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Update on Shell employee safety issues from Bill Campbell, former Shell HSE Group Auditor, Shell International

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Update on Shell employee safety issues from Bill Campbell, former Shell HSE Group Auditor, Shell International. 20 May 2008. 

With reference to the article in Upstream Oil Industry Magazine recently (Courtesy of Chris Hopson) re increased pressure on Shell I would also suggest that there is, or needs to be, increased pressure put on the OSD of the HSE to fulfil their statements re getting tougher on Shell and others.  

The analysis attached shows certainly up to the beginning of 2008 increasing enforcement actions on Shell but no subsequent deterrence through prosecution to make that particular Leopard change its spots.  This is explained further in the attachments.

I am a might suspicious that Shell and the other usually high offenders such as BP and Petrofac have had no notices issued in 2008.  Is this truly the sign of a marked and sustainable improvement or is it because of the increased use of these statistics by media that such data is being withheld or delayed?

No doubt the Trade Unions will have the answer.

Indeed for the whole of the offshore energy extraction Industry in 2008 to date there are only four notices in the HSE database, two for Wood Group, one for Nexen and one for Talisman.  So on the face of it, at least for Shell there seems to have been a reduction in enforcement notices although Notices may be pending for the concerns raised again by Upstream on Lifeboats. 

As we approach the Piper Alpha anniversary there has been increased media interest in this subject and the attachment link to the recent DWP Select Committee gave evidence which is a damming indictment of HSE officials McLaren and Powell for their failures in 2003 to issue any Notices with reference to the appalling conditions on 16 other installations other than Brent Bravo, all these installations having present at the time the same common failure modes exhibited on Brent Bravo.  

http://www.publications.parliament.uk/pa/cm200708/cmselect/cmworpen/246/246we19.htm

To give you an idea of the situation for ESD valves alone there should have been issued 10 Prohibition Notices, for unapproved temporary repairs which could have been materially defective 16 Prohibition Notices and for over 1000 Fire and Gas Systems in a potential fail to danger condition 16 Improvement Notices amounting in my estimation to circa 90 breaches of either the Health and Safety at work Act or the daughter legislation under the Offshore Installation Safety Case Regulations.

This Select Committee report is in the public domain and any copied part is free to publish any part of it, it went unchallenged by the HSE CEO Geoffrey Podger who is unable or unwilling to answer the question of why his officials did not act at that time in line with their role to protect people by reducing risk.  This despite the fact that the evidence obtained about the role of the named officials was given to me freely and without prejudice by HSE as a result of their own internal investigation.  For my part I am still pursuing this matter with the support of a number of MP’s and in dialogue with the Lord President and the Lord Advocate. 

Because these Notices were not issued, and no subsequent prosecutions took place Society as a whole were hoodwinked into the understanding that the problems at that time were local to Brent Bravo whilst in fact they represented a total collapse of essential controls in all of Shell’s offshore operations.  None of this evidence was led at the subsequent Inquiry and therefore the Sheriff was not able to get to the root cause not only of the conditions that had persisted for a prolonged period of time on Brent Bravo but also across the field. 

If you do not get to the root cause of a failure then the prognosis for the future is not good because the behaviour particularly of the Managers and Directors has not changed thus we are now recording some 40 Notices, with a number of serious repeat offences, amounting to 88 separate breaches of the Law with no prosecution since the fatalities.  And also a marked increase in the number of high potential incidents.

A worrying aspect is that a number of Notices which are currently in place to reduce the probability of potential multiple fatality, major accident events, are being delayed for 12 months or more.  

I would hope that Trade Unions are aware of this and have challenged Shell and the HSE on the justification of these delays. 

The detail of all this is included in the attachments. 

FIRST ATTACHMENT

SECOND ATTACHMENT

Update of Shell Offshore Safety Statistics

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. 

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 

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