(Also read related article… “Shell not a hoodlum organisation says its Company Secretary, Michiel Brandjes”)
Shell Brent Bravo fatalities – why a criminal investigation is in progress
By Bill Campbell, former HSE Group Auditor, Shell International
On the 3rd of September 1999 an Audit was carried out on the Brent Bravo installation. Subsequently a further 6 audits were completed on other North Sea installations operated at that time by Shell Expro, a subsidiary of Shell UK Ltd.
The results of these combined audits was presented to Shell management on 22nd October 1999 and the opinion of the audit was that there were serious deficiencies in the management of health and safety offshore.
Audit findings in the main try to avoid apportioning blame but the consensus opinion was that the cause of what was verified to be a negative safety culture both onshore and offshore was due to the drivers and messages emanating from the then Managing Director Malcolm Brinded.
Brinded did not take these findings well and took action to dismiss the Lead Auditor who was an SIEP employee and savaged the rest of the team who were Shell Expro employees all but one being internal auditors.
The consequences of all this proved fatal (see ongoing explanation) because the audit, still in its early stages lost focus, was disheartened and essentially was unable to exercise any influence on the behaviours witnessed at the time.
The SIEP lead Auditor recommended in 1999 that the Brent Field Management team be suspended from duty pending an investigation into their conduct, but this recommendation was not carried out. An investigation into these matters carried out in 2004/5 led by the then Group Chief Internal Auditor Jakob Stausholm found that Brinded had considered the removal of the Brent Asset Manager. He had declined to do this however because he was concerned that this decision would have a negative effect on that individuals mental stability.
The most important information provided by Stausholm supported by Richard Sykes was that they could find no evidence that the short term immediate actions to reduce risks on Brent Bravo were ever undertaken. They also reported that the longer-term actions to correct the negative behaviour within the organisation had been effectively truncated whilst only 20% complete.
These findings were presented on 25th July 2005, in the C16 building of the headquarters to the then CEO Jeroen Van der Veer in the presence of his legal counsel Beot Hess. A general discussion ensued as to whether the failure of Shell Expro to react positively to the 1999 findings contributed directly or indirectly to the subsequent deaths on Brent Bravo in September 2003. The only significant contribution made by the CEO was that whatever the consequences no blame, in his opinion, could or should be apportioned to the Shell Directors Brinded and Finlayson. To quote his words verbatim he said Directors dont sign permits. It was clear from this statement that he considered that the deceased had been liable in great part for their own misfortune because they had gone into the enclosed shaft to repair a leaking temporary repair without a permit.
Lets consider the evidence as to why the failure to follow-up on the 1999 findings proved to have fatal consequences?
The Fatal Accident Inquiry into the Brent Bravo deaths reported that the deceased had entered the shaft to effect repairs to a temporary patch on the liquid drain line from a degassifier vessel. This vessel had been for a prolonged period knowingly operated with a faulty level control valve and a downstream ESD valve known to be in a failed condition. When the patch gave way a significant volume of rich hydrocarbons flooded into the enclosed space causing the death of two persons through asphyxiation. In 1999 a principal concern on Brent Bravo was that the main test separator was being operated in the same condition. The behaviour of operating production equipment knowingly whilst it was in a dangerous condition had clearly not been corrected in the prolonged period between 1999 and 2003.
In 1999 the Audit reported that violation of the permit system was common. In 2003 a Shell investigation post the fatalities found that to carry out work under the so called operation envelope, in essence by-passing the permit system, have become common practice not only on Brent Bravo but throughout the field.
In 1999 the Audit reported that ESDV were being regularly operated when they had failed their leak-off tests and in some cases the performance results of these tests had been falsified. The Shell investigation post the fatalities indicated that to operate ESDV in this manner had occurred on at least ten installations and false reporting of performance results was common. The Sheriff reported that the failure of the specific ESDV in line with the degassifier vessel significantly contributed to the amount of gas entering the enclosed space. This ESDV was but one of 14 ESDV on that specific installation which had failed during tests carried out during the shutdown process in August only weeks before the fatalities.
Lastly, in 1999 the Audit found lack of essential controls in the management of temporary repairs. Many repairs were not listed on any register and were not pre-approved by a technical authority. The Shell investigation post the fatalities in 2003 found some 30 other repairs on Brent Bravo and circa 500 in the field some 50% of which had not been approved. By November 2003 a number of these repairs were found to be materially defective similar to the repair on the degassifier rundown line which according to the Sheriff was the initiating event leading to the deaths.
When all this came under public scrutiny in June 2006 following a BBC Frontline Scotland programme and following considerable coverage in the Oil Industry paper Upstream Shell vehemently rejected any suggestion of wrongdoing. In the press release it stated that it had vigorously pursued the 1999 audit findings and made significant progress in improving safety on its offshore installations between 1999 and 2003 and absolutely refuted any suggestion that it had operated any of its installations in a dangerous condition.
This press release ignored in its entirety the findings of Stausholm and Sykes. According to Stausholm despite his efforts he and Sykes were ignored, coerced and bullied into silence to protect the reputation of the Company, but specifically of the Directors who in 1999 so patently failed their duty of care to their many employees offshore.
This matter was raised in an official complaint to the new RDS Chairman Jorma Ollila in 2007 but the request for him to investigate the conduct of his CEO and Executive Director on these matters was ignored.
The reply from the Chairman and the information passed to him initiating that reply were passed along with other corroborating evidence some time ago to Grampian police.
This had resulted in a major investigation by the Scottish Crown Prosecution Service led by the Area Procurator Fiscal for Grampian assisted by the Area Procurator Fiscal for Central region. They have indicated that they consider the allegations as very serious and could if proved valid highlight criminal corruption and obstruction of justice by HSE officials and Shell Directors.
Because investigations are ongoing not much more needs to be or can be said at this time. The justification for such an investigation is clearly based on the clear contradiction between what the investigators have ascertained to be the facts and what actions were taken, or not taken, by both Shell and the enforcing authority, the HSE both in 1999 and 2003.
For example, none of the evidence that degradation of Shell facilities had been sustained over a prolonged period of time was presented at the Fatal Accident Inquiry, either by the HSE or Shell. Thus a Sheriff, operating blind, did not get to the root cause of the fatalities. The boundary of his Inquiry being set by events only a few weeks previously on Brent Bravo and he was not made aware of information that the same failures co-existed on 16 other offshore installations.
The investigation authorities have clearly established beyond reasonable doubt, both from evidence from an internal HSE investigation, and from the Shell post fatalities investigation shared with HSE officials in November 2003, by the then Shell Expro Production Director Greg Hill, that from 1999 till 2003 there was a sustained and significant decline in the technical integrity of some 17 Shell installations including Brent Bravo.
Specifically, in the latter case that the four principal causative factors so apparent in 2003 were identical to the failures listed above and verified by Audit to exist in 1999.
The credibility of Jorma Ollila therefore is called very much into question as to whether he was an accessory after the fact in the cover-up of all this or whether he was duped and misled by the executives reporting on these matters to him.
Jorma Ollila has indicated in the last few days that RDS will fully co-operate with the investigating authorities. He has personally not raised, or indicated his intention to raise any objections, legal or otherwise, to what is contained in this Note, all of which he is aware of. I have specifically requested that he pass a copy of the 2005 Stausholm/Sykes findings to them. I am not privy to whether he has done this or not.
EMAIL CORRESPONDENCE WITH SHELL RELATING TO THIS MATTER WILL BE PUBLISHED ON FRIDAY 31 July 2009