcreteorearthwalls.Theirpurposeistoholdany escapingliquidsandanywaterorchemicalsusedinfirefighting SEPA

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SeeScottishEnvironmentProtectionAgency

SevesoII In1976,amajoraccidentoccurredinSeveso,Italy,wherethe accidentalproductionandreleaseofadioxinasanunwantedbyproductfroma runawaychemicalreactionledtowidespreadcontamination.Anumberofsuch incidents,andtherecognitionofthedifferingstandardsofcontrolsoverindustrial activitieswithintheEuropeanCommunity,ledtheEuropeanCommissionto proposeaDirectiveonthecontrolofmajorindustrialaccidenthazards.The DirectiveontheMajorAccidentHazardsofCertainIndustrialActivities (82/501/EEC)wasadoptedon24June1982,andisgenerallyknownastheSeveso Directive.FollowingacompletereviewoftheDirectivebytheEuropean Commissionanewone,nowknownasSevesoII,cameintoforceon3February 1997andwasimplementedinGreatBritainon1April1999bytheControlof MajorAccidentHazardsRegulations1999,exceptforlanduseplanning requirements,whichwereimplementedbychangestoplanninglegislation Silvercommand MajorIncident Theworkingnameforthetacticalcommandcentreduringa

StrategicCoordinatingGroup Representationofallagenciesdeployedtoresolve theBuncefieldincidentwasestablishedthroughameetingprocessknownasthe StrategicCoordinatingGroup,alsoknownasGoldCommand surfacewater andstreams Waterthatsitsorflowsaboveland,includinglakes,seas,rivers

tankfarm A facilitywhere hazardoussubstances,veryoftenpetroleumproducts, arestoredintanks tertiarycontainment Thesitesurfaceandassociateddrainage,boundarywalls, roads,containmentkerbsandanyfeaturessuchasroadhumpsthatcanprovide someretentionofliquids.Properdesignofdrainagesystemswilllimitlossof productoutofthesiteandpreventlostproductpermeatingintothegroundwith thepotentialriskthatitcanmigratetogroundwater,orcontaminatesurface watersandland tier TheControlofMajorAccidentHazardsRegulations1999applywhere thresholdquantitiesofdangeroussubstancesidentifiedintheRegulationsarekept orused.Therearetwothresholds,knownaslowertierandtoptier,and COMAHsitesfallintooneorotherofthese topography Thephysicalconfigurationofthesurfaceoftheland,includingits elevation,slope,andorientation toptier Seetier

ultimatehighlevelswitch Partofthesystemtopreventoverfillingofthetank, theultimatehighlevelswitchisanindependentmechanismwhichshouldbe triggeredwhentheultimatehighlevel(iethespecifiedmaximumcapacity)is reachedinatanktowhichitisfitted,bothcausinganalarmtosoundandshutting downthesupplyoffueltothetank vapourpressure A measureofthetendencyofamaterialtoformavapour. Thehigherthevapourpressure,thehigherthepotentialvapourconcentration volatility Thereadinessofasubstancetoevaporate Structuralstiffeningringattachedtothetanksidewall
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windgirder

Furtherinformation

Usefullinks BuncefieldMajorIncidentInvestigation MarloweRoom,RoseCourt 2 SouthwarkBridge London,SE19HS Tel: 02077176909 Fax: 02077176082 Email: buncefield.inforequest@hse.gsi.gov.uk Web: www.buncefieldinvestigation.gov.uk Community/Businesssupport DacorumBusinessContactCentre Tel: 01442867805 BusinessLinkHelpline Tel: 01727813813 HertfordshireChamberofCommerce Tel: 01727813680 DacorumCommunityTrustMayorsFund Toapply,callthefreephonehelplineon08001313351. Linesareopen9.30am4.30pm,MondaytoFriday DacorumBoroughCouncil Tel: 01442228000 Web: www.dacorum.gov.uk HemelHempsteadCitizensAdviceBureau 19HillfieldRoad,HemelHempsteadHP24AA Tel: 01442213368 Localauthoritiesandemergencyservices DacorumBoroughCouncil Tel: 01442228000 Web: www.dacorum.gov.uk (DacorumBoroughCouncilDigestnewsletter,availablemonthly DacorumBoroughCouncilBuncefieldUpdateNewsletter) StAlbansDistrictCouncil Tel: 01727866100 Web: www.stalbans.gov.uk HertfordshireCountyCouncil Tel: 01483737555 Web: www.hertsdirect.org

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HertfordshireFireandRescueService Web: www.hertsdirect.org/yrccouncil/hcc/fire/buncefield HertfordshireConstabulary Web: www.herts.police.uk/news/buncefield/main.htm HertfordshireChamberofCommerce Tel:01727813680 Web: www.hertschamber.com Governmentlinks DepartmentforCommunitiesandLocalGovernment FireandResilienceDirectorate Web: www.communities.gov.uk GovernmentOfficefortheEastofEngland Web: www.goeast.gov.uk EnvironmentAgency Web: www.environmentagency.gov.uk DepartmentofTradeandIndustry OilandGasDirectorate Web: www.og.dti.gov.uk HealthandSafetyExecutive HazardousInstallationsDirectorate Web: www.hse.gov.uk/hid ControlofMajorAccidentHazards Web: www.hse.gov.uk/comah DepartmentfortheEnvironment,FoodandRuralAffairs Web: www.defra.gov.uk HealthProtectionAgency Web: www.hpa.org.uk FoodStandardsAgency Web: www.food.gov.uk DrinkingWaterInspectorate Web: www.dwi.gov.uk Industrylinks UnitedKingdomPetroleumIndustryAssociation(UKPIA)
Tel: 02072400289
Web: www.ukpia.com
ChemicalIndustriesAssociation
Tel: 02078343399
Web: www.cia.org.uk
ThreeValleysWater
Tel: 08457823333
Web: www.3valleys.co.uk

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Investigationreports BuncefieldMajorIncidentInvestigation:

ProgressReport,published21February2006 SecondProgressReport,published11April2006 ThirdProgressReport,published9May2006

Availablefromwww.buncefieldinvestigation.gov.uk DEFRA:InitialreviewofAirQualityaspectsoftheBuncefieldOilDepot Explosion www.defra.gov.uk/environment/airquality/buncefield/buncefieldreport.pdf HertfordshireFireandRescueServicesReportintotheFireResponsetobe publishedinNovember2006 AngusFire,BuncefieldOilTerminalIncidentDecember2005:Reviewofpart playedbyAngusFireandlessonslearned www.angusfire.co.uk Otherrelatedreports/information EastofEnglandDevelopmentAgencyreportbySQW,EconomicDevelopments Consultantson:TheBuncefieldOilDepotIncident:EconomicandBusiness ConfidenceImpactStudy, June2006 www.eeda.org.uk SwissFireService:QuickLookReportBuncefieldFire11December2005 ContractresearchreportsforHSE

W.S.AtkinsScienceandTechnology:Derivationoffatalityprobability functionsforoccupantsofbuildingssubjecttoblastloadsPhases1,2,&3 147/1997andPhase4151/1997 BiomedicalSciencesChemicalandBiologicalDefenceSectorDefence EvaluationandResearchAgency:Reviewofblastinjurydataandmodels 192/1998

Availablefrom:www.hsebooks.com GovernmentAdvisoryBodies

Committeeonmutagenicityofchemicalsinfood,consumerproductsandthe environment(COM) Committeeoncarcinogenicityofchemicalsinfood,consumerproductsandthe environment(COC) Committeeontoxicityofchemicalsinfood,consumerproductsandthe environment(COT)

www.advisorybodies.doh.gov.uk/coc/

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HSEpricedandfreepublicationsareavailablebymailorderfromHSEBooks, PO Box1999,Sudbury,SuffolkCO102WATel:01787881165 Fax:01787313995Website:www.hsebooks.co.uk(HSEpricedpublicationsare alsoavailablefrombookshopsandfreeleafletscanbedownloadedfrom HSEswebsite:www.hse.gov.uk.) ForinformationabouthealthandsafetyringHSE'sInfolineTel:08453450055 Fax:08454089566Textphone:08454089577email:hse.infoline@natbrit.com orwritetoHSEInformationServices,CaerphillyBusinessPark,Caerphilly CF833GG. BritishStandardsareavailablefromBSICustomerServices,389ChiswickHigh Road,LondonW44ALTel:02089969001Fax:02089967001 email:cservices@bsiglobal.comWebsite:www.bsiglobal.com Crowncopyright Thispublicationmaybefreelyreproduced,exceptfor advertising,endorsementorcommercialpurposes.Firstpublished07/06. PleaseacknowledgethesourceasHSE. 07/06 C10

PrintedandpublishedbytheHealthandSafetyExecutive

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