Posted By raymondoscaff
Hi,
The Whole issue of enforcement by our regulator needs addressing.
I work offshore, where 1000's of workers work on platforms that are dropping to bits.
In some cases the HSE have known about serious non-compliances, but, take a look at the report by Bill Campbell" The non-compliant regulator" it is with permission I use it's contents.
The Non-Compliant Regulator – is failure to prosecute leading to the next major accident event?
Last years Ministerial comments that we were to see a new, a get tougher approach by the Regulator towards an oil industry where safety was on the brink seems to have been presentational, hot air.
If you look at Shell for example, whose assets comprise almost 30% of the infrastructure offshore in the UK North Sea a steady and significant deterioration is evident post the 2003 fatalities. It is true that HSE is serving more Enforcement Notices, but such attempts to enforce behavioural changes without the deterrence that prosecution can bring is demonstrably ineffective.
A 300% increase in the rate of issue of Enforcement Notices is not the only problem. The following data including the most recent update of the Chronology of Major Events gives evidence of a significant increase also in high potential incidents. It gives examples of serious breaches of legislation being oft repeated, and of risks persisting because Notices are being extended well past the original completion date for unknown and possibly unjustified reasons.
This is exactly similar to the circumstances evident from 1999 onwards indicating the presence of a negative safety culture whose sustenance over a prolonged period led inevitably to the major accident event in September 2003. The failure of the Fatal Accident Inquiry to get anywhere near the root cause of the fatalities has allowed this culture to persist and allowed a failed safety regime to continue without the structural changes necessary to make it more effective.
Anyway, judge for yourself, the data is the wholly owned property of HSE and Shell and it begs the question, when, if nothing changes, will the next major accident event occur?
Statistical Summary Post Fatalities
• Of the 42 Notices issued since the fatalities only two led to prosecution, these were both related to the fatalities
• 27 of these 42 Notices related to reducing risks of potential major accident events with multiple fatalities. So 66% of the Notices according to the HSC policy definitions were related to breaches which gave rise to significant risk
• 15 of the 42 Notices related to reducing risks of potential single fatality such failure to guard the moving parts of machinery
• In total after the fatalities there have been 85 separate breaches of both the Health and Safety etc at Work Act or the daughter legislation the Offshore Safety Case Regulations – this is because often a Notice identifies more than one breach
• The 7 serious repeat offences amount to 18 separate breaches
• Given the absolute amount of breaches, and the span and interlacing of these breaches, since the fatalities in 2003 Shell UK not been in continual breach of some legislative requirement or other – see electronically attached power-point slide
• None of the above takes into account that in 2003 HSE failed to raise 10 Prohibition Notices on installations where the ESD valves were impaired, or had failed, and where in some instances performance test records had been falsified (circa 20 breaches)
• None of the above takes into account that in 2003 HSE failed to raise 16 Prohibition Notices on installations where there were over 200 unapproved and thus potentially defective repairs on hydrocarbon pipe-work (circa 32 breaches)
• None of the above takes into account that in 2003 HSE failed to raise 16 Improvements Notice on installations where there were over 1000 fire and gas sensors in a potentially failed condition (circa 32 breaches)
----------------------------------------------------------------------------------------------------------------------------Some Recent developments
Lifeboats
Upstream Magazine reported and made Society aware on 14th March technical problems with lifeboats on Brent Bravo and Tern. Although the HSE now confirm that lifeboats had now been repaired it was neglect of maintenance and failure to invest in replacement lifeboats which led to the problems arising. All this in a Company earning net profits of circa $3 million per hour and which in the last day or two announced record quarterly profits. This is a Company that constantly replays in response to any criticism that Safety is its Number 1 priority and it would never compromise safety.
Risk from Asbestos on the Leman C Complex
The first indication that asbestos dust was harmful to humans was published in the early 50’s, lets for argument sake say 50 years ago. By the 1970’s an industry had been created around removal of the white stiff safely and by certified competent persons. It appears that Shell is a bit slow in the uptake on all this. The most recent failure of Shell as listed in the attached Chronology of Major events related to a Prohibition Notice served on 8/11/07 the wording of which is below
Shell has failed to provide a written plan identifying those parts of the premises concerned, the measures to be taken for managing the risk and failure to ensure that information about the location & condition of any asbestos or any such substance was provided to every person liable to disturb it.
An update on Post Fatalities Statistics
The asbestos failure listed above is the 42nd failure of Shell UK to comply with the Law in its offshore operations since the unlawful deaths on Brent Bravo on September 11th 2003. In fairness, and since it does not cover the area of responsibility of the Offshore Safety Division of the HSE, I have not listed the other failures recorded for onshore plants such as the St Fergus Plant.
Breakdown of the 42 enforcement notices September 2003 to end 2007
• 13 were immediate Prohibition Notices (the risks are so great that something needed to be done right away)
• 29 were Improvement Notices (the risks are unacceptable and the Notice must be completed within an agreed timetable, the risks are present till the remedial work is completed in full)
• In total the 42 Enforcement Notices equate to 85 separate breaches of legislation
• The average rate of issue of a Notice on Shell for its North Sea operations since the fatalities is one per 36 days, or if you like, circa two breaches per 36 days in the 51-month period since the fatalities
• Two of these Notices were as a direct consequence of the fatalities but the 40 others were not.
Why under the Health and Safety at Work Act is Prosecution necessary?
In the UK the Enforcement Policy is policed by the HSE named as an enforcing authority under the H&S at Work Act. The policy is that of the Health and Safety Commission (HSC) which has oversight and governance over the operations in the UK of the Executive.
The HSC policy is well written and unambiguous.
The Policy states that the purpose of enforcement is to ensure that Duty Holders take action to deal immediately with serious risks and to promote and achieve sustained compliance with the law. And further to ensure duty holders who breach health and safety requirements, and Directors or Managers who fail in their responsibilities, may be held to account.
HSC also expects that, in the public interest, enforcing authorities will consider prosecution, or consider recommending prosecution, where following an investigation or other regulatory contact, one or more of the following circumstances apply:
• it is appropriate in the circumstances as a way to draw general attention to the need for compliance with the law and the maintenance of standards required by law, and conviction may deter others from similar failures to comply with the law
• a breach which gives rise to significant risk has continued despite relevant warnings from employees, or their representatives, or from others affected by a work activity
So you can see that Prosecution is not just punitive action resulting in monetary fines on the Duty Holder but rather as the founding fathers wanted a deterrent.
Prosecution is a mechanism allowing public ventilation of the facts and through this process the Duty Holder under such scrutiny will alter his behaviour or face the consequences of not so doing. This Prosecution publicity would not only alert employees who have a statutory right to be made aware but alert Society as a whole that a Duty Holder was persistently, and with malice, breaking the Law through repeated failure to comply.
Prior to the fatalities some 15 Notices were served with 35 separate breaches and although Shell were prosecuted on one occasion it did not relate to those 35 breaches. If Prosecution had followed the number of serious repeat offences from 1999 onwards would the deceased still be alive? I think it is a possibility.
An example of some Repeat Offences after the fatalities where no Prosecution followed
Under the HSC policy on enforcement prosecution is recommended where breaches have caused a significant rise in the risk to workers exposed to those risks. And where these breaches are repeated or persistent providing evidence of poor compliance.
On 26/11/04 only a year after the fatalities in the utility shaft a repeat Notice was served on Brent Bravo because Shell had failed to provide adequate training for persons entering the utility shaft. A similar repeat offence occurred on 8/12/04 when a similar Notice was issued on Dunlin.
There has since 1999 been repeated failures by Shell to maintain their facilities and neglect of maintenance was determined by the Sheriff to be a contributory factor in the deaths.
On 24/3/05 a Notice was served on Inde for complete failure of its maintenance regime and on 30/11/06 a similar Notice was served on Clipper.
Corrosion is of epidemic proportions offshore particularly on the first generation installations and on 22/5/06 Notices were served on Brent Bravo and Brent Delta requesting Shell to replace corroded cell fill lines.
The Notices related to the cell fill lines first issued on 22/5/06, and due for completion by 30/11/07 have now been extended till January 2009, why? As previously stated the risks will persist till January 2009 also and if this delay is for economic reasons, or for production taking priority over safety, then it is clearly unacceptable.
Whilst on the subject of delay, the Notice served on Anasuria, in that Shell failed to ensure the watertight integrity of the installation and the installations stability if that integrity were to be lost, was due to be completed by 30/8/07. This has been extended to 31/12/09 so the risks associated with this offence still persist also.
Examples of negative safety culture being sustained but no prosecutions followed
A Prohibition Notice was served on Brent Bravo on 27/7/06. Employees continued to use a stairway in the utility shaft blissfully unaware that it had been condemned in an inspection report. The Notice issued by the HSE was to rectify this failure.
Further on 5/4/07 Shell failed to report to HSE a significant gas leak. These were serious offences but no prosecution followed.
High Potential Incidents
In addition to the Notices the Chronology of Major Events tables list 13 events since the fatalities. The majority of these were high potential incidents causing the evacuation of non-essential personnel and an alarming amount of these events occurred in enclosed Utility Shafts or concrete columns in a similar location to where the deaths occurred in 2003.
The rate of high potential incidents has also increased by about the same factor as the issuance of Notices
Updated Chronology of major events after the fatalities. The Tables catalogue failures to comply with the Law and also lists High Potential Incidents due mainly to neglect of maintenance
15/09/03 Prohibition Notice served on Brent Bravo Quote Potential hydrocarbon leaks from the degasser rundown pipework in the Utility Shaft in close proximity to level control valve LCY 6600 could harm platform personnel if it is not repaired or renewed Unquote A further breach of Offshore legislation
17/09/03 Prohibition Notice served on Brent Bravo Quote the palfinger and grab assembly have not been maintained in order to prevent the inadvertent opening of the pipe grab jaws Unquote A further breach of Offshore legislation
18/09/03 Prohibition Notice served on Brent Bravo Quote Integrity standards of Utility Shaft hydrocarbon facilities and related safety systems are not being adequately maintained and operated so far as is reasonably practicable, to prevent harm to platform personnel Unquote A further breach of Offshore legislation
28/9/03 Improvement Notice served on Lowestoft: Quote - Shell have failed to demonstrate, that for Major Capital Brown Field Projects, the organisation and systems which are in place effectively control the preventive and protective measures required to assure compliance with the requirements and prohibitions placed upon them by or under the relevant statutory provisions associated with Major Hazards - Unquote A further breach of Offshore legislation
06/02/04 Prohibition Notice served on Brent Alpha Quote - You have failed to provide adequate guards or other measures to prevent persons coming into contact with the dangerous parts of the HVAC Extract fans ME16 and ME17 – Unquote A further breach of Offshore legislation
09/02/04 Improvement Notice served on Brent A – Quote - It is possible for persons to come into contact with dangerous part of HVAV fans ME16 and ME17 whilst the fans are in motion - unquote A further breach of Offshore legislation
10/03/04 Prosecutions to which Shell Pled guilty under the various Provisions of the Health and Safety at Work act Brent Alpha A further breach of Offshore legislation
25/03/04 Prohibition Notice served on Brent Delta Quote - The aforementioned fans are not so guarded as to prevent anyone from coming into contact with the dangerous parts – Unquote A further breach of Offshore legislation
May 2004 64 non-essential personnel evacuated from Brent Delta after a gas leak in the Utility Shaft Potential major accident event
01/06/04 Improvement Notice served on Tern Alpha Quote - That during a high pressure water jetting undertaking a person not in your employment, operating the equipment, was struck by the high pressure jet which penetrated his unsuitable safety footwear, causing a major injury to his foot – Unquote A further breach of Offshore legislation
August 2004 A gas leak occurred in a Utility Shaft of Dunlin Alpha Potential Major accident
October 2004 A gas leak occurred on Cormorant Alpha Potential major accident
08/10/04 Improvement Notice served on Cormorant Alpha Quote - That you have failed to prevent an unplanned escape of fluids from the well in that there was a major release of gas from a faulty flexible hose on well CA26 on the 28th Sept 2004 - Unquote A further breach of Offshore legislation
08/10/04 Improvement Notice served on Cormorant Alpha Quote - That you have failed to maintain the diesel fire pump 7250 in an efficient state, in an efficient working order and in good repair, in that the prime mover is subject to overheating in foreseeable emergencies - Unquote A further breach of Offshore legislation
27/10/04 Improvement Notice served on Auk Quote - That you have failed to maintain the integrity of the fabric of the installation in that there are severely corroded gratings and handrails on the installation - Unquote A further breach of Offshore legislation
28/10/04 Prosecutions to which Shell Pled guilty under the various Provisions of the Health and Safety at Work act Brent Delta A further breach of Offshore legislation
02/11/04 Improvement Notice served on Brent C Quote - You have failed to ensure that equipment, namely the platform's instrument air supply system supplying the Temporary Refuge Heating and Ventilation System Fire Dampers is maintained in an efficient state, efficient working order and in good repair – Unquote A further breach of Offshore legislation
16/11/04 Prohibition Notice served on Fulmar Quote - The current design of the equipment is inadequate and the operation is unsafe - Unquote A further breach of Offshore legislation
20/11/04 Prohibition Notice Served on Brent Bravo – failure to guard machinery A further breach of Offshore legislation
26/11/04 Improvement Notice served on Brent Bravo Quote - You have failed to provide such information, instruction and training as was necessary to ensure the health and safety of your employees and others, in that whilst work was being undertaken at the 101 m level of the Utility Shaft, access to the dangerous parts of machinery of the lift mechanism was possible – Unquote A further breach of Offshore legislation – this is a serious repeat offence since the deaths on BB related to procedural anarchy displayed at that time and lack of training etc to persons working in Utility Shafts
26/11/04 Improvement Notice served on Clipper Quote - Your ship collision avoidance performance standard and procedure do not provide sufficient warning to enable effective emergency response and are not adequately controlled by a management system and do not therefore constitute a safe system of work - Unquote A further breach of Offshore legislation
26/11/04 Prohibition Notice served on Brent Bravo Quote - You have failed to prevent persons coming into contact with the dangerous parts of the Utility Shaft lift machinery – Unquote A further breach of Offshore legislation
08/12/04 Improvement Notice served on Dunlin Alpha Quote - Improvements are required for breathing apparatus self rescue set training for Utility Shaft authorised and leg competent personnel within confined space legs with potential for a hydrocarbon or toxic gas atmosphere is inadequate as it does not require these personnel to don the self rescue sets (or training sets) over their heads and breathe through them while in a realistic escape scenario - Unquote A further breach of Offshore legislation – this is a serious repeat offence since the deaths on BB related to procedural anarchy displayed at that time and lack of training etc to persons working in Utility Shafts
28/02/05 Improvement Notice served on Brent Alpha Quote - You are failing to ensure that work equipment is maintained in an efficient state, in efficient working order and in good repair in that, the cable supports in the pallet deck area are severely corroded and are not providing adequate support for the electrical systems and the Ex electrical lighting in the same area was showing signs of water ingress - Unquote A further breach of Offshore legislation
17/03/05 Prohibition Notice served on Inde Quote - Shell has not taken all reasonable practical steps to maintain a safe place of work - Unquote A further breach of Offshore legislation
24/03/05 Improvement Notice served on Inde Quote - Your present maintenance regime is not maintaining the integrity of the Juliet installation, and will not maintain integrity throughout the remaining life cycle of the installation – Unquote A further breach of Offshore legislation
01/04/05 Improvement Notice served in Brent Bravo Quote - The water deluge system in Modules D3W and D3E is not maintained in an efficient state as was demonstrated by the failure of parts of the system to meet the relevant performance standard when tested on 21 and 22 March 2005 respectively – Unquote A further breach of Offshore legislation
28/04/05 Three prosecutions to which Shell Pled guilty under the various Provisions of the Health and Safety at Work act related to the fatal accident event on 11th September 2003 These failings to comply with the Law directly contributed to the deaths
14/06/05 Improvement Notice served on N Cormorant Quote - Numerous process system valves and numerous other safety critical system valves have no unique identifying number marked or labelled on them A further breach of Offshore legislation
20/06/05 Improvement Notice served on Gannet: You have failed to ensure doors for use in an emergency are so fastened that they can readily be opened by any person who may require to use them in an emergency. Further, this violation has compromised the integrity of the TR. TR boundary air lock door at the smoking area lounge was wedged off its seal by the use of a square block A further breach of Offshore legislation
August 2005 85 non essential personnel were evacuated from Brent Bravo after an oil leak in the Utility Shaft Potential major accident event
August 2005 Less than two weeks later 71 non-essential personnel were evacuated from Brent Bravo following a gas leak Potential major accident event
12/11/05 Prohibition Notice served on Clipper Quote - You have not carried out a suitable and sufficient task risk assessment, and implemented suitable controls to reduce risks to ALARP, and record significant findings – Unquote A further breach of Offshore legislation
19/12/05 Improvement Notice served on Clipper Quote - You have failed to put in place controls to : clarify health & safety roles and responsibilities and to ensure persons understand clearly what they have to do to discharge them; ensure activities of everyone are well co-ordinated, and carry out on site active monitoring to ensure preventative and protective measures are in place and effective – Unquote A further breach of Offshore legislation
23/12/05 Improvement Notice served on Clipper in relation to a fatality to improve the safe system of work and monitoring arrangements A further breach of Offshore legislation
08/03/06 Prohibition Notice served on Anasuria – You have failed to take effective measures to prevent contact with dangerous parts of machinery A further breach of Offshore legislation
22/05/06 Improvement Notice served on Brent Delta: Failing to ensure the health and safety of your employees and others by failing to ensure that the Utility Shaft cell fill lines have been maintained in an efficient state, in efficient working order and in good repair – Unquote
This work due to be completed by 30/11/07 has been extended to 31/1/09 so the RISKS associated with this offence still persist This is a serious repeat offence since the deaths on BB in Sept 2003 related to loss of containment from a corroded line which had a materially defective temporary repair
22/05/06 Improvement Notice served on Brent Bravo Quote - Failing to ensure the health and safety of your employees and others by failing to ensure that the Utility Shaft cell fill lines have been maintained in an efficient state, in efficient working order and in good repair – Unquote
This work due to be completed by 30/11/07 has been extended to 31/1/09 so the RISKS associated with this offence still persist A further breach of Offshore legislation – this is a serious repeat offence since the deaths on BB in Sept 2003 related to loss of containment from a corroded line which had a materially defective temporary repair
May 2006 On 15th May a pinhole leak was found on the Brent Alpha oil import line Potential major accident event due to loss of containment
June 2006 On the 5th of June there was a release of gas on Brent Bravo and around 20 - 60 litre of oil were spilled during pigging operations. The platform was shutdown whilst the module was safely isolated’ Potential major accident event due to loss of containment
June 2006 Work had to be stopped in the Brent Bravo Utility Shaft after an alert caused by a seep from a pipeline bringing seawater into the platform. Potential major accident event due to loss of containment
26/07/06 Improvement Notice served on Brent Bravo Quote - You have failed to, ensure the health and safety of your employees and others by failing to ensure that the 12” Oil Export Pipework P-137-1106Y, so far as is reasonably practicable, has been maintained in an efficient state, in efficient working order and in good repair – Unquote A further breach of Offshore legislation
27/07/06 An Improvement Notice was served on Brent Bravo - A report had been prepared which condemned the stairway in the Utility Shaft as unsafe for use due to severe corrosion. This report was subverted. The matter was only highlighted when the report contents in part were leaked to the OILC. The HSE intervened to raise an improvement notice stating yet again that Shell had failed its legal obligations
An example that despite the fatalities in 2003 three years later the negative safety culture persisted. It was onshore Management that covered up the inspection report
27/07/06 Improvement Notice served on Dunlin Alpha Quote - You have failed to prevent access to dangerous parts of machinery, specifically the Dunlin Utility Shaft C winch and the Dunlin Utility Shaft D winch. – Unquote A further breach of Offshore legislation
01/09/06 Improvement Notice served on Leman A Quote - Lifting equipment was not being adequately controlled through the rigging loft. The AK gantry cranes were inadequately maintained and the on site control of lifting operations was seen to be inadequate – Unquote A further breach of Offshore legislation
20/09/06 Prohibition Notice served on Cormorant Alpha Quote - Level 9 C4 Utility Shaft – Winch is inadequately guarded – Unquote A further breach of Offshore legislation
06/11/2006
Improvement Notice served on Clipper Quote - Failure to comply with the Provisions for the Use of Work Equip Regulations 1998 - Unquote A further breach of Offshore legislation
30/11/2006
Improvement Notice served on Clipper – Quote - Shell has failed to implement a suitably resourced maintenance regime to achieve compliance with their own maintenance strategy. This has lead to excessive backlog of maintenance activities for safety critical equipment and non safety critical equipment leading to poor working order and repair of equipment – Unquote A further breach of Offshore legislation
12/02/07 Improvement Notice served on Clipper in that Shell are required to implement a programme to clear unacceptable levels of safety critical maintenance backlog A further breach of Offshore legislation
05/04/07 Improvement Notice served on Dunlin Quote - on the 30th March 2007 you failed to notify the relevant enforcing authority (HSE) that there had been a dangerous occurrence (a gas leak) – Unquote
A Dangerous Occurrence as defined by the H&S etc at Work Act. Failure to Report is an offence in Law but the HSE has failed to prosecute
14/05/07 Improvement Notice served on FPSO Anasuria – Shell failed to ensure the watertight integrity of the installation and the installations stability if that integrity were to be lost –
This work due to be completed by 30/8/07 has been extended to 31/12/09 so the risks associated with this offence still persist A further breach of Offshore legislation
29/06/07 Improvement Notice served on Dunlin Alpha – Shell failed to prevent or control exposure of employees to substances hazardous to their health – this Notice is still ongoing so the RISKS associated with it are still present A further breach of Offshore legislation
07/07/07 Shell report gas release on its Eider offshore installation A Dangerous Occurrence as defined by the H&S etc at Work Act
07/08/07 Shell forced to evacuate 60 employees from its Brent Bravo installation due to prolonged loss of power Indication of neglect of maintenance
25/09/07 Circa About 100 workers were evacuated from the North Cormorant installation after one of the two boilers broke down. Indication of neglect of maintenance
25/09/07 Circa about 100 workers were evacuated from the Cormorant Alpha installation after one of the three power generators failed Indication of neglect of maintenance
Nov/07 In relation to concerns raised by trade unions related to manning and competency levels on Shell offshore installations the HSE uphold all but one of the concerns raised by the workforce It remains to be seen if enforcement actions or prosecution will follow
Nov /07 A fire is reported on North Cormorant, on the same day Cormorant Alpha suffers a prolonged outage of power due to failure of utility systems It remains to be seen if enforcement actions or prosecution will follow
08/11/07 Prohibition Notice served on Leman A for failure to manage risks to health of employees from Asbestos Another breach of Offshore legislation
14/03/08 Upstream Magazine publish concerns related to the failure to maintain safety critical equipment namely Lifeboats on Brent Bravo and Tern Another breach of Offshore legislation
These enforcement Notices listed were to eliminate the risks of potential multiple fatality events. For example failure in essential management and supervisory controls to ensure the health and safety of all the employees on a specified offshore installation, for example failures in the application of the safety critical equipment performance verification schemes
These Enforcement Notices were to eliminate the risks of potential single fatality events, for example failure to guard machinery properly
Note:
Enforcement Notices i.e. either Prohibition or Improvement Notices are legal documents. Failure to comply with the Notice is an offence, which can lead to prosecution. The Notice when served requires the unacceptable risks identified in the Notice to be completely eliminated within the specified time on the said Notice
A Prohibition Notice when served takes immediate effect to prohibit the use of hardware, process or systems of working etc until such times as the unacceptable risks identified in the Notice are completely eliminated.
Until the actions required under the terms of the notice are completely implemented the risks to persons on board the installation effected by the notice remain above the statutory level ALARP as specified in the installation Safety Case
Prosecutions for which Shell pled guilty
High Potential incidents due to loss of technical integrity