Buncefield Final Report
Buncefield Final Report
Buncefield Final Report
11 December 2005
The final report of the
Major Incident Investigation Board
Volume 2
15.00
I S B N 978-0-7176-6318-7
780717 663187
The Buncefield Incident 11 December 2005 The final report of the Major Incident Investigation Board Volume 2
ii
The Buncefield Incident 11 December 2005 The final report of the Major Incident Investigation Board Volume 2
Contents
Foreword
Buncefield Major Incident Investigation: Initial Report to the Health and Safety
Commission and the Environment Agency of the investigation into the explosions
and fires at the Buncefield oil storage and transfer depot, Hemel Hempstead,
on 11 December 2005
13 July 2006
Recommendations on land use planning and the control of societal risk around
major hazard sites
15 July 2008
iii
The Buncefield Incident 11 December 2005 The final report of the Major Incident Investigation Board Volume 2
iv
The Buncefield Incident 11 December 2005 The final report of the Major Incident Investigation Board Volume 2
Foreword
This second volume of our final report brings together all of our previous eight
reports in their original form. We have not abridged any of the reports because to do
so would diminish their usefulness as an accurate record of the Buncefield Boards
work over the thirty-four months of its existence. We expect this collection of reports
to be useful for anyone with a responsibility for bringing into effect our
recommendations or for understanding them, and for those with an interest in how
the Boards thinking developed over the period of its tenure.
Each of our reports had a specific purpose. The first three reports were from me to
the Board describing progress with the investigation in understanding the incident;
the first confirming a vapour cloud explosion had occurred, the second describing
the environmental impact, and the third describing what had happened, and how.
Our fourth report was the Boards own Initial Report and discharged our fifth term
of reference. It marked the stage at which the Board set out its main areas of
concern and turned its full attention to making recommendations for improvements
in these areas. Accordingly, the next four reports made recommendations on design
and operation of fuel storage depots; on the emergency preparedness, response to
and recovery from major incidents; on the mechanism of the Buncefield explosion;
and on land use planning and the control of societal risk around major hazard sites.
We placed extensive annexes, glossaries and references in all of our reports to
enhance the understanding of the reports, to support the recommendations, and to
direct the interested reader towards further information. All of theses annexes,
glossaries and reference sections are included in their original form here in Volume 2.
As well as making our reports available as soon as we could, we tried to be
accessible at all times to everyone via an open e-mail system and website. We
placed all of our reports, public statements, key correspondence and other relevant
information on our website. The website was recorded on CD, a copy of which is
included here in Volume 2.
Taf Powell
Chief Inspector, Investigation Manager
Buncefield Major Incident Investigation Board
The Buncefield Incident 11 December 2005 The final report of the Major Incident Investigation Board Volume 2
vi
Contents
Foreword 3
Part 1 The Investigation so far 4
1.1 The incident 4
1.2 What is known about the explosions and fire 9
1.3 The continuing Investigation 12
1.4 Review of HSE/EA roles in regulating activities at Buncefield
1.5 Major Incident Investigation Board 15
Part 2 Background 16
2.1 Site description 16
2.2 Regulation of high-hazard sites
14
19
Annexes
1 Background to the COMAH Regulations 21
2 HSEs current approach to land use planning 22
3 Investigation terms of reference 25
4 Major Incident Investigation organogram 26
5 Further information 27
Glossary 28
Photographs are courtesy of the Chiltern Air Support Unit and Hertfordshire County Council
Foreword
At the first meeting of the Major Incident Investigation Board (MIIB) on 24 January
I was asked to prepare, for the second (10 February) meeting, a progress report on
the Buncefield Major Incident Investigation by the Health and Safety Executive
(HSE) and the Environment Agency (EA). This was to bring together relevant
background material and to cover progress with the investigation and such facts as
have been established to this point.
The MIIB said that this progress report would not constitute the initial report
required by Terms of Reference 6, since some of the main facts have yet to be
established. This progress report is a stepping stone towards the initial report.
The report describes the incident and the nature of the site and surrounding
communities and the initial responses by EA and HSE. Importantly, the report
describes the most likely nature of the explosion and fires that have so far been
ascertained from eyewitness statements and CCTV records. The explanation of
what the investigation team believes is most likely to have led to the devastation of
the area is not yet verified by scientific modelling and other evidence but I have
sufficient confidence in the evidence to believe on balance it should be made
public.
The report does not describe how what happened occurred. This is because I am
not in a position to say anything with sufficient confidence for it to be other than a
line of inquiry amongst others. Speculating publicly on causation would be
undesirable because I am not in a position to confirm the likelihood of the theory,
nor to deal authoritatively with the implications arising out of the theory. It may also
lead to nugatory remedial actions by depot operators. I believe verification is
required from records of fuel movement and storage to confirm any theory related
to loss of containment, not least of all because this may alter the balance between
system and mechanical failure, and this knowledge is vital in formulating a
competent response to the Buncefield incident.
Taf Powell
Buncefield Investigation Manager and Member of Buncefield Major Incident
Investigation Board
2 The fire burned for several days, destroying most of the site and emitting large
clouds of black smoke into the atmosphere, dispersing over southern England and
beyond. Large quantities of foam and water were used to control the fire, with risks
of contaminating water courses and ground water (see Figure 2).
Emergency response
3 The emergency services (primarily the Fire and Rescue Service and the police)
led the initial response to the incident and its immediate aftermath. As a Category 1
responder under the Civil Contingencies Act, EA worked closely with the Fire and
Rescue Service, the police, the Health Protection Agency (HPA) and the Strategic
Health Authority, including advising on the water pollution aspects of the firefighting activities. HSE is a Category 2 responder, so during the early phase of the
incident stood ready to provide advice and expertise on request in support of the
emergency services and EA.
4 Hertfordshire Police co-ordinated the emergency response and worked closely
with other responders including the Hertfordshire Fire and Rescue Service,
Hertfordshire County Council, Dacorum Borough Council, EA and HPA. The police
set up an exclusion zone around the site which remained in position for several
days. The Hertfordshire Fire and Rescue Service was supported by staff drafted in
from many other brigades and used equipment and foam brought in from around
the country. Shortly before Christmas the police were able to hand back the
security of the site to the depot operators but the fire service retained a presence
on site until the New Year as quantities of uncontained fuel remained on site.
5 At the peak of the incident on Monday lunchtime, 12 December there were
26 Hertfordshire pumps on site, 20 support vehicles and 180 firefighters. More
than 250 000 litres of foam concentrate were used, together with 25 million litres of
water and 30 km of high-volume hose.
6 The investigation team wishes to acknowledge the work of the emergency
services and especially the invaluable support given to HSE and EA in securing vital
evidence in the initial period when the site was dangerous and under the control of
the emergency services.
Securing the site
7 Once the Buncefield fire had been extinguished, HSE issued formal notices on
the two operators of the part of the depot that had suffered the greatest damage.
Prohibition Notices were served on both Hertfordshire Oil Storage Ltd (HOSL)3 and
British Pipeline Agency Ltd (BPA) on 16 December 2005 prohibiting operations on
site under their control unless appropriate risk assessments had been agreed with
HSE. Each of these operators were also served with Notices requiring that the
parts of the depot under their control were left undisturbed. The Notices were
issued to ensure that key pieces of evidence remained in place for examination by
the investigation team and that the clear up operations were carried out in a safe
manner. The operators have co-operated with HSE and EA to achieve these goals.
Water pollution
8 EA worked with the Fire and Rescue Service to develop a plan that minimised
the potential for firewater run-off. This included recirculating cooling water. The
main concern was the containment of liquid on site due to the presence of a
drinking water aquifer nearby. Some material did leave the site into Three Cherry
Trees Lane. EA believe most of this was contained by the natural contours of the
land, which prevented it reaching surface waters. Pollution of the River Ver is low
and no impact on its fish and animal life has been seen.
9 From the start of the incident both the Meteorological Office (using a longrange pollution dispersion model) and EA (using a short-range model) worked to
model the plume and provided data to HPA on likely plume direction and ground
level concentrations. On the advice of HPA a number of schools were closed as a
precaution.
10 Air pollution in London and the Home Counties was measured by four regional
air quality monitoring networks managed by Kings College, London, and
comprising over 130 local authority monitoring sites. A number of parameters were
measured including particulates. Air samples were sent for particulate analysis and
the results are awaited.
For more details of the HOSL and BPA sites see Part 2.1 of this report.
11 The Buncefield Depot is close to the Maylands Industrial Estate, home to some
630 businesses employing about 16 500 people. All businesses were disrupted by
the explosions and fire, some severely. The premises of 20 businesses employing
500 people were destroyed; the premises of 60 businesses employing 3500
people are under repair and not yet usable. Most businesses face difficulties in
delivering pre-incident levels of service from dispersed and temporary
accommodation. Reduced trading and supply disruptions have affected businesses
over a wider area. Impact on employment has been limited so far, but job losses
could become significant over the next few months.
Lagoon
Bund A
N
Catherine
House
Thre
eC
her
ry
Tre
e
sL
Fircones
an
Tank 12
The
Cottage
Fuji
building
Buncefield Lane
Boundary Way
Keystone
House
High Grange
Bund B
Th
r
3-Com
building
Ch e
rry T
rees
L
ane
British
Pipelines
Agency
e
Lan
eld
cefi
Bun
Boundary Way
Northgate
building
ee
RO
building
Loading
gantry
Site features
12 The incident also damaged nearby housing, mainly in Dacorum district, but also
in St Albans district. Some houses closest to the site suffered significant structural
damage; several families are living in temporary accommodation while their houses
are repaired. At least 300 houses suffered lesser damage.
13 The incident disrupted fuel supply to London and South-East England. Remedial
measures by the industry have restored supplies of road transport, commercial and
domestic fuels generally back or close to pre-incident levels. However, supplies to
Heathrow remain disrupted. This has required fuel rationing by the BAA to allow the
airport to function normally, with no flight cancellations. For all supplies the industry
is trying to find permanent solutions to replace the current transitional arrangements.
I
I
Witnesses describe seeing mist at about 05:50 GMT in the vicinity of one of the
tanks in bund A4 (see Figure 4). They also describe a mist variously between one
and three feet in height rolling from bund A towards the tanker loading gantry.
Witnesses also report a moving mist near the trees (along Buncefield Lane to the
west of the site) about one and a half feet high and wisps of vapour on the
ground near the end of the loading bay.
These witnesses mention a strong smell at this time, variously described as
petrol or aviation gasoline.
None of the witnesses describe the flames reaching them as they moved from
the tanker loading gantry towards the site exit. None of them report having
suffered burn injuries.
16 Off-site in the vicinity of the Fuji building carpark to the west of the site:
I
Witnesses describe a thick fog above head height or between 15 and 20 feet
high between 05:50 and 06:00 GMT. This was first seen near the junction
where Three Cherry Trees Lane meets Buncefield Lane. The fog continued to
spread to the west towards Catherine House.
These witnesses noticed a strong smell, but were not certain of its nature and in
general there is a degree of disagreement among witnesses as to the nature of
the smell. These witnesses also describe various responses from their car
engines including revving uncontrollably, running rough and stalling.
From the witness statements and lack of burn injuries, the flame does not
appear to have travelled as far as Boundary Way.
CCTV records
17 Examination of CCTV images for the HOSL site and for the RO building off-site
has provided the following evidence.
A bund is an enclosure designed to contain fluids should they escape from the tank or
vessel inside the bund.
9
18 HOSL West
I
I
I
I
I
I
I
Before the event there was no evidence of mist or fog at ground level showing
on any of the camera images. This includes the surface of the fire water lagoon
in the north-west corner of the HOSL West site.
The first unusual indication was at 05:38 GMT, 23 minutes before the
explosion. At the north-west corner of bund A, a light mist is seen flowing from
inside bund A towards the west. This is at the north-west corner of bund A.
The mist is low-lying and about one metre deep. Its appearance is consistent
with a mist that is denser than the surrounding air.
During the next few minutes mist is seen flowing towards Three Cherry Trees
Lane via the lagoon and flowing out of bund B at the north-east edge of the
site, along the roadway on-site.
Cameras at the eastern edge of the HOSL site adjacent to the BPA site first
show the mist eight minutes after its first appearance crossing the wall of
bund A.
By this time, the cameras along the western edge of the site, along Buncefield
Lane, show that the mist has thickened to about two metres deep. It is now so
dense that it is not possible to see through it. It appears to flow away from
bund A in all directions.
There is no indication on the cameras that the visible mist has spread as far
south as the tanker filling gantry.
All the cameras stopped recording at the time of the explosion.
19 HOSL East
I
There is no evidence of the mist seen on the HOSL West site having reached
as far as any of the cameras on the HOSL East site. The cameras show
evidence of the fire, but it is not possible to learn anything of significance.
20 RO building
I
10
This building is to the south of the Northgate building, approximately level with
the tanker loading gantry on the HOSL West site. There is no evidence of the
mist having reached as far as any of the cameras at this building. The images
show a flash of light at the time of the explosion, followed by evidence of
explosion damage.
Scorched vegetation on a row of trees between the Northgate building and the
3-Com building.
Scorched leaves underneath these trees.
Scorched upholstery to unignited cars at this location.
22 In addition the north-east corner of the Northgate building has been on fire.
There are burnt cars and trees between the Northgate building and the Fuji
building.
23 Cars on Three Cherry Trees Lane near to Catherine House were set on fire and
vegetation along the side of Three Cherry Trees Lane was scorched at this location.
24 Evidence of the extent of any flammable mixture over the HOSL site is masked
by damage from the resulting tank and bund fires.
Initial conclusions regarding the extent of the flammable mixture.
25 The explosion(s) that caused the extensive damage on and off site, and the
early fires, can probably be ascribed to the ignition of a flammable mixture that is
thought to have been associated with the visible mist reported by eyewitnesses
and visible on CCTV records.
26 Initial indications are that the flammable mixture of fuel and air extended to the
west almost as far as Boundary Way in the gaps between the 3-Com, Northgate
and Fuji buildings. To the north-west it extended as far as the nearest corner of
Catherine House.
27 It may have extended to the north of the HOSL site as far as BPA tank 12. It
may have extended across part of the HOSL site, but there is no evidence of it
having spread as far south as the tanker filling gantry, although the visible mist had
just started to reach this point. Figure 5 shows the most likely extent of the
flammable mixture based on the investigation so far.
28 The visible mist seen in the CCTV records and described by witnesses is
assumed to arise from the evaporation of the more volatile fractions of an escape
of fuel. This evaporating fuel would be cold compared to the surrounding air, which
is known from weather records to have had high humidity. The cooling would result
in the condensation of water in the air. The visible mist thus indicates the
approximate extent of the fuel air mixture.
29 The source of the fuel release is not yet known, although the CCTV records
indicate that it was in the vicinity of bund A on the HOSL West site. The most
plausible scenarios involve large-scale loss of containment of vessels or pipework
within bund A. Resources are being directed to clarify these early indications and to
find out what underlying causes there may have been.
11
14
the Investigation is carried out effectively and the best professional advice is
used in establishing causation;
the confidence of the public is maintained in the work and findings of the
Investigation;
the eight points of the terms of reference (Annex 3) are met, even if in some
cases delivery is the responsibility of other parties;
information is made public in a timely way, but subject to legal considerations.
15
Part 2 Background
2.1 Site description
54 Buncefield Oil Storage Depot is a large strategically important fuel storage site
(known as a tank farm) operated by a number of companies. Figure 5 shows the
layout of the site and its immediate surroundings.
55 The Depot receives petrol, aviation fuel, diesel and other fuels by pipeline. It stores
and then distributes these fuels by pipeline and road tanker to London and SouthEast England, including to Heathrow Airport. The UK Petroleum Industry Association
(UKPIA) reports that, prior to the events of 11 December 2005, Buncefield handled
8% of overall UK oil supplies into the market, including 20% of supply to consumers
in the South East. The terminal acted as a main pipeline transit point to meet 40% of
Heathrows demand for aviation fuel. On 11 December the site held over 35 million
litres of petrol, diesel and aviation fuel.
56 The Depot contains three sites which are so-called top-tier sites under the
COMAH Regulations (see Part 2.2 of this report on regulation of high-hazard sites),
although the HOSL and BP sites did not acquire top-tier status until changes were
made to the Regulations in July 2002. This required submission of safety reports for
these sites by July 2003:
I
Hertfordshire Oil Storage Ltd (HOSL) a joint venture between Total UK Ltd (60%)
and Texaco Ltd (40%). This site is in two sections, HOSL East and HOSL West.
HOSL West was at the centre of the fire. The site had consent to store 34 000
tonnes of motor spirit and 15 000 tonnes of kerosene. The COMAH safety report
assessment process had not been completed.
British Pipeline Agency Ltd (BPA) a joint venture between Shell and BP that
operates the site and the pipeline system, while the assets are owned by UK Oil
Pipelines Ltd (UKOP). This site is split between the North (or Cherry Tree Farm)
section and the main section. It was substantially damaged by fire. It had consent
to store 70 000 tonnes of motor spirit and other fuels. The COMAH safety report
assessment process had been completed.
BP Oil Ltd. The BP facility to the south of the Depot was furthest from the fire and
appears to have escaped with superficial damage. It is out of operation while the
full extent of damage is assessed. It has consent to store 75 000 tonnes of motor
spirit, all product being received from the BPA site pipelines. The COMAH safety
report assessment process had been completed.
57 The fuels arrive at the sites in batches through a system of three pipelines,
namely:
I
I
I
58 After separation of the multi-fuel product entering the sites from the pipelines, the
fuel is stored in tanks individually dedicated to specific product types. Product then
leaves the sites either by road tanker or, in the case of aviation jet fuel, via two
dedicated 6 and 8 pipelines from the BPA site into the West London Walton
Gatwick pipeline system. Fuel leaving the site by road is loaded by dedicated vehicle
loading facilities at HOSL West, BP and to a lesser extent BPA.
16
59 There are also fire-fighting facilities on site, some of which are shared. The site
water treatment is operated by BPA, collecting run-off water from the whole site into a
water treatment plant in the north-east corner of the Depot.
60 For land use planning purposes the Depot is surrounded by a consultation
distance of 190 metres (see page 22). The local planning authority must consult HSE
about developments within that distance, but not those outside it.
Site conditions at the time of the incident
61 Information provided by HOSL indicates that during the hours leading up to the
explosion, the HOSL site was importing unleaded petrol through the FinaLine pipeline
from the Lindsey Oil Refinery. In addition, unleaded petrol was being imported through
the Thames pipeline and diesel through the Mersey line. Unleaded petrol was being
exported from the site by filling road tankers at the gantry on the HOSL West site.
Weather conditions
62 Meteorological Office records have been obtained for two sites at Luton Airport
(13 km to the east-north-east) and Northolt (24 km to the south). These indicate that
during the early morning of 11 December 2005 the weather was calm, cold, stable and
humid. Atmospheric stability at Northolt was stable (Pasquill stability category F). The
relative humidity was recorded as 99%. The air temperature was 1.7 oC at Northolt
and 1 oC at Luton. There was no wind recorded at Northolt, while Luton recorded an
average wind speed of 6 knots (approximately 3 metres per second) during the 10
minutes before 06:00 GMT. The average wind direction was recorded as 280 degrees
measured from true north (this is the direction from which the wind was blowing).
63 At Luton there was a light wind west to east. Further south there was no wind.
Geology
64 The Buncefield Depot and the immediate surrounding area are positioned on a
variable layer of clay with flints over Upper Chalk. The clay with flints layer is classified
as a low permeability surface deposit and is believed to be present at a variable
thickness of between 2 m and 10 m. This layer should inhibit the vertical and lateral
migration of contaminants and protect the chalk aquifer below where present in
sufficient depth.
65 The Upper Chalk is classified as a major aquifer, which provides water supplies
regionally. The Depot is located within the catchment of a ground water abstraction
point located to the south and east of the Depot. Ground water is present typically at a
depth of 45 metres below ground level and flow is generally towards the south-east.
Natural holes in the chalk which allow quicker water flow than normal may be present,
but none have been positively identified in the immediate area.
66 Within the Depot site boundary a layer of made-ground, comprising a sand clay
dominated soil mixture, overlies the clay.
Water
67 A local ground water abstraction point that is used as cooling water is located
approximately 500 m south of the Depot.
68 The River Gade is located approximately 3 km to the south-west and the River Ver
approximately 3.5 km east of the Depot.
17
69 During normal operation, surface water from the Depot drains to the Depot
effluent treatment plant. It is then pumped into the public surface water system at
Pratts Dell to the north-west of the Depot. This in turn drains to the surface waterbalancing pond at Redbourne Road and subsequently to the River Red, a tributary
of the River Ver.
70 Maylands pond is another surface water-balancing pond situated to the southwest of the Depot. It was used as a source of fire-fighting water during the
incident.
General background
71 Land to the west and north of the Depot is largely used for the growing of
arable crops.
72 There are no listed buildings within 1 km of the Depot and no recorded
monuments within 500 m of the Depot.
73 The Depot is not located within a 100-year flood plain as defined by the EA
flood maps.
74 There are no sites of special scientific interest within 2 km of the Depot and the
nearest site designated under the Habitats Directive is Ashridge Common Special
Area of Conservation, approximately 8 km north-west of the Depot.
18
19
20
Annex 1
Backgound to the COMAH Regulations
1 Certain industrial activities involving dangerous substances have the potential
to cause accidents that give rise to serious injury to people or damage to the
environment both close to and further away from the site of the accident. Such
activities are known as major accident hazards.
Flixborough
2 In Great Britain, a disastrous explosion at a chemical plant at Flixborough in
1974 profoundly influenced the approach to regulating major hazards. There were
28 workers killed, the plant was destroyed and there was extensive damage to
property off site. Following that accident, a committee of experts, the Advisory
Committee on Major Hazards (ACMH), was appointed by the Health and Safety
Commission to consider the problems of major accident hazards and make
recommendations. They proposed a three-part strategy:
(a) identification of the sites;
(b) control measures to prevent major accidents; and
(c) mitigatory measures to limit the effects of any accidents which do occur.
European Union Directive
3 Other major accidents occurred in Europe during the 1970s, the most
significant of which took place in Seveso, Italy in 1976. Here, the accidental
production and release of a dioxin as an unwanted by-product from a runaway
chemical reaction led to widespread contamination. Such incidents, and the
recognition of the differing standards of controls over industrial activities within the
European Community, led the European Commission to propose a Directive on the
control of major industrial accident hazards. The three-part strategy proposed in
the UK was highly influential in shaping the Directive. The Directive on the Major
Accident Hazards of Certain Industrial Activities (82/501/EEC) was adopted on 24
June 1982, and is generally known as the Seveso Directive.
4 Following a complete review of the Directive by the European Commission a
new one, now known as Seveso II, was adopted in 1996. The Seveso II Directive
retained the basic principles of major accident hazard controls set out in the
original Seveso Directive but addressed some weaknesses and omissions. The
new Directive followed a review carried out by the European Commission in
conjunction with the Committee of Competent Authorities for the Seveso Directive
(made up of representatives of all Member States governmental bodies enforcing
the Seveso Directive). It came into force on 3 February 1997 and was implemented
in Great Britain on 1 April 1999 by the COMAH Regulations, except for land use
planning requirements (article 12) which were implemented by changes to planning
legislation.
5 An amending Directive in 2003 was implemented by changes to the COMAH
Regulations. These came into force on 30 June 2005.
21
Annex 2
HSEs current approach to land use planning
Policy and practice
1 Under the Planning (Hazardous Substances) Regulations, the presence of
hazardous chemicals above specified threshold quantities requires consent from
the Hazardous Substances Authority (HSA), which is usually also the local planning
authority (LPA). HSE is a statutory consultee on all hazardous substances consent
applications. HSEs role is to consider the hazards and risks which would be
presented by the hazardous substance(s) to people in the vicinity, and on the basis
of this to advise the HSA whether or not consent should be granted.
2 In advising on consent, HSE may specify conditions that should be imposed by
the HSA, over and above compliance with statutory health and safety
requirements, to limit risks to the public (eg limiting which substances can be
stored on site, or requiring tanker delivery rather than on-site storage). HSAs
should notify HSE of the outcome of all applications for consent and where
consent has been granted should supply copies of the site plans and conditions.
3 HSE uses the information contained in consent applications to establish a
consultation distance (CD) around the installation. This usually comprises three
zones (or risk contour areas) see paragraph 6. The CD is based on the
maximum quantity of hazardous substance(s) that the site is entitled to have under
its consent. HSE notifies the LPAs of all CDs in their areas. The General
Development Procedure Order 1995 requires the LPA to consult HSE about certain
proposed developments (essentially those that would result in an increase in
population) within any CD.
4 HSE advises the LPA on the nature and severity of the risks presented by the
installation to people in the surrounding area so that those risks are given due
weight by the LPA when making its decision. Taking account of the risks, HSE will
advise against the proposed development or simply note that it does not advise
against it. This advice balances the ACMH principle of stabilising and not increasing
the numbers at risk, with a pragmatic awareness of the limited land available for
development in the UK.
5 HSEs role in the land use planning system is advisory. It has no power to
refuse consent or a planning application. It is the responsibility of the HSA or LPA
to make the decision, weighing local needs and benefits and other planning
considerations alongside HSE advice, in which case they should give HSE advance
notice of that intention. LPAs may be minded to grant permission against HSEs
advice. In such cases HSE will not pursue the matter further as long as the LPA
understands and has considered the reasons for HSEs advice. However HSE has
the option, if it believes for example that the risks are sufficiently high, to request
the decision is called in for consideration by the Secretary of State, in England
and Wales (a very rare situation). In Scotland, if the planning authority is minded to
grant permission they have to notify the Scottish Ministers who can decide to call
in the application.
Consultation distances and risk contours
6 Using consent information, HSE undertakes a detailed assessment of the
hazards and risks from the installation and produces a map with three risk contours
representing defined levels of risk or harm which any individual at that contour
22
would be subject to. The risk of harm to an individual is greater the closer to the
installation. In each case the risk relates to an individual sustaining the so-called
dangerous dose (see Figure 9) or specified level of harm. The three contours
represent levels of individual risk of 10 cpm (chances per million), 1 cpm and
0.3 cpm per year respectively of receiving a dangerous dose or defined level of
harm. The contours form three zones (see left), with the outer contour defining the
CD around major hazard sites. The LPA consults HSE on relevant proposed
developments within this CD.
Figure 9
COMAH site
Figure 10
Inner Zone
Middle Zone
Outer Zone
23
Figure 11
Level of sensitivity
1
2
2
4
Development in
Inner zone
DAA
AA
AA
AA
Sensitivity level 1
Sensitivity level 2
Sensitivity level 3
Example
Example
Example
Sensitivity level 4
Example
Development in
Middle zone
DAA
DAA
AA
AA
Development in
Outer zone
DAA
DAA
DAA
AA
Factories
Houses
Vulnerable members of society
eg primary schools, old peoples homes
Football ground/large hospital
24
Annex 3
Investigation terms of reference
1
To ensure the thorough investigation of the incident, the factors leading up to it,
its impact both on and off site, and to establish its causation including root
causes.
To identify and transmit without delay to duty holders and other appropriate
recipients any information requiring immediate action to further safety and/or
environmental protection in relation to storage and distribution of hydrocarbon
fuels.
To examine the Health and Safety Executives and the Environment Agencys
role in regulating the activities on this site under the COMAH Regulations,
considering relevant policy guidance and intervention activity.
To work closely with all relevant stakeholders, both to keep them informed of
progress with the investigation and to contribute relevant expertise to other
inquiries that may be established.
To produce an initial report for the Health and Safety Commission and the
Environment Agency as soon as the main facts have been established. Subject
to legal considerations, this report will be made public.
To ensure that the relevant notifications are made to the European Commission.
25
Annex 4
Major Incident Investigation organogram
Phil Kemball
Lord Newton
Richard Turfitt
MIIB Secretary
Chair
Legal advice
from HSE
David Ashton
Dr Paul Leinster
Dr Peter Baxter
Professor
Dougal Drysdale
Taf Powell
HSE
representative
EA
representative
Health expert
Fire Safety
Engineering expert
Investigation
manager
Dr Graham
Green-Buckley
Bob Woodward
Paul Woodhouse
Regulatory review
EA lead
Primary
Investigation lead
Regulatory review
HSE lead
MIIB
26
Annex 5
Further information
Useful links
Dacorum Borough Council
www.dacorum.gov.uk
Tel: 01442 228000
St Albans District Council
www.stablans.gov.uk
Tel: 01727 866100
Hertfordshire County Council
www.hertsdirect.org
Tel: 01483 737555
Hertfordshire Chamber of Commerce
www.hertschamber.com
Tel: 01727 813680
Government links
Government Office for the East of England
www.go-east.gov.uk
Environment Agency
www.environment-agency.gov.uk
Department of Trade and Industry Oil and Gas Directorate
www.og.dti.gov.uk
Health and Safety Executive
www.hse.gov.uk
Industry links
United Kingdom Petroleum Association (UKPIA)
www.ukpia.com
Tel: 020 72400289
Chemical Industries Association
www.cia.org.uk
Tel: 020 78343399
Useful sources of information
Dacorum Borough Council Digest newsletter, available monthly
Dacorum Borough Council Buncefield Update Newsletter
27
Glossary
The Health and Safety Commission (HSC) is responsible for health and safety
regulation in Great Britain. The Health and Safety Executive (HSE) (and local
authorities) are the enforcing authorities who work in support of the HSC. Both are
statutory bodies, established under the Health and Safety at Work etc Act 1974
(the HSW Act).
HSCs statutory functions include conducting and sponsoring research; promoting
training; providing an information and advisory service; and submitting proposals to
Ministers for new or revised regulations and approved codes of practice. HSC has
a chair plus nine members nominated by organisations representing employers,
employees, local authorities and others. They are appointed by the Secretary of
State for Work and Pensions.
HSE is a body of three people appointed by HSC with the Secretary of States
approval. HSE advises and assists HSC and has specific statutory responsibilities
of its own, notably for enforcing health and safety law. HSEs staff of around 4000
(inspectors, policy advisors, technologists, scientific and medical experts etc) is
collectively known as HSE.
HSE regulates health and safety in factories, farms, mines, nuclear installations,
offshore installations, hospitals, schools and many other sectors. Local authorities
are responsible for enforcement in offices, shops and other services.
The Environment Agency (EA) is the lead regulator in England and Wales with
responsibility for protecting and enhancing the environment. It was set up by the
Environment Act 1995 and is a non-departmental public body, largely sponsored
by the Department for Environment, Food and Rural Affairs (DEFRA) and the
National Assembly for Wales (NAW). EAs prime responsibilities include flood risk
management, tackling pollution incidents, reducing industrys impact on the
environment, restoring and improving rivers, coastal waters, contaminated land,
and wildlife habitats.
EA also advises on sustainable drainage, water conservation and management,
planning issues, nature conservation and waste management.
The Control of Major Accident Hazards Regulations (COMAH) are enforced by a
joint Competent Authority (CA) comprising HSE and EA in England and Wales, and
HSE and the Scottish Environment Protection Agency (SEPA) in Scotland.
28
3-com
ACMH
Aquifer
BAA
Boreholes
Bund
Catherine
House
COMAH
Regulations
COMAH sites
Competent
Authority
dangerous
dose
dioxin
duty holder
fire water
foam
concentrate
Fuji
hazard
human factors
hydrocarbon
Northgate
on- and off-site Operators of top-tier COMAH sites must prepare adequate
and emergency emergency plans to deal with the on-site consequences of
plans
possible major accidents and to assist with off-site mitigation.
Local authorities for areas containing top-tier COMAH sites must
prepare adequate emergency plans to deal with the off-site
consequences of possible major accidents, based on information
supplied by site operators
particulates
29
Prohibition
Notice
responder
risk
RO
run-off
safety reports
tier
volatile
watercourses
Published 02/06
30
Contents
Foreword 3
Part 1 Progress with the primary investigation 4
1.1 Loss of containment of fuel and contaminants 4
Background 4
Loss of fuel from vessel(s) 4
Loss of fuel and contaminants from bunds 7
Loss of contaminants from the site 9
1.2 Monitoring of environmental impact
Air quality 12
Surface water 12
Ground water 14
Drinking water 16
Land investigations 16
Disposal of fire water 17
12
18
Foreword
I present a second progress report that focuses mainly on the environmental
impact on land, surface water and ground water of the fuel and fire water that
escaped from the Buncefield site. It is important, in my view, that the vital work
being done by the Environment Agency and others is brought to public attention.
My report also contains for completeness a brief update on progress with the
investigation into how fuel escaped, thereby breaching the primary containment
barriers. It reveals that cloning of a number of important computer records has
been successful and that vapour formation modelling is underway. Although briefly
stated, this is important new information it was quite possible that these disks
would be too badly damaged for the information on them to be recovered.
The report is, as I say, mainly a description of loss of containment of fuel and fire
water from bunds (secondary containment) and from the site itself (tertiary
containment).
There are important early observations that sealant used in some bund walls was
not capable of withstanding fires and/or the hydraulic pressure in bunds or
adjacent tanks. Bund performance during the incident forms an important but as
yet inconclusive aspect of the investigation.
There was massive loss of containment at the site boundaries and fuel and fire
water escaped from the site to the surrounding lands. The report describes the
monitoring work by the Environment Agency and others to identify whether or not
short and long-term pollution of watercourses and ground waters has or is likely to
occur, particularly potential contamination of the important chalk aquifer that
underlies Buncefield. The pathways for pollutants are still being investigated. It is
important to emphasise that if contamination of the aquifer occurs from the
Buncefield incident, it could take months or years to materialise. However, we have
been reassured by Three Valleys Water Company and the Drinking Water
Inspectorate that drinking water is of a high quality and has not been affected by
this incident.
A further report to the Board on the means of escape of the fuel and the formation
of flammable vapours is suggested as possible within a month of this report,
provided we are able to continue the good rate of progress that the investigation is
making.
Taf Powell
Buncefield Investigation Manager and Member of Buncefield Major Incident
Investigation Board
www.buncefieldinvestigation.gov.uk
a flammable mixture with the air. Little was known about how primary containment
was lost or how the escaping fuel formed into a flammable mixture. (Figure 1
shows a schematic of the bunds.)
9 Progress has been made in determining the main source of escaped fuel.
CCTV recordings recovered from the south side of the BPA site show the visible
mist, associated with the loss of containment of the fuel, drifting eastwards onto
the site from the adjacent HOSL West site shortly before the first explosion. This is
consistent with the evidence obtained from other CCTV coverage and detailed in
5
the first progress report, and appears to confirm that the initial escape of fuel was
from the HOSL West site. CCTV records from the Northgate building provide
further confirmation of the spread of the flammable cloud away from the HOSL
West site. This information also supports the initial forensic conclusions about the
extent of the flammable cloud in this vicinity.
10 A significant amount of information has now been obtained from the extensive
electronic equipment used to control and monitor the operations on site. Much of
the equipment was housed in damaged buildings and great care had to be taken
to ensure its safe removal and subsequent restoration and examination. This has
revealed important information on key parameters such as fuel levels in tanks, flow
rates and valve positions. Work is continuing to extract this information and to
examine it in detail so as to conclude with confidence how the fuel escaped. It is
hoped this work will be completed within five weeks of this report.
11 A key aspect of the investigation is to determine how the escaping fuel
vaporised so rapidly. Work has been commissioned from the Health and Safety
Laboratory (HSL) to assist with this. The work is being carried out as quickly as
possible to enable feedback to the investigation team within the next month. In
particular, priority is being given to the composition of the fuel and to modelling
how the escaping fuel could have been vapourised under the prevailing weather
conditions. This work should provide a link between the possible release events
indicated by the control and instrumentation records and the clear evidence of mist
formation coming from witness statements and CCTV records.
0
Ch
e rr
yT
ree
100
La
ne
200
Ch
er
ry
Tre
eL
an
e
300
400
500
ne
field La
Bunce
Cherr
y Tree La
ne
A
0
B
100
200
300
134 m
132 m
130 m
128 m
126 m
124 m
532
400
500 532m
Figure 3
Figure 4
Figure 5
Figure 6
17 Many of the bunds around the site have suffered varying degrees of sealant
damage. Figure 6 shows fire water and product leaking from such a joint in the
later stages of the incident.
18 Another two leakage mechanisms can be seen in Figure 7. Here a corner joint
has opened up, releasing fire water and product. Visible along the lower edge of
the bund wall, a tide mark shows where liquids were seen to seep through the
concrete itself.
19 Figure 8 shows the base of a bund where the concrete panels have undergone
significant heave which has resulted in the escape of product and fire water.
Figure 7
Figure 8
Figure 9
Figure 10
26 During the incident, the internal roadways were submerged by fire water and
fuel flowing to the lowest point. Fire water and fuels flowed through the site
drainage and along the roads within the site perimeter. At the low point on the site
perimeter the flows overtopped the road edge, which was not kerbed, and flowed
into Cherry Tree Lane.
Figure 12
10
27 A large pool of liquid, consisting of fire water and fuels that escaped from tanks
and pipes, collected in Cherry Tree Lane. It is estimated that this pool was 200 m
in length and between 10 and 20 m wide. Road tankers removed the liquids in the
pool by the first week in January this year.
28 The investigation has highlighted a number of potential pathways by which fuel
and contaminated water could have entered the environment. Within the site,
shallow boreholes of 4-5 m depth exist within the terminal, and a deep borehole is
located in the Chevron/Texaco tanker park, directly due south of the HOSL and
BPA sites that were on fire. This borehole is 42 m deep, extending into the chalk
layer.
29 A number of places where contaminants could penetrate the ground have
been found around the perimeter of the site: on the northern and southern verges
of Cherry Tree Lane; on the western verge of Buncefield Lane; and the southern
verge of Hogg End Lane. These drains and chambers were either submerged in
fire water and fuel or had drains connected to them that delivered such
contaminants.
30 Cherry Tree Lane has a number of road drains, some of which are connected
to deep chambers. At the bottom of one appears to be a borehole at least 40 m
deep penetrating the chalk aquifer. For a description of the local geology and
aquifer, see paragraph 41.
Figure 13
11
Figure 14
38 No direct impact of spills was found in the first days after the incident. By the
third day of the incident, detectable but low concentrations of PFOS were noted in
the balancing lagoons, at the Maylands outfall and in the River Ver downstream of
the outfall. In addition, there was an increase in zinc above background
concentrations.
39 PFOS was identified at all monitoring points, including in the River Colne. The
PFOS concentrations, however, were less than the provisional water quality
threshold concentration specified by the Drinking Water Inspectorate (DWI) and no
identifiable environmental consequences have been observed in the river habitat.
40 Levels of PFOS started to drop in the River Ver in the middle of January, falling
below detectable limits in February. The flow of water from the Maylands outfall
stopped in February. However, the water that remains within this lagoon has low
concentrations of PFOS.
13
Ground water
Geology
41 The Buncefield Depot and the immediate surrounding area are positioned on a
variable layer of clay with flints over Upper Chalk. The clay with flints layer is
classified as a low permeability surface deposit and is believed to be present at a
variable thickness of between 2 and 10 m. This layer should inhibit the vertical and
lateral migration of contaminants and protect the chalk aquifer below, where
present in sufficient depth.
42 The Upper Chalk is classified as a major aquifer, which provides water supplies
regionally. The Depot is located within the catchment of a ground water abstraction
point located to the south and east of the depot. Ground water is present typically
at a depth of 45 m below ground level and flow is generally towards the southeast. Natural holes in the chalk rocks, which allow quicker than normal water
migration, may be present, but none have been positively identified in the
Buncefield area. Ground water is water held naturally in the chalk rocks
underground. This can be abstracted for drinking water and other purposes.
43 Regional ground water in the vicinity of the Buncefield site flows to the south
east but there are possibly some local variations or preferential flow along dry
valleys that may put Bow Bridge, Mud Lane/Holywell and Hunton Bridge pumping
stations at a higher risk of contamination.
Monitoring
44 Ground water and ground water abstraction boreholes have been monitored
up to 9 km surrounding the site. These include six pumping stations operated by
Three Valleys Water Company, two private boreholes and a number of Environment
Agency monitoring sites.
45 Three new observation boreholes have been drilled closer to the Buncefield site
to provide early detection of any ground water pollution: Butlers Farm (between
Buncefield and Bow Bridge Pumping Station); Breakspear House (south of
Buncefield); and Hogg Lane (on the east boundary of Buncefield see Figure 16).
This is part of an ongoing monitoring regime that will provide further boreholes
surrounding the site. They have each been sampled once, along with drinking
water boreholes, and analysed for pollutants.
Figure 15 Picture of
Maylands Tank outfall into
River Ver
14
15
Results of monitoring
46 It is too early to rule out potential contamination of the ground water, as it can
take many months or years for water to drain through the ground into the chalk
aquifer. Overall, the results received to date do not suggest any identifiable
contamination pattern which is directly attributable to pollution from the incident.
47 A limited number of results have indicated the presence, at limits just above
detection, of PFOS and other contaminants such as oil or polycyclic aromatic
hydrocarbons. These results need to be considered in relation to the overall
picture for the whole of the aquifer, especially as the ground-water flow has not
been established.
48 The 42 m deep borehole located on the Chevron/Texaco lorry park on the
Buncefield site, south of HOSL West has been sampled (see paragraph 28). Initial
results indicate fuel is present at low concentrations. It is not yet known if this
contamination is historic or a result of the incident. Investigations continue.
49 The four points of ground penetration around the perimeter of the site reported
in paragraph 29 are being investigated. Some of the chambers and deep
boreholes associated with these entry points may contain contaminants from the
incident.
Drinking water
50 The closest drinking water abstraction point to the Buncefield site is the Bow
Bridge pumping station approximately 3 km due east. Drinking water was not
being pumped from here prior to the incident and the station remains out of
operation as a precautionary measure. As a further safeguard, non-return valves
have been fitted to prevent any possible backflow of water from the site. Changes
have also been made to the supply arrangements to ensure drinking water
supplies are maintained. The other drinking water abstractions are located in a ring
around Buncefield at a distance of more than 5 km.
51 Water supply in the area is the responsibility of Three Valleys Water Company
which has the detailed operational knowledge required to manage the local
response. The regulation of drinking water quality is the responsibility of DWI.
52 Three Valleys Water Company and DWI are working closely together to ensure
that drinking water supplies remain of the highest quality. Water companies treat
and monitor the quality of water before it is distributed to the public as drinking
water, thus providing reassurance of its quality.
Land investigations
53 Investigations to assess the extent of land contamination started in February
2006 along Cherry Tree Lane. Trial pits were excavated at points along the Lane
and on site and a number of samples taken for laboratory analysis. The locations
of the trial pits are indicated in Figure 18.
54 The initial findings indicate that the surface layer of the soils, the top 30 cm
approximately, was contaminated with fuel and fire-fighting products. No visible
free product was detected in any of the trial pits at depth. PFOS, hydrocarbons
and polycyclic aromatic hydrocarbons have been reported in the laboratory
analysis.
16
56 The disposal of these fire waters is the responsibility of the oil companies. The
Environment Agency await definitive risk assessments from the companies on their
proposed best practicable disposal options to avoid risk of contamination of the
environment.
57 Rainfall will give rise to more contaminated water within the Buncefield site.
This will be contained on site before being safely removed.
18
19
74 Separately, work to ascertain why control of fuel was lost forms a continuing and
key part of the primary investigation.
Hertfordshire Constabulary
www.herts.police.uk/news/buncefield/main.htm
Hertfordshire Chamber of Commerce
www.hertschamber.com
Tel: 01727 813 680
Government links
Office of the Deputy Prime Minister
Fire and Resilience Directorate: www.odpm.gov.uk
Government Office for the East of England
www.go-east.gov.uk
Environment Agency
www.environment-agency.gov.uk
Department of Trade and Industry
Oil and Gas Directorate: www.og.dti.gov.uk
Health and Safety Executive
Hazardous Installations Directorate: www.hse.gov.uk/hid
Control of Major Accident Hazards: www.hse.gov.uk/comah
Department for the Environment, Food and Rural Affairs
www.defra.gov.uk
Health Protection Agency
www.hpa.org.uk
Food Standards Agency
www.food.gov.uk
Drinking Water Inspectorate
www.dwi.gov.uk
Industry links
United Kingdom Petroleum Industry Association (UKPIA)
www.ukpia.com
Tel: 020 7240 0289
Chemical Industries Association
www.cia.org.uk
Tel: 020 7834 3399
Other useful sources of information
Dacorum Borough Council Digest newsletter, available monthly
Dacorum Borough Council Buncefield Update Newsletter
22
To ensure the thorough investigation of the incident, the factors leading up to it,
its impact both on and off site, and to establish its causation including root
causes.
To identify and transmit without delay to duty holders and other appropriate
recipients any information requiring immediate action to further safety and/or
environmental protection in relation to storage and distribution of hydrocarbon
fuels.
To examine the Health and Safety Executives and the Environment Agencys
role in regulating the activities on this site under the COMAH Regulations,
considering relevant policy guidance and intervention activity.
To work closely with all relevant stakeholders, both to keep them informed of
progress with the investigation and to contribute relevant expertise to other
inquiries that may be established.
To produce an initial report for the Health and Safety Commission and the
Environment Agency as soon as the main facts have been established.
Subject to legal considerations, this report will be made public.
23
Crown copyright
all rights reserved,
HSE 100021025 2006
24
Glossary
The Health and Safety Commission (HSC) is responsible for health and safety
regulation in Great Britain. The Health and Safety Executive and local authorities are
the enforcing authorities who work in support of the HSC. Both are statutory
bodies, established under the Health and Safety at Work etc Act 1974.
The Environment Agency is the lead regulator in England and Wales with
responsibility for protecting and enhancing the environment. It was set up by the
Environment Act 1995 and is a non-departmental public body, largely sponsored
by the Department for Environment, Food and Rural Affairs (DEFRA) and the
National Assembly for Wales (NAW). The Environment Agencys prime
responsibilities include flood risk management, tackling pollution incidents, reducing
industrys impact on the environment, restoring and improving rivers, coastal
waters, contaminated land, and wildlife habitats. The Environment Agency also
advises on sustainable drainage, water conservation and management, planning
issues, nature conservation and waste management.
aquifer
borehole
bund
COMAH
COMAH sites
Competent
Authority
containment
contaminants
foam
concentrate
fire water
hazard
hydraulic
pressure
hydrocarbon
Northgate
outfall
PFOS
Polycyclic
A group of chemicals commonly found in residues from burning
aromatic
coal, fuel and oil
hydrocarbons
and compounds
26
pool fire
primary
containment
The equipment and facilities which have direct contact with the
products under normal containment (eg tanks and pipe work),
and their operation and management
Prohibition
Notice
risk
safety reports
secondary
containment
surface water
Water that sits or flows above land, including lakes, seas, rivers
and streams
surfactant
tertiary
containment
watercourses
Contents
Foreword 3
Introduction 4
Timeline of events
11
18
20
Annexes
1 Memo to Area PIR Team Leaders from Martin Bigg, Head of Industry
Regulation, Environment Agency dated 10 April 2006 21
2 Further information 23
3 Investigation terms of reference 25
4 Site maps 26
Glossary 27
Foreword
This is my third progress report into the explosions, fires and aftermath at
Buncefield. In this report I am able to explain with reasonable clarity and confidence
that Tank 912 in bund A on the Hertfordshire Oil Storage Ltd (HOSL) West site
overflowed at around 05.30 hours on 11 December while being filled at a high rate.
The environmental conditions, flow rate of fuel, and physical configurations of the
tank top and wall provide a suitable mechanism for rapid formation of a fuel-rich
vapour that flowed off site following the ground topography.
As the vapour flowed off site, driven by gravity and the formation of more vapour in
bund A, it would have mixed with more air and by the time it reached the Fuji and
Northgate car parks, may have become an almost ideal flammable mixture.
Several likely sources of ignition are discussed, a primary one on site and another
in the Northgate car park. The explosion sequence is also discussed, but here
there is far less confidence in the mechanism for the high overpressures seen and
modelling of this may take some time. Nonetheless I believe the most important
facts leading up to the explosions at Buncefield are known with reasonable
confidence and they are presented below.
Updates are also given on environmental issues, and on further contacts with local
businesses and residents, though the main focus is on the important information
about how fuel escaped and vaporised leading to the explosions.
The ongoing investigation and other work are briefly described.
Taf Powell
Buncefield Investigation Manager and Member of Buncefield Major Incident
Investigation Board
Introduction
1 This report describes where and how fuel escaped from storage at the
Buncefield Oil Storage Depot on 11 December 2005 and how it vaporised, forming
a flammable mixture that subsequently ignited at around 06.00 that morning with
devastating consequences. It summarises the work carried out to analyse the
electronic records that were recovered from site and experimental work undertaken
by the Health and Safety Laboratory (HSL) to explain what happened to the fuel
after it was released. So the heart of this report is a narrative, setting out the
sequence of events leading up to the explosions.
2 For the complete picture of what is now known, this report should be read in
conjunction with its predecessors, the details of which are not repeated here (see
www.buncefieldinvestigation.gov.uk). The first progress report, published on
21 February, described in some depth the incident and emergency response. It
concluded that the escape of fuel came from the area around bund A at the north
west of the site and set out what was then known about the nature of the
explosions and fire. The second progress report, published on 11 April, focused
mainly on the environmental impact of the incident, and reported on the failure of
some of the bunds to contain the fuel, foam and fire run-off water. It also set out
the measures in hand to monitor any potential pollution levels.
Figure 1 Layout of
depot and surroundings
3 The values and other data presented in this report are subject to ongoing
rechecking as is usual in an investigation of this kind. They are presented as
indicative and should be used in that context.
Lagoon
Bund A
N
Catherine
House
Thre
eC
her
ry
Tre
e
sL
Fircones
an
Tank 12
The
Cottage
Fuji
building
Buncefield Lane
Boundary Way
Keystone
House
High Grange
Ch
err
yT
ree
La
ne
Bund B
Tank
912
Local area
features
3-Com
building
0
50
100
150
British
Pipelines
Agency
e
Lan
eld
cefi
Bun
Site features
Boundary Way
Buncefield
depot sites
Northgate
building
RO
building
Loading
gantry
Timeline of events
10 December 2005
Around 19.00, Tank 912 in bund A at the HOSL West site started receiving
unleaded motor fuel from the T/K South pipeline, pumping at about 550 m3/hour
(flow rates are variable within limits).
11 December 2005
At approximately midnight, the terminal was closed to tankers and a stock check
of products was carried out. When this was completed at around 01.30, no
abnormalities were reported.
From approximately 03.00, the level gauge for Tank 912 recorded an unchanged
reading. However, filling of Tank 912 continued at a rate of around 550 m3/hour.
Calculations show that at around 05.20, Tank 912 would have been completely
full and starting to overflow. Evidence suggests that the protection system which
should have automatically closed valves to prevent any more filling did not
operate.
From 05.20 onwards, continued pumping caused fuel to cascade down the side
of the tank and through the air, leading to the rapid formation of a rich fuel/air
mixture that collected in bund A.
At 05.38, CCTV footage shows vapour from escaped fuel start to flow out of the
north-west corner of bund A towards the west. The vapour cloud was about 1 m
deep.
At 05.46, the vapour cloud had thickened to about 2 m deep and was flowing
out of bund A in all directions.
Between 05.50 and 06.00, the pumping rate down the T/K South pipeline to
Tank 912 gradually rose to around 890 m3/hour.
By 05.50, the vapour cloud had started flowing off site near the junction of
Cherry Tree Lane and Buncefield Lane, following the ground topography. It
spread west into Northgate House and Fuji car parks and towards Catherine
House.
At 06.01, the first explosion occurred, followed by further explosions and a large
fire that engulfed over 20 large storage tanks. The main explosion event was
centred on the car parks between the HOSL West site and the Fuji and
Northgate buildings. The exact ignition points are not certain, but are likely to
have been a generator house in the Northgate car park and the pump house on
the HOSL West site.
At the time of ignition, the vapour cloud extended to the west almost as far as
Boundary Way in the gaps between the 3-Com, Northgate and Fuji buildings; to
the north west it extended as far as the nearest corner of Catherine House. It
may have extended to the north of the HOSL site as far as British Pipelines
Agency (BPA) Tank 12 and may have extended south across part of the HOSL
site, but not as far as the tanker filling gantry. To the east it reached the BPA site.
5 The three pipelines all operated in a similar way by transporting fuel oils and
motor spirit in discrete batches, of known volume, under pressure. These batches
were separated by an interface or buffer, which are small amounts of mixed
product. The volume of this interface mix varies dependant on the flow rate and
operating conditions prevalent while the product batches are being transported
through the pipeline.
6 On arrival at site, the batches of product were diverted into dedicated tanks for
each product type. The interface mix when it entered the site system, being a mix
of two products, was either re-injected in small quantities into the large tanks of
specific product if the product specification allowed, or it was transported back to
a refinery as slops for reprocessing.
7 The fuel stored in the tanks at Buncefield was then either transported off site in
road tankers for distribution, or in the case of the majority of aviation fuel, via two
BPA-operated 6 pipelines to London airports.
eight vents
for ullage void
servo level
gauge
independent ultimate
high level switch
ventilated
ullage void
liquid level
reference
flexible seal at
clearance gaps
thermowell
pocket for
temperature probe
PETROL
12 Figure 2 depicts the basic layout of Tank 912. This was a floating deck tank
whereby in addition to the fixed roof, there is a deck inside the tank which floats on
the fuel, thus minimising the emission of vapour from the fuel surface.
16 The tank also had an independent safety switch, which provided the operator with a
visual and audible alarm in the control room when the level of liquid in the tank reached
its specified maximum level (the ultimate high level). This alarm also initiated a trip
function to close valves on relevant incoming pipelines. The ultimate high level safety
switch on the tank sensed when the liquid reached its specified maximum level, should all
other alarms and controls fail to prevent this. Its purpose was to provide an alarm to
operators in the control room and to initiate automatic shutdown of delivery once the
maximum level was reached. The switch was intended to alert the control room operator
via a flashing lamp (one for each tank) and an audible buzzer. In addition, the ultimate
high level safety switch alarm signal from any overflowing tank in HOSL West would be
sent to computer control and instrumentation relating to both the FinaLine and BPA
pipelines.
17 When the BPA site received an alarm/trip signal from the HOSL West site, the BPA
computer control system should have closed the relevant pipeline manifold valve feeding
in product to the tank(s) on the HOSL West site. BPA also had a high-level supervisory
control and data acquisition (SCADA) system, which had the facility for alarm and event
logging both locally at Buncefield and remotely at the BPA control centre at Kingsbury,
Warwickshire.
18 An override keyswitch in the HOSL West control room could be used to inhibit the
alarm/trip signal to BPA during testing of the ultimate high level safety switches. Putting
the keyswitch in the override position would illuminate a red lamp on the annunciator
panel.
29 CCTV records from the HOSL West site show the first appearance of a mist
from Bund A at about 05.38, supporting the view that the overflow began at
around 05.20. For most of the time between the onset of loss of containment and
ignition, the flow rate from vents would have been around 550 m3/hour.
Approximately seven minutes before the incident, shutting down of the flow from
the BPA line to Kingsbury led to a sharp increase in the rate of delivery to
Buncefield with a corresponding increase in the overflow rate.
30 To simulate a loss of containment from Tank 912, a full-scale model of one
eighth of the whole tank top, including one of the breather vents, has been built at
HSL in Buxton, Derbyshire (see Figure 4). It includes a deflector plate at the edge
of the tank top, visible in the third and fourth pictures in Figure 4. The original plate
was designed to direct water from sprinklers on the top of the tank onto the sides
of the tank to provide cooling in the event of fire engulfment. Liquid running off the
top of the tank strikes this plate and is directed back onto the side of the tank.
31 Considerable work has been carried out on this model, pumping water through
the breather hole at a flow rate equivalent to 550 m3/hour for an entire tank top.
These flows are sufficiently high that differences in viscosity and surface tension
between water and petrol will make little difference to the results as regards
observing initial flow behaviour.
Figure 4a-d Liquid flow from the breather holes on the tank top
Figure 4a
Figure 4b
10
32 These tests demonstrate that the deflector plate was effective in channelling
the majority but not all of the liquid onto the tank wall, but only spread it laterally
over approximately one third of the wall. Images captured from video records are
shown in Figure 4.
Figure 4c
Figure 4d
11
deflector
plate
wind
girder
impact
zone
12
37 The conclusion of this work is that the flow is likely to be very efficiently
fragmented, and would create relatively small droplets falling freely through air
around the tank. These conditions would promote the evaporation of the lighter
chemical components of petrol, eg butanes, pentanes and hexanes.
38 The free fall of fuel droplets through the air also leads to entrainment of air and
mixing between the air and fuel vapour. Calculations based on a simplified
composition of unleaded petrol suggest that the ambient air already at 0 oC and fully
saturated with water vapour, would have cooled below zero by a further 7-8 oC from
fuel evaporation. As a result, roughly half the initial water content of the air would
precipitate as an ice mist, and this mist would persist even as the vapour is diluted.
This is consistent with the cloud of mist highly visible on CCTV cameras. It supports
the contention that the mist can be used as an indicator for determining the size of
the fuel/air vapour mixture created by the overfilling and how it was dispersed.
HOSL East site. This is a little way beyond the extent of the burn damage shown in
Figure 6. According to witnesses, the depth of the visible mist varied from about
1 m in the area between bund A and the loading gantry to between 5 and 7 m in
Three Cherry Trees Lane.
41 In addition to defining the overall extent and location of the flammable vapour
cloud, dispersion modelling is being used to analyse how concentrations of
hydrocarbons vary within the cloud. In the meantime some features of dispersion of
the hydrocarbon-rich vapour can be deduced from observations of burn damage at
the site. Figures 7 and 8 illustrate this.
42 The telegraph pole shown in Figure 7 is in Buncefield Lane relatively close to the
wall of bund A containing Tank 912. The bottom part of the pole shows soot
blackening, characteristic of objects exposed to burning of a very rich vapour
mixture. Video records of the fire confirm that this area was not affected by the
smoke plume during the fire.
43 The tree trunk in the Northgate car park shown in Figure 8 is much further from
the site and has been exposed to an explosion propagating in a more dilute vapour
mixture with a composition close to the optimum for complete combustion. There is
no soot on exposed surfaces but the left-hand side facing the camera has been
deeply abraded by grit driven into it at high speed by the explosion. Examples of
this kind of damage were found across most of the area covered by the Northgate
and Fuji car parks.
44 Such observations of burn damage support the conclusion that additional air
mixed with the rich vapour as it flowed out across the Northgate and Fuji car parks.
This reduced the vapour concentration to the point where it could support an
explosion.
13
14
52 Other sources of ignition cannot be ruled out, given that off site there would
have been no precautions in place to control ignition sources. There is also the
possibility that there were near-simultaneous ignitions at a number of locations.
7001000 mbar in the Northgate and Fuji car parks, leading to extensive
damage to adjacent buildings;
decaying to 710 mbar at 2 km distant, causing breakage of some windows in
local homes and premises.
Fircones
N
sL
an
Lagoon
The
Cottage
Tank 12
Buncefield Lane
Fuji
building
Boundary Way
Keystone
House
High Grange
Bund B
Ch
e
r ry
Tree
s
Lane
50
0
3-Com
building
e
Lan
eld
cefi
Bun
Boundary Way
100
150
Northgate
building
Bund A
RO
building
HOSL
west
Loading
gantry
HOSL
east
British
Pipelines
Agency
15
16
75 PFOS concentrations started to drop in the River Ver in the middle of January,
one month after the incident, to below detectable levels in February. Occasionally,
low concentrations of surfactants are found in the River Ver. The flow of water from
the Maylands outfall stopped in February. The Redbourn outfall started to flow in
February, with low concentration of PFOS, feeding into the River Ver. The
Maylands tank contains low PFOS concentrations. Results to date indicate the
levels to be generally below the DWI advisory limit (3 micrograms/litre).
76 PFOS has been identified at all monitoring points, including during a survey on
the River Colne. The PFOS concentrations, however, have not exceeded the DWI
advisory limit and no identifiable environmental consequences have been observed
in the river habitat. More recently, fluoro-surfactants (other than PFOS), which may
be associated with fire-fighting foam, have been detected in the river at low
concentrations.
18
84 The current storage does not present a significant environmental risk and
measures are in place to protect the environment.
85 In response to the significant loss of primary and secondary containment
after the incident, the Environment Agency issued specific advice to its officers to
ensure that operators have assessed and provided suitable containment, primarily
bunding (secondary containment) at fuel depots over the next three months.
Some of these investigations will take place at the same time as Competent
Authority (HSE and Environment Agency) investigations, following the safety alert
issued to industry by HSE following publication of the first progress report
(see www.buncefieldinvestigation.gov.uk). A copy of the Environment Agency
advice is at Annex 1.
19
20
Annex 1
Memo to Area PIR Team Leaders from Martin Bigg,
Head of Industry Regulation, Environment Agency dated
10 April 2006
BUNCEFIELD INVESTIGATION UPDATE 11 April 2006
ENVIRONMENT REVIEW AT OIL/FUEL STORAGE SITES
Introduction
On 11 April 2006 the Buncefield Major Incident Investigation Board (BMIIB) will
publish its second progress report on the investigation. This memo identifies
actions to be taken by Environment Agency staff with responsibility for the
regulation of oil/fuel storage sites under the COMAH Regulations.
At this stage nothing can be said in relation to the causes leading to the loss of
primary containment. Some information relating to issues of secondary and tertiary
containment will be made available, though it is recognised that not all the details,
which would be normally be used to inform inspections, will be available.
Given this situation, at this stage, our actions should be limited to a basic risk
assessment of the secondary and tertiary containment measures across the sector,
with the aim of identifying those sites with obvious basic deficiencies. This basic
risk screening will inform further inspection and actions when conclusions from the
Buncefield investigation are known.
Second progress report
In summary the BMIIB second progress report raised the following points regarding
secondary and tertiary containment:
Secondary containment
I
I
I
I
Tertiary containment
I
Following loss of containment, fuel and fire water found numerous pathways
into the environment. These included a number of shallow boreholes and one
deep borehole within the site and flow across site roadways and overtopping of
kerbs onto public roads and consequent escape via surface water gullies.
Are the tanks holding oil/fuel within a bund or bunds of such integrity that they
would contain any leak of the tank and fire water, and prevent loss including
into the ground?
21
I
I
I
I
I
Is the bund capacity at least 110% of largest tank in the bund or at least 25% of
all the tanks in the bund?
Is the bund capable of holding the significant volumes of imported fire water
used during an incident for either direct fire fighting and/or cooling of adjacent
tanks?
Is the bund design sufficiently robust to remain serviceable following a pool fire
that may last for a considerable period of time? This assessment should take
account of whether sealants1 and waterstops2 have been used as part of the
construction and expansion joints.
Is there any pipework penetrating the bund which could cause the containment
to fail including when subject to fire?
Given that pumps and powered valves will be lost if site power is lost due to fire
or explosion, the behaviour of liquids flowing under gravity should be
considered. This includes the loss of liquids from secondary containment. Has a
study been made of the directions and volumes of flow and are provisions in
place to contain these liquids within the boundaries of the site?
Has an assessment been made of drainage paths to the environment and are
the plans available to the off-site emergency response teams? This should
include all on-site and near-off-site drainage and its relationship to the surface
water systems, geology and hydrogeology.
Please contact Mark Maleham (Tel: 0117 914 2813) if clarification is required.
Martin G Bigg
Head of Industry Regulation
22
Waterstops are preformed strips of durable impermeable material that are wholly or
partially embedded in the concrete during construction. BS 8007: 1987 Code of practice
for design of concrete structures for retaining aqueous liquids British Standards
Institution ISBN 0 580 16134 X
23
Hertfordshire Constabulary
www.herts.police.uk/news/buncefield/main.htm
Hertfordshire Chamber of Commerce
www.hertschamber.com
Tel: 01727 813 680
Government links
Office of the Deputy Prime Minister
Fire and Resilience Directorate: www.odpm.gov.uk
Government Office for the East of England
www.go-east.gov.uk
Environment Agency
www.environment-agency.gov.uk
Department of Trade and Industry
Oil and Gas Directorate: www.og.dti.gov.uk
Health and Safety Executive
Hazardous Installations Directorate: www.hse.gov.uk/hid
Control of Major Accident Hazards: www.hse.gov.uk/comah
Department for the Environment, Food and Rural Affairs
www.defra.gov.uk
Health Protection Agency
www.hpa.org.uk
Food Standards Agency
www.food.gov.uk
Drinking Water Inspectorate
www.dwi.gov.uk
Industry links
United Kingdom Petroleum Industry Association (UKPIA)
www.ukpia.com
Tel: 020 7240 0289
Chemical Industries Association
www.cia.org.uk
Tel: 020 7834 3399
Other useful sources of information
Dacorum Borough Council Digest newsletter, available monthly
Dacorum Borough Council Buncefield Update Newsletter
24
To ensure the thorough investigation of the incident, the factors leading up to it,
its impact both on and off site, and to establish its causation including root
causes.
To identify and transmit without delay to duty holders and other appropriate
recipients any information requiring immediate action to further safety and/or
environmental protection in relation to storage and distribution of hydrocarbon
fuels.
To examine the Health and Safety Executives and the Environment Agencys
role in regulating the activities on this site under the COMAH Regulations,
considering relevant policy guidance and intervention activity.
To work closely with all relevant stakeholders, both to keep them informed of
progress with the investigation and to contribute relevant expertise to other
inquiries that may be established.
To produce an initial report for the Health and Safety Commission and the
Environment Agency as soon as the main facts have been established.
Subject to legal considerations, this report will be made public.
25
Crown copyright,
all rights reserved,
HSE 100021025 2006
26
Glossary
The Health and Safety Commission (HSC) is responsible for health and safety
regulation in Great Britain. The Health and Safety Executive and local authorities are
the enforcing authorities who work in support of the HSC. Both are statutory
bodies, established under the Health and Safety at Work etc Act 1974.
The Environment Agency is the lead regulator in England and Wales with
responsibility for protecting and enhancing the environment. It was set up by the
Environment Act 1995 and is a non-departmental public body, largely sponsored
by the Department for Environment, Food and Rural Affairs (DEFRA) and the
National Assembly for Wales (NAW). The Environment Agencys prime
responsibilities include flood risk management, tackling pollution incidents, reducing
industrys impact on the environment, restoring and improving rivers, coastal
waters, contaminated land, and wildlife habitats. The Environment Agency also
advises on sustainable drainage, water conservation and management, planning
issues, nature conservation and waste management.
ATG
bund
COMAH
Regulations
COMAH sites
Competent
Authority
containment
contaminants
fire waters
hazard
hydrocarbon
Northgate
Overpressure
PFOS
Perfluorooctane sulphonate
27
28
Prohibition
Notice
risk
safety reports
SCADA system
servo level
gauge
ullage
wind girder
BUNCEFIELD
MAJOR INCIDENT
INVESTIGATION
Initial Report to the Health and Safety Commission and
the Environment Agency of the investigation into the
explosions and fires at the Buncefield oil storage and
transfer depot, Hemel Hempstead, on 11 December 2005
Buncefield Major Incident Investigation Board
BUNCEFIELD
MAJOR INCIDENT
INVESTIGATION
Initial Report to the Health and Safety Commission and
the Environment Agency of the investigation into the
explosions and fires at the Buncefield oil storage and
transfer depot, Hemel Hempstead, on 11 December 2005
Buncefield Major Incident Investigation Board
ii
Contents
Executive summary
iv
Introduction 1
Part 1 Summary of the incident and subsequent Investigation 5
M Overview of Buncefield operations 5
M Timeline of key events 7
M Emergency response to the Buncefield incident 10
M The Investigation 11
Part 2 Issues of concern arising from the Investigation to date
M Design and operation of storage sites 18
M Emergency response to incidents 21
M Advice to planning authorities 23
18
Annexes
1 Terms of reference and progress 24
2 Members of the independent Board 27
3 Planning history of Buncefield site and neighbouring developments
4 UK petroleum refinery, pipeline and storage system 35
5 Incidents that have similarities with the Buncefield incident 37
6 Fire and explosion hazards from petrol 39
7 Product composition at Buncefield 44
8 Regulatory framework for high hazard sites 46
9 Regulation of perfluorooctane sulphonates (PFOS) 49
10 Legal considerations 51
Glossary
28
54
Further information 58
iii
iv
Executive summary
The terms of reference of the Investigation directed by the Health and Safety
Commission into the explosions and fires at the Buncefield oil storage and transfer
depot, Hemel Hempstead, on 11 December 2005 require an initial report to be
produced for the Health and Safety Commission and the Environment Agency
when the main facts of the incident have been established.
The independent Board set up to supervise the Investigation has previously
published three Progress Reports submitted to the Board by the Investigation
Manager. The Initial Report presents the Boards view that enough of the facts
have been established, as described in the Progress Reports, to set out with
reasonable confidence the sequence of events leading to the incident on
11 December. This also allows the Board to identify several issues of concern for
the effective regulation of fuel storage sites such as Buncefield.
This does not however lessen the need for effective secondary and tertiary
containment (bunds and drains, mainly) that prevent pollutants from escaping the
site and contaminating the environment should primary containment be lost.
Emergency response to incidents
Overall, the response to the incident was very impressive. The incident has
highlighted the need to have effective emergency arrangements, both on and off
site, in the event of a major incident of this kind. Lessons from Buncefield provide
a very important opportunity to bring about improvements in emergency
preparedness of resilience groups throughout Britain, and further afield. There are
a number of reviews into the effectiveness of the emergency response to Buncefield
being carried out by the agencies concerned, and the Board intends to return to
this important area in the future.
Advice to planning authorities
The Buncefield incident poses fundamental questions about residential and
commercial developments around sites like Buncefield. Continuing uncertainty in
this area creates serious problems for local communities, particularly those directly
affected by the Buncefield incident. This is a complex issue requiring a balance to
be made between the risks and benefits of development. The Board intends to
address these issues in detail once the preliminary conclusions of HSEs current
review of its advice to planning authorities are known.
A measured approach is justified since the likelihood of a similar explosion
remains low, and should be made lower still by a programme of actions designed
to increase the reliability of primary containment. In our view, the importance of
reaching conclusions that are considered, costed and sustainable greatly outweighs
any benefit that might be derived from coming to summary judgements.
Introduction
1 This report is the initial report required by the terms of reference of the
Investigation into the explosions and fires at the Buncefield oil storage and transfer
depot, Hemel Hempstead, Hertfordshire on 11 December 2005.1 The Investigation
was directed by the Health and Safety Commission (HSC) using its powers under
section 14(2)(a) of the Health and Safety at Work etc Act 1974.
2 The Investigation is being carried out jointly by the Health and Safety
Executive (HSE) and the Environment Agency. HSC appointed an independent
Investigation Board, chaired by Lord Newton of Braintree, to supervise this
investigation.2 This report has been prepared by the Investigation Board, based on
information arising from the continuing HSE/Environment Agency Investigation.
Throughout the Investigation, the Board has been supplied with Progress Reports
from the Investigation Manager, Taf Powell, which the Board has published.3
3 This report does not repeat all the material contained in the Progress Reports,
which should be read for a fuller understanding of the Investigation up to May
2006. Part 1 summarises, and updates where necessary, key points of the
Investigation for completeness and to aid in understanding the Investigation
Boards initial conclusions set out in Part 2. The Board has included significant
new findings from the Investigation that have emerged since the publication of the
Third Progress Report on 9 May. Other new material is contained in the annexes
to this report.
4 The Investigation terms of reference require an initial report to be submitted to
HSC and the Environment Agency as soon as the main facts of the incident have
been established. The Investigation is still continuing. Nevertheless, the
Investigation Board considers that, with publication of the Third Progress Report
in May, enough facts have been established to set out with reasonable confidence
the sequence of events leading to the incident on 11 December. In particular,
enough is known for the Board to be able to identify several issues of concern for
the effective regulation of fuel storage sites such as Buncefield. As well as the main
facts of the incident, the Board has included in Part 2 of this report its emerging
thoughts about future action to address these issues of concern.
5
The full terms of reference are reproduced in Annex 1. Term of reference 6 requires an
initial report.
The Members of the Investigation Board are listed in Annex 2.
Details of the three published Progress Reports are contained in Further information.
2
3
9 The three pipelines all transported fuel products in discrete batches, separated
by an interface or buffer of mixed product. At the terminal, the operators
monitored the arrival of the various grades of fuel and separated them out into
dedicated tanks by fuel type. The interface of mixed fuel was diverted to special
small tanks to be reinjected into the main large storage tanks, if the fuel
specification allowed, or transported back to the refinery as slops for re-refining.
5
6
Details of the three published Progress Reports are contained in Further information.
These reports have not been revised to take account of more recent findings.
Texaco Limited became Chevron Limited on 3 July 2006.
The regulatory framework for high hazard sites, including the main requirements of
COMAH, is summarised in Annex 8.
Catherine
House
Three Cherry
Trees Lane
Lagoon
Pumphouse
Tank 12
Bund B
Boundary
Way
Cherry Tree Lane
Bund A
Fuji
building
12
915
913
912
Northgate
building
910
914
911
6
8
5
7
3-Com
building
Lagoons
303
304
301
302
loading
gantry
Buncefield
Lane
Nursery
Hertfordshire Oil
Storage Ltd (west)
Hertfordshire Oil
Storage Ltd (east)
Shell UK Oil Ltd
until April 2003.
Consent remains
British Petroleum
Oil UK Ltd
Boundary Way
British Pipeline
Agency (south)
British Pipeline
Agency (north)
100 m
200 m
10 The separated products left the depot either by road tanker or, in the case of the
majority of aviation fuel, via two dedicated pipelines from the British Pipeline
Agency Limited main site into the West London Pipeline system, which supplies
Heathrow and Gatwick Airports. Tankers operating from Buncefield were of 44 or
18 tonnes capacity and were increasingly operated by specialised transport operators.
Calculations show that at around 05.20 Tank 912 would have been completely
full and starting to overflow. Evidence suggests that the protection system
which should have shut off the supply of petrol to the tank to prevent
overfilling did not operate. From this time onwards, continued pumping caused
fuel to cascade down the side of the tank and through the air, leading to the
rapid formation of a rich fuel/air mixture that collected in Bund A.
At 05.38 vapour from the escaping fuel is first visible in CCTV footage from a
camera looking down the western edge of Bund A, flowing out of the northwest corner of Bund A towards the west.7
At 05.46 the vapour cloud had thickened to a depth of about 2 m and was
flowing out of Bund A in all directions.
By 05.50 the vapour cloud had started flowing off site near the junction of Cherry
Tree Lane and Buncefield Lane, following the ground topography. It spread west
into Northgate House and Fuji car parks and towards Catherine House.
Between 05.50 and 06.00 the pumping rate down the T/K pipeline to
Hertfordshire Oil Storage Limited West, and onwards to Tank 912, gradually
rose to around 890 m3/hour.
By 06.01 the vapour cloud extended to the west almost as far as Boundary Way
in the gaps between the 3-Com, Northgate and Fuji buildings; to the north-west it
extended as far as the nearest corner of Catherine House. It probably extended to
the north of the Hertfordshire Oil Storage Limited site as far as Tank 12, operated
by British Pipelines Agency Limited, and probably extended south across part of
the Hertfordshire Oil Storage Limited site, but not as far as the tanker filling
gantry. To the east it reached the British Pipeline Agency Limited site.
At 06.01 the first explosion occurred, followed by further explosions and a
large fire that engulfed over 20 large storage tanks. The main explosion event
appears to have been centred on the car parks between the Hertfordshire Oil
Storage Limited West site and the Fuji and Northgate buildings.
Timings deduced from CCTV footage have been corrected for any inaccurate setting of
the CCTV timers.
12 December 2005
Noon. Peak of the fire. 25 Hertfordshire pumps were on site with 20 support
vehicles and 180 fire-fighters.
There was some loss of secondary containment, as the bunds were unable to
fully contain the escaped fuel and water used in fire-fighting (known as firewater), which overtopped (ie spilled over the top of) the bund walls.
14 December 2005
HSE assumed control of the Investigation from Hertfordshire Constabulary.
M
M
Damage to bunds caused by the intense heat of the fire caused significant loss
of secondary containment on the Hertfordshire Oil Storage Limited West and
British Pipeline Agency Limited sites. There was also extensive loss of tertiary
containment at the site boundaries and large amounts of contaminated liquids
escaped off site. The fire service recovered as much of the contaminated run off
as possible, but was unable to prevent contamination of groundwater and
surface water.
15 December 2005
Fire all out declared by the Fire Service.
M
M
786 000 litres of foam concentrate and 68 million litres of water (53 million
clean and 15 million recycled) were used overall to contain the incident
during the period of fire-fighting operations.
Strategic Co-ordinating Group (Gold command) convened for the last time.
16 December 2005
The on-site investigation started (the preliminary planning and information
gathering had commenced earlier). HSE issued notices to secure the site, to
ensure both that evidence was left undisturbed and that clean up operations
were conducted safely. Key parts of the site remained too dangerous for
investigators to access for weeks or months.
18 December 2005
M Hertfordshire Oil Storage Limited started surveying roads and buildings on the
site.
Monitoring by the Meteorological Office showed that the visible plume was mainly
black carbon (soot). Full details of the plume and related air quality monitoring
arrangements are given in the Department for the Environment, Food and Rural
Affairs Initial review of the air quality aspects of the Buncefield oil depot explosion,
available at www.defra.gov.uk/environment/airquality/buncefield/index.htm.
20 December 2005
M HSC formally directed HSE and the Environment Agency to investigate the
incident and to make a special report. HSE appointed Taf Powell, Director of
HSEs Offshore Division, to be the Investigation Manager. HSC also
announced the appointment of an independent Board to supervise the
Investigation.
M
The control room on the Hertfordshire Oil Storage Limited West site was
sufficiently structurally sound to allow entry for gathering records and other
evidence.
23 December 2005
M The Investigation team, with assistance from Hertfordshire Constabulary and
Hertfordshire Fire and Rescue Service, recovered computers from damaged
offices and placed them in safe storage.
5 January 2006
M Hertfordshire Fire and Rescue Service handed control of the site over to the
Investigation team. Hertfordshire Constabulary and Hertfordshire Fire and
Rescue Service continued to give invaluable support to the Investigation team
that was working to gather and secure evidence.
12 January 2006
M HSC appointed Lord Newton of Braintree to chair the independent Board.
February 2006
M All fire-water had been removed from site and stored, pending safe disposal.
The area around the loading gantry had been made safe for access and tankers,
which were present at the time of the incident, were removed.
M
M
Strategic - Gold
Tactical - Silver
Operational - Bronze
12 The emergency services (primarily the Fire and Rescue Service and the police)
led the initial response to the incident and its immediate aftermath. Representation
of all agencies deployed to resolve the Buncefield incident was established through
a meeting process known as the Strategic Co-ordinating Group, also known as
Gold command. This included the Environment Agency as a Category 1 responder
under the Civil Contingencies Act 2004.10 The Strategic Co-ordinating Group
made decisions to ensure that the implementation of strategic aims was delivered
by the tactical (Silver) and operational (Bronze) commands.
13 The Strategic Co-ordinating Group had its first multi-agency meeting at 09.00
on 11 December at Hertfordshire Police Headquarters, chaired by the Police
Strategic Co-ordinating Group Commander. A decision was made at this meeting
to evacuate those with damaged homes and workplaces, and to tell everyone in the
immediate vicinity to shelter go in, stay in, tune in.
14 The Strategic Co-ordinating Group remained in place until 18:30 on Thursday
15 December.
Disposal of fire-water
15 The contaminated fire-water was removed from the site during the first three
weeks following the fire, although an unknown quantity contaminated the surface
waters and groundwater. Following the event, further contaminated water resulting
from rainfall or cleaning operations was removed from the site by tanker and
stored along with the fire-water in a number of locations around the country.
16 The fire-water remains in temporary storage, and it is important for this matter
to be resolved. The Board understands that the decontamination of fire-water on
such an unprecedented scale may require the use of several processes to render the
water suitable for its return to the environment. The oil companies are developing
options to achieve this, which will be assessed by the Environment Agency to
ensure that they have the minimum impact possible on the environment.
17 On 21 June 2006, the Environment Agency was informed that some 800 000
litres of this contaminated water had been released inadvertently from storage into
a sewage treatment plant and thereafter into the River Colne, a tributary of the
River Thames. The Environment Agency launched an investigation with the
assistance of Thames Water Utilities Limited, who operate the storage facility and
associated sewage treatment works. This investigation has yet to be concluded.
10
10
The Investigation
18 Progress Reports 1-3 detail four key aspects of the Investigation, briefly
summarised below:
M
M
M
M
11
11
Fuel
cools
a s it
f a lls
Liquid fuel
gathers in bund
12
bund wall
Not to scale
CCTV. The fuel/air mixture and its accompanying ice mist were heavier than air
and so were initially contained within the bund. As the volume of the mixture
grew from the continuing overfilling of the tank, it flowed out of the bund,
dispersing and flowing off site. Further mixing with the air would have reduced the
vapour concentration to the point where significant volumes of the mixture could
support an explosion.12
27 Since publication of the Third Progress Report, further work to simulate the
overflow of liquid from the full height of Tank 912 has confirmed the pattern of
fuel dispersal and vaporisation shown in Figure 2.
The explosions
28 The Third Progress Report described a number of potential ignition sources of
the main explosion that occurred at 06.01 on 11 December. The prime candidate
appears to be an explosion within the emergency generator cabin on the south side
of the Northgate building; this is consistent with the site of the main explosion
event. However, further study of the CCTV evidence shows a sudden illumination
of the east face of the Fuji building, consistent with an explosion or a flash fire at
the location of the pumphouse to the east of the lagoon on the Hertfordshire Oil
Storage Limited West site. This illumination was recorded by a camera before it
was destroyed by the overpressure, suggesting that this explosion or flash fire
occurred before the main explosion at 06.01. The pumphouse is the subject of
continuing forensic investigation.
29 Much uncertainty remains about why the explosion was so violent, generating
overpressures of a magnitude much greater than current understanding of vapour
cloud explosions would predict. For example, a method in current use would
predict overpressures of 20-50 millibar (mbar) in the open areas of the Northgate
and Fuji car parks. The current best estimates of the overpressures that actually
occurred in these areas are of 700-1000 mbar, leading to extensive damage to
adjacent buildings. Annex 6 describes the mechanics of fire and explosion hazards
from fuels such as petrol, as currently understood.
30 Continuing work relevant to gaining a better understanding of the explosion
has included extensive sampling to identify the composition of the released fuels, as
well as to verify the product distribution throughout the depot. It shows that the
released fuel probably had a butane content of 10% and consequently would have
had a high vapour pressure, ie it would be capable of evaporating rapidly to
produce a flammable vapour. The total butane content is specified in the standard,
and depends on whether the product is winter or summer grade. For winter grade
petrol the vapour pressure limits are defined as 70-100 kiloPascals (kPa) and for
summer they are reduced to 45-70 kPa. See Annex 7 for further information about
standards and fuel composition.
31 Further research is needed to try to discover the actual mechanism for
generating the unexpectedly high overpressures seen at Buncefield. The Board
refers to this again in paragraph 76, and in relation to terms of reference 1 and 5
in Annex 1.
32 The number and severity of injuries at Buncefield was low compared to some
other major incidents involving explosions, and there were no fatalities. Annex 6
provides more information about explosion overpressures, and includes tables
which show the levels of damage or injury that would normally be expected to
result from different overpressures.
12
13
Environmental monitoring
Air quality
33 An initial report on the results of the air quality monitoring and the impact of
the plume on human health and vegetation was published by the Department for
the Environment, Food, and Rural Affairs (DEFRA) in May 2006.13 Overall, the
report concluded there are unlikely to have been widespread air quality impacts at
ground level due to pollutants emitted from the Buncefield fires. It went on to say
that overall it was concluded that the fire at Buncefield Oil Depot did not result in
substantial pollution of soil and grasses and that pollutant levels were, in general,
unexceptional and typical of UK urban environments.
34 The prevailing meteorological conditions at the time of the incident and the
high buoyancy of the smoke plume from the fire resulted in most of the plume
material reaching a high altitude in the atmosphere. It then dispersed over a wide
area with minimal mixing down to ground level.
Land investigations
35 Trial pits were excavated starting in February on and surrounding the site to
assess the impact on land. The initial findings indicate that the surface layer is
contaminated with fuel and fire-fighting products.
36 The extent and degree of the contamination of the land within the Buncefield
depot is continuing to be established. Many trial pits have been excavated to
investigate the soil beneath the concrete hardstanding and under the bases of the
bunds. All of this information will inform the continuing Investigation and allow
the Environment Agency to assess the oil companies proposed remediation of the
contamination when that is formally submitted to the Competent Authority.
Surface water and groundwater monitoring
37 Extensive surface water monitoring immediately following the incident was
carried out at a number of locations, as detailed in the Second Progress Report.
Monitoring will continue for the foreseeable future at these locations to determine
any long-term effects on the aquatic environment.
38 The Environment Agency started to monitor the groundwater under and
around the Buncefield site soon after the incident. This monitoring has shown that
there is contamination of the groundwater by fire-fighting products, fuels, and
fuel-related products. This has been reported in the previous Progress Reports and
on the Environment Agency website.
39 Following the detection of contamination, the Environment Agency reviewed
the sampling locations for the existing groundwater monitoring network (details of
which were reported in the Second Progress Report) and concluded that further
monitoring boreholes were required at specified locations. Some of the new
boreholes are already installed.
13
14
This report presents and summarises the air quality measurements made during the
Buncefield incident, and includes results obtained from targeted local monitoring,
measurements from long-term monitoring networks, the modelling undertaken by the
Meteorological Office, and emissions estimates of the pollutants from the fire.
See Further information for further details.
40 The new monitoring boreholes will ensure that the extent of pollution is
understood. Also, the increased groundwater monitoring network will improve the
understanding of flow and contaminant transport within the chalk aquifer.
41 In addition to the extensive sampling that is currently underway, the Environment
Agency is developing a groundwater conceptual model to assist in understanding the
movement of pollutants within the groundwater and aquifer so that it may assess the
likely extent of contamination. This model is a conceptual representation of the
environment (in this case an aquifer) and the interactions within it.
42 All of the above will aid the assessment of the impact of the contamination on
the environment and to human health. It will also assist in determining the best
solutions for the clean up of the groundwater and the aquifer.
Perfluorooctane sulphonates (PFOS)
43 Perfluorooctane sulphonates are a group of chemicals, collectively identified
as PFOS, which have been shown to be hazardous (persistent, bioaccumulative
and toxic). PFOS chemicals have been used in a diverse range of applications,
including as an additive to aid the spreading properties of fire-fighting foam.
PFOS does not appear to degrade in the natural environment. Due to this
stability, it has now become widespread both in humans and in the environment.
Annex 9 describes the environmental hazards presented by PFOS and the current
approach to its regulation.
44 PFOS was not routinely monitored and analysed in any surface water or
groundwater in the UK prior to the Buncefield incident. Sampling and analysis for
PFOS are not straightforward and until very recently there has been no recognised
recommended limit for PFOS levels in groundwater or drinking water against
which to assess any results.
45 PFOS was present in some of the foam used to combat the Buncefield fire. At
the start of the Buncefield incident, PFOS in the fire-water was recognised as an
important potential contaminant for land, surface water and groundwater. The
Environment Agency and others have sampled groundwater and surface water
extensively for PFOS and other contaminants both on and off site from soon after
the explosion. The Board notes that it is the responsibility of the local water
company to monitor the quality of drinking water (as opposed to groundwater and
rivers), and that the Drinking Water Inspectorate (DWI) regulates the activities of
water companies in relation to drinking water quality.
Results of monitoring
46 PFOS was detected in the Rivers Ver and Colne in the days immediately
following the incident, however, these levels dropped below the lowest threshold
detectable by the Environment Agency after a short period. Ongoing testing still
shows sporadic detection of PFOS in the rivers. No direct impact has been detected
either at the time or in the intervening months on fish or other aquatic species in
these waters. Only long-term monitoring will identify if there has been a lasting
environmental consequence of the presence of PFOS and its associated fluorinated
compounds.
47 Results to date (six months since the incident) of groundwater monitoring have
shown the presence of fuels, fuel-related products and residues from the firefighting foams in groundwater at a number of locations, but they are most
prevalent under and close to the site.
15
48 Although PFOS above the level of three microgrammes per litre (which is the
advisory level set by the DWI for PFOS in drinking water) has been detected in
environmental monitoring samples, these levels have not been detected in samples
of drinking water.
49 It could be many months before the full extent of the contamination of the
groundwater is known. The Environment Agency is working with DWI and the
local water supply companies to ensure that they are fully aware of sampling
results, and are able to act appropriately to safeguard public water supplies.
Further monitoring
50 In view of the apparent widespread occurrence of trace quantities of PFOS
around the Hemel Hempstead area, some apparently unconnected with Buncefield,
the Environment Agency is conducting a targeted national groundwater sampling
exercise to investigate the wider prevalence of PFOS and related compounds in
groundwater.
51 The initial monitoring programme is being carried out in the period April to
July 2006. Groundwater is being sampled at selected sites on the Environment
Agencys national groundwater monitoring network. A range of sites have been
selected in rural, urban and industrial areas. Some sites are where fire-fighting
foams may have been used, eg fire stations, airbases etc, while others are where
such use is not suspected. Approximately 150 sites will be sampled as a part of this
programme.
52 If perfluorosurfactant compounds are detected in groundwater, repeat sampling
will be carried out to verify the initial results and to investigate persistence. If
widespread detection occurs, the programme will be extended beyond July and, if
necessary, selected compounds added to the routine monitoring programme. A
similar sampling exercise is planned for surface waters to take place over the
period July to December 2006.
Notification to the European Commission
53 The Competent Authority (at Buncefield, jointly HSE and the Environment
Agency) is required under regulation 21(1) and (2) of the COMAH Regulations to
inform the European Commission of any major occurrence on a COMAH site.
HSE, on behalf of the Competent Authority, issued a short report on 10 March
2006 for inclusion on the Major Accident Reporting System. As further
information of international significance becomes known, the Competent
Authority will also pass this on to the European Commission and hence the
international community.
54 DEFRA has established threshold criteria defining a Major Accident To The
Environment (MATTE), based on Schedule 7 (part 1) of the COMAH Regulations.
The Environment Agency, using these criteria, has determined that the Buncefield
incident is a MATTE, and the Competent Authority has recently reported this to
the European Commission. This determination is based on the results of
Environment Agency monitoring of groundwater beneath and in the vicinity of the
Buncefield site, which has been shown to be contaminated with fuels and firefighting foam by-products. This area of contamination is deemed to extend over
the one hectare threshold described in the Regulations. The reporting of this
MATTE to the European Commission has no impact on the continued monitoring
and remediation programme that is already taking place.
16
17
60 We believe these, together with our examination of HSEs and the Environment
Agencys roles in regulating the activities on the Buncefield site, will form the
broad scope of our further work.
Primary means are the tanks, pipes and vessels that hold liquids, and the
devices fitted to them to allow them to be safely operated.
Secondary means are enclosed areas around storage vessels (often called
bunds), created usually by concrete or earth walls. Their purpose is to hold
any escaping liquids and any water or chemicals used in fire-fighting.
Tertiary means are things such as drains designed to limit the passage of
chemicals off site, raised kerbs to prevent liquids that have breached the
bunds from escaping into the general area around the site, etc.
62 The Board has already seen sufficient information from the Investigation to be
able to express an obvious, but nonetheless important opinion that safety, health
and environmental protection are of paramount importance at sites like Buncefield.
We would expect this point to be uppermost in the mind of the industry-chaired
task group recently convened by HSE to pursue improvements to safety and
environmental protection at fuel depots.
18
14
At Buncefield, the formation of a flammable vapour cloud at the tanker loading gantry,
as opposed to the tank storage areas, was considered by the Competent Authority and
site operators, but the level of off-site hazard this would pose was judged to be lower
than a large pool fire originating from the tank storage area.
19
M
M
the electronic monitoring of tanks and pipework, and associated alarms that
warn of abnormal conditions;
the detection of flammable vapours in the immediate vicinity of tanks and
pipework;
the response to the detection of abnormal conditions, such as automatic
closure of tank inlet valves and incoming pipeline valves;
the extent to which the exterior construction of tanks (eg tank top design)
inhibits, or contributes to, flammable vapour formation;
the siting and/or means of protection of emergency response facilities; and
the recording of monitoring, detection and alarm systems and their availability
(eg off site) for periodic review of the effectiveness of the control measures by
the operator and the Competent Authority, as well as in root cause analysis
should there be an incident.
72 Where a need for additional systems is identified, HSC and the Competent
Authority should satisfy themselves that current legal requirements are robust
enough, and supported with sufficient resources, to ensure that these systems are
provided and maintained at every fuel storage site where the risks require them,
without relying upon voluntary compliance. It has not been established whether
changes in the law or in the resources available to the Competent Authority are
required to achieve this end. The Board is, however, clear that the severity of the
Buncefield incident makes a compelling case for any such changes to be made as a
matter of very high legislative priority, should the need be identified.
20
15
Operators of oil storage depots should review their on-site emergency plans
and the adequacy of information they supply to local authorities to ensure
they take full account of the potential for a vapour cloud explosion, as well as
fires. From the forthwith actions taken by depot operators and the
Competent Authority in response to the Competent Authoritys Safety Alert of
21 February 2006, responsible operators should have already undertaken such
reviews. The Competent Authority must ensure that this is the case and work
with the industry to ensure that all learning is fully shared.
21
16
22
Given the huge cost of the Buncefield incident, it is essential not to miss any of
the lessons it has provided for emergency response. Like the response itself, this
is a multi-agency task that requires a clear lead. It will be part of the Boards
ongoing work to establish a clear picture of the lead provided by central
Government for first responders.
The public health impacts of Buncefield appear to have been minimal.
Nevertheless, the incident has revealed the importance of prompt, useful advice
to early responders such as the Fire and Rescue Services, and to the public.
There may also be scope to improve the co-ordination of sampling and
monitoring activities, particularly in the early stages of major incidents. The
Board welcomes the establishment of a Health Protection Agency-led working
group aiming to establish frameworks and agreed working practices for any
future post-incident environmental sampling, and awaits with interest the
results of this work. The Board also welcomes the steps being taken by the
Health Protection Agency to draw to the attention of regional resilience fora in
Britain the immediate lessons of Buncefield for the provision of health
protection advice during a major incident.
The local residential and business communities have interests to be considered,
eg the maintenance of employment and support in effecting a rapid return to
social normality. This appears to be both a regional and, on the scale of
Buncefield, a national issue. It is not clear to the Board how far emergency
planning arrangements have taken account of this aspect in the past. The
Secretary of State for Communities and Local Government, through the
Government Office for the East of England, recently established a task force to
investigate options for Government support to businesses and local economies
in the period following an exceptional disaster. This initiative is very welcome
and the Board hopes swift progress will be made in this work.
The low impact on public health of the Buncefield incident is an initial conclusion of the
Health Protection Agency. Their review of the health effects of the Buncefield fire is
available at www.hpa.org.uk/explosions/hemel.htm.
17
The history of development within a 3 km radius of the Buncefield depot site between
1966 and 2005 is shown in Figure 5, Annex 3.
23
Annex 1
Terms of reference and progress
This annex sets out the eight terms of reference for the Investigation and explains
the progress that is being made towards accomplishment of each of them.
The Chairman of the Buncefield Board wrote to the Chief Executive of the Health
Protection Agency on 3 July enquiring into progress with informing regional resilience
groups of early lessons learned from Buncefield, focusing on public health issues in
the immediate aftermath of a major airborne incident.
3 To examine the Health and Safety Executives and the Environment Agencys
role in regulating the activities on this site under the COMAH Regulations,
considering relevant policy guidance and intervention activity
Work is progressing steadily on both parts of the review, concerning respectively
HSEs and the Environment Agencys prior regulatory activities at Buncefield. The
full findings of the review will be incorporated into the Boards final report (see
term of reference 8). Any immediate important lessons from the examination of
the Competent Authoritys prior role will be incorporated into the lessons learned
programme under term of reference 5.
4 To work closely with all relevant stakeholders, both to keep them informed
of progress with the Investigation and to contribute relevant expertise to other
inquiries that may be established
The ongoing impact on residents and businesses of the Buncefield incident has
been reported in all three Progress Reports. The Board has maintained an active
interest in releasing as much new information as possible to the community and its
representatives, such as the local MP Mike Penning, to assist in understanding the
events of 11 December 2005, and to maintain public confidence that progress is
being made with the Investigation. Residents and businesses have shown
remarkable resilience in great adversity. Dacorum Borough Council in particular,
but also St Albans and Hertfordshire Councils, have performed extremely
effectively in very difficult circumstances, and have supported the Board in its
engagement with residents and businesses, as has Mike Penning MP.
The Board has also kept key Government stakeholders informed of the
Investigations progress, and has maintained its interest in developments that have
taken place since Buncefield to help manage the aftermath and support a return to
normality for residents and businesses.
The Board has engaged with all the public sector agencies involved in the
emergency response to Buncefield and has met with a number of the key agencies,
particularly the Category 1 (Gold) responders. This is not an issue in which the
Board has primary responsibility but, as reported in this Initial Report, the Board
is giving further consideration to emergency response and emergency preparedness
issues, and will say more on this later.
The Buncefield Major Incident Investigation made presentations to two multiagency debriefing sessions on 21 and 28 June to inform regional resilience groups
around Britain of the response to the Buncefield incident.
25
6 To produce an initial report for the Health and Safety Commission and the
Environment Agency as soon as the main facts have been established. Subject
to legal considerations, this report will be made public
This element is discharged by the publication of this report.
26
Annex 2
Members of the independent Board
The Rt. Hon. Lord Newton of Braintree has been a life peer since 1997 after
spending 23 years as a Conservative Member of Parliament for Braintree, Essex.
From 1982 to 1988 he held ministerial positions at the Department of Health and
Social Security. In 1988 he joined the Cabinet as Chancellor of the Duchy of
Lancaster and Minister at the DTI. He then held the post of Secretary of State for
Social Security from 1989 to 1992 when he was appointed Leader of the House of
Commons, which he held until 1997. In 2002 he chaired the Committee that
reviewed the operation of the Anti-Terrorism, Crime and Security Act 2001.
Professor Dougal Drysdale is one of the leading international authorities in Fire
Safety Engineering. He was the Chairman of the International Association of Fire
Safety Science until September 2005 and is currently the editor of the leading
scientific journal in the field, Fire Safety Journal. His wide range of research
interests includes the ignition characteristics of combustible materials, flame spread
and various aspects of fire dynamics. He is a Fellow of the Royal Society of
Edinburgh and a Fellow of both the Institution of Fire Engineers and the Society of
Fire Protection Engineers.
Dr Peter Baxter is a Consultant Physician in Occupational and Environmental
Medicine at Cambridge University and Addenbrookes Hospital, Cambridge. In the
past he has advised the Government on the impacts on public health relating to air
quality standards, major chemical incidents, natural disasters and climate change.
Taf Powell is Director of HSEs Offshore Division. He graduated in Geology and
Chemistry from Nottingham University. His oil field career has been split between
working in the UK and abroad in offshore exploration and development and
regulation of the sector in licensing, well operations, policy and safety regulation.
In 1991 he joined HSEs Offshore Division from BP and started work to develop
the new offshore regulatory framework, one of Lord Cullens recommendations
following his inquiry into the Piper Alpha disaster. As HSEs Operations Manager,
based in Aberdeen, he then led inspection teams and well engineering specialists
responsible for enforcing the new regulations until 2000 when he took up his
current role.
Dr Paul Leinster is Director of Operations at the Environment Agency. Up until
March 2004 he was the Director of Environmental Protection, having joined the
Agency in 1998. Prior to this he was the Director of Environmental Services with
SmithKline Beecham. Previous employers also include BP International, Schering
Agrochemicals and the consultancy firm Thomson-MTS where he was Managing
Director. Paul has a degree in Chemistry, a PhD in Environmental Engineering
from Imperial College and an MBA from the Cranfield School of Management.
Paul has worked for 30 years in the health and safety and environmental field.
David Ashton is Director of HSEs Field Operations North-West and Headquarters
Division. He joined HSE in 1977 as an inspector in the west of Scotland where he dealt
with a wide range of manufacturing and service industries, including construction,
engineering and the health services. In 1986 he joined Field Operations HQ to deal
with machinery safety. He then held the post of Principal Inspector of manufacturing in
Preston for two years, before being appointed as a management systems auditor to
examine offshore safety cases in the newly formed Offshore Division. In 1993 he
became Head of HSEs Accident Prevention Advisory Unit, looking at the management
of health and safety in organisations. Between 1998 and 2003 David was HSEs
Director of Personnel, before being appointed to his current position.
27
Annex3
Planning history of Buncefield site and neighbouring developments
1 Planning permission was granted in 1966 to Shell Mex and BP Limited, Regent
Oil Co Limited, Mobil Oil Co Limited, and Petrofina (GB) Limited to develop 91
acres of land at Buncefield for the construction of a storage and distribution depot
for petroleum products. St Albans Rural District Council initially refused the
application on the grounds that it was an inappropriate development in the Green
Belt and would have a detrimental effect on the amenity of the locality. On appeal,
the Minister of Housing and Local Government granted permission subject to a
number of conditions relating to design of the site, tree planting and restrictions on
the size of office premises.
2 At the time that the terminal was built in 1968, the site was well screened by
hedges and trees, but there were about nine dwellings on the periphery of the site
to the north whose amenities were affected by the site, and a farm to the south.
One of the nine dwellings to the north was converted in 2000 to create five
separate properties. Since 1968 there has been general encroachment and
development of adjacent land. This can be seen on the map in Figure 5. The
majority of this building development took place during the period from the mid
1960s to the early 1980s, comprising the construction or redevelopment of
residential properties and a number of schools and industrial premises to the west
of the site, all of which fell within a 3 km radius as shown on the map. Between
1990 and 2006, a few additional industrial premises were built around the site.
3 Dacorum Borough Council is the principal planning authority for the site, but
a small section to the north of Cherry Tree Lane falls to St Albans District Council.
4 The local planning authority decides whether developments can go ahead. But
arrangements have existed since 1972 for local planning authorities to obtain
consultee advice from HSE and its predecessors about the safety implications for
developments from risks associated with major hazards. Between 1991 and 2005,
28 applications were passed to HSE for advice relating to a variety of commercial
or residential developments around the Buncefield site. HSE advised against four
of these proposals and advised that seven others could be allowed subject to
certain conditions. As far as is known, the local authority followed HSEs advice
in these cases.
5 In addition to these specific developments on which HSE was a statutory
consultee, HSE is from time to time consulted on other matters. For example, HSE
was consulted on four local structure plan revisions.
6 The complex began operations in 1968 after a pipeline was constructed to link
two Shell refineries at Stanlow at Ellesmere Port in Cheshire and Shell Haven on
the Thames Estuary at Stanford-le-Hope in Thurrock. The depot operated
originally under licence given under the Petroleum (Consolidation) Acts 1928 and
1936. The Planning (Hazardous Substances) Act 1990 and subsequent statutory
provisions, the Planning (Hazardous Substances) Regulations 1992 (PHS
Regulations) and later the Planning (Control of Major Accident Hazards)
Regulations 1999 introduced new procedures for consent to be sought from the
hazardous substances authority to store hazardous substances.
28
7 The consent identifies the hazardous substances and their location on site and
defines certain conditions of use such as maximum size, temperature and pressure
of storage vessels. Figure 6 contains some details of consents obtained for the
Buncefield depot. The consents for Shell UK Oil Limited have been included in
this table as they have not been revoked, although Shell no longer operates from
this site.
HSEs role in land use planning
8
M
9 HSEs approach to land use planning is set out in more detail in Annex 2 of
the first Progress Report. Some of this process is now being devolved to certain
local planning authorities.
10 The consultation distance represents the furthest distance at which HSE wishes
to be consulted about developments near hazardous installations/major accident
hazard pipelines. This does not mean that there is no risk beyond the consultation
distance, just that the predicted risks are sufficiently low that they need not be part
of a planning decision.
11 Within the consultation distance, HSE undertakes an assessment of the hazards
and risks from the installation and produces a map with three contours
representing defined levels of harm or risk which any individual at that contour
would be subject to, based on information relating to the hazardous substances
consent. The harm or risk to an individual is greater the closer to the installation.
29
The contours form three zones, with the outer contour defining the consultation
distance around major hazard sites. The local authority consults HSE on relevant
proposed developments within this consultation distance.
COMAH site
Inner zone
Middle zone
Outer zone
Figure 3 Consultation
distance and zones
Consultation distance
Level of sensitivity
Development in
inner zone
Development in
middle zone
Development in
outer zone
1
2
3
4
DAA
AA
AA
AA
DAA
DAA
AA
AA
DAA
DAA
DAA
AA
Sensitivity level 1
Sensitivity level 2
Sensitivity level 3
Example
Example
Example
Sensitivity level 4
Example
Factories
Houses
Vulnerable members of society eg
primary schools, old peoples homes
Football ground/large hospital
31
32
0
0.25
0.5
1
Miles
1990s Leisure
1990s Industrial
3 km radius
Consultation Distance
Buncefield Site
A Map
to show
all all
building
developments
byby
type
between
A Map
to show
building
developments
type
betweenmid
1960's
and
2005
within
a
3km
radius
of
the
Buncefield
Site.
mid 1960s and 2005 within a 3 km radius of the Buncefield
site
Figure 5 Developments within 3 km of the Buncefield site between 1966 and 2005
Texaco Limited
Hertfordshire Oil
Storage Limited
BP Oil UK Limited
petroleum spirits
21 October 2003: 15 200 tonnes automotive petrol and
10 522 tonnes petroleum products classified as dangerous for
the environment (most likely to be gasoline or diesel)
3 May 2005: 26 900 tonnes automotive petrol and
10 522 tonnes petroleum products classified as dangerous for
the environment (most likely to be gasoline or diesel)
British Pipeline
Agency Limited
Figure 6 Hazardous
substances consents issued
* Note: The first applications for consent were in 1992, before then different arrangements were in
place, ie these were notifications under NIHHS and consent was not required.
33
Hertfordshire Oil
Storage Ltd (west)
Hertfordshire Oil
Storage Ltd (east)
Shell UK Oil Ltd
until April 2003.
Consent remains
British Petroleum
Oil UK Ltd
British Pipeline
Agency (south)
British Pipeline
Agency (north)
Consultation
distance
Boundary Way
Inner zone:
closer than 120 m
Middle zone:
closer than 135 m
Outer zone:
closer than 185 m
34
Figure 7 Plan representing the hazardous substances consents and consultation area around
the Buncefield depot since July 2001 (for illustration only)
Annex4
UK petroleum refinery, pipeline and storage system
Refineries
1 Petroleum products in the UK are predominantly supplied from nine refineries
where crude oil is refined into liquefied petroleum gas (LPG), petrol, diesel,
aviation fuel, gas oil, heating oil and residual bitumen. From a typical barrel of
North Sea crude oil, approximately 3% becomes LPG, 37% petrol, 25% diesel,
20% kerosene (aviation fuel/heating oil) and 12% fuel oil (for power generation).
Figure 8 shows the location of the refineries. They are sited on the coast or on
estuaries so that they can receive crude oil by ship.
Orkney
Shetland
Stromness
Lerwick
oil storage/distribution
oil refinery
Lindsey
refinery
Stanlow refinery
Kingsbury
Northampton
London
Heathrow
Airport
Buncefield
Coryton refinery
London
Gatwick
Airport
35
2 Storing, moving and delivering these fuels to the end user are important
elements of the UK economy. Each year approximately 75 million tonnes of
petroleum products are moved around the UK.
3 All nine main refineries in the UK have substantial storage for finished products
coming out of the refinery. However, given the location of refineries, there are also
large storage terminals around the country, generally near major conurbations.
These terminals are mainly supplied from the refineries by pipeline, rail and sea.
Often they are run as joint ventures between a number of oil companies.
Commercial arrangements are commonly negotiated between companies to draw
products on exchange from another companys terminal. This avoids the need to
transport products over long distances from one terminal to another. Figure 9 shows
the place of oil storage and transfer depots in the UK oil distribution system.
Petroleum pipelines
4 The UK mainland has a network of approximately 1500 miles of petroleum
pipelines. Some of them are owned by individual oil companies dedicated to supplying
their own terminals, and some are owned by joint ventures such as United Kingdom
Oil Pipelines Limited (UKOP). Others belong to the Government. Once installed,
underground pipelines offer substantial environmental and safety benefits, not least
from the elimination of road tanker journeys or transportation by rail or sea.
36
5 These pipelines are used to transport a variety of fuels, including petrol, diesel,
heating oil and aviation fuel. After a batch of predetermined volume of one fuel has
been delivered through the pipeline, a different fuel may be transported. As the fuels
travel along the pipeline, a relatively small degree of mixing will occur at the
interface. As this volume of mixed fuels has to be reprocessed, the pipeline operator
manages the flow rates continually to minimise these interfaces to reduce wastage.
Around 30 million tonnes of fuel are moved around the UK in this way in a year.
Annex 5
Incidents that have similarities with the Buncefield incident
Location
Comments background
Comments explosion
Ref
see over
1 Houston,
Texas, USA
April 1962
2 Baytown, Texas,
USA
27 January 1977
3 Texaco, Newark,
New Jersey, USA
7 January 1983
After 00.00 hrs
4 Naples Harbour,
Italy
21 December
1985
5 St Herblain,
France
7 October 1991
04:00 hours
6 Jacksonville,
Florida, USA
2 January 1993
03:15 hours
7 Laem Chabang,
Thailand
2 December 1999
23:25 hours
Note: The root cause of each of the above incidents was the spillage (loss of containment)
of a large quantity of gasoline (eg >100 tonnes) due to overfilling of a tank, or failure of
pipework inside a bund. In each case, the windspeed was very low, or zero, and a significant
vapour cloud was able to form. The feature of the Buncefield explosion that appeared
unique was the apparent lack of obstacles which could induce turbulence and thereby lead
to rapid flame propagation, sufficient to produce the high overpressures recorded.
Accordingly, incidents 2, 4 and 5 may not be relevant. As the lack of confinement cannot
be quantified, the relevance of the other incidents might be superficial. More information is
required. Work is in hand to identify other incidents that may be relevant.
37
References
38
Annex 6
Fire and explosion hazards from petrol
Introduction
1 This annex sets out a general explanation of the fire and explosion hazards
from fuels such as petrol, as currently understood. It is not limited to the
circumstances of the Buncefield incident.
Flashpoint
2 The physical properties of highly flammable liquids, such as petrol, are such
that if they are mishandled or released they present a significant risk of fire or
explosion. In this context, perhaps the most important property of petrol is its high
volatility. At normal ambient temperatures, the vapour released by simple
evaporation from the fuel surface can readily be ignited as it mixes with air. It is
classified legally as a Highly Flammable Liquid, ie it has a flashpoint (measured in
a closed cup apparatus) below 32 oC.
3 Flashpoint is used to define the hazard associated with liquid fuels and to
help determine safe working conditions. The flashpoint is defined as the minimum
temperature at which a liquid fuel produces sufficient vapour to form a flammable
or ignitable mixture with air. Petrol has a flashpoint of around minus 40 oC, well
below normal (ambient) temperatures, and can be ignited very easily. It is the
vapour that burns, releasing heat, some of which is transferred to the surface of
the fuel, thus increasing the rate of evaporation that supplies the flame with fuel
vapour. Paragraph 7 of this annex provides more information about fuel fires.
4 Not all concentrations of fuel vapour in air are flammable, ie capable of being
ignited by a small ignition source such as a spark or a flame. Ignition can only
occur if the mixture of flammable vapour in air falls within certain concentrations,
known as the lower and upper explosion (or flammability) limits. For petrol
vapour, concentrations below 1.4% in air are too lean to burn, while those above
7.6% are too rich.18 At all concentrations between these two limits, known as the
flammable range, the mixtures will burn, in that a flame will propagate away from
the ignition source.
5
The flash point and the flammable range are determined by standard test methods.
18
The concentration of petrol vapour in a partially full petrol tank is above the upper
explosive limit and therefore too rich too burn.
39
and air mix by diffusion, and it is the type of flame associated with fires involving
liquid and solid fuels. Heat transferred from the flame to the fuel provides the
energy required to maintain the flow of fuel vapours that support the flame. The
flames associated with a liquid pool fire will completely cover the surface and will
continue to burn as long as there is fuel remaining. The flames of a petrol pool fire
will extinguish when all the petrol is consumed, or if air can be excluded from the
flames, or if the vapour release can be prevented or inhibited (as happens when the
liquid surface is completely covered with a layer of fire-fighting foam).
8 With large hydrocarbon pool fires such as those at Buncefield, the flames are
so large that mixing of fuel vapour and air is not efficient. This leads to the
formation of species within the flame that cause the release of copious amounts of
black smoke. The immediate precursors of the smoke are minute soot particles
which radiate, producing the characteristic yellow colour associated with almost all
diffusion flames. The hazards arising from such fires are due to heat transfer by
radiation to neighbouring surfaces and to the hot fire products (rich in smoke and
toxic gases) carried aloft by buoyancy. Pressure effects are negligible and could not
cause structural damage, but heat transfer to structures immersed in the flames will
cause weakening and eventual collapse.
Explosions
9 For an explosion involving petrol vapour to occur, the vapour/air mixture must
be within its flammable range when it encounters a potential source of ignition.
A flame will propagate rapidly, spreading spherically from the ignition source
throughout the entire flammable mixture. The heat released as the fuel is
consumed causes the gases to expand as a result of the associated temperature rise.
If confined, eg if the mixture is contained within a building, the gases cannot
expand freely and the pressure will rise until parts of the confining structure (such
as the windows of a building) fail and relieve the pressure. This is normally a
violent event and may produce a shock wave that can cause remote damage.
10 High temperature effects from the explosion are transient, but they will ignite
highly flammable liquids and can ignite lightweight combustible solids (eg tissue
paper). Some can be left burning after the explosion has passed. The flame created
by an explosion of petrol vapour in air is blue or very pale yellow, depending on
the fuel/air mixture. It is known as a premixed flame as the fuel vapour and air are
mixed before ignition occurs. The amount of smoke produced is negligible
compared to that produced in a fire.
11 In general terms, overpressures are not developed if an unconfined petrol
vapour/air mixture is ignited because the gases can expand freely. However, the
speed at which the flame travels through the flammable mixture can vary
considerably, depending on a number of different factors. If the flame speed is very
high, some overpressure will be created as the expansion cannot occur rapidly
enough, despite the (apparent) lack of confinement. Factors that affect the speed
with which a flame will travel through a flammable mixture include:
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18 The following table lists commonly accepted damage figures from blast
overpressure and can be used for comparative purposes. However, care has to be
taken in using this data as it does not take into account the duration of the
pressure wave.
Commonly accepted damage figures from blast overpressure
Pressure
(psi)
Pressure
(millibar)
Damage
0.02
1.4
0.10
0.15
10
0.30
21
0.40
28
0.5-1.0
34-70
0.75
52
0.9
63
1.0
70
1.0-2.0
70-140
2.0
140
3.0
210
3.0-4.0
210-280
4.0-5.0
280-350
5.0
350
7.0-9.0
490-630
8.0-10
560-700
>10
>700
70
4900
Commonly accepted figures for direct harm to people from blast overpressure
Pressure
(psi)
Pressure
(millibar)
138
1.5-2.9
103-200
10-15
690-1035
12-15
830-1035
30-34
19 HSE uses the following levels of overpressure for providing land use planning
advice around hazardous installations. These are based on estimates of fatalities
within occupied buildings.
Pressure
(psi)
Pressure
(millibar)
8.6
600
140
70
43
Annex 7
Product composition at Buncefield
1 Extensive sampling of the various petroleum products at the Buncefield depot
has been carried out to verify the product distribution through the site from the
different supply pipelines, and also to identify the composition of the released
materials. The majority of the samples were taken from the Hertfordshire Oil
Storage Limited site but samples were also taken from the two pipelines feeding
unleaded petrol to the site, the United Kingdom Oil Pipelines Limited T/K pipeline
and the FinaLine pipeline from the Lindsey refinery.
2 As a release of unleaded petrol is considered to be the initiating event for the
explosion and subsequent fire, all petrol samples have been tested against the
standard BS EN 228 for automotive fuels, together with a full chemical analysis by
an independent accredited test house.19 Samples of other products handled on site
including diesel, aviation fuel and gas oil have been subject to simple laboratory
tests to confirm their identity.
Product identification
3 The test results from the samples taken on site are consistent with the product
type identified from the site plans or by the company as being contained or held
within any particular plant or section of pipework. Many of the samples showed
degradation or contamination caused by heat-damaged plant or open pipework as
a result of the incident. This degradation is particularly noticeable by the loss of
the more volatile components, including butane, from many of the samples.
4 The loss of volatile components from the samples has made a direct
comparison of their analytical results and subsequent tracking of the different
product sources through the site extremely difficult. In addition representative
samples from Tank 912 after the incident are not available as this tank completely
burnt out, and only fire-damaged residues consisting mainly of water could be
extracted from the tank bottom. The samples of the material feeding Tank 912,
taken by the operator prior to the incident and retained on site, were destroyed
during the incident.
Product composition
5 The evidence to date is consistent with the release of petrol from Tank 912
while it was being fed from the British Pipeline Agency Limited manifold. Petrol is
a blend of many different hydrocarbons, each of which will have an impact on the
vapour pressure. The British Pipeline Agency Limited manifold feeding Tank 912
was being supplied by a parcel of unleaded petrol from the British Petroleum PLC
oil refinery at Coryton, Essex. That in turn was made up from the feed from four
separate tanks. No sample of the parcel is available as the part-batches from the
feeder tanks are not blended and tested as a composite batch before being pumped
from site. British Petroleum PLC has provided the Conformity Certificates for the
individual feeder tanks showing their analysis against the British Standard. The
British Standard is a performance specification and only details specific limits for
44
19
BS EN 228: 2004 Automotive fuels. Unleaded petrol. Requirements and test methods.
Available online at www.bsonline.bsi-global.com.
the chemicals lead and benzene. By way of example, the standard does not
specifically limit the content of butane, which comprises a mixture of butanes and
butenes, and therefore the presence and levels of these individual components are
not routinely determined. The total butane content, however, will affect the vapour
pressure and this is specified in the standard depending on whether the product is
marketed as winter or summer grade. For winter grade petrol the vapour pressure
limits are defined as 70-100 kPa and for summer they are reduced to 45-70 kPa.
6 The Conformity Certificates show that the vapour pressure for the four partbatches were all at or very close to 100 kPa. This was corroborated by evidence
obtained from the British Pipeline Agency Limited site after the incident. This
corresponded to a total butane content of 10.0%. By contrast, other samples of
petrol taken from the site after the incident and which had been degraded by
exposure to the fire were found to have lower vapour pressures and
correspondingly lower butane levels. Therefore the product released on site was at
the top end of the winter grade limit for vapour pressure. A reasonable estimate of
the butane content of the released material is 10% by weight.
45
Annex 8
Regulatory framework for high hazard sites
1 The regulatory framework for sites such as Buncefield, which present potential
major accident hazards, comprises requirements imposed on the site operators
under both health and safety and environmental legislation, complemented by the
requirements of planning law. In particular, the Control of Major Accident
Hazards Regulations 1999 (COMAH) apply.
Health and safety law
2 Operators in the process industries are subject to the requirements of the
Health and Safety at Work etc Act 1974 (the HSW Act) and the Management of
Health and Safety at Work Regulations 1999 which require, respectively, safety
policies and risk assessments covering the whole range of health and safety risks.
Control of Major Accident Hazards Regulations 1999 (COMAH)
3 COMAHs main aim is to prevent and mitigate the effects of those major
accidents involving dangerous substances, such as chlorine, liquefied petroleum gas
and explosives which can cause serious damage/harm to people and/or the
environment. The COMAH Regulations treat risks to the environment as seriously
as those to people. They apply where threshold quantities of dangerous substances
identified in the Regulations are kept or used. There are two thresholds, known as
lower-tier and top-tier. The requirements of COMAH are fully explained in The
requirements of COMAH are fully explained in A guide to the Control of Major
Accident Hazards Regulations 1999 (COMAH). Guidance on Regulations L111
HSE Books 1999 ISBN 0 7176 1604 5.
4 The COMAH Regulations are enforced by a joint Competent Authority
comprising HSE and the Environment Agency in England and Wales, and HSE and
the Scottish Environment Protection Agency (SEPA) in Scotland. Operators will
generally receive a single response from the Competent Authority on all matters to
do with COMAH. The Competent Authority operates to a Memorandum of
Understanding, which sets out arrangements for joint working.
5 The COMAH Regulations require operators of top-tier sites to submit written
safety reports to the Competent Authority with the purpose, among others, of
demonstrating that major accident hazards have been identified and that the
necessary measures have been taken both to prevent such accidents and to limit
any consequences. Operators of top-tier sites must also prepare adequate
emergency plans to deal with the on-site consequences of possible major accidents,
and to assist with off-site mitigation. Local authorities for areas containing top-tier
sites must prepare adequate emergency plans to deal with the off-site consequences
of possible major accidents, based on information supplied by site operators.
46
47
48
Annex 9
Regulation of perfluorooctane sulphonates (PFOS)
1 Perfluorochemicals are a family of chemicals used in products designed to repel
dirt, grease and water, including kitchenware, carpet treatments, food wrappers,
sprays for leather and other clothing, paints and cleaning products.
2 A group of these substances, perfluorooctane sulphonates (collectively
identified as PFOS), has been shown to be hazardous (persistent, bioaccumulative
and toxic). PFOS has been used in a diverse range of applications, from firefighting foam additives to use as a mist suppressant in chromium plating. PFOS
was also used in common household anti-soil treatments often referred to by the
trade name Scotchgard (a trademark of 3M PLC).
3 The UK Committee on Toxicity of Chemicals in Food, Consumer Products and
the Environment (COT), an independent scientific committee that provides advice
to the Food Standards Agency, the Department of Health and other Government
Departments and Agencies on matters concerning the toxicity of chemicals - is
currently evaluating PFOS, most recently in May 2006.20
4 On the basis of the preliminary COT discussions, the Health Protection Agency
advised the Drinking Water Inspectorate in March 2006 that, It appears unlikely
that a lifetimes consumption of drinking water containing concentrations up to
three microgrammes (of PFOS) per litre would harm human health and that
drinking-water concentrations of PFOS should not exceed three microgrammes
per litre. The Health Protection Agency will review its advice when COT has
finalised its assessment of PFOS.
5 In the light of current Health Protection Agency advice, the Drinking Water
Inspectorates view (29 March 2006) is that to safeguard human health, PFOS should
not be present in drinking water supplies above three microgrammes/litre (g/l).
6 PFOS does not appear to undergo any degradation in the natural environment.
Due to this extreme stability it has now become widespread both in man and the
environment. The biological persistence of PFOS in living organisms is high, with
an estimated elimination half-life for humans of the order of four to eight years.
7 These concerns resulted in the principal manufacturer of PFOS (3M) announcing
a voluntary phase-out of PFOS manufacture from 2001 onwards. PFOS, however,
continues to be produced by some companies and is used in some industrial
processes, for example semiconductor production and chromium plating. PFOS was
used as an ingredient in some AFFF Class B fire-fighting foam concentrates until a
few years ago. These concentrates have a shelf life of at least ten years and remaining
stocks will therefore continue to be available for use on oil fires.
8 DEFRA consulted on a national action to restrict the use of PFOS and
substances that may degrade to PFOS in October 2004. This included proposals to
phase out the use of PFOS in fire-fighting foams. In December 2005, the European
Commission issued a proposal for a Directive restricting the marketing and use of
PFOS. In this draft Directive PFOS used in fire-fighting foams as well as
20
The COT minutes and background working paper are available from
www.food.gov.uk/science/ouradvisors/toxicity/cotmeets/cot2006/334454.
49
21
50
Annex 10
Legal considerations
Prosecution decision making
1 The Board is aware that the process of making enforcement decisions is
complex. Every duty holder and situation is unique. The prosecution decision can
only be considered once the criminal investigation is fully complete, ie all
reasonable lines of enquiry have been followed (in line with the Code of Practice
issued pursuant to the Criminal Procedure and Investigations Act 1996). In the
case of HSE, the HSC Enforcement Policy Statement sets out the approach to be
followed, in accordance with the aims of the Governments Principles of Good
Enforcement and requires HSE to apply the Code for Crown Prosecutors (The
Code).
2 The Environment Agency has its own Enforcement and Prosecution Policy,
which also relies on those principles and commits the Agency to take account of
the Code. Each case is unique and will be considered on its own merits. Any
prosecution decision requires a careful balancing of individual factors present in
that particular case and will be taken by a lawyer who is independent of the
Investigation.
3 The Code states that the decision-maker (prosecutor) must be fair, independent
and objective. It is their duty to review cases and to ensure that the law is properly
applied, that all relevant evidence is put before the court and that obligations of
disclosure are complied with. The prosecutor will also ensure that the investigators
have identified any material that might undermine the prosecution case or assist
the defence, and that they have acted in compliance with the Human Rights Act
1998. The more complex the circumstances of a case and/or the technical evidence,
the longer this process may take.
Evidential stage
4 There is a strict order in which the prosecutor must apply the two stages which
form the Full Code Test under the Code. The prosecutor must first consider the
evidential stage. If there is not the required level of evidence then no prosecution
can go ahead, no matter how important the case or how strong the public interest
is in favour of prosecution. The prosecutor must be satisfied that the evidence is
admissible to meet the evidential test.
5 To pass the evidential stage the Approval Officer must be satisfied that there is
enough evidence to form a realistic prospect of conviction against each defendant
on each charge. This is a different test to the one that magistrates or juries have to
apply. This is not simply a case of percentages. The evidential stage is met if there
is sufficient evidence to ensure that a jury or bench of magistrates, with a correct
understanding of the law, is more likely than not to convict the defendant of the
alleged charge.
51
6
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Does the witness have a motive that might influence his or her evidence?
Is there any concern over the accuracy or credibility of a witness? If so, what is
the basis for that concern?
10 The Environment Agency will consider the environmental effect of the alleged
offence, the foreseeability of the offence or the circumstances leading to it, the
intent of the offender, any history of offending, the attitude of the offender,
whether a prosecution is required in order to ensure deterrence, and the personal
circumstances of the offender. Again the list is not exhaustive.
11 There is a presumption that the Environment Agency will prosecute where one
or more of the following are present:
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12 The Code for Crown Prosecutors also lists other relevant factors for and
against prosecution, which again are not exhaustive. The prosecutor balances the
factors for and against prosecution.
Views of the victim(s) (part of the public interest stage)
13 The prosecutor will also take into account the consequences for the victim of
the decision to prosecute or not to prosecute, and any views expressed by the
victim or the bereaved. While the prosecutor will take into account their views,
neither enforcement authority is bound to follow those views when reaching the
final decision on enforcement.
53
Glossary
ambient temperature
fire-water
Water stored for use during, and used during, fire-fighting operations
foam In the context of this report, a foam used during operations to extinguish
hydrocarbon fires
forthwith action The Investigation terms of reference require the Investigation
team and Board to identify and transmit without delay to duty holders and other
appropriate recipients any information requiring immediate action to further safety
and/or environmental protection in relation to storage and distribution of
hydrocarbon fuels. This is referred to as forthwith action for both the
Investigation, the Competent Authority, and duty holders
Gold command
The working name for the strategic command centre during a
Major Incident - also known as the Strategic Co-ordinating Group
groundwater All water below the water-table, as opposed to ground waters,
which include groundwater but also sub-surface water above the water-table. The
term ground water, where used in the previous progress reports, should normally
have read groundwater
hazard Anything with the potential to cause harm
Health and Safety Commission The Health and Safety Commission is a statutory
body, established under the Health and Safety at Work etc Act 1974, responsible
for health and safety regulation in Great Britain
Health and Safety Executive The Health and Safety Executive is a statutory body,
established under the Health and Safety at Work etc Act 1974. It is an enforcing
authority working in support of HSC. Local authorities are also enforcing
authorities under the Health and Safety at Work etc Act 1974
HSC
See kiloPascal
lower-tier
See tier
55
overpressure For a pressure pulse (or blast wave), the pressure developed above
atmospheric pressure
perfluorooctane sulphonates A group of chemicals, collectively identified as
PFOS, which have been shown to be hazardous (persistent, bioaccumulative and
toxic). PFOS chemicals have been used in a diverse range of applications, including
as an additive to aid the spreading properties of fire-fighting foam
perfluorosurfactant In the context of the Buncefield incident, a surfactant is a
chemical added to fire-fighting foam which allows the foam to form a thin sealing
film over the burning fuel. Perfluorosurfactants are a type of surfactant
PFOS See perfluorooctane sulphonates
pool fire
primary containment The tanks, pipes and vessels that normally hold liquids, and
the devices fitted to them to allow them to be safely operated
pumphouse In the context of this report, the structure enclosing the pumping
equipment used to move water around the Buncefield site prior to the incident.
It principally stored water intended for fire-fighting operations
risk
The likelihood that a hazard will cause a specified harm to someone or
something
run off Uncontained liquid, either deposited on site as rain, or in the context of
the Buncefield incident, fuel and/or fire-water not contained as part of the
operation to control the incident
Safety Alert Where the Competent Authority considers that an issue poses
significant risk, it can choose to issue a Safety Alert to operators of COMAH sites
informing them of the issue and possibly requiring them to undertake certain
activity
SCG See Strategic Co-ordinating Group
Scottish Environment Protection Agency The public body which is responsible
for the protection of the environment in Scotland
secondary containment Enclosed areas around storage vessels (often called
bunds), created usually by concrete or earth walls. Their purpose is to hold any
escaping liquids and any water or chemicals used in fire-fighting
SEPA
56
Water that sits or flows above land, including lakes, seas, rivers
tank farm A facility where hazardous substances, very often petroleum products,
are stored in tanks
tertiary containment The site surface and associated drainage, boundary walls,
roads, containment kerbs and any features such as road humps that can provide
some retention of liquids. Proper design of drainage systems will limit loss of
product out of the site and prevent lost product permeating into the ground with
the potential risk that it can migrate to groundwater, or contaminate surface
waters and land
tier The Control of Major Accident Hazards Regulations 1999 apply where
threshold quantities of dangerous substances identified in the Regulations are kept
or used. There are two thresholds, known as lower-tier and top-tier, and
COMAH sites fall into one or other of these
topography The physical configuration of the surface of the land, including its
elevation, slope, and orientation
top-tier
See tier
ultimate high-level switch Part of the system to prevent overfilling of the tank,
the ultimate high-level switch is an independent mechanism which should be
triggered when the ultimate high level (ie the specified maximum capacity) is
reached in a tank to which it is fitted, both causing an alarm to sound and shutting
down the supply of fuel to the tank
vapour pressure A measure of the tendency of a material to form a vapour.
The higher the vapour pressure, the higher the potential vapour concentration
volatility
wind girder
Further information
Useful links
Buncefield Major Incident Investigation
Marlowe Room, Rose Court
2 Southwark Bridge
London, SE1 9HS
Tel:
020 7717 6909
Fax:
020 7717 6082
E-mail: [email protected]
Web: www.buncefieldinvestigation.gov.uk
Community/Business support
Dacorum Business Contact Centre
Tel:
01442 867 805
Business Link Helpline
Tel:
01727 813 813
Hertfordshire Chamber of Commerce
Tel:
01727 813 680
Dacorum Community Trust Mayors Fund
To apply, call the freephone helpline on 0800 131 3351.
Lines are open 9.30 am-4.30 pm, Monday to Friday
Dacorum Borough Council
Tel:
01442 228 000
Web: www.dacorum.gov.uk
Hemel Hempstead Citizens Advice Bureau
19 Hillfield Road, Hemel Hempstead HP2 4AA
Tel:
01442 213368
Local authorities and emergency services
Dacorum Borough Council
Tel:
01442 228 000
Web: www.dacorum.gov.uk
(Dacorum Borough Council Digest newsletter, available monthly
Dacorum Borough Council Buncefield Update Newsletter)
St Albans District Council
Tel:
01727 866 100
Web: www.stalbans.gov.uk
Hertfordshire County Council
Tel:
01483 737 555
Web: www.hertsdirect.org
58
Investigation reports
Buncefield Major Incident Investigation:
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www.advisorybodies.doh.gov.uk/coc/
60
07/06
C10
Recommendations on the
design and operation
of fuel storage sites
Recommendations on the
design and operation
of fuel storage sites
ii
Contents
Introduction 1
The Boards approach 2
Scope of the recommendations 3
Status of the recommendations 3
The Baker report 5
Further work to investigate explosion mechanism 6
The recommendations 6
Systematic assessment of safety integrity level requirements 8
Recommendation 1
Protecting against loss of primary containment using high integrity systems 10
Recommendations 2-10
Engineering against escalation of loss of primary containment 14
Recommendations 11-16
Engineering against loss of secondary and tertiary containment 16
Recommendations 17-18
Operating with high reliability organisations 18
Recommendations 19-22
Delivering high performance through culture and leadership 20
Recommendations 23-25
Annexes
1: Terms of reference and progress 22
2: Members of the independent Board 25
3: Rationale for Recommendation 3 Independent and automatic storage tank
overflow prevention 26
4: Background and supporting material for improved components and systems
(Recommendation 8) 28
5: High reliability organisations (Recommendations 19-22) 30
6: BS EN 61511 Functional safety - safety instrumented systems for the process
industry sector 32
7: Examples of incidents that have involved loss of primary containment from
storage tanks 34
References 36
Glossary 38
Further information 41
iii
iv
Introduction
1 This report sets out recommendations to improve safety in the design and
operation of fuel storage sites. We make these recommendations as the independent
Investigation Board, chaired by Lord Newton of Braintree, set up to supervise the
investigation into the explosions and fires at the Buncefield oil storage and transfer
depot, Hemel Hempstead, Hertfordshire on 11 December 2005. The investigation
was directed by the Health and Safety Commission (HSC) using its powers under
section 14(2)(a) of the Health and Safety at Work etc Act 1974.
2 Item 5 of the investigations terms of reference requires us to make
recommendations for future action to ensure the effective management and
regulation of major accident risk at COMAH1 sites. This should include
consideration of off-site as well as on-site risks and consider prevention of
incidents, preparations for response to incidents, and mitigation of their effects.
3 Our initial report, published on 13 July 2006, identified four principal
workstreams that would form the basis for our continuing work and developing
recommendations. Those workstreams are:
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examination of the Health and Safety Executives (HSEs) and the Environment
Agencys roles in regulating the activities on the Buncefield site.
4 This report concentrates on the first of these design and operations. Future
reports will make recommendations on other areas, though we anticipate some
overlap as the workstreams are closely related. Improving control measures goes
hand in hand with improving emergency arrangements and with considering the
potential impacts of major incidents on local communities. This report builds on
the broad conclusions set out in paragraphs 61-77 of our initial report, which in
turn reflect the findings of the investigation, as summarised in the initial report and
in the three progress reports preceding it. That material is referenced, but not
repeated, in this report. In preparing this report we have also considered
information from other sources, such as the Buncefield Standards Task Group,2 the
Competent Authority3 and the Baker report (see paragraph 15). Our broad aim in
making these recommendations is to catalyse improvement in the fuel storage
sector so that it is continually alert to the major hazard potential of its operations.
The Control of Major Accident Hazards Regulations 1999. These Regulations are
enforced by a joint Competent Authority comprising HSE and the Environment Agency
in England and Wales and HSE and the Scottish Environment Protection Agency in
Scotland.
The joint Competent Authority/Industry Standards Task Group set up to review safety
and environmental protection standards at fuel storage sites following the Buncefield
incident. The Task Group published its initial recommendations on 12 October 2006.
See footnote 1. The Competent Authority issued Safety Alerts in February and July
2006.
Primary means of containment are the tanks, pipes and vessels that hold liquids and the
devices fitted to them to allow them to be operated safely.
Secondary means of containment are enclosed areas around storage vessels (often called
bunds), created usually by concrete or earth walls. Their purpose is to hold any escaping
liquids and any water or chemicals used in firefighting. Tertiary means are features such
as drains designed to limit the passage of chemicals off site, or raised kerbs to prevent
liquids that have breached the bunds from escaping into the general area around the site.
The Task Group initial recommendations apply to petrol stored at COMAH top and
lower tier sites in vertical, cylindrical, non-refrigerated, above ground storage tanks
with side walls greater than 5 metres in height and where the filling rate is greater than
100 cubic metres/hour.
COMAH requires operators of major hazard sites subject to the Regulations to take all
measures necessary to prevent major accidents and limit their consequences to persons
and the environment. Operators of top tier COMAH sites (like Buncefield) are also
required to submit written safety reports to the Competent Authority; and to prepare
emergency plans to deal with the consequences of a major accident. Operators and
others (including contractors, designers, suppliers) also have relevant duties under the
Health and Safety at Work etc Act 1974 and related regulations and under
environmental legislation.
13 Where the recommended improvements are self evidently necessary or where the
sector is already intent on their implementation we expect the recommendations to
be implemented without undue delay. Some recommendations, particularly those
involving large-scale engineering improvements, will be easier to implement in new
sites than in existing sites. Other recommendations, such as those needing cultural
and leadership changes, should be addressed immediately, though their effects may
not be apparent in the short term. It is essential to have clear timescales, understood
both by the industry and the Competent Authority, against which progress can be
measured and reported. We therefore ask the Competent Authority to start without
delay a programme of reviews with operators of Buncefield-type sites of their
response to these recommendations, leading to site-specific timed action plans.
14 Where commitments have already been made (eg through the Buncefield
Standards Task Group) or the need for action is self-evident, we have not made
detailed cost-benefit assessments. In most cases we consider the costs will be
reasonable and the benefits, in preventing another Buncefield incident, beyond
argument. We are exploring further the costs and other implications of some
recommendations relative to their perceived benefits, though we expect this to
confirm our belief that the improvements we recommend are affordable. In agreeing
priorities for the action plans we call for in paragraph 13, the Competent Authority
will need to take account of cost, as described in paragraph 31.
The recommendations
20 Our recommendations are grouped under the following six headings:
M
M
M
M
Systematic assessment of
safety integrity level
requirements
21 The recommendations under this and the next two headings are based on the
conclusions set out in paragraphs 61-77 of our initial report and on the findings of
the first and third progress reports. The Buncefield incident highlighted the need
for high integrity systems, which we discuss further in the next section. However,
our firm belief is that before protective systems are installed there is a need to
determine the appropriate level of integrity that such systems are expected to
achieve. The sector currently lacks a common methodology to ensure a systematic
approach to this determination process. Several methodologies exist, but there is
no consistency. A common methodology would provide greater assurance.
22 Recommendation 1 is in line with work now underway following the
Buncefield Standards Task Groups initial recommendations relating to tank
overfill protection, particularly paragraph 9, which states The overall systems for
tank-filling control must be of high integrity with sufficient independence to
ensure timely and safe shutdown to prevent tank overflow. Site operators should
meet the latest international standards.
Recommendation 1 The Competent Authority and operators of Buncefield-type
sites should develop and agree a common methodology to determine safety
integrity level (SIL)8 requirements for overfill prevention systems in line with the
principles set out in Part 3 of BS EN 61511.(ref 3) This methodology should take
account of:
M
Figure 5 General view of fuel storage tanks with associated pipework and instrumentation
10
A liquid fuel is classified under the Planning (Control of Major Accident Hazards)
Regulations 1999 according to its flashpoint, defined as The minimum temperature at
which a liquid, under specific test conditions, gives off sufficient flammable vapour to
ignite momentarily on the application of an ignition source. A highly flammable liquid
is defined as one with the flashpoint below 21oC. As petrol has a flashpoint in the
region of c -40oC, it is therefore classified as a highly flammable liquid.
servo level
gauge
independent ultimate
high level switch
ventilated
ullage void
liquid level
reference
flexible seal at
clearance gaps
thermowell
pocket for
temperature probe
PETROL
27 Annex 2 to this report sets out our arguments for developing improved
components and systems (Recommendation 8). Recommendations 9 and 10 are
needed to help monitor and review the effectiveness of improved control measures.
Recommendation 2 Operators of Buncefield-type sites should, as a priority,
review and amend as necessary their management systems for maintenance of
equipment and systems to ensure their continuing integrity in operation. This
should include, but not be limited to reviews of the following:
M
the arrangements and procedures for periodic proof testing of storage tank
overfill prevention systems to minimise the likelihood of any failure that
could result in loss of containment; any revisions identified pursuant to this
review should be put into immediate effect;
the procedures for implementing changes to equipment and systems to ensure
any such changes do not impair the effectiveness of equipment and systems in
preventing loss of containment or in providing emergency response.
10
The factors that determine the type of independent automatic system required will
include the effects on the upstream system, for example if filling from a refinery
process, a ship or a railway vessel. For all systems the outcome required is the same, ie
automatically stopping supply to the dangerously full tank by means that are fully
independent of the tank gauging system.
11
12
Figure 7 General view of fuel terminal in Aberdeens harbour area
M
M
11
13
Engineering against
escalation of loss of primary
containment
28 The recommendations under this heading follow on from our earlier arguments
about the importance of primary containment see paragraph 23 above. The
Buncefield incident demonstrated the potential for a vapour cloud to form from a
loss of primary containment of a highly flammable liquid such as petrol. We have
adopted a precautionary approach in drawing up these recommendations as we
believe they are appropriate in the light of the Buncefield incident, notwithstanding
that the investigation into the severity of the explosion continues.
Recommendation 12, in particular, anticipates our coming recommendations on
emergency response arrangements.
Recommendation 11 Operators of Buncefield-type sites should review the
classification of places within COMAH sites where explosive atmospheres may
occur and their selection of equipment and protective systems (as required by the
Dangerous Substances and Explosive Atmospheres Regulations 2002(ref 6)). This
review should take into account the likelihood of undetected loss of containment
and the possible extent of an explosive atmosphere following such an undetected
loss of containment. Operators in the wider fuel and chemicals industries should
also consider such a review, to take account of events at Buncefield.
14
15
12
16
For example, in preventing tank overfilling, structural failure and loss of integrity (eg
gasket failure) of pipework and valve joints.
13
18
understanding and defining the role and responsibilities of the control room
operators (including in automated systems) in ensuring safe transfer
processes;
providing suitable information and system interfaces for front line staff to
enable them to reliably detect, diagnose and respond to potential incidents;
training, experience and competence assurance of staff for safety critical and
environmental protection activities;
defining appropriate workload, staffing levels and working conditions for
front line personnel;
ensuring robust communications management within and between sites and
contractors and with operators of distribution systems and transmitting sites
(such as refineries);
prequalification auditing and operational monitoring of contractors
capabilities to supply, support and maintain high integrity equipment;
providing effective standardised procedures for key activities in maintenance,
testing, and operations;
clarifying arrangements for monitoring and supervision of control room
staff; and
effectively managing changes that impact on people, processes and
equipment.
That is, robust organisations with a strong safety culture that have a high probability of
achieving safe and reliable performance. More detail is given in Annex 5.
Recommendation 20 The sector should ensure that the resulting guidance and/or
standards is/are implemented fully throughout the sector, including where
necessary with the refining and distribution sectors. The Competent Authority
should check that this is done.
20
14
15
Such as HSEs Offshore Hydrocarbon Releases Database and the Rail Safety and
Standards Boards National Incident Reporting System, NIR-Online.
21
Annex 1
Terms of reference and progress
This annex sets out the eight terms of reference for the Investigation and explains the
progress that is being made towards accomplishment of each of them.
1 To ensure the thorough investigation of the incident, the factors leading up
to it, its impact both on and off site, and to establish its causation including
root causes
The Board has published three progress reports from the Investigation Manager. This
was followed by the Boards initial report on 13 July 2006, which summarised the
three preceding reports and set out the Boards four main areas of concern. These
have revealed the main facts of the incident, but have not speculated on why control
of the fuel was lost. The explosion mechanism, ie the means by which unexpectedly
high overpressures were generated, is subject to significant further investigation.
Wider expert consultation has been undertaken on whether and what further research
may be required and this is explained in this report.
The criminal investigation is pursuing all reasonable lines of inquiry into the facts and
causes of the incident to enable the Competent Authority (HSE and the Environment
Agency) to take a view on legal proceedings.
2 To identify and transmit without delay to dutyholders and other
appropriate recipients any information requiring immediate action to further
safety and/or environmental protection in relation to storage and distribution
of hydrocarbon fuels
The Competent Authority issued a Safety Alert to around 1100 COMAH dutyholders
on 21 February 2006. Special attention was paid to 108 fuel depot owners storing
COMAH quantities of fuel in Great Britain, seeking a review of arrangements for
detecting and dealing with conditions affecting containment of fuel. Most dutyholders
responded to the alert by the Easter deadline. Meanwhile, the Competent Authority
visited all 108 depots to follow up the alert. An interim report was published on
13 June 2006 and is available at www.hse.gov.uk/comah/alert.htm.
The Environment Agency issued further advice to its inspectors to investigate
secondary (bunding) and tertiary (drains and barriers) containment at depots in
England and Wales in response to the Second progress report. The Environment
Agency continues to monitor the effects of Buncefield on the surrounding
environment and to issue updates on its website, www.environmentagency.gov.uk.
The initiative is being handled separately for Scotland by the Scottish Environment
Protection Agency, with joint inspections undertaken with HSE covering primary,
secondary and tertiary containment, and management systems. However, it is
understood that an overall view of the situation in Britain will be available following
the publication of this report by the Buncefield Board.
On 16 June 2006 investigators served two Improvement Notices on the
manufacturers of the high level alarm switch installed on Tank 912, having identified
a potential problem at other sites related to the setting of the switch for normal
operations following testing. This was followed up by a Safety Alert from HSE on
4 July 2006 alerting operators relying on such switches of the potential problem.
22
The Chairman of the Buncefield Board wrote to the Chief Executive of the Health
Protection Agency on 3 July 2006 enquiring into progress with informing regional
resilience groups of early lessons learned from Buncefield, focusing on public health
issues in the immediate aftermath of a major airborne incident, following up with a
meeting December 2006. HPA is assisting the Board with its recommendations for
improving emergency preparedness and response to major incidents which is likely
to be the subject of the next report from the Board.
3 To examine the Health and Safety Executives and the Environment Agencys
role in regulating the activities on this site under the COMAH Regulations,
considering relevant policy guidance and intervention activity
Work is progressing steadily on both parts of the review, concerning respectively
HSEs and the Environment Agencys prior regulatory activities at Buncefield. The
full findings of the review will be incorporated into the Boards final report (see
term of reference 8). Immediate important lessons from the examination of the
Competent Authoritys prior role will be incorporated as appropriate into the
lessons learned programme under term of reference 5.
4 To work closely with all relevant stakeholders, both to keep them informed
of progress with the Investigation and to contribute relevant expertise to other
inquiries that may be established
The ongoing impact on residents and businesses of the Buncefield incident has been
reported in the three progress reports and in the initial report in which, in Part 2,
the Board set out its main areas of concern. The Board has maintained an active
interest in releasing as much new information as possible to the community and its
representatives, such as the local MP Mike Penning, to assist in understanding the
events of 11 December 2005, and to maintain public confidence that progress is
being made with the Investigation. As has been reported previously, residents and
businesses continue to show remarkable resilience in the difficult aftermath to the
Buncefield incident. Dacorum Borough Council in particular, but also St Albans and
Hertfordshire Councils, have performed extremely effectively in very difficult
circumstances, and have supported the Board in its engagement with residents and
businesses, as has Mike Penning MP.
The Board has also kept key Government stakeholders informed of the
Investigations progress, and has maintained its interest in developments that have
taken place since Buncefield to help manage the aftermath and support a return to
normality for residents and businesses.
The Board has engaged with all the public sector agencies involved in the emergency
response to Buncefield and has met with a number of the key agencies, particularly
the Category 1 (Gold) responders. This is not an issue in which the Board has
primary responsibility but, as reported in this Initial Report, the Board is giving
further consideration to emergency response and emergency preparedness issues,
and will say more on this in its report on emergency preparedness and response.
The Buncefield Major Incident Investigation made presentations to two multiagency
debriefing sessions on 21 and 28 June 2006 to inform regional resilience groups
around Britain of the response to the Buncefield incident.
5 To make recommendations for future action to ensure the effective
management and regulation of major accident risk at COMAH sites. This
should include consideration of off-site as well as on-site risks and consider
prevention of incidents, preparations for response to incidents, and mitigation
of their effects
23
Staff seconded from HSE, the Environment Agency and the Health Protection Agency
are assisting the Investigation Manager and the Board to make sensible, practical and
affordable recommendations for improvements in the light of the Buncefield incident.
Key workstreams are in environmental protection; land use planning; fire and
explosion mechanisms; control and instrumentation; human and organisational
factors; health; emergency response and preparedness; and regulatory impact.
This report, making recommendations for the design and operation of Buncefieldtype sites, is the first report under this term of reference. HSE has convened an
industry chaired task group (the Buncefield Standards Task Group) that includes the
Environment Agency and the Scottish Environment Protection Agency, to also
consider design and operation issues in parallel with the Boards work. This initiative
has been welcomed by the Board in this report.
Work is advanced in producing recommendations on emergency preparation for, and
response to, extreme events such as Buncefield. This work is supported by an
immense amount of work undertaken by other agencies such as Hertfordshire
Resilience, Hertfordshire Fire and Rescue Service, and the Health Protection Agency.
The Board intends to join together the many strands of this subject, including issues
concerning support to communities and businesses in the aftermath of an extreme
incident.
The Board is close to recommending suitable arrangements for further research and
modelling of explosion mechanisms in flammable vapour clouds.
HSE has completed its initial work on changes to land use planning advice and has
issued a public consultation document seeking views by 22 May 2007 (see
http://hse.gov.uk/consult/condocs/cd211.htm). The Board will be setting out its own
views to the consultation document in due course. HSE is also working closely with a
Cabinet Office led team on applying new knowledge of risks to society in the
planning system. The Health Protection Agency is consulting key agencies to improve
public health advice and support during significant pollution events.
6 To produce an initial report for the Health and Safety Commission and the
Environment Agency as soon as the main facts have been established. Subject
to legal considerations, this report will be made public
This element is discharged by the publication of the Boards initial report on
13 July 2006.
7 To ensure that the relevant notifications are made to the European
Commission
A report from the Environment Agency and HSE was made to the European
Commission on 10 March 2006. Subsequently, the Environment Agency declared
Buncefield a major accident to the environment (MATTE), and the Competent
Authority has recently reported this to the European Commission.
8 To make the final report public
The timing for the publication of the final report remains uncertain and is of course
linked to progress on the main terms of reference and to any decision on any
criminal proceedings that might be considered. The possibilities include a further
interim report or reports; decisions must necessarily depend on the timing of
developments and consideration of the public interest.
24
Annex 2
Members of the independent Board
The Rt. Hon. Lord Newton of Braintree has been a life peer since 1997 after
spending 23 years as a Conservative Member of Parliament for Braintree, Essex.
From 1982 to 1988 he held ministerial positions at the Department of Health and
Social Security. In 1988 he joined the Cabinet as Chancellor of the Duchy of
Lancaster and Minister at the DTI. He then held the post of Secretary of State for
Social Security from 1989 to 1992 when he was appointed Leader of the House of
Commons, which he held until 1997. In 2002 he chaired the Committee that
reviewed the operation of the Anti-Terrorism, Crime and Security Act 2001.
Professor Dougal Drysdale is one of the leading international authorities in Fire
Safety Engineering. He was the Chairman of the International Association of Fire
Safety Science until September 2005 and is currently the editor of the leading
scientific journal in the field, Fire Safety Journal. His wide range of research
interests includes the ignition characteristics of combustible materials, flame spread
and various aspects of fire dynamics. He is a Fellow of the Royal Society of
Edinburgh and a Fellow of both the Institution of Fire Engineers and the Society of
Fire Protection Engineers.
Dr Peter Baxter is a Consultant Physician in Occupational and Environmental
Medicine at Cambridge University and Addenbrookes Hospital, Cambridge. In the
past he has advised the Government on the impacts on public health relating to air
quality standards, major chemical incidents, natural disasters and climate change.
Taf Powell is Director of HSEs Offshore Division. He graduated in Geology and
Chemistry from Nottingham University. His oil field career has been split between
working in the UK and abroad in offshore exploration and development and
regulation of the sector in licensing, well operations, policy and safety regulation.
In 1991 he joined HSEs Offshore Division from BP and started work to develop
the new offshore regulatory framework, one of Lord Cullens recommendations
following his inquiry into the Piper Alpha disaster. As HSEs Operations Manager,
based in Aberdeen, he then led inspection teams and well engineering specialists
responsible for enforcing the new regulations until 2000 when he took up his
current role.
Dr Paul Leinster is Director of Operations at the Environment Agency. Up until
March 2004 he was the Director of Environmental Protection, having joined the
Agency in 1998. Prior to this he was the Director of Environmental Services with
SmithKline Beecham. Previous employers also include BP International, Schering
Agrochemicals and the consultancy firm Thomson-MTS where he was Managing
Director. Paul has a degree in Chemistry, a PhD in Environmental Engineering
from Imperial College and an MBA from the Cranfield School of Management.
Paul has worked for 30 years in the health and safety and environmental field.
David Ashton is Director of HSEs Field Operations North-West and Headquarters
Division. He joined HSE in 1977 as an inspector in the west of Scotland where he dealt
with a wide range of manufacturing and service industries, including construction,
engineering and the health services. In 1986 he joined Field Operations HQ to deal
with machinery safety. He then held the post of Principal Inspector of manufacturing in
Preston for two years, before being appointed as a management systems auditor to
examine offshore safety cases in the newly formed Offshore Division. In 1993 he
became Head of HSEs Accident Prevention Advisory Unit, looking at the management
of health and safety in organisations. Between 1998 and 2003 David was HSEs
Director of Personnel, before being appointed to his current position.
25
Annex 3
Rationale for Recommendation 3 Independent and automatic
storage tank overflow prevention
1 It is common practice to employ an ultimate high level detection system to
detect when the liquid in a storage tank has reached a level beyond which any
further filling is likely to result in an overspill of liquid unless suitable averting
action is taken. The benefit of such a system being independent of the tank gauging
system is recognised in the current standards and guidance for storage tank
operations.(refs 4,7,8) However, the current standards and guidance (other than in
the case of reference 2 for unattended facilities only) do not require the overfill
prevention system to be automatic.
2 Nevertheless, the benefit of an automatic overfill prevention system is
recognised by the Energy Institute(ref 7) which says that where tank filling
operations are complex, such as with tanks fed by cross-country pipelines,
consideration should be given to the fitting of high level alarms and devices for
automatically cutting off the supply. Ideally automatic cut-off devices should be
high integrity and independent of any normal measuring alarm or system. We also
note that a draft revision to API Code 2350 considers requiring automatic
independent shutdown systems to control filling of tanks at Buncefield type sites.
3 The benefit of an automatic overfill prevention system stems from the diversity
that such a system provides in combination with the tank gauging system. Without
such diversity the combination of the systems is vulnerable to common cause
failures as they would both rely on human operators. For example, abnormal
events may distract or disable the operators such that they fail to properly control
the tank gauging system and then also fail to respond to the ultimate high liquid
level alarm in time to prevent overfilling. Such common cause failures can
significantly degrade the overall integrity of the gauging and overfill prevention
systems such that the likelihood of an overspill is much higher than would be
evaluated by considering the systems as being independent.
4 It is our considered view, having consulted with experts in the industry, that the
assurance for the overall integrity of containment provided by the diversity of
manual and automatic systems justifies overfill prevention systems being automatic
in Buncefield like sites. This is particularly so given the potentially high
consequences for both safety and the environment, together with the associated
societal concern, that may result from a substantial overspill of petrol or similar
substance in such sites.
5 We consider that a further benefit of an automated overfill prevention system
stems from the greater confidence in testing, inspection, verification and auditing
that competently engineered arrangements allow for, compared with that afforded
by manually operated systems.
26
6 However, even with such an approach it remains vital that both the gauging
system and the overfill prevention systems are maintained in effective working
order. It also remains important to properly evaluate the required safety integrity
level (SIL) for the automated overfill prevention system, taking into account the
associated risks in line with Recommendation 1 of this report. This will ensure a
low enough level of residual risk taking into account a realistic view of the
reliability of the systems.
27
Annex 4
Background and supporting material for improved components and
systems (Recommendation 8)
Alternative means of ultimate high level detection
1 The detection of ultimate high liquid level in storage tanks often relies on a
switch mounted on the roof of the tank (or on the uppermost level of the tank
wall). This is commonplace within the industry. For example it is illustrated in
API RP 2350.(ref 4) However, the arrangement suffers from a number of
disadvantages with regard to safety, namely:
M
the operation of the switch cannot be tested fully in situ other than by raising
the liquid level in the tank to the ultimate high level. Any other means of
testing will leave a number of potential failure modes uncovered and so leave
the switch in a faulty state unbeknown to the operator or maintenance staff.
However, such testing itself introduces the possibility of overfilling so must be
undertaken under strict supervision. There is often a reluctance to undertake
such testing;
simple switches do not benefit from on line diagnostics. More advanced
sensors (such as those based on tuning fork or thermocouple technology)
incorporate diagnostics so that all foreseeable failure modes are detected as
they occur.
28
tapping could be made without the need to empty the main tank, although this
would need to be confirmed. This would significantly reduce the installation costs.
The potential benefits on the face of it justify a recommendation to encourage the
industry to explore this approach further.
29
Annex 5
High reliability organisations (Recommendations 19-22)
1 A high reliability organisation (HRO) is a robust organisation with a strong
safety culture that has a high probability of achieving safe, reliable and quality
performance over a long period of time.
Background
2 Since the early 1980s studies have been made of organisations that operate
high-hazard, low-risk technologies at very high levels of reliability;(refs 10-13) examples
are in the air traffic control sector, and on aircraft carriers. The manufacturing and
banking sectors also contain examples of companies that have elected to build HROs
that are significantly in advance of their peer groups. The studies show that safe
operation is not just a matter of compliance with various regulations, codes and
standards, but also crucially depends on organisational design and culture. HROs have
developed a culture of reliability to drive the business (including high productivity),
without sacrificing the drive for improvement or the capability to change.
Culture
3 The ethos of a HRO is based on the prevention of unplanned events (including
accidents) through good organisational design and management. The culture of a
HRO is one that expects its organisation and sub-systems to fail and works very
hard to avoid failure and to minimise its impact. This preoccupation with the
possibility of failure leads to a continual state of mindfulness combined with a
strong desire to be a learning organisation. High reliability organisations actively
seek to know what they do not know, design systems to make all knowledge relating
to a problem available to everyone in the organisation, learn quickly and efficiently,
train staff to recognise and respond to system abnormalities, empower staff to act,
and design redundant systems to catch problems early. Maintenance and proof
testing are optimised to increase knowledge and to raise productivity to very high
levels through avoidance of unplanned interruptions of which major accidents are
the extreme examples.
Characteristics
4
M
30
Higher quality standards. HROs will maintain high quality standards and
avoid quality degradation as core values. This will involve regular evaluation
of the organisations performance, capabilities and goals.
Perception of risk. The HRO will be aware of all risks and, importantly, the
significance of each key risk and suitable (but not excessive) control measures
will be in place.
Command and control systems that will include:
-
31
Annex 6
BS EN 61511 Functional safety Safety instrumented systems for
the process industry sector
Background
1 BS EN 61511(refs 14,15,16) is the process industry standard for safety
instrumented systems. Such systems are widely used in the chemical and
petrochemical process industries to measure and control process variables (such as
liquid levels and temperatures or gas pressures) so as to ensure that the safe
working limits of plant items are not exceeded and thereby avoid hazardous events
such as loss of containment of flammable or toxic materials. Other common terms
for safety instrumented systems (SIS) are emergency shutdown (ESD) systems,
trip systems, safety interlock systems or safety shutdown systems (SSD).
2 The standard (comprising three parts) was first published by the International
Electrotechnical Commission (IEC) as IEC 61511 in 2003. It was developed by an
international working group comprising experts from the chemical and
petrochemical industries. As such it represents the worldwide consensus view on
how such systems should be engineered to ensure safety. It covers all aspects of the
lifecycle of a system from initial specification and design through to installation,
operation, maintenance and eventual decommissioning.
3 Member countries of the IEC agree to adopt IEC standards as national
standards. IEC 61511 as adopted as the national standard for the UK when it was
published by the British Standards Institution (BSI) as BS IEC 61511 in 2003.
Subsequently, the standard was adopted by the European standardisation body for
Electrotechnical matters, CENELEC, and is now published by BSI as BS EN
61511. The standard has similarly been adopted by all member countries of the
IEC. For example, in the USA it is published as ANSI/ISA-84.00.01-2004.
Principles of BS EN 61511
4 The principles of BS EN 61511 were established by the generic standard for
functional safety, BS EN 61508.(ref 17) The overall aim is to ensure that the
performance of a safety instrumented system, in terms of both the functions it
provides and their integrity, is adequate to ensure safety. It defines four levels of
safety integrity, SIL1, SIL2, SIL3 and SIL4. The higher the SIL level the higher the
associated safety level and the lower the probability that the system will fail to
perform properly. The required SIL is determined by a hazard and risk assessment
taking into account any measures that reduce the risks associated with the hazard
under consideration and the tolerable risk target for the specific application.
Generally it is preferred to avoid sole reliance on SIS, particularly in high hazard
applications. Consequently, most SIS in the chemical and petrochemical process
industries in the UK are specified as SIL1 or SIL2.
32
33
Annex 7
Examples of incidents that have involved loss of primary
containment from storage tanks
Records of incidents of this type are held by the companies involved for purposes of
monitoring the effectiveness of their health and safety policy. The following table
gives some examples of such incidents to illustrate the fact that they should not be
considered as rare events. Data have been compiled by a reputable operator in the
USA that indicate that overfilling occurs once in every 3300 filling operations.
Location
Date
Fuel released
Consequence
Jacksonville,
Florida, UK
1993
Unleaded petrol/
gasoline
Coryton, UK 1997
Unleaded petrol/
gasoline
Belgium
2001
Hexene
Sour Lake,
Texas, USA
2003
Crude oil
Torrance,
California,
USA
2004
Jet fuel
Bayonne,
New Jersey,
USA
2004
Fuel oil
Casper,
2004
Wyoming,
USA
Unleaded petrol/
gasoline
Rensselaer,
NY, USA
Unleaded petrol/
gasoline
2005
34
Cause
Consequence
Fawley
Corrosion
of tank base.
Leak from
damaged sump
escaped through
permeable floor
of bund.
Corrosion of the
tank base and a
permeable bund
base.
Poole 2006
Harbour
Diesel escaped
No injuries. Pollution of ground but
through damaged not of the harbour.
base plate and
through cracks in
concrete bund floor.
Diesel oil
(19 tonnes)
Table 2 Loss of primary containment from fuel storage tanks, some with environmental
consequences
35
References
1 Buncefield Standards Task Group Initial Report 2006
(www.hse.gov.uk/comah/buncefield/bstg1.htm)
2 Safety Review Panel (The Baker Report) BP US Refineries Independent Safety
Review Panel 2007
3 BS EN 61511: 2004 Functional safety. Safety instrumented systems for the
process industry sector British Standards Institution
4 API RP 2350 Overfill protection for storage tanks in petroleum facilities
(Third edition) January 2005
5 Developing process safety indicators: A step-by-step guide for chemical and
major hazard industries HSG254 HSE Books 2006 ISBN 978 0 7176 6180 0
6 Dangerous Substances and Explosive Atmospheres Regulations 2002
SI 2002/2776 The Stationery Office 2002 ISBN 978 0 11 042957 1
7 Model Code of Safe Practice in the Petroleum Industry, Part 2, Design,
Construction and Operation of Petroleum Distribution Installations
(Third edition) Energy Institute September 2005
8 The storage of flammable liquids in tanks HSG176 HSE Books 1998
ISBN 978 0 7176 1470 7
9 Remotely operated shutoff valves (ROSOVs) for emergency isolation of
hazardous substances: Guidance on good practice HSG244 HSE Books 2004
ISBN 978 0 7176 2803 2
10 Hofmann D, Jacobs R and Landy F High reliability process industries:
Individual, micro, and macro organisational influences on safety performance
Journal of Safety Research 1995 26 (3) 131-149
11 Reason J Managing the Risks of organisational accidents Aldershot,
Ashgate 1997 ISBN 978 1 84014 105 4
12 Roberts K New challenges to understanding organisations Macmillan,
New York 1993 ISBN 978 0 02 402052 9
13 Weick K and Sutcliffe K Managing the unexpected: Assuring high performance
in an age of complexity Jossey-Bass, San Francisco 2001
14 BS EN 61511-1: 2004 Functional safety Safety instrumented systems for the
process industry sector Part 1: Framework, definitions, system, hardware and
software requirements British Standards Institution
15 BS EN 61511-2: 2004 Functional safety Safety instrumented systems for the
process industry sector Part 2: Guidelines for the application of BS EN 61511-1
British Standards Institution
36
37
Glossary
API American Petroleum Institute. It is the American national trade association
for the petroleum industry, but it has an increasingly collaborative stance with
other bodies such as BSI. API produces a number of guides to standards and
recommended practices. Of interest is API Recommended Practice 2350 Overfill
protection for storage tanks in petroleum facilities which is currently being
reviewed
BSI Formerly British Standards Institution, now the BSI Group, it was founded
in 1901 as the Engineering Standards Committee, it is now diversified into making
standards, certifying management systems, product testing and other engineering
services related to quality
bund An enclosure designed to contain fluids should they escape from the tank
or vessel inside the bund, as well as any additional materials added to the
container area such as firefighting water and foam, etc
Buncefield Standards Task Group The joint Competent Authority/industry
standards working group set up to review safety and environmental protection
standards at fuel storage sites following the Buncefield incident. The Task Group
published its initial recommendations on 12 October 2006
CENELEC
COMAH
Water stored for use during, and used during, firefighting operations
firewater lagoon An artificial pond that principally stores water intended for
firefighting operations
flashpoint The lowest temperature at which a liquid gives off sufficient vapour to
form a flammable mixture
hazard
HSE
IEC
39
manual emergency switches Simple and robust push switches that will initiate
emergency action such as shutting down pumps or interrupting process operations,
and which are located at strategic and accessible locations around the site
MATTE
overpressure For a pressure pulse (or blast wave), the pressure developed above
atmospheric pressure
primary containment The tanks, pipes and vessels that normally hold liquids,
and the devices fitted to them to allow them to be safely operated
pumphouse In the context of this report, the structure enclosing the pumping
equipment used to move water around the Buncefield site prior to the incident. It
principally stored water intended for firefighting operations
risk The likelihood that a hazard will cause a specified harm to someone or
something
Safety Alert Where the Competent Authority considers that an issue poses
significant risk, it can choose to issue a Safety Alert to operators of COMAH sites
informing them of the issue and possibly requiring them to undertake certain
activity
safety integrity level (SIL) A safety integrity level (SIL) is a measure of safety
system performance, in terms of the probability of failure on demand. There are
four discrete integrity levels, SIL 1-4. The higher the SIL level, the higher the
associated safety level and the lower the probability that a system will fail to
perform properly
Scottish Environment Protection Agency The public body that is responsible for
the protection of the environment in Scotland
secondary containment Enclosed areas around storage vessels (often called
bunds), created usually by concrete or earth walls. Their purpose is to hold any
escaping liquids and any water or chemicals used in firefighting
SEPA
tertiary containment The site surface and associated drainage, boundary walls,
roads, containment kerbs and any features such as road humps that can provide
some retention of liquids. Proper design of drainage systems will limit loss of
product out of the site and prevent lost product permeating into the ground with
the potential risk that it can migrate to groundwater, or contaminate surface
waters and land
ultimate high level switch Part of the system to prevent overfilling of the tank,
the ultimate high level switch is an independent mechanism which should be
triggered when the ultimate high level (ie the specified maximum capacity) is
reached in a tank to which it is fitted, both causing an alarm to sound and shutting
down the supply of fuel to the tank
40
Further information
Useful links
Buncefield Major Incident Investigation
Marlowe Room, Rose Court 2 Southwark Bridge London, SE1 9HS
Tel: 020 7717 6909 Fax: 020 7717 6082
E-mail: [email protected]
Web: www.buncefieldinvestigation.gov.uk
Community/Business support
Dacorum Business Contact Centre Tel: 01442 867 805
Business Link Helpline Tel: 01727 813 813
Hertfordshire Chamber of Commerce Tel: 01727 813 680
Dacorum Community Trust Mayors Fund
To apply, call the freephone helpline on 0800 131 3351. Lines are open 9.30 am to
4.30 pm, Monday to Friday
Dacorum Borough Council Tel: 01442 228 000
Web: www.dacorum.gov.uk
Hemel Hempstead Citizens Advice Bureau
19 Hillfield Road, Hemel Hempstead HP2 4AA
Tel: 01442 213368
Local authorities and emergency services
Dacorum Borough Council Tel: 01442 228 000
Web: www.dacorum.gov.uk
(Dacorum Borough Council Digest newsletter, available monthly Dacorum
Borough Council Buncefield Update Newsletter)
St Albans District Council Tel: 01727 866 100
Web: www.stalbans.gov.uk
Hertfordshire County Council Tel: 01483 737 555
Web: www.hertsdirect.org
Hertfordshire Fire and Rescue Service
Web: www.hertsdirect.org/yrccouncil/hcc/fire/buncefield
Hertfordshire Constabulary
Web: www.herts.police.uk/news/buncefield/main.htm
Hertfordshire Chamber of Commerce Tel: 01727 813 680
Web: www.hertschamber.com
41
Government links
Department for Communities and Local Government
Fire and Resilience Directorate
Web: www.communities.gov.uk
Government Office for the East of England
Web: www.goeast.gov.uk
Environment Agency
Web: www.environmentagency.gov.uk
Department of Trade and Industry
Oil and Gas Directorate
Web: www.og.dti.gov.uk
Health and Safety Executive
Hazardous Installations Directorate
Web: www.hse.gov.uk/hid
Control of Major Accident Hazards
Web: www.hse.gov.uk/comah
Department for the Environment, Food and Rural Affairs
Web: www.defra.gov.uk
Health Protection Agency
Web: www.hpa.org.uk
Food Standards Agency
Web: www.food.gov.uk
Drinking Water Inspectorate
Web: www.dwi.gov.uk
Scottish Environment Protection Agency
Web: www.sepa.ork.uk
Buncefields Standards Task Group (BSTG)
Chair: Ken Rivers Tel: 0151 951 4078
Industry links
United Kingdom Petroleum Industry Association (UKPIA)
Tel: 020 7240 0289 Web: www.ukpia.com
Chemical Industries Association
Tel: 020 7834 3399 Web: www.cia.org.uk
Three Valleys Water
Tel: 0845 782 3333 Web: www.3valleys.co.uk
United Kingdom Onshore Pipeline Operators Association (UKOPA)
Tel: 01773 852003 Web: www.ukopa.co.uk
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Investigation reports
Buncefield Major Incident Investigation:
M
44
Reprinted 05/07
C16