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Flixborough Explosion (Inquiry's Report)

Volume 892: debated on Monday 12 May 1975

The text on this page has been created from Hansard archive content, it may contain typographical errors.

I will with permission, Mr. Speaker, make a statement about the Report of the Court of Inquiry into the Flixborough Disaster. My right hon. Friend deeply regrets not being able to make this statement himself, but I know the House will well understand the reasons why he cannot do so and, equally, why there should be no delay in making a statement to the House on this matter.

My right hon. Friend set up the court of inquiry under Section 84 of the Factories Act 1961 on 27th June 1974 and appointed Mr. Roger Parker, QC to be its Chairman. The report, which was presented to my right hon. Friend on 11th April 1975, is now available and copies are in the Vote Office. I am sure that the House will not wish me, in presenting this report, to recapitulate the tragic events of 1st June 1974.

The court concludes that the cause of the explosion was the ignition of a massive vapour cloud formed by the escape of cyclohexane under conditions of high pressure and temperature consequent upon the rupture of an inadequately supported 20 inch diameter dog-leg pipe which had been temporarily installed between two expansion bellows as part of a bypass assembly to bridge a gap following the removal of one of a train of reactors. The integrity of a well-designed and constructed plant had thereby been destroyed.

Although other hypotheses were presented the court came firmly to the conclusion that the disaster resulted from the failure of this 20 inch assembly and that no prior explosion or other mechanical failure occurred.

The report says that:
"the fact that the bridging of the gap presented engineering design problems was not appreciated by anyone at Nypro, with the result that there was no proper design study, no proper consideration of the need for support, no safety testing, no reference to the relevant British Standard and no reference to the bellows manufacturer's Designers Guide".
As a result of these omissions the assembly was, in the court's judgment, liable to rupture at pressures well below safety valve pressure and at, or below, operating temperatures.

My right hon. Friend asked the court to report on any immediate lessons to be learned from the disaster. It has identified a number and makes recommendations for dealing with many of them. These recommendations require careful scrutiny and all industry—especially the chemical and petroleum industries—should as a matter of urgency consider them carefully and take steps to implement them.

My right hon. Friend has referred the recommendations in the report to the Chairman of the Health and Safety Commission who has already discussed both immediate and long-term implications in a meeting of the commission and with the Health and Safety Executive. The chairman has assured me that the commission will take full responsibility for pursuing the action needed to follow up all recommendations of the report. He is confident that the legal powers in the Health and Safety at Work Act 1974, which has come into force since the Flixborough explosion, provides an adequate framework for action now seen as necessary on immediate issues or long term developments. The Health and Safety at Work Act provides powers to enable any immediate remedial measures to be required. The Act provides very wide powers for the making of regulations, including licensing of premises, processes or individuals where appropriate and the control of individual factories.

The report contains a number of recommendations of a general nature on wide issues such as management structure, the maintenance of plant integrity, the lay-out and the siting of plant. These are issues which require further study.

The commission has asked for the advice of the Committee of Experts on Major Hazards which it set up last year and which has already started its deliberations. The chairman of the commission is meeting the committee next week to put the report to it. Among the questions it will consider is the conditions which would be necessary if licensing was required in special circumstances. The committee is already considering how the present arrangements for giving advice to planning authorities on industrial risks can be improved.

There are a number of more immediate lessons to be learned from the inquiry's report. The commission has already discussed these and agreed action. Since the explosion resulted from the failure of a part, albeit a modified part, of the plant containing flammable material under pressure, the report directs attention to the crucial need for the utmost care in maintaining the integrity of such systems. Therefore, inspectors of factories have been instructed to reinforce the advice on this point which has already been given. This follows up the action started when the Chief Inspector wrote to manufacturers 10 days after the Flixborough explosion.

It would be appropriate to issue regulations to cover these pressure systems and the commission has instructed the executive to pursue urgently the action to prepare such regulations. In the meantime inspectors of the executive have powers under the Act to enforce their advice. Immediate advice will be given by the inspectorate on other relevant matters as, for instance, the manufacture and supply of inerting material. Technical advice on metallurgical phenomena will be provided to industry.

The commission has instructed the executive to enter into consultations immediately with appropriate bodies representing local authorities on the responsibility for control of the storage of large quantities of flammable materials.

This is not a complete list, but I think it is enough to show that the commission has already tackled with determination the many problems to which this report has directed attention, and that action based on the report will be carefully considered and resolutely pursued.

The House will, I am sure, wish me to thank the chairman and members of the court for their report and also those who assisted the court—especially those scientists and engineers whose research in the service of the court has led to an increase of our knowledge of the technical problems involved in these large-scale chemical plants.

I am sure the House is grateful to the Minister for his lengthy statement and for the fact that the Government have not hesitated to make a statement now that they have had the report of the Court of Inquiry into the Flixborough Disaster.

May I ask three short questions? First, when will the advice from the Committee of Experts on Major Hazards be available, particularly on the layout and siting of plant and the advice to planning authorities?

The Minister referred to the executive being instructed to pursue urgently the need to prepare regulations relating to the problems of pressure systems. May we know when the Government expect such regulations to be published?

Third, will the Government ensure that in the consultations between the executive and the local authorities on the question of storage of large quantities of flammable materials the public will have an opportunity to make their views known? As the Minister is aware, there are certain parts of the country where there is acute public anxiety about the storage of flammable materials.

We are all anxiously awaiting an early report from the Committee of Experts, but the hon. Gentleman and the House will understand, I hope, that that will inevitably now be delayed because of the necessity for that committee to have a full scrutiny of the recommendations of the court of inquiry. None the less, I am anxious that we should be able to make a report as soon as possible. I can say that the Committee of Experts established four sub-committees which are expected to report shortly to the main committee.

With regard to regulations on pressure systems, I was astonished to learn that apparently pressurised processes such as this process with which the report concerns itself are apparently not at present the subject of regulations and statutory control. We now have the powers under the new Act to make regulations. I am asking the Chairman of the Health and Safety Commission to deal with this as a matter of some urgency, but the general powers under the Act enable us to have statutory control and statutory means of enforcement that we did not have previously.

With regard to the public involvement in consultations which will take place on the storage of flammable liquids, these consultations will take place with the local authorities, and to that extent there will be public participation.

I ask the hon. Gentleman to allow me to reflect on what he has said and to draw his views to the attention of the Chairman of the Health and Safety Commission.

Will my hon. Friend confirm that the report says that if the recommendations are carried out, the risk of a similar incident will be lessened? Will he also confirm that the report draws attention to the fact that there was insufficient mechanical engineering expertise available in the considerations which led to the fitting of the 20-inch diameter dogleg pipe which subsequently collapsed, and also the serious fact that the post of the works engineer was vacant at the time?

Does my hon. Friend agree that we must remedy a situation in which, however safe the basic design, it will be of no avail if adaptation and repair are not subject to the same stringent considerations as are applicable to the basic design? Does he agree that if this is not done, the tragedy which overtook so many of my constituents and, I understand, one of his, is inevitable?

Finally, will my hon. Friend pay tribute to the work which the Transport and General Workers' Union and other unions did in representing their workers at the hearing? Does my hon. Friend also recognise that they have incurred considerable costs, and will he give sympathetic consideration to making a contribution towards meeting those costs?

I am grateful to my hon. Friend for recognising my constituency interest. I am sure the House will want me to pay tribute to the way in which he has assiduously pursued the interest of his constituents since the disaster occurred, in connection with the various consideration involved.

Paragraph 226 of the report, in the summary, says:
—that is the court—
"use the phrase 'already remote' advisedly for we wish to make it plain that we found nothing to suggest that the plant as originally designed and constructed created any unacceptable risk. The disaster was caused wholly by the coincidence of a number of unlikely errors in the design and installation of a modification. Such a combination or errors is very unlikely ever to be repeated."
The report goes on to say:
"Our recommendations should ensure that no similar combination occurs again and that even if it should do so, the errors would be detected before any serious consequences ensued."
Likewise there are paragraphs in the report, in particular paragraphs 209 and 210, which follow the point which my hon. Friend made about the way in which the integrity of the plant was destroyed by the introduction of this modification, and the court recommends
"that any modifications should be designed, constructed, tested and maintained to the same standards as the original plant",
which is the point which my hon. Friend stressed and for which he says there is obviously a need. In my main statement I said that these recommendations and the lessons to be learned were the subject of consideration by the Health and Safety Commission and its executive.

The report draws attention to the fact that the key post of works engineer was vacant at the crucial time and that apparently none of the senior personnel of the company was capable of recognising the existence of what was in essence a simple engineering problem, let alone of solving it.

I join my hon. Friend in his tribute to the work done by the trade unions in representing their members during the proceedings before the court, and the work which was done by the legal representatives of those unions. As to the question of costs, the report makes reference to this issue in the summary, and lays no obligation on Nypro, in view of the commitments already undertaken by the company, to meet any further legal costs. In the light of that conclusion of the court, it is for the Government to give further consideration to what they can do with regard to the costs incurred by the unions.

My hon. Friend will know that during the proceedings of the court the trade unions involved wrote on this subject to my right hon. Friend. Clearly, a decision had to be deferred pending the outcome of the court of inquiry. In the light of the court's recommendation, we shall have to give careful thought to the representations made by the unions.

Order. This is obviously an important matter, and I wish to say this to the House: it is not often that I have control over the matters put down for business, but next week on the day when we rise for the Whitsun Recess I shall look favourably on an application for a short debate on this matter. Today, I remind the House, we are to debate the Second Reading of the New Towns Bill—I already have the names of about 12 hon. Members who represent new towns, all with cast-iron reasons for wishing to speak—and we have other matters to deal with before we come to the New Towns Bill. Therefore, if the House will allow me, I shall call only one or two more hon. Members to put questions. I repeat that I shall look favourably at any suggestion for an Adjournment debate on this matter on Friday week.

Will the Under-Secretary of State agree that this terrible disaster has wide implications for all communities which are obliged to live close to concentrations of oil, chemical and gas installations, and that the sooner the lessons of Flixborough are learned the better? With regard to the implications, is the hon. Gentleman aware, for example, that if it be true—I have not yet seen the report—that at Flixborough an underground pipe was fractured by an aboveground explosion, the implications of that for places such as Canvey Island, where the main United Kingdom gas grid and the main United Kingdom oil pipeline pass in parallel between a sea wall and a proposed new refinery, are extremely serious? May we be assured, therefore, that the Committee of Experts on Major Hazards will look specifically at our situation on Canvey Island?

I recognise the hon. Gentleman's continuing concern about the situation on Canvey Island, and we acknowledge the basis of his concern there. I regret that I cannot answer his specific question about the fracture of an underground pipe at Flixborough, and I am not sure that it is dealt with in the report. No doubt, the hon. Gentleman will carefully examine what the report says. As regards problems which might arise in connection with coping with the possible fracture of underground pipes in the hypothetical situation to which the hon. Gentleman refers, I think that there are relevant recommendations in the report. For example, it is said in paragraph 222:

"In any area where there is a major disaster hazard a disaster plan for the co-ordination of"
all the relevant services
"is desirable"—
and the court goes on to suggest that this problem and the need to give further consideration to it should be drawn to the attention of the special committee. There is a relevant reference to be found also in paragraph 194.

However, I stress to the hon. Gentleman and to the House that the crucial need is to take all necessary steps to prevent an incident of this kind occurring in the first place. We must seek to avoid the problems to which the hon. Gentleman refers by following up the recommendations here which, I suggest, if they are fully implemented, will minimise the likelihood of such a disaster occurring.

Will my hon. Friend agree that the lesson of the Flixborough disaster is that there ought to be a continuing high level of inspection by the Factory Inspectorate? Is my hon. Friend satisfied that the proposed reorganisation, which, as he knows, has been bitterly opposed by the inspectorate in one of the trial areas at Slough, will lead to the maintenance of such high levels of inspection? Second, does my hon. Friend agree that the Flixborough disaster shows that the Health and Safety at Work Act 1974 needs toughening so that absolute duties are not weakened by codes of practice or qualified duties?

Third, what hope can my hon. Friend give the House that the new regulations on pressure systems which he mentioned will be produced with alacrity, since the Health and Safety Commission has signally failed to produce the trade union safety committee regulations in conjunction with the implementation of the Act on 1st April, and does not my hon. Friend agree that the institution of trade union safety committees would lead to the sort of scrutiny which would prevent further Flixboroughs?

My hon. Friend has asked me a number of questions, and because of his propensity to misunderstand or mishear what I say at this Box, I shall spell out my answers carefully, if I may. My hon. Friend returned yet again to the question of reorganisation. I regret that he chose to misinterpret my reply to him at Question Time on the last occasion when my Department was answering Questions. Perhaps he will do me the courtesy of looking at the correction in Hansard to correct his misleading article in the Tribune newspaper last week. As regards the Factory Inspectorate, I gave a full Written Answer to my hon. Friend the Member for Bradford, North (Mr. Ford) last week, and I suggest that my hon. Friend the Member for Keighley (Mr. Cryer) looks carefully at it.

My hon. Friend knows full well that the Health and Safety at Work Act was not in operation at the time of the Flixborough disaster. It became fully operative only on 1st April this year, whereas the Flixborough disaster occurred in June 1974. Of course, there are many lessons to be learned. Those lessons are spelled out in the report, and we expect the Health and Safety Commission and its executive to have full regard to them. As regards the qualifications in the Health and Safety at Work Act, in connection with "reasonably practicable", I urge my hon. Friend to look at the evidence submitted by Dr. Marshall, the safety adviser to the Transport and General Workers' Union, which is referred to in paragraph 195 of the report of the court of inquiry. Dr. Marshall having stated that
"hazard analysis recognises that hazard cannot be entirely eliminated and it is necessary to concentrate resources on those risks which exceed a specific value".
On my hon. Friend's final point, I cannot add to what I said in reply to the hon. Member for Bedfordshire, South (Mr. Madel). We recognise the need for urgently making regulations regarding pressure systems, and we have asked the Health and Safety Commission to urge upon the executive the need to produce them quickly.

Since the Act has been fully operative only from 1st April, and the executive was established on 1st January, I think that it was rather unfair of my hon. Friend to expect the commission and the executive to move with excessive haste. These are early days yet. There have been many meetings of the commission, and, as for delay in producing the regulations on work safety representatives, I share my hon. Friend's anxiety to get these put before the House as soon as possible.

Will my hon. Friend take it that many of us who represent areas with huge chemical complexes within them take the attitude "There but for the grace of God go we", and we are very sympathetic? On one specific issue, did I understand my hon. Friend to say that there has been no proper design study? If that is so, could not a similar incident take place elsewhere? Is it a general problem? If it is, it is astonishing news.

I am not sure that I follow my hon. Friend's question about a design study. The report points out that the plant as originally designed and constructed did not create any unacceptable risk, and the court said in paragraph 225 that

"The integrity of a well designed and constructed plant was … destroyed."

In common with the hon. Member for West Lothian (Mr. Dalyell), I am concerned about chemical plants in my area, and an ammonia plant, in particular. Will the hon. Gentleman take it that all of us who are involved in these matters are now extremely concerned since the ghastly disaster at Flixborough? Believing as he does that prevention is better than cure, will he discuss as a matter of urgency with the Secretary of State for the Environment and the Secretary of State for Scotland whether local authorities are sufficiently well staffed to be able to deal with planning applications from chemical and oil companies, and whether some interim guidelines could be issued by the Department to ensure that the design of any new plant conforms to the very high standards that I am sure the Minister wishes to see?

I recognise the hon. Member's legitimate concern. That concern is shared by the whole House. In 1972 a circular was issued by the Department of the Environment along the lines of the action for which the hon. Member is calling, stressing to local authorities the crucial need to have the fullest consultation with the Factory Inspectorate, as it was then, and the Health and Safety Executive as it is now, where there are applications for installations that might cause a major hazard.

The circular defines what constitutes a major hazard and gives advice to the local authorities about steps they should take. I understand that since then, and more particularly since the Flixborough disaster, the process for consultation between the inspectorate and the local authorities has been strengthened. I hope that the hon. Member will have regard to the passage in my statement which stressed that the Health and Safety Executive has been instructed to enter into further urgent consultations with local authorities.

Will the Minister give an assurance that he will at least consider publishing any reports that the Committee of Experts on Major Hazards may make? Is he aware that there are no fewer than 184 major hazard sites containing more than 100 tons of liquefied petroleum gas in this country, 23 of them in Wales, and one in my constituency? They are causing deep concern. Is it not time that the Government at least prohibited in future the siting of such installations in urban areas, and considered removing those already located in urban areas to places of greater safety?

I have said that the question of siting is being carefully considered by the Committee of Experts. He asked whether we would consider publishing the committee's eventual report. That is primarily a matter for the Health and Safety Commission. I shall draw his remarks to the committee's attention, but I must stress that any idea of a report listing the various hazard sites and the degree of hazard is not on. That would be to misunderstand the purpose and function of the Committee of Experts which is to draw up guidelines and other general advice and guidance.

Is it correct that the crux of this whole matter is that the person who designed the temporary structure was not professionally qualified to do that job? If that is so, and if regulations cannot be made for some time, is the question of prosecution under existing law being considered? If not, will my hon. Friend in the meantime warn employers that even without regulations there is plenty of power under Section 2 of the Act to prosecute, and that this power will be used to save lives?

On the first part of the question, it would be inadvisable for me in ally way to depart from the words of the report, and hence of the court of inquiry. It says in the summary that

"The blame for the defects in the design, support and testing of the by-pass must be shared between the many individuals concerned, at and below Board level but it should be made plain that no blame attaches to those whose task was fabrication and installation. They carried out the work, which they had been asked to do, properly and carefully. As between individuals, it is not for us to apportion blame."
It would be unwise for me to go beyond that.

As for prosecution, I understand that under the law as it was at the time of the disaster there were inadequate grounds on which to base a criminal prosecution. However, my hon. and learned Friend is correct in pointing out that the new Act, particularly in Section 2, enormously widens the scope. I am advised by the director of the Health and Safety Executive that had this disaster occurred at a time when the provisions of the new Act were operative and effective, he would not have hesitated to go for a prosecution on indictment.

It would be unwise for me to go beyond that, since the inquest on those who died was adjourned and will be resumed. It is not for me, notwithstanding what I said about non-prosecution by the Health and Safety Executive, in any way to preclude the possibility of the papers being referred to the Director of Public Prosecutions as a result of the findings.