COMAH

COMAH
Major Accidents Notified to the European Commission
England, Wales & Scotland 2001-2002
Report of the Competent Authority
CONTENTS
Synopsis
Executive Summary
Introduction
Regulatory Background
EC Notification Procedure
EC Reportable Accidents 2001-2002
Conclusions
Feedback
References
Appendix A Summary of EC Reportable Accidents 2001-2002
Appendix B COMAH Regulations Schedule 7
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endorsement or commercial purposes. Please acknowledge the source as HSE.
November 2003
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SYNOPSIS
The Control of Major Accident Hazards (COMAH) Regulations 1999 are implemented by a
Competent Authority (CA) comprising of the Health & Safety Executive (HSE) working
jointly with the Environment Agency (EA) & the Scottish Environment Protection Agency
(SEPA).
This report covers the period April 2001 to March 2002 and provides details of 4 COMAH
major accidents in England, Wales & Scotland notified to the European Commission (EC).
The report describes the causes of the accidents, their consequences and the
enforcement action taken by the CA. In publishing it, the CA is aiming to show how the
COMAH regime is working in an open and transparent way. The report will also enable
lessons to be learned so that accidents can be prevented in the future.
This is the third report to be published in the series following reports covering 1999/00 and
2000/01. The CA intends to publish the report for the period 2002/2003 in 2004.
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1
EXECUTIVE SUMMARY
The COMAH Regulations 1999 apply to approximately 1100 establishments that have the
potential to cause major accidents because they use, or store, significant quantities of
dangerous substances, such as oil products, natural gas, chemicals and explosives. The
general duty of the regulations is that ‘Every operator shall take all measures necessary to
prevent major accidents and limit their consequences to persons and the environment’.
The regulations are unusual in that they are implemented by a Competent Authority (CA)
comprising of the Health & Safety Executive (HSE) working jointly with the Environment
Agency (EA) and the Scottish Environment Protection Agency (SEPA). This arrangement
reflects the requirements to ensure the protection of both persons and the environment.
The CA is required to notify certain major accidents to the EC. The criteria include; the
release of a specified quantity of a dangerous substance, specified harm to persons (e.g. 1
death), specified harm to the environment (e.g. significant damage to more than 10km of
river) or in some circumstances a ‘near miss’ of particular technical interest. This report
describes the 4 EC Reportable Accidents (ECRAs) that occurred during the period
2001/02, their consequences and enforcement action taken by the CA. A summary is
provided in tabular form at Appendix A.
The key points to note are that of the 4 accidents:
·
·
·
·
·
·
·
3 occurred at top tier sites and 1 at a lower tier site;
The CA investigated all 4 accidents. 3 investigations are ongoing;
1 accident resulted in 3 fatalities and 17 other injuries to employees, 5 of whom were
detained in hospital in intensive care. This also resulted in on-site property damage in
excess of 2 million Euros;
1 accident resulted in 1 fatality and 3 other injuries that required hospital treatment for
respiratory problems. This also resulted in a prosecution with a fine of £250,000
imposed;
1 accident resulted in 1 minor injury to an employee. This also resulted in on-site
damage and post-event inspection costing £15,000,
1 accident resulted in 3 minor injuries (1 on-site, 2 off-site);
None of the accidents caused damage to the environment.
The principal conclusions are:
·
·
·
There were 4 ECRAs in 2001/02. This is similar to the average number of major
accidents that were reported each year under the previous CIMAH regulations;
Whilst recognising that it is difficult to draw conclusions from such a small sample,
ECRAs can be used as a crude measure of safety performance. The Accident
Frequency Rate (AFR) for the period April 2001 to March 2002 is 3.6 ECRAs per
thousand COMAH establishments per annum. Alternatively this can be expressed as
1 ECRA per 277 COMAH establishments per annum;
There is concern at the magnitude and frequency of these accidents and at the
repeated underlying causes of major accidents. The CA will continue to use the
COMAH Regulations as the vehicle for improving corporate governance of major
hazard sites.
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2
INTRODUCTION
In April 1999 the Control of Major Accident Hazards (COMAH) Regulations came into force
in England, Wales and Scotland, replacing the Control of Industrial Major Accident
Hazards (CIMAH) Regulations that had been in place since 1984.
The COMAH regulations require the CA to notify the EC of certain major accidents. This is
a continuation of the CIMAH requirements and there have typically been an average of 4
such accidents in the UK each year. The EC uses the data to inform its decisions on
future changes to legislation regarding major accident hazards. The data is also made
publicly available, including on the Internet, so that it can be used to learn lessons from the
past and help to prevent accidents in the future.
This report provides details of the 4 COMAH major accidents notified to the EC between
April 2001 and March 2002. It is the third report to be published in the series following the
reports covering 1999/00 and 2000/01. The CA intends to publish the report for the period
2002/2003 in 2004.
3
REGULATORY BACKGROUND
The first European Council directive concerned with controlling major accident hazards
involving dangerous substances was adopted in 1982. Known as the 'Seveso' directive,
(82/501/EEC), it was incorporated into UK law by means of the Control of Industrial Major
Accident Hazards Regulations 1984 (CIMAH). In 1996, the 'Seveso II' directive (96/82/EC)
superseded the earlier Directive. The principal changes were a broadening of scope to
include a wider range of dangerous substances and enhanced requirements to protect the
environment. Most of the requirements of 'Seveso II' have been implemented by the
COMAH Regulations 1999.
The general duty of the COMAH regulations is that 'Every operator shall take all measures
necessary to prevent major accidents and limit their consequences to persons and the
environment'. The regulations apply to over 1100 establishments in England, Wales and
Scotland. Approximately 730 are ‘lower tier’ sites, where operators must prepare a Major
Accident Prevention Policy. The remaining 370 sites with larger inventories of dangerous
substances are classified as ‘top tier’ and are subject to additional requirements. These
include submitting a safety report to the CA to demonstrate how they are preventing or
limiting the consequences of a major accident and providing information to local authorities
to enable off-site emergency plans to be developed.
4
EC NOTIFICATION PROCEDURE
COMAH Regulation 21 requires the CA to notify the EC of any major accident meeting
certain criteria. The criteria and the information to be provided are given in Schedule 7 of
the regulations. Part 1 is reproduced as Appendix B of this report.
The notifications are sent to the Major Accident Hazards Bureau of the European
Commission Joint Research Centre (JRC), based at Ispra in Italy. The Bureau gives
support to Environment Directorate General (DG ENV) of the European Commission.
There are 2 forms provided for the purpose; the short form is for immediate notification of
an accident and provides basic information, the long form is to be sent later when the
investigations have been completed and the causes of the accident have been
established.
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The data is entered onto the Major Accident Reporting System (MARS). The names and
addresses of the operators are removed before the data is made available to the public on
the JRC website http://mahbsrv.jrc.it. Data searches and analyses can also be carried out
on-line. For further information contact Michalis Christou, European Commission, Joint
Research Centre, TP 670, I-21020 Ispra (Va), Italy. Email: [email protected] or by
fax: +39 0332 78 9007.
5
EC REPORTABLE ACCIDENTS 2001 – 2002
4 major accidents were reported to the EC because they satisfy one of the criteria given in
paragraph 1 of Schedule 7 of the COMAH Regulations.
The 4 accidents are listed below in chronological order. Details are provided against each
accident on the causes, consequences, the emergency response and the action taken by
the CA.
5.1
CONOCO LTD, Humber Refinery, South Killingholme, Immingham
Incident Date – 16 April 2001
This COMAH top tier site is an oil refinery. On 16 April 2001, following the release of
approximately 179 tonnes of extremely flammable hydrocarbon gases (a mixture of
ethane, propane and butane), a fire broke out in the Saturate Gas Plant.
The incident occurred when the de-ethaniser column overhead pipework failed, resulting in
the escape of the hydrocarbons. The escaping gas formed a vapour cloud and exploded.
The ignition source for the cloud was a nearby coking plant direct-fired heater. Once
ignited, the fire led to two further line ruptures and subsequent fireballs.
Both on-site and off-site Fire Services attended the scene and the Police set up
roadblocks in the surrounding area. There were three minor injuries reported: one on-site
and two off-site. All on-site personnel were evacuated from the immediate vicinity. There
was extensive damage off-site to local homes and businesses, including shattered
windows and damage to roller shutter doors and lightweight panels in the adjacent
industrial units. There was no damage to the environment.
This was an ECRA as it resulted in a fire and the loss of more than 5% of the qualifying
quantity of dangerous substances as laid out in Part 1 of Schedule 7 of the COMAH
regulations.
Subsequent to the incident, the CA issued an alert advising refinery operators to ensure
that pressure pipework was properly inspected and maintained, particularly where it was
vulnerable to internal corrosion/erosion.
The incident is still under investigation by the CA.
5.2
PARK ENVIRONMENTAL SERVICES LTD, Newport
Incident Date – 16/17 July 2001
At the time of the incident, this treatment plant for processing chemical waste was a
COMAH lower tier site. On 16 July 2001 there was a release of an estimated 186m3 of
hydrogen sulphide gas from a 500m3 treatment tank.
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A road tanker load of waste alkali solution (approximately 20 tonnes) had been transferred
to a treatment tank. As part of the chemical waste treatment process, mixed waste acids
were added to the tank with a view to controlling the pH level (the measure for determining
the strength or weakness of acids/alkalis). During the processing, the acid reacted with
the polysulphide contaminants in the waste alkali solution, producing hydrogen sulphide
gas. The tank had no lid and this resulted in the escape of the toxic gas from the tank.
The gas then settled at ground level.
Fire, Police and Ambulance Services all attended the scene and remained for
approximately 8 hours, until it was certain the site had been made safe from the threat of
further releases. The local area surrounding the site was cordoned off by Police and public
traffic excluded. There was 1 fatality from asphyxiation and 3 other injuries to employees
who were all taken to hospital suffering from the effects of exposure to hydrogen sulphide
gas. The gas left the site and its pungent smell was detected in the vicinity. There was no
evacuation and no damage to the environment.
This was an ECRA as laid out in Part 1 of Schedule 7 of the COMAH regulations, as it
resulted in serious danger to human health and involved the release of one or more
dangerous substances. Note: although neither of the waste products involved in the
incident were in themselves the subject of COMAH Regulations notification, mixing them
caused the formation of a dangerous substance.
An investigation by the CA revealed that there had been insufficient analysis of the waste
chemicals (prior to treatment in the tank) to determine the nature and volume of toxic gas
that would be generated during processing. There was evidence of inadequate
maintenance, as the lid of the tank had severely corroded, to the extent it had collapsed
into the tank. The extraction system was neither designed for, nor adequate for use with
an open vessel and could not prevent the loss of containment of the toxic gas formed.
HSE brought 3 charges under the Health and Safety at Work etc Act 1974 Section 2,
reflecting the most serious failings, i.e. the failure of the tank lid; an ineffective extraction
system; the failure to provide suitable and sufficient safe systems of work for the treatment
of waste streams likely to evolve toxic gases, including hydrogen sulphide.
The company pleaded guilty at Magistrates Court in September 2002 to the first two
charges and was committed to Crown Court for sentencing. The company pleaded guilty
to the 3rd charge on indictment to Crown Court on 20 January 2003 and a total fine of
£250,000 was imposed.
As a result of several incidents in the chemical waste industry, an enforcement initiative
has been carried out nationwide to look more closely at the industry and its
safety/environmental standards.
Other emerging issues/factors relevant to the incident:
·
·
·
Mixing of incompatible chemical substances and wastes
Procedures for receipt and classification of waste materials
Maintenance strategy for structural integrity of storage tanks and associated ventilation
systems
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5.3
CONOCO LTD, Immingham Pipeline Centre, Immingham Dock, Immingham
Incident Date – 27/28 September 2001
This COMAH top tier site refines oil and markets refinery products. Late on 27 September
2001 there was a release of 16.10 tonnes of liquid propane from the emergency drain
valve of a fully laden road tanker. The tanker was parked outside the garage workshop,
adjacent to other vehicles and positioned approximately above the drain interceptors. The
release lasted for a period of 2 hours 10 minutes.
The release occurred when a vehicle fitter was attempting to drain off liquid propane for
sampling into a metal bucket. He went underneath the rear of the tanker on a crawler
board and removed the weather cap from the emergency drain line. He then fitted an inhouse designed and constructed adaptor and hose/valve assembly onto the emergency
drain valve outlet of the tanker. Once fitted, he attempted to use the assembly but nothing
came out. In order to investigate the problem, the fitter closed the tanker globe valve to
enable him to remove the bespoke assembly unit. However, the tanker globe valve
remained partially open, resulting in the spillage of almost a full tank of liquid propane.
There is an excess flow valve fitted upstream on the globe valve, but this did not operate
because it is designed as an emergency measure only and responds to full-bore flow,
rather than low-flow leaks.
Both the Emergency Response Team from the nearby refinery and the local Fire Service
attended the scene. The emergency lasted for approximately 6 hours. The Port Authority
and neighbouring establishments were also alerted. The off-site emergency plan was not
implemented. The fitter suffered minor frost burns to his cheek and arm. A substantial
quantity of liquid propane entered the surface water drains and reached the oil/water
interceptors. The liquid propane flashed off there but did not ignite. The pressure lifted the
interceptor covers, resulting in damage to the underside of the adjacent vehicles estimated
at £5000. A structural inspection of the interceptors using closed circuit television was
estimated to cost a further £10000. There was no damage to the environment.
This was an ECRA as it resulted in the loss of more than 5% of the qualifying quantity of a
dangerous substance as laid out in Part 1 of Schedule 7 of the COMAH regulations.
The incident is still under investigation by the CA.
5.4
CORUS (UK) LTD, Port Talbot Works, Port Talbot
Incident Date – 8/9 November 2001
This COMAH top tier site is an integrated steelworks. On 8 November 2001 there was a
major fire and explosion within Blast Furnace No 5, which destroyed its integrity and
allowed an unknown quantity of extremely flammable and toxic blast furnace gas (mainly
carbon monoxide) to be released.
The furnace was constructed in two sections, the top half having limited vertical movement
on a lap joint with the bottom half. It had a 3.5cm thick steel outer shell and a refractory
lining in which were inserted approximately 1400 copper coolers. Water was pumped
through the coolers to remove the heat. The furnace was approximately 90m high and
had a shallow cone profile with a maximum diameter of 12m towards the base. It was
capable of containing approximately 2000 tonnes of burden (iron ore, coke, and limestone)
and had 24 tuyeres (nozzles) located at the base just above the hearth. Typically, this
process involves hot air being blasted into the bottom of the furnace through the tuyeres
(capable of delivering 180m³ per hour of hot blast), leading to the production of several
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thousand tonnes of iron per day. The oxygen in the air combusts with the coke to form
carbon monoxide and generates a great deal of heat. The carbon monoxide flows up
through the blast furnace and removes the oxygen from the iron ores on their way down,
thereby leaving iron. The heat within the furnace melts the iron and the resulting liquid iron
is tapped (removed) at regular intervals by opening a hole in the bottom of the furnace and
allowing it to flow out.
On the day of the incident the blast furnace operating team were experiencing problems
tapping from Blast Furnace No 5. Some time earlier, an oxygen lance had been inserted
into the tap hole. An explosion occurred within the furnace, sufficient to lift the top half off
and beyond the lap joint. The top half of the furnace remained upright and re-located itself
on the bottom half, but in an unstable state. It had rotated during the lift and was no longer
seated correctly. The estimated distance of lift was between 0.5m and 0.75m. This allowed
some burden, slag and molten metal (approximately 200 tonnes) and a large volume of hot
blast gases to be ejected. The blast furnace gas subsequently ignited and flames
enveloped the furnace for a brief period. At the time of writing, the exact cause and
sequence of events leading up to the explosion is unknown.
Both on-site and off-site emergency plans were initiated and Fire, Police and Ambulance
Services attended the scene. To restrict access, the Police cordoned off the furnace area.
The incident resulted in 3 fatalities and 17 other injuries to employees (5 of whom were
detained in hospital in intensive care, critically ill from burns and lung damage sustained by
inhalation of hot gas). There was minimal disruption to the surrounding area on the night
of the incident and no damage was caused to the environment.
This was an ECRA as laid out in Part 1 of Schedule 7 of the COMAH regulations, as it
resulted in serious danger to human health, involved one or more dangerous substances
and damage to property exceeded 2 million Euros (approximately £1.4 million)
The initial investigation by the CA revealed that approximately 48 hours prior to the
incident there had been problems operating Blast Furnace No 5. Cooling water had been
leaking into the furnace and it had become ‘chilled’. Only 5 of the 24 tuyeres were
operational, with the rest being blocked by solid material.
The incident is still under investigation by the CA.
6
CONCLUSIONS
There were 4 ECRAs in 2001/02. This is similar to the average number of major accidents
reported annually under the previous CIMAH Regulations.
Whilst recognising that it is difficult to draw conclusions from such a small sample, ECRAs
can be used as a crude measure of safety performance. The Accident Frequency Rate
(AFR) for the period April 2001 to March 2002 is 3.6 ECRAs per thousand COMAH
establishments per annum. Alternatively this can be expressed as 1 ECRA per 275
COMAH establishments per annum.
There is concern at the magnitude and frequency of these accidents and at the repeated
underlying causes of major accidents. The CA will continue to use the COMAH
Regulations as the vehicle for improving corporate governance of major hazard sites.
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HSE is also working in partnership with the main chemical industry trade associations
through the Chemical and Downstream Oil Industry Forum (CDOIF - a tripartite forum of
HSE, industry and workforce representatives to discuss and set health and safety priorities
and targets) to prevent major accidents and reduce the number of ECRAs by 20% by
2004, as part of the UK Revitalising Health and Safety Strategy.
7
FEEDBACK
This is the third annual report that has been published, giving details of EC reportable
accidents in England, Wales and Scotland. The CA believes it will provide an insight into
the safety performance of industry and its own performance as a regulator. It will also
enable lessons to be learned from past accidents, thus helping to prevent similar accidents
occurring in the future.
The CA would welcome feedback on any aspect of this report. Any comments or requests
for further information should be addressed to the following contacts:
Anton Wilson, Health and Safety Executive, Hazardous Installations Directorate,
Chemical Strategy and Support Unit (Land Division), 4th Floor, St Anne's House, Stanley
Precinct, Bootle, Merseyside L20 3RA (email: [email protected]) or;
John Garraway, COMAH Policy Advisor, Environment Agency,
Block 1, Government Buildings, Burghill Road, Westbury on Trym, Bristol BS10 6EZ
(email: [email protected]), or;
John Burns, Policy Advisor, SEPA Edinburgh Office, Clearwater House,
Heriot-Watt Research Park, Avenue North, Riccarton, Edinburgh EH14 4AP
(email: [email protected]).
8
REFERENCES
1
The Control of Major Accident Hazards Regulations 1999, S.I. 1999 No.743,
ISBN 0-11-082192-0, The Stationery Office £5.80.
2
The Control of Industrial Major Accident Hazards Regulations 1984, SI 1984 No. 1902,
ISBN 0-11-047902-5, The Stationary Office.
3
This document is located on the Internet under ‘COMAH Major Accidents Notified to
the European Commission England, Wales and Scotland 2001-2002’ and can be
accessed using the following address:
http://www.hse.gov.uk/comah
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APPENDIX A
Summary Details of COMAH EC Reportable Accidents 2001-2002
Operator, Location
& Date
Conoco Ltd,
Humber Refinery,
South Killingholme,
Immingham,
16 April 2001
Park Environmental
Services Ltd,
Newport
16/17 July 2001
Accident
Description &
Dangerous
Substances
Release & ignition of
179 tonnes of
extremely flammable
hydrocarbons (a
mixture of ethane,
propane & butane)
from the de-ethaniser
column overhead
pipework.
Release of 186m3 of
hydrogen sulphide
gas from a 500m3
treatment tank during
transfer of waste
alkali solution from a
road tanker.
Accident Consequences & Causes and Actions Taken
ECRA Notification Criteria
Three minor injuries: 1 to on-site
personnel & 2 to members of the
public. On-site personnel were
evacuated from the immediate
vicinity. Extensive damage to
off-site homes & businesses. No
damage to the environment.
Fire & loss of more than 5% of the
top tier threshold inventory.
1 fatality from asphyxiation & 3
further injuries to on-site
personnel from exposure to
hydrogen sulphide gas. No
damage to the environment.
Serious danger to human health &
involved the release of one or
more dangerous substances.
Failure of the de-ethaniser
column overhead pipework due
to erosion/corrosion causing
release of extremely flammable
hydrocarbons.
Inspection strategy for
pipework. The investigation is
ongoing.
Insufficient analysis of waste
chemicals to determine the
nature & volume of toxic gas
that would be generated during
processing. Evidence of
inadequate maintenance, in
that the tank lid had severely
corroded & collapsed into tank
& the extraction system was
inadequate to prevent release.
Company prosecuted for three
breaches of Health and Safety
at Work etc Act Section 2 & a
fine imposed totalling £250000.
Conoco Ltd,
Release of 16.10
1 minor injury to on-site
Vehicle fitter attempting to
Immingham Pipeline tonnes of liquid
personnel. The emergency lasted drain off liquid propane for
Centre,
propane during
for approximately 6 hours & no
sampling in parking area
Immingham Dock,
sampling from a road damage to the environment.
outside garage workshop.
Immingham
tanker.
Damage to adjacent vehicles
Failure to close the tanker
27/28 September 2001
estimated at £5000 & inspection globe valve fully resulted in the
of interceptors using CCTV
spillage, which entered the
estimated at £10000.
surface water drains & reached
Loss of more than 5% of the top the oil/water interceptors. The
tier threshold inventory.
liquid propane flashed off but
did not ignite. The pressure
lifted the interceptor covers.
The investigation is ongoing.
Corus (UK) Ltd,
Fire and explosion in 3 fatalities and 17 injured
An explosion occurred in Blast
Port Talbot Works,
Blast Furnace No 5 (5 were detained in hospital under Furnace No 5. The blast
Port Talbot
allowing an uknown intensive care, being critically ill
furnace gas subsequently
8/9 November 2001
quantity of extremely from burns & lung damage). No
ignited & flames enveloped the
flammable & toxic
furnace for a short period.
damage to the environment.
gas (mainly carbon Serious danger to human health & The cause of this incident has
monoxide) to be
not been established & the
release of one or more
released.
substances. Damage to property investigation is ongoing.
exceeded 2 million Euros
(approximately £1.4 million).
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APPENDIX B
COMAH Regulations 1999, Schedule 7, Part1
SCHEDULE 7
Regulation 21(1) and (2)
CRITERIA FOR NOTIFICATION OF A MAJOR ACCIDENT TO THE
EUROPEAN COMMISSION AND INFORMATION TO BE NOTIFIED
PART 1
Criteria
(This part sets out the provisions of Annex VI to the Directive)
The criteria referred to in regulation 21(1) are as follows1.
Any accident covered in sub-paragraph (a) or having at least one of the
consequences described in paragraphs (b), (c), (d) and (e) must be notified to the
commissiona.
substances involved:
any fire or explosion or accidental discharge of a dangerous substance involving a
quantity of at least 5 per cent of the qualifying quantity laid down in column 3 of Parts 2
and 3 of schedule 1;
b.
injury to persons and damage to property:
an accident directly involving a dangerous substance and giving rise to one of the
following events:i.
ii.
iii.
iv.
v.
vi.
a death
six persons injured within the establishment and kept in hospital for at least
24 hours,
one person outside the establishment kept in hospital for at least 24 hours,
dwellings outside the establishment damaged and unusable as a result of the
accident,
the evacuation or confinement of persons for more than two hours (person x
hours): the value is at least 500,
the interruption of drinking water, electricity, gas or telephone services for
more than two hours (person x hours): the value is at least 1,000;
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c.
immediate damage to the environment:
i.
permanent or long term damage to terrestrial habitats:- 0.5 ha or more of a habitat of environmental or conservation importance
protected by legislation,
- 10 or more hectares of more widespread habitat, including agricultural
land;
ii.
significant or long term damage to freshwater and marine habitats:
-
iii.
significant or long term damage to an aquifer or underground water:
-
d.
1 ha or more;
damage to property:
i.
ii.
e.
10 km or more of river or canal,
1 ha or more of lake or pond,
2 ha or more of delta,
2 ha or more of coastline or open sea;
damage to property in the establishment of at least 2 million ECU (Euro),
damage to property outside the establishment of at least 0.5 million ECU
(Euro);
cross-border damage:
any accident directly involving a dangerous substance giving rise to effects outside
the territory of the Member State concerned
2. Accidents or 'near misses'; which Member States regard as being of particular
technical interest for preventing major accidents and limiting their consequences and
which do not meet the quantitative criteria above should be notified to the Commission.
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