page 1 1 Tuesday, 8th July 2008 2 (10.35 am) 3 MR MARTIN: My Lord, the next witness is Mr David Robert 4 Inglis. I should say that some checking has been done 5 of the reference numbers contained in the Inquiry 6 statements and some discrepancies have been identified 7 and revised Inquiry statements have been circulated for 8 the following, I think, four witnesses. There is no 9 differences in substance but in some cases the 10 references will be changed. 11 DAVID ROBERT INGLIS (called) 12 Examined by MR MARTIN 13 Q. Mr Inglis, good morning. I understand you would prefer 14 me to read the statement on your behalf and ask you 15 questions as we go through. Your full name is David 16 Robert Inglis. I shall read in the first person: 17 "I am presented employed as an engineer at Johnston 18 Gas Limited, Standhill, Bathgate. Since providing my 19 original statement I no longer install cast tanks. 20 I have not done that since maybe a year after the 21 explosion. I have now been drafted in to do oil central 22 heating boilers in the domestic market. I am mainly 23 involved in servicing and maintenance of those. I hold 24 certificates as accredited by CORGI which are in my name 25 rather than in the company's name so I am in possession page 2 1 of the certificates. These can be supplied if 2 requested. 3 "Qualifications. 4 "When I was 16 years old I started as a joiner. 5 I obtained a City and Guilds and advanced City & Guilds 6 in joinery. I then obtained a SCOTVEC ordinary national 7 degree in building. I later attended a higher national 8 degree in building but only completed 60 to 70 per cent 9 of that course. 10 "As a joiner I always worked for my father's company 11 of IB Contracts. This was a joinery/building firm but 12 mainly joinery. Part of the work involved changing Aga 13 cookers from coal to oil. I therefore started going on 14 oil courses run by Dobbies Heating Centres, who used to 15 be owned by BP. Oil manufacturers used to attend those 16 courses and inform how to use their equipment. 17 "In 1992 I attained accreditation. At that time 18 I attended a course in Telford College, Edinburgh. It 19 was a course overseen by CORGI. Every 5 years you have 20 to attend such a course in order to be allowed to work 21 in the gas industry. Such courses involve a Safety Core 22 Course which lasts for approximately a week and includes 23 a 2-day exam. 24 "In 1997 I attended this course and obtained 25 accreditation but I cannot remember where this course page 3 1 was held. It was run by Zurich who were the people who 2 made up the exams. CORGI overseen it. 3 "In 2002 I obtained accreditation in Lauder College, 4 Dunfermline. Again, this involved a Safety Core Course, 5 which lasted a week and then a 2-day exam. However, the 6 course had changed in that you could do modules on 7 specialist areas. I did four or five modules. It was 8 run by the CITB. I do not know what that stands for, 9 but they were the people who made up the exams." 10 It is understood, Mr Inglis that CITB is the 11 Construction Industry Training Board. 12 I sat and passed modules specific to what I do, for 13 example LPG changeover. In other words, if someone 14 wanted to change from natural gas to LPG. 15 I also sat and passed a module on the installation 16 of LPG tanks an LPG pipework and the dangers of working 17 of working with LPG. The basic danger is that LPG is 18 heavier than air. It therefore does not float away and 19 instead sits on the ground, whereas natural gas goes up 20 and mixes with air. At the end of a module you have to 21 sit a written and practical exam and you fit and test a 22 tank. It includes everything you would do on site. 23 Every 5 years at this course it includes discussions 24 regarding and changes in the Codes of Practice. 25 Sometimes there is very little change or it can be page 4 1 discussed how certain words are to be interpreted. I am 2 due to go back to the be re-accredited in 2008. It is 3 a very strict course. An example being that in the 4 safety core examination there are about 200 to 300 5 questions. You have to get every one right. If you get 6 one wrong then they give you a second chance to answer 7 it. If you then get it wrong then they write the 8 question out in layman's terms. If you fail that then 9 you have failed the whole exam and you are not allowed 10 to fit a gas tank. It is very expensive to go on these 11 courses. It is about £200 to £300 a module. I have now 12 been re-accredited as I went through the exam, again at 13 the end of 2007. I have the certificates/documentation 14 that can be supplied if requested. 15 "Johnston Oils have sent me on a liquid course run 16 by Schneider in Chepstow which covers auto gas 17 installations. Auto gas is an LPG tank that dispenses 18 liquid and is mixed with the petrol as a source of fuel 19 in the car. I have not been on another course run by 20 Schneider since the original one I attended. 21 "I am IITB accredited and my registration number is 22 00375235/1. This enables me to work on LP vessel 23 pipework 0.1M expires 19/08/2008, LP vessel pipework 24 0.1M expires 26/08/2008, LE fusion jointing expires 25 19/08/2008, Test and Purge, VP expires 26/08/2008. page 5 1 Since providing the original statement I am no longer 2 going to resit the exams for CITB accreditation as I no 3 longer do this type of work as I solely deal with the 4 oil boilers in the domestic market." 5 May I just ask you, Mr Inglis, formally to confirm 6 that the qualifications which I have read out and are 7 contained in that part of your Inquiry statement are the 8 qualifications which you hold? 9 A. Yes. 10 Q. Thank you. 11 "Experience in installing tanks. 12 "I think it was about 1992 that first started to 13 install bulk gas tanks. In a week I could install about 14 3 to 10 bulk gas tanks depending on the workload. 15 I still install tanks today." 16 I think that has been overtaken by what you have 17 said elsewhere; is that right? 18 A. Yes. 19 Q. "I would estimate that throughout the years I have 20 installed more than 200 tanks. Since providing the 21 original statement, I now no longer install tanks. 22 "While I was employed at my father's company 23 Johnston Oils used subcontractors to install bulk gas 24 tanks and maintain the tanks. I would install the tanks 25 for them and my Dad would only do it if I were on page 6 1 holiday. 2 "About two and a half years ago I went full-time 3 with Johnston Oils. At that time my Dad was going to 4 retire and Johnston Oils offered me a job as a full-time 5 engineer. I took that job. My dad is now semi-retired. 6 When I started with Johnston Oils I was the only 7 full-time engineer. They have now started Donald Smith 8 [not a witness] as an engineer. 9 "I now don't fit as many tanks as I used to. Donald 10 Smith now fits the tanks because this is a job he can 11 do. I spend more time working on boilers. This no 12 longer applies as I am not fitting any tanks at all. 13 "I consider myself competent in relation to LPG 14 storage and pipework because I have passed exams on this 15 and have fitted 200 or more tanks. I do still consider 16 myself competent in relation to LPG bulk storage and 17 pipework but as previously advised I do not carry out 18 the work any longer. 19 "The parts of a tank." 20 Could I have up please, page 013137. 21 "I was shown this image which showed a standard 22 1,000-kilogram tank. I observed that this image showed 23 a hood on top of the tank." 24 Could I have page 013139, please. 25 "I observed this image showed a close up view of the page 7 1 hood. This hood opens up to reveal valves, et cetera, 2 as discussed in detail below." 3 Could have page 013149, please. 4 "I observed that this image showed the items beneath 5 the hood. On the left-hand side of the tank there is 6 the contents gauge which showed how much LPG there was 7 in the tank. This is not of any relevance to my job. 8 It is used by the delivery driver when filling the tank 9 and by the customer to see how much LPG they have in the 10 tank. 11 "To the right of the contents gauge and to the rear 12 of the tank was the liquid offtake valve. This is 13 basically used to empty the tank or to fit a grain 14 dryer. A grain dryer is used by farmers because when 15 the wheat comes out of a field it is damp and it has to 16 be dried to a certain percentage for the brewery. This 17 allows the farmer to burn liquid and not gas from the 18 tank. It is also used to empty the tank. For example, 19 if the customer does not want the tank any more and it 20 is to be moved or if the customer wants some LPG 21 removed, or when it is to be removed prior to 22 transporting." 23 Can we just be clear, Mr Inglis, as to the item you 24 are referring to in that paragraph. Is it the circular 25 feature which in the photograph is level with or just page 8 1 about level with and to the left of the blue cap and on 2 the other side of the pipe which seems to consist of 3 a hexagonal screwed fitting with a hexagonal cap on the 4 top? 5 A. Yes. 6 Q. "To the right of the liquid offtake valve was the filler 7 valve which had a blue cap on it in this image. This is 8 used only by the delivery driver when filling the tank. 9 In the middle of this image right in front of the hinge 10 was the vapour offtake valve. The vapour offtake valve 11 supplies the gas from the tank for the pipework." 12 As is obvious, is that the item which in the 13 photograph is almost directly above the hinge of the 14 open cover and it is a fitting that screws into the tank 15 and then has items on it and connects through 16 a right-angled union with pipe that then moves to the 17 right of the photograph and out of the photograph? 18 A. Yes. 19 Q. Could I have photograph 013144, please. 20 "I observed this image showed the pressure relief 21 valve which was shown in this image with the yellow cap. 22 In the tank there is a pressure between 100 and 150 23 pounds per square inch and a pressure relief valve is 24 set at perhaps about 200PSI. It is the outside surface 25 area of the tank that heats the liquid inside the tank. page 9 1 If the tank becomes too hot or is overfilled, for 2 example, if a fire were lit underneath it then this 3 would cause the LPG to boil the liquid producing too 4 much gas. When the pressure inside the tank reaches a 5 high level caused by too much gas the spring inside the 6 pressure relief valve will rise and it allows the gas to 7 escape through a hole, which is no larger than the nib 8 of a pen. The gas is then released under controlled 9 conditions and looks like a heat haze. 10 "In my 20 years of working with LPG tanks I have 11 only ever seen this happen twice. On both occasions 12 this was caused by overfilling with LPG and was not 13 caused by heat. Its purpose is to stop too much gas 14 going downstream and damaging the first stage regulator 15 and possibly the customer's appliance. A tank is very 16 thick and it is extremely unlikely to explode. It would 17 require an enormous amount of pressure. I have never 18 heard of a tank exploding." 19 Just to understand if I may, Mr Inglis, the 20 photograph which you are looking at has the pressure 21 relief valve which is situated outside the cover or hood 22 when it is closed so it is always open to the air for 23 reasons which are obvious? 24 A. Yes. 25 Q. Do I take it that if the pressure relief valve were to page 10 1 blow in the circumstances which you have described, the 2 yellow cap would simply blow off the top -- 3 A. Not necessarily. You see the big hexagon about three or 4 four inches below the yellow cap. There's a hole in the 5 side of that. I don't know what side it's on but that's 6 a tiny wee hole about the size of the end of a pen and 7 that's where the gas comes out. The upper body of that 8 valve holds the spring so the spring rises and just lets 9 a small amount, a controlled amount of gas out through 10 the hole. 11 Q. Returning to your Inquiry statement paragraph 25: 12 "Exchanging a tank. 13 "Basically when I would be installing a replacement 14 tank this would be a like-for-like change. I would 15 connect a replacement tank as follows ..." 16 Could I again have 013149, please. 17 "I observed this image showed a copper pipe. This 18 pipe would be in place when I would be attending to fit 19 a replacement tank. It would have been fitted to the 20 previous tank." 21 Is that the copper pipe which runs away from the 22 tank fitting past the blue filler cap towards the top 23 right-hand side of the photograph? 24 A. Yes. 25 Q. "I would connect this copper pipe by screwing it to the page 11 1 pol connector." 2 Can you just explain that in a little more detail, 3 please, Mr Inglis. What is the pol connector P-O-L 4 connector? 5 A. The pol connector is the fitting that goes into the 6 fitting of the tank. It's basically a left hand thread 7 so you can't put a normal thread into it. See where the 8 right angle comes out the valve, the pol connector is 9 the hexagon there. That's the pol connector. 10 Q. Where the arrow is pointing now? 11 A. Yes. 12 Q. The arrow is pointing at the union just to the right. 13 Are we talking about that union or are we talking about 14 the whole of that item that screws into the top of the 15 tank? 16 A. That fitting with the right angle bit that comes as one 17 piece and that's the pol connector. 18 Q. Is it the pol connector which screws into the tank with 19 the left-hand thread? 20 A. Yes. 21 Q. Thank you. 22 Paragraph 27. That is the same image. You were 23 shown this image which showed the pol connector. The 24 pol connector is the fitting that connects the tank to 25 the pipework. The pol connector contains a left-hand page 12 1 thread and is not readily available to members of the 2 public and can only be purchased by a specialised LPG 3 suppliers. The pol connector is the only fitting that 4 will connect to the tank, which means that without it, 5 no pipe can be connected to a tank. 6 "The pipe is screwed on to the left-hand thread of 7 the pol connector and screwed into the valve in an 8 anticlockwise direction. It is screwed in 9 anti-clockwise to prevent misuse. In other words 10 preventing someone else trying to screw something on to 11 the tank. The pipe is then connected to the vapour 12 offtake valve. The vapour offtake valve supplies the 13 gas from the tank to the pipework. This is the tank 14 connected. I would then test the line, which is the 15 visible pipework leading from the tank to the building." 16 I wonder if, again, I could attempt to clarify, 17 Mr Inglis, my own understanding of this. At the bottom 18 of what you have referred to as the vapour offtake valve 19 or pol connector is the tank itself and the item is 20 screwed into the tank, which presumably has a thread 21 tacked into the metal work; is that right? 22 A. Yes. 23 Q. Is the item which is actually screwed immediately into 24 the tank described as the vapour offtake valve or as 25 a pol connector or as what? page 13 1 A. Vapour offtake valve. 2 Q. So that is the cast item which, at least on the version 3 shown in this photograph, is -- it's really got four 4 corners to it, if you like, and it is screwed into the 5 tank. 6 Is that a left-hand thread or a normal thread? 7 A. No, it's a tapered thread. 8 Q. Again is that a special taper through to prevent someone 9 connecting something else? 10 A. A normal thread wouldn't screw in. It would only go in 11 maybe two threads -- that'd probably go in a bit, maybe 12 three-quarters of an inch right into the thread. 13 Q. So on the vapour offtake valve, once it is screwed into 14 the tank, in the photograph we can see, first, closest 15 to the bottom of the photograph a little screw. It is 16 just to the left of the red arrow as it is at the 17 moment, if the arrow could be moved over, please. 18 Is that the ulage valve? 19 A. Yes. 20 Q. To the left of that, at the end of the vapour offtake 21 valve which points towards the bottom left-hand corner 22 of the photograph, what is that? 23 A. It's a plug. 24 Q. Is that a screw plug? 25 A. Yes. Sometimes there's a pressure gauge fitted to that. page 14 1 Q. On the top of the vapour offtake valve there is a round 2 item which is in the centre if the arrow could be put to 3 that. What is that? 4 A. That's the on/off valve that turns it on and off. 5 Q. And that is how immediately out of the tank you can turn 6 the supply or flow of gas off and on? 7 A. Yes. 8 Q. Then if you can just take that arrow away, please. 9 Thank you. 10 To the right of that is the pol connector which has 11 a red arrow to it which is the left hand thread with the 12 hexagonal thread you described? 13 A. Yes. 14 Q. And immediately turning right-angled through a union; is 15 that right? 16 A. Yes. 17 Q. Then that union is connected to the copper pipe which 18 you have described? 19 A. Yes. 20 Q. So far as the item between the right-angled union and 21 where the copper pipe starts, is that item of any 22 significance or is it just part of a union which 23 connects the pol connector to the pipe? 24 A. That's just taking it from the pol connector to a copper 25 fitting. page 15 1 Q. Thank you. 2 Could I have 013143, please. 3 "I observed that this image showed the 4 above-mentioned copper pipe connecting to a steel pipe. 5 The first part of the pipe from the tank to the steel 6 pipe is copper because it is more flexible. The steel 7 pipe is a schedule 80 steel pipe." 8 May I take it that is simply a technical 9 specification of the quality of the pipe? 10 A. Yes. 11 Q. "It is a very strong pipe in that unlike normal pipes, 12 it has no seam. This makes it stronger and therefore 13 very unlikely to fail. In my opinion, if a lorry ran 14 over it, it still wouldn't burst because it doesn't have 15 a seam. This steel pipe allows the gas to flow more 16 easily and thus give a maximum flow of gas and a bigger 17 capacity to the burner." 18 Could I then, please, have 013139. 19 "I observed this image showed the steel pipe then 20 going upwards and along." 21 Just before I pass from that, Mr Inglis, it is 22 perhaps not so clear on this photograph but where the 23 copper pipe connects with the steel pipe and it is 24 obviously held in place by a bracket attached to the top 25 of the tank, is there anything significant about the page 16 1 screwed union which is placed in that position? 2 A. No. 3 Q. Am I right that the bracket in that photograph which 4 holds the pipe is connected to a flange at the top of 5 the tank which is actually also used to lift tanks in 6 and out? 7 A. Yes. 8 Q. Could I have the next image 013140, please: 9 "I observed this image showed the steel pipe then 10 going two different routes. One route goes down into 11 the first stage regulator and into the ground. The 12 second route is connected to two 47-kilogram balls, 13 which are gas cylinders." 14 May I just ask, Mr Inglis, is the word "balls" there 15 correct? 16 A. I think it is bottles. 17 Q. "Basically these cylinders are smaller versions of the 18 tank and they are put there for back-up in case the 19 customer runs out of LPG from the tank. 20 "I think I remember two cylinders beside the LPG 21 tank at ICL Technical Plastics Limited. I seem to 22 recall that these cylinders were not connected. I am 23 sure that I did not fit these two cylinders to the pipe 24 as shown in this image because the hose is too tight 25 leading from the pipe to the cylinders. I would not page 17 1 have allowed that and had I seen it then I would have 2 disconnected the cylinders and plugged the pipe because 3 the stress on this rubber hose could cause the hose to 4 crack and cause gas to escape. I would only ever 5 connect cylinders if I was specifically asked to do so 6 by Johnston Oils. There may be the occasion where if 7 they could not get a tanker in, then they might want to 8 supply gas to a customer by cylinder bottles and if that 9 were the case, then they would want them fitted up." 10 You refer there to the rubber hose which is under 11 stress and can cause it to crack. Is the rubber hose 12 the length of pipe which comes up from the closer of the 13 two bottles or tanks almost vertical and then turns 14 through a sharp angle before it connects with the metal 15 pipework which is close to the wall behind it? 16 A. Yes. 17 Q. "I would then carry out a test on the visible pipework. 18 I would firstly open the tank by turning on the vapour 19 offtake valve." 20 Could I again have 013149, please. 21 "I was shown this image. I would turn on the vapour 22 take valve [I think it should be offtake valve] by 23 turning the wheel on top of it, which was shown in this 24 image with the letter 'O' on the wheel." 25 We have already discussed the vapour offtake valve, page 18 1 Mr Inglis. Your eyesight I suspect may be better than 2 mine. I could not actually see an O on the top -- 3 A. It's actually an arrow. There's an arrow going round 4 the outside and there's an O on the left-hand side at 5 the top of the valve. 6 Q. That just indicates, what, the arrow direction to close 7 it or to open it? 8 A. Open. 9 Q. "I would turn this in an anticlockwise motion to turn 10 the gas on. That releases the gas into the line, in 11 other words into the pipes. I would then spray the 12 visible pipes with a leak detector fluid. If there were 13 a leak then this would cause the fluid to foam up at the 14 point of the leak. I would try to sort the leak, which 15 would normally be at the site of a connecting joint, by 16 tightening the connecting joint. If it were not at 17 a connecting joint that was leaking then I would have to 18 disconnect the tank and tell the customer that their 19 pipework needed to be replaced." 20 Do you recall actually doing that on any occasion 21 when you changed a tank at the ICL premises or are you 22 simply describing the normal procedure that you would 23 follow? 24 A. That's what I do. I do that at every job you go to. 25 All visible pipe is checked with the leak detector page 19 1 fluid. 2 Q. If we could go back to 013140, please, we see there the 3 pipework and we know from the area photograph that 4 the tank is just out of shot to the left and then the 5 pipework comes across horizontally and then it turns to 6 be vertical down into the ground. You have already said 7 that your recollection is that the tanks would not be 8 connected by you. 9 Is that a length of pipe that you would have checked 10 on an occasion such as this? 11 A. Yes. 12 Q. We have also heard elsewhere, Mr Inglis, that a check 13 for leaking joints can be done using soapy water. Is 14 the special fluid you put on it, is a similar idea, is 15 it? 16 A. It's more sensitive to gas. It comes in an aerosol can. 17 Q. You just spray it on and look at it and if bubbles 18 appear then you know gas is escaping? 19 A. Yes. 20 Q. It is as simple as that? 21 A. Yes. 22 Q. Paragraph 34: 23 "I would then carry out a tightness test which was 24 formerly known as a soundness test." 25 Do you know when the title was changed and if so page 20 1 why? 2 A. I don't know. They just changed -- I mean, originally 3 it was a pressure test, then it was a tightness test and 4 then soundness and probably next year they'll come up 5 with another name. 6 Q. But it is the same test? 7 A. It's the same thing. 8 Q. "The commissioning of a tightness test was not done at 9 the customer's request. The test was carried out as 10 part of my normal duties. I would conduct the tightness 11 test as part of a new installation, an exchange of tanks 12 or at a change of first stage regulator. The tightness 13 test has nothing to do with customer's requirements. 14 If, when working on any installation or maintenance of 15 a tank, if the system is broken into or a bit of 16 pipework has to be taken out, et cetera, then once it is 17 all put back together again, then the engineer needs to 18 be sure that there are no leaks. A tightness test will 19 only be carried out if the system is broken into, such 20 as when you might be changing a regulator, for example. 21 "I would ask for all gas appliances to be switched 22 off because otherwise gas would be taken out of the pipe 23 through the burners. I would also switch the gas off 24 from the tank by turning the wheel on the top of the 25 vapour offtake valve." page 21 1 When you say you would ask for all gas appliances to 2 be switched off, who would you ask to do that? 3 A. It would just be somebody that was a responsible person 4 that knew where to turn them off and how to turn them 5 off. 6 Q. Would you yourself go and see where the gas was being 7 turned off? 8 A. Sometimes, yes. 9 Q. Can you recall if on the occasions that you went to the 10 ICL premises either who you asked to turn off the gas 11 supply, the appliance, and whether you went to check 12 yourself where that was being done? 13 A. The first time I went in to see one it was one oven and 14 it was turned off at the side of the oven. 15 Q. So you can -- you think you can recall going inside and 16 seeing it being turning off beside the oven? 17 A. Yes. 18 Q. You then turned off at the tank by turning the wheel on 19 the top of the vapour offtake valve? 20 A. Yes. 21 Q. Item or page 013152, please. You were shown this image 22 which showed the first stage regulator and I think we 23 can see by reference to the previous photograph it is 24 shown in front of one of the two standing gas bottles or 25 tanks. page 22 1 "The first stage regulator is set for a certain 2 amount of pressure depending what the customer's 3 requirements are. A higher pressure would give a higher 4 flame and a lower pressure a lower flame depending on 5 the customer's appliance. 6 "When doing a tightness test I would leave the first 7 stage regulator pressure gauge in its normal position 8 and I would remove the plug at the opposite side of the 9 first stage regulator pressure gauge and fit my test 10 gauge." 11 Is that the gauge which we can see in the photograph 12 of the other side of the valve from the camera? 13 A. Yes. 14 Q. "I would check the before inserting my test gauge what 15 the pressure was on the first stage pressure gauge dial. 16 This would show the working pressure that the company 17 works at and this would be the pressure that I would 18 test at. Normally a pressure gauge would be set at 1 to 19 1.5-bar. However, the level of the bar does depend on 20 the customer's needs. For example, ICL would adjust 21 their pressure bar depending on the heat that they 22 wanted their ovens to be at. Normally the ovens 23 required the pressure to be set at 1.5 bars." 24 Does that mean, Mr Inglis, that for the purpose of 25 testing and knowing what pressure is being used in the page 23 1 operating of the system that is the gauge that will tell 2 you what that pressure is? 3 A. Yes. 4 Q. And that depends on what the customer wants in terms of 5 temperature in the ovens? 6 A. Normally, if it's just a first stage regulator 7 installation it would be set for 1.5-bar. 8 Q. Is that because it may actually be reduced by the second 9 stage regulator further, closer to the appliance? 10 A. Yes. 11 THE CHAIRMAN: Forgive me for interrupting, Mr Martin. I am 12 not quite following this and I am sure it is my fault, 13 but I can see the pressure gauge in the first stage 14 regulator where the gas bottles are but what about the 15 first stage regulator at the tank? Is there no 16 pressure -- 17 A. There's no regulator at the tank. That's the first 18 stage regulator. 19 THE CHAIRMAN: That is the first stage for the whole system? 20 A. Yes. 21 THE CHAIRMAN: Thank you. 22 MR MARTIN: Paragraph 39: 23 "I would then turn the tank on by turning the wheel 24 on top of the vapour offtake valve. 25 "My test gauge would then show what pressure the page 24 1 first stage regulator had been set at. My test gauge 2 would have been calibrated. It is calibrated when 3 purchased and once a year it is sent away to be 4 calibrated. At the time of testing at ICL Plastics 5 I would have been employed by my father's company, IB 6 Contracts, and I would have used the test gauge from my 7 father's company. Each year that it was calibrated 8 a certificate was sent back to confirm that it had been 9 calibrated. My Dad and I have looked for the 10 certificate in relation to the test gauge used. We 11 cannot find the certificate. I seem to recall that the 12 test gauge that I used was a new one and it was 13 perhaps less than a year old and this is the reason why 14 we cannot find the calibration certificate. When 15 I joined Johnston Oils I used their equipment and they 16 would have their own certificate. 17 "The test gauge is extremely accurate. The 18 regulator in comparison is crude. The regulator is set 19 on a spring and diaphragm to measure the pressure. 20 Therefore, you are relying on a piece of rubber and 21 a spring. The test gauge is very, very accurate and is 22 measured in millibars. A bar is 14 pounds per square 23 inch PSI, and you divide that by 1,000 to get a 24 millibar. Therefore the test gauge is 1,000 more 25 accurate that the regulator. I always the test gauge to page 25 1 set the pressure given. It is more accurate. 2 "Once the line had been pressured with gas, I would 3 turn off the vapour offtake valve by turning the wheel 4 in a clockwise motion. I would reduce the pressure 5 behind the first stage regulator by disconnecting the 6 pol connector." 7 Just if we could go back to 13149, please. 8 Are you saying that at this point, Mr Inglis, you 9 would actually unscrew and disconnect the pol connector 10 from the vapour offtake valve? 11 A. Not totally, all I'm doing here is loosening that pol 12 connector to let the gas escape from this side of the 13 first stage regulator. 14 Q. Why do you do that? 15 A. So that the pressure is held above the regulator at that 16 pressure that's there. If you left that pol connector 17 connected plus the pressure behind it, it would just 18 feed because that pressure is higher than what it is at 19 the first stage regulator. 20 Q. This is because you are testing the system from the 21 first stage regulator to, in this case, the appliance or 22 the valve at the appliance? 23 A. Yes. 24 Q. Therefore, you do not want to have a greater pressure on 25 the tank side of the first stage regulator which could page 26 1 mask a loss of pressure between the first stage 2 regulator and the appliance? 3 A. Yes. 4 Q. Thank you. 5 "A very small amount of gas will be released from 6 the pol connector because the pressure is being 7 maintained in the pipe by the first stage regulator, 8 which holds the pressure downstream from the pipe 9 beneath the first stage regulator to the appliance 10 inside the building. The reason for the disconnection 11 of the pol connector is because the pressure coming from 12 the tank can hold the pressure in test gauge dial. 13 A high pressure from the tank could keep the gauge 14 constant for a long period of time, perhaps even a day 15 or two at the working pressure and if there is a tiny 16 leak upstream then it could take a long time to show in 17 the test gauge depending on the size of the leak. By 18 disconnecting the pol connector this ensures an accurate 19 test given that it is only the pressure from the first 20 stage regulator onwards that is betting tested. The 21 pipework from the tank to the first stage regulator are 22 all visible and would, as per described above, have been 23 checked with leak detection fluid. This description was 24 given to the Procurator Fiscal to explain how 25 a tightness test is carried out. There was page 27 1 a pressurised line from the tank to the building and 2 there was no external valve at the point where the pipe 3 entered the building. I shutoff all appliances by the 4 valve at the ovens. The valve would then be turned off 5 at the tank. I would then take the gas out from behind 6 the regulator and that gas would then go to nothing so 7 from the point forward from the regulator to the 8 building, it forms a lock up which causes the gas to be 9 trapped in that part of the system. If the gauge reads 10 1.5 bars then you normally wait around 15 minutes or so 11 and if the gauge drops over that time period then you 12 know you have a leak. We would only carry out 13 a tightness test for pipework buried underground or not 14 visible. If the pipework is visible, then you would do 15 the soapy water test instead." 16 I take it by the soapy water test, you mean using 17 the aerosol? 18 A. Yes. 19 Q. Which is the equivalent. 20 "If the above-mentioned cylinders had been connected 21 to the pipework, then when carrying out a tightness test 22 I would have shut the gas off on both cylinders, 23 switched off the valve on the pipe beside the cylinders 24 and capped the pipe to ensure that no gas was going to 25 the first stage regulator. For work being carried out page 28 1 on domestic boilers, CORGI stipulate that an engineer 2 always has to do two tightness tests. One is carried 3 out as soon as you walk in the door and then another one 4 is carried out just before you leave the premises. 5 However, for tank work, there is only ever one test 6 carried out after the maintenance has been done. The 7 rationale for carrying out a tightness test is for 8 a company such as Johnston Oils to be absolutely 9 satisfied that since doing any work on the system, no 10 damage has been caused to the pipework. However, as 11 soon as you have left the site after the tightness test 12 has been carried out you do not know what might happen 13 to cause damage to the pipes so the test is only as good 14 as the time it is carried out. With LPG, there is not 15 allowed to be any leak or drop in the gauge as it must 16 sit at 1.5 bars at all times. If you were dealing with 17 natural gas then you can afford a drop by 8 millibars. 18 In that instance you would not report it or look for 19 a leak if there was an 8 millibar drop. It is because 20 you are working at different pressures. With LPG you 21 are working at double the pressure for natural gas. The 22 normal pressure for LPG would be 37 millibars whereas 23 for natural gas it would be 20 millibars. However, ICL 24 were operating a high pressure system (which is a bit 25 more unusual) at between 1 to 1.5-bar. page 29 1 "I would allow the test to sit for about five 2 minutes to allow the tank to stabilise. At the end of 3 the five minutes the pressure should still stand. 4 I would then wait 15 minutes to see if the gauge dropped 5 during that time. However, you will usually know within 6 the first two minutes if there is a leak as it will 7 normally drop off fairly quickly. 8 "If the gauge did not drop then this would signify 9 that there was no leak. I would then repeat the test on 10 the visible pipework as described above by spraying it 11 with leak detector fluid. At our accreditation training 12 we are told we only need to do the leak detector test 13 once. However, I am very pernickety and carry it out 14 twice because it is always better being safe. 15 "At the completion of a successful test I do not 16 switch the gas back on. It is for the customer to 17 switch it back on because any problems with the 18 pipework after my test is their responsibility. An 19 example being if minutes after the test someone drove 20 over a pipe causing damage to it, then by that time 21 I have completed my work, switched off the gas and it is 22 no longer my concern. 23 "If there were no problems with the tightness test 24 then I did not report this to the customer nor record it 25 anywhere. There was no need if the test was fine. If page 30 1 the test were successful I would then inform the 2 customer that they could then continue to work from the 3 tank. 4 "If the pressure dropped then the pipes have failed. 5 It is not allowed to drop at all with LPG. If it drops 6 then this signifies a leak. If there were a leak 7 I would disconnect the tank and plug the pipework and 8 tank. I would shut down the supply and remove the pol 9 connector." 10 Could I have photograph 013143, please. 11 You were shown this image. 12 "I would apply a plug where the copper pipe used to 13 meet the solid steel pipe. This plug could only be 14 removed with a spanner." 15 Could I have, again, 013149. 16 "I would also apply a plug at the left-hand thread. 17 This plug could only be removed with special tools." 18 That is after you have disconnected the pol 19 connector; is that right? 20 A. Yes. 21 Q. "If the pipework from the first regulator to the 22 building had failing, then I would inform the company of 23 the fault because I would have to switch off their tank 24 and not allow them to use it. I would also inform 25 Johnston Oils that it had failed but basically it is up page 31 1 to the customer to get someone in to repair it. I would 2 not record this on paper. Since providing the original 3 statement, Johnston Oils now do have reams of paperwork 4 that have to be filled in when any work is carried out 5 or there is a failure in pipework, et cetera. 6 "If the leak were underground then I would recommend 7 that the pipework was not dug up but the pipework 8 replaced. This is because to dig up the pipework and 9 try to locate the leak would be difficult. 10 "At the Maryhill factory the pipework was underneath 11 tarmac and concrete so to inspect it would have been 12 impossible to do without damaging the pipework. The 13 recommendation given to the customer would have been to 14 tell them that they had a leak somewhere underground 15 that needed to be found and at the same time, if I had 16 ever found a leak, I would also have told Johnston Oils 17 and they would then have arranged for something to have 18 been done. 19 "The HSE recommended the change in the period for 20 replacements of the pressure relief valves. It was 21 decided that the actual spring in the valve would last 22 for longer. The spring is set for pressure. If the 23 pressure of gas rises, then the spring in the valve is 24 hit and compressed and it lets out gas through a tiny 25 wee hole. Once the pressure drops the spring then page 32 1 resets itself. 2 "A tightness test is normally carried out at working 3 pressure. The only difference being if a new system was 4 installed, in other words new pipework, which I think 5 that it is tested at 1.5 times working pressure. For 6 new pipework it certainly used to be 1.5 times working 7 pressure but the regulations seem to change almost every 8 year. It is carried out 1.5 times working pressure to 9 ensure that there are no leaks in the new pipework." 10 If I may pause there for a moment, Mr Inglis, we 11 heard described in earlier evidence that the pressure 12 test is carried out using a stirrup pump or some other 13 device actually to pressure the pipe with air rather 14 than with the gas. 15 Do I understand the procedure that you followed was 16 to use the gas itself -- 17 A. Yes. 18 Q. -- which was trapped between the first stage regulator 19 and the shutoff valve at the appliance? 20 A. Yes. 21 Q. Have you ever used or been aware of the alternative of 22 using some sort of pressurising device to carry out 23 a pressure test? 24 A. That's only new installations. 25 Q. Secondly, in relation to the end of paragraph 50 where page 33 1 you have referred to the fact that the HSE have 2 recommended a change in the period for replacement of 3 pressure relief valves because it had been decided that 4 the spring in the valve could last for longer, is that 5 the change in the recommended period from 5 years to 10 6 years and from 10 years to 20 years that we have heard 7 about elsewhere? 8 A. Yes. 9 Q. The next section of your evidence: 10 "Would the length of the pipework affect the 11 tightness test? If there were a bigger stretch of pipe, 12 then I would carry out a longer tightness test. An 13 example being that after the settlement period for a 10 14 feet piece of pipe, I would conduct the test for 15 a period of approximately 10 minutes. However, for a 30 16 feet piece of pipe, I would perhaps monitor over 30 17 minutes. There is a calculation available that can be 18 used based on volume but if you do not know the size of 19 the pipework underground, then you just do a site survey 20 to determine the length of the pipework and estimate the 21 test time accordingly. 15 minutes would be definitely 22 long enough for a test because a leak would be seen in 23 the first few minutes when the test gauge will drop. 24 "1, 5- and 10-year tank tests. A tank examination 25 is carried out every year and every 10 years. It used page 34 1 to be carried out every 5 years when the pressure relief 2 valve was replaced. However, this was later changed to 3 10 years because it was decided that the pressure relief 4 valve could last for 10 years. 5 "The yearly tank examination is carried out by the 6 driver. This examination will also include a spray test 7 on visible pipes. 8 "The 10-year test is carried out by an engineer such 9 as myself. At that 10-year test I would do a tightness 10 test. I would also do a thickness test on the tank. 11 This is done by using an ultrasonic tester, which 12 is similar in size to a calculator. It is put on the 13 side of the tank and tells the thickness of the metal 14 being used. It is placed at different places on the 15 tank. I would then record the thickness and inform 16 Johnston Oils of this. Johnston Oils would then 17 decide if the tank is okay, or if it were worn away from 18 the inside, then it would be scrapped. I am sure that 19 at the time the test was carried out there was not an 20 actual need to do a tightness test at the 10-year 21 examination." 22 Could I ask for document 12476, please. 23 In your Inquiry statement, Mr Inglis, you say: 24 "I was shown Johnston Oils test form. This showed 25 that a tightness test was not part of our 1, 5 or page 35 1 10-year test. Since providing the statement, we do now 2 do a tightness test at the 10-year examination." 3 It may be that this is not an appropriate document, 4 but as far as we can see it might be helpful. Is this 5 a document which to any extent can help us on indicating 6 that the tightness test was not at the time part of the 7 1, 5 or 10-year test? 8 A. There doesn't seem to be anything on it that I can see 9 that involves a tightness test. 10 Q. This is a form that was dated 11th June 2003 and 11 concerned the test carried out on 9th June 2003 at 12 Grovepark Mills. Looking at the checklist which has 13 been expanded on the screen, is there any reference to 14 something that might indicate the carrying out of 15 a tightness test? 16 A. No. 17 Q. Is it that situation which has been changed and an 18 up-to-date form would show a tightness test being part 19 of the 10-year examination? 20 A. Yes. 21 Q. Thank you. 22 "Ownership of pipes. In my opinion, the pipework 23 belongs to the customer as soon as a tank is fitted, 24 this being the scenario for new pipework being fitted or 25 at changeover of tanks. The reason why in my opinion page 36 1 the pipework belongs to the customer is because the 2 customer purchases the pipework. The customer rents the 3 tank and this is why the tank is our responsibility. 4 I base my opinion not on documentation but on common 5 sense that if the customer purchases the pipe, then they 6 must own it. 7 "ICL Technical Plastics Limited. Installation of 8 the first Johnston Oils tank. While I worked for 9 IB Contracts, I was contracted to Johnston Oils 10 to install a 1-tonne gas tank for a company called ICL 11 in Maryhill. This would have been about six years ago 12 and the tank I fitted replaced a Calor Gas tank. The 13 tank for Calor Gas would have been gone by the time 14 I carried out the job and to the best of my knowledge 15 was the case. 16 "I remember there being two big gates at the door 17 and that the tank was inside the gates at the right-hand 18 side. I remember turning at a Jaguar garage to get 19 there." 20 If you look to the model just on your right, 21 Mr Inglis, can you see, by reference to your 22 recollection, the gates that you are talking about and 23 the position of the tank inside the gates at the 24 right-hand side? 25 A. Yes. page 37 1 Q. In the model, the part closest to you, there is in fact 2 what is shown as a large sliding gate with a metal steel 3 arch beam over the top and then inside that to the right 4 is the representation of the green-coloured tank. 5 Is that what you recollect at the site at the time? 6 A. Yes. 7 Q. "I was shown Johnston Oils delivery ticket dated 19th 8 March 1998." 9 Could I have 012076, please. I think we need the 10 second page of that which is 012077 just to show the 11 critical missing item. 12 "I observed that this is for fitting tank serial 13 number S38768 at ICL Plastics Limited, Grovepark Mills, 14 Hopehill Road, Glasgow. I observed that it is for 15 a 1,000-kilogram tank." 16 If you look at the second part of this document. 17 Mr Inglis, do we see on the right-hand side in 18 handwriting a reference to the serial number S3876 and 19 it is a little bit unclear, it might be a 5 or it might 20 be an 8, but that is where it is seen on the form. Is 21 that the case? 22 A. Yes. 23 Q. "This delivery ticket had nothing to do with my fitting 24 of the tank. I do not recognise any of the signatures 25 on the ticket. One of the signatures on the ticket is page 38 1 from the Johnston Oils driver. Sometimes the driver 2 would be with me to help remove the old tank and put the 3 new tank in place. 4 "I note that the fitting of this thank was about 5 seven years ago. That could have been when I fitted the 6 tank but I'm not very good with dates. 7 "I think I disconnected the previous tank. Normally 8 the other company who provided a tank, such as Calor, 9 would disconnect it and move it. I think I disconnected 10 it and moved it to the side to be collected. I presume 11 our driver was there and he would have had a lorry with 12 a high ab, which is a telescopic crane that would lift 13 the old tank off and position the new tank in the yard. 14 I think it was just the one tank that needed to be 15 disconnected and moved. There was nothing unusual about 16 this tank exchange. It was just a normal routine 17 like-for-like tank exchange." 18 May I clarify the lifting out of the old tank and 19 lifting in of the new one would be done by connecting 20 with the flanges we saw earlier, one at each end which 21 are welded on to the tank? 22 A. Yes. 23 Q. "While I was fitting the tank I remember asking one of 24 the company employees where the external valve was 25 positioned in order to turn off the gas. I was told at page 39 1 that time there was no external valve. It was not 2 unusual for it not to have one due to the age of the 3 premises, but it should have had one fitted. I can't 4 remember if there was valve just outside the tank but 5 I do remember there being a valve at the side of the 6 oven." 7 Is that the oven inside the building? 8 A. Yes. 9 Q. "I remember that at the plastics factory they didn't 10 have a valve before where the tank went into the 11 building. A valve should have been attached to the pipe 12 connecting it to the wall of the building. This valve 13 is used to shutoff the gas and thus isolate everything 14 inside the building. Had they had an external valve, 15 then the tightness test would be carried out from the 16 first stage regulator to the non-visible pipes under the 17 ground and leading to the external valve outside the 18 building. This would be the normal test carried out at 19 most buildings. However, as they had no external 20 shutoff valve, then my tightness test would have been 21 from the tank to the customer's appliances in the 22 building. The customer would have to switch off their 23 equipment during the test. 24 "I don't know anything about the oven apart from it 25 appearing old. My job ended at the valve beside the page 40 1 oven because that was the only place I could it close it 2 off in order to test the pipe pressure." 3 Can you remember, Mr Inglis, where inside the 4 building the oven was at which the gas valve was turned 5 off for you to carry out your tightness test? If you 6 want to look at the model, please do so. 7 A. I'm not actually sure. I think I walked in a door and 8 it was on the right-hand side as I walked in the door. 9 Q. You mean a door from the outside to the inside of the 10 building? 11 A. Yes. 12 Q. And it was to the right? 13 A. We went over to the right. 14 Q. Can you remember how far from the door inside the 15 building was the LPG oven? 16 A. No. 17 Q. I think the evidence elsewhere demonstrates that by 18 reference to the model it was the oven which is towards 19 the eastern end or far away end of the building as you 20 view the model. Is that possible? 21 A. It could be. 22 Q. Paragraph 67. 23 "The pipe pressure would have been tested to do more 24 than 1.5-bar pressure but I can't remember. It is 25 normal to use the existing fitting and that includes the page 41 1 regulator but I can't remember if I changed it on this 2 occasion. The initial fitting of the tank had no 3 problems or additional visits. I don't think any form 4 of parer trail was conducted with regards to the test 5 results." 6 I take it you mean or is meant there paper trail? 7 A. Yes. 8 Q. "The tank is serviced at 10-year intervals and each one 9 has a certificate which stays with the tank for its 10 life. 11 "I remember asking a worker at the factory, who I do 12 not recall, the whereabouts of the emergency shutoff 13 valve on the pipe as it entered the building. He 14 replied that they didn't have one. He said that the 15 pipework went straight across the yard but I did not see 16 where it entered the building. I would have mentioned 17 there being no valve there to Johnston Oils. It was an 18 option for ICL Plastics to install a valve. However, 19 rather than digging down to connect it to a pipe it 20 would have been far better to replace the pipework from 21 the tank to the building. The pipework could then have 22 been in plastic. Johnston Oils would probably have 23 supplied and fitted the new pipes for the customer for 24 nothing to keep the customer sweet because the customer 25 was using a lot of gas. My labour charge to Johnston page 42 1 Oils would have been about £80 to £90." 2 You say there, Mr Inglis, that you would have 3 mentioned there being no valve to Johnston Oils. 4 Do you recall if you actually did do that and how 5 you did it or, if you do not recall it, how would you 6 have done it? 7 A. I don't recall saying anything to Johnston Oils. 8 Q. If you would have mentioned, although you cannot recall, 9 how would you have done that? 10 A. I would have just probably phoned the office. 11 Q. Was that something that happened rarely or quite 12 frequently when you went out to do a tank replacement or 13 an exchange of some sort that you would find that there 14 was no external valve on the outside of the building? 15 A. It's pretty rare. 16 Q. Even on commercial or industrial installations? 17 A. Some commercials go straight in, some don't. It just 18 depends on the situation. 19 Q. We have heard elsewhere that at an earlier date at least 20 there was a positive requirement that there be an 21 external valve on domestic premises but there was not 22 a requirement at commercial or industrial premises? 23 A. No. It was good practice to put a valve outside the 24 building. 25 Q. "Installation of second Johnston Oils tank. page 43 1 "I don't remember exchanging our replacement tank 2 with another replacement tank. I had been previously 3 asked about this by the Health and Safety and police but 4 it doesn't ring a bell. However, if IB Contracts have 5 given Johnston Oils an invoice detailing a tank exchange 6 then it's most likely that I carried it out. Sometimes 7 I can't remember going to places more than once. In the 8 past I have had to phone van drivers to find out the 9 location of a place and then when I get there I remember 10 that I have been there before. It is possible that 11 I have forgotten about this second tank exchange. There 12 would have been nothing unusual about this tank 13 exchange. It would have been just a normal routine 14 tank-for-tank exchange. At that time Johnston Oils used 15 engineers who were based in Perth, Aberdeen, Dundee and 16 the Borders but I was the one doing most of the tank 17 installations." 18 Would it be the case, Mr Inglis, that if you did do 19 that second exchange it would be exactly the same as the 20 way in which you have described the first one? 21 A. Yes. 22 Q. "Fitting of regulator by Johnston Oils. 23 "I was shown invoice dated 13th April 2002." 24 Could I have document 12388, please. 25 "This detailed that on 8th April 2002 we changed the page 44 1 regulators on the LPG tank at a cost of £80.60. I do 2 remember going and fitting this new first stage 3 regulator." 4 Could I have 013153, please. You were shown this 5 image. 6 "I replaced the whole regulator, which is red in 7 colour in this image. It would probably be because the 8 company were not getting pressure through. The first 9 stage regulator controls the pressure of gas through to 10 their appliance." 11 This was a photograph, Mr Inglis, taken after the 12 disaster and may we take it that that is a photograph of 13 the regulator that you recall installing? 14 A. Yes. 15 Q. By reference to the photograph, it does not seem to be 16 in particularly good condition. Is that a result of the 17 events of the explosion and the time between your 18 installation -- 19 A. Aye. 20 Q. -- and the disaster happening? 21 So when you installed it, was it a new item or 22 previously used? 23 A. It was new. 24 Q. "When fitting a first stage regulator, it does not come 25 with a pressure gauge attached. I would firstly attach page 45 1 my test gauge into the hole for the pressure gauge. The 2 reason why I would not insert my test gauge into the 3 opposite side of the hole for the pressure gauge is 4 because the seal on the opposite side of the pressure 5 gauge would be broken if I inserted my test gauge there 6 at this time. This would, therefore, create another 7 hole for the gas to escape. I would leave that seal 8 unbroken until I carried out a tightness test at a later 9 date. I would set the pressure with my test gauge to 10 1.5 bar unless someone from the company, in this case 11 ICL Plastics, told me they required a different 12 pressure. I would then test to 1.5 bar or whatever 13 pressure they required. After the test I would remove 14 my test gauge and replace it with the pressure gauge." 15 May I just understand the practicalities of that. 16 If we look at the photograph, Mr Inglis, we can see the 17 pressure gauge on the opposite side of the regulator 18 from the camera and is that screwed into a union on that 19 side of the regulator? 20 A. Yes. 21 Q. Is that where you would have inserted your own test 22 pressure gauge, carry out the test and then afterwards 23 insert the customer's pressure gauge? 24 A. Yes. 25 Q. The opposite side pressure gauge union, is that the page 46 1 little almost circular item that we can see in the 2 photograph on the opposite side of the regulator from 3 the pressure gauge and presumably has a little screwed 4 cap into it? 5 A. Yes -- it's just a plug. 6 Q. It's just a little plug and you can unscrew that? 7 A. You can either put the pressure gauge in one side or the 8 other. 9 Q. But so as not to disturb the system any more than you 10 would have to at least when you were installing it, you 11 leave that one in place? 12 A. Yes. 13 Q. And you know presumably that it will have been tested at 14 the factory and, therefore, is not leaking there and you 15 put your pressure gauge in the other side? 16 A. Yes. 17 Q. Paragraph 74: 18 "If I was doing a pressure test on a system and it 19 failed the test I would condemn it. I would disconnect 20 the tank from the pipework and plug the tank. 21 "With regards to underpressure and overpressure 22 regulators, if you are were working on domestic 23 appliances you have to have under/over regulators 24 fitted. With regards to commercial premises, it all 25 depends on what specification the job requires. page 47 1 Normally it would be the company fitting the tank who 2 decides if they are fitted." 3 What is an over/under regulator? 4 A. It's a safety device for domestic appliances. It's 5 a lower pressure that's going through. Instead of 1.5 6 bars it's only 37 millibars. 7 Q. Presumably domestic we're talking about -- 8 A. Into the house. 9 Q. -- cooking and central heating? 10 A. Yes. 11 Q. And operates at a much lower pressure than industrial? 12 A. Yes. 13 Q. But no over/under regulators necessary on commercial 14 premises? 15 A. No. 16 Q. Paragraph 77: 17 "I would do a pressure test after every 18 installation. You would normally also do a pressure 19 test after changing a regulator. The basic point of the 20 pressure test is to make sure there are no leaks in the 21 line -- after you disturb the line you should leave it 22 knowing it is tight, ie no leaks. Since providing the 23 original statement, the pressure test referred to should 24 really be described as the tightness test. 25 "The first thing is you pressurise the line after page 48 1 putting your pressure gauge into a suitable part of the 2 line. You can pressurise using the gas, as it is an 3 existing line. Then you would raise it to a set 4 pressure, usually the working pressure, then you would 5 need to stabilise for ten minutes -- you need to 6 stabilise to let it settle, and in case any air had got 7 in while you were working on the line. Then you test 8 it. You shutoff the gas at the tank, reduce the 9 pressure behind the regulator, that leaves the pipe 10 pressurised from the regulator onwards into the building 11 then leave it on test for a further 10 to 15 minutes and 12 that is it. If you get a drop in the gauge then you 13 have a leak. There is no allowable leak rate. All you 14 need is a pressure gauge, a Borden 6 gauge, O-2-bar. 15 For that type of installation the working pressure is 16 normally 1 or 2 bar, although that company did vary the 17 pressure they needed. This is really just a more 18 detailed description of the tightness test. 19 "The pressure test does not involve an inspection of 20 the pipe runs, unless you have a leak. If there was 21 a leak you would investigate any visible pipes, spray 22 them with soap solution. If there was still a leak, but 23 not in the visible pipe run, then it probably means it 24 is underground. I would simply shut the system off. 25 This has happened to me, normally on domestic page 49 1 installations where galvanised joints, without Denso 2 wrap, had leaked around the threads. You don't normally 3 get it on the high pressure lines because schedule 80 4 (the specification of the pipe) is drawn from a solid 5 piece of steel, has no seams, is thicker and therefore 6 stronger. Again, this is more detail about the 7 tightness test rather than it being described as 8 a pressure test. 9 "In theory there would have been a valve just below 10 the first stage regulator. You could therefore have 11 done the tightness test up to that point. The standard 12 practice was to test the whole of the pipework to the 13 entrance to the building. 14 "I would tell the responsible person on site about 15 an underground leak. The pipe is the customer's and so 16 it is up to them to take any further action." 17 Could I have photograph 013161, please. 18 "I have been shown this photograph. It shows 19 a 1-tonne tank and associated pipework. It also 20 shows two 47-kilogram LPG cylinders. I can say 21 100 per cent sure that the two 47-kilogram cylinders 22 would not have been there while I fitted the tank 23 because I would not connect the two cylinders to the 24 associated pipework. I do not know who would have 25 fitted the two cylinders. In my opinion, had the page 50 1 cylinders been fitted by a responsible engineer, then 2 that individual would not have fitted the bottles the 3 way that I remember them being fitted. In my opinion 4 the occupier should not have fitted the cylinders. It 5 would have been someone who was CORGI registered." 6 I think you mean it should have been someone who was 7 CORGI registered. 8 A. Yes. 9 Q. Could I have photograph 013158, please. 10 "With regards to this photograph, it shows a valve 11 and then a clamp holding a rubber hose on. In my 12 opinion, the hose does not snap. The hose should be 13 changed every year and, in my opinion, the hose shown is 14 more than a year old." 15 What do you mean, Mr Inglis, by saying the hose does 16 not snap? 17 A. See where the hose goes on to the valve. That's onto 18 a brass hose connector and it's not very strong and with 19 that sort of a pressure on it, the chances are it could 20 snap. 21 Q. So are you actually saying in that photograph where the 22 rubber hose joins with the metal fittings, including the 23 cut-off valve, then the way in which it has been done 24 could cause the hose to snap? 25 A. Yes, actually where the hose connector fits into the page 51 1 valve there's a chance that could break. 2 Q. Is that because it being a rubber pipe under the tension 3 on the bend, it is putting a sideways pressure on the 4 metal fitting where the rubber pipe is connected to the 5 metal pipe? 6 A. Yes. 7 Q. Thank you. 8 "Opinion on LPG in a basement. 9 "I would not recommend LPG being piped into 10 a basement and I would try and make sure the pipework 11 was rerouted away from a basement. This is because if 12 there is a leak in a basement that has no ventilation, 13 this will cause a build-up of LPG and, if ignited, this 14 could cause an explosion. This is because LPG is 15 heavier than air and would sit. I had not been aware 16 that the pipework at plastics factory had gone into 17 a basement. It was either Health and Safety or the 18 police who told me that. Had I seen the pipework going 19 into a basement then, as per what I had been taught on 20 courses, I would have spoken to the responsible person, 21 who in this case would be the customer, and recommended 22 having the pipe rerouted away from the basement. I also 23 would have told Johnston Oils. I probably would have 24 shut the gas off as I had the power and authority to do 25 that and then I would have told the customer and also page 52 1 told Johnston Oils. 2 "For maintenance of underground pipes the main 3 safety procedure is to wrap it in Denso tape, which 4 protects it against moisture. The shelf life of 5 unwrapped pipes depends largely on the circumstances in 6 the ground. 7 "Opinion on the condition of the ICL pipes. 8 "If the customer had any doubts regarding the 9 pipework and if they did not know its condition, then 10 I would advise the customer that they should replace it 11 given they could not inspect it, as it is underground. 12 If a metal pipe is wrapped properly in Denso tape, then 13 there should be no problems and the pipe should outsee 14 everyone." 15 By that what do you mean? That it should last -- 16 A. If the pipework has been properly wrapped, the pipe 17 should be as good as the day it went in. That should 18 last for ages, for years. 19 Q. "However, if it is not Denso wrapped and exposed to the 20 elements then there is the danger that at some point the 21 pipe will corrode and leak. I would only have given 22 a recommendation to the customer if they actually 23 approached me for advice. I would have told them to 24 replace the pipework which would have been a relatively 25 straightforward job. Once a new track is laid, then it page 53 1 takes around 10 to 15 minutes to put in a new plastic 2 pipe. 3 "With a pipe being underground it cannot be 4 physically examined to view the condition other than 5 digging it up. To dig it up would be expensive and 6 could also cause damage to the pipework. I would 7 therefore recommend that it be replaced with plastic 8 pipes. It would be preferable for the new pipes to not 9 be underground but this would depend on where the new 10 pipework was being led to. 11 "Even if a test showed no leaks, I would still 12 recommend to the customer that they should replace the 13 pipework if they are unsure of the condition of the 14 pipework. The reason being that the tightness test is 15 only good during the time that it was actually tested. 16 An example being a minute after my test, an hour after 17 my test, or a day after my test, et cetera, a driver 18 could drive over a stone which could cause a pipe to 19 burst. In other words, a pipe could corrode or be 20 damaged any time after my test. I would only have given 21 the recommendations to the customer if I had been 22 approached by the customer for advice. 23 "An example being that one day I did a tightness 24 test on a new plastic pipe for a company and then two 25 days later I had to go back because someone had dropped page 54 1 a cigarette into the open trench, which had not been 2 filled, causing the pipe to melt." 3 In relation to the pipework with which we are 4 concerned, Mr Inglis, may I take it that you did not 5 carry out any investigation to identify whether or not 6 the pipework went underground and, if so, what was its 7 condition? 8 A. There's no way of telling what the pipework is like 9 underground unless you dig it up. All you can see is 10 the bit of pipe below the first stage regulator. 11 Normally -- I mean, that's all you've got to go on. 12 Q. Do you recall if you actually did look at the pipework 13 as far as the ground just beyond the first stage 14 regulator to identify what condition it was in? 15 A. Well, I mean, you can identify it. You can just look 16 along the ground and you can see where the track was but 17 you can't inspect the pipe unless you dig it up. 18 Q. But you did know that the pipe was obviously going into 19 the ground because it went into the ground just below 20 the regulator that you were changing at least on the 21 last time you were there? 22 A. Yes. 23 Q. Did you speak to anyone in the works or at Johnston Oils 24 about the fact that the pipe went into the ground? 25 A. No. page 55 1 Q. "Distribution of documentation to customers. 2 "At the time of the Maryhill tragedy my Dad and 3 I were only subcontracted by Johnston Oils to go in and 4 do a job and therefore we never distributed any guidance 5 documents to customers. At that time anything to do 6 with documentation would have been done by Johnston 7 Oils. 8 "Since the tragedy, we now offer leaflets to all 9 customers informing them that their pipework should be 10 tested and checked. Johnston Oils would charge the 11 customer for this given it is the customer's pipework. 12 The leaflets are issued mostly to commercial customers. 13 "Opinion on cause of tragedy. 14 "I have been informed by Health and Safety that it 15 was a corroded LPG pipe that caused the explosion. 16 I would be very surprised if that was what caused the 17 explosion. I would be surprised because LPG has a very 18 detectable smell. It has a smell that is a lot stronger 19 than natural gas. It can be smelt from about 10 feet 20 away. Also, if it had been leaking, then I would have 21 expected it to have exited out of a hole in the ground 22 or tracked the pipe and came out at the equipment and 23 thus people would have been able to smell it and would 24 have been alerted to the leak. I still think that if 25 there had been a massive amount of LPG in the basement, page 56 1 someone would have smelt it. The LPG has a manmade 2 odour and it stinks. It is much stronger than the odour 3 that is put in natural gas for domestic premises and you 4 would not be able to miss it." 5 Mr Inglis, are you suggesting any alternative 6 explanation for the explosion and collapse which 7 occurred, given that someone could well have smelt the 8 LPG but no-one apparently did? 9 A. Well, I don't know how it happened but, as I say, I am 10 very surprised somebody didn't smell the actual gas. 11 Q. I mean, is that the only reason why you would be 12 surprised if it was a leak and build-up of LPG in the 13 basement area that caused the explosion, the fact that 14 you expect someone would have smelt it? 15 A. I would -- that's all I can think of. 16 Q. You confirm that contents of this statement true. 17 Thank you, Mr Inglis, if you would not mind 18 remaining there you may be asked further questions? 19 THE CHAIRMAN: We will stop for ten minutes now. 20 (11.50 am) 21 (A short break) 22 (12.05 pm) 23 THE CHAIRMAN: Mr Macauley, do you wish to ask some 24 questions. 25 MR MACAULEY: A few. page 57 1 THE CHAIRMAN: Mr Macauley, I have extended the time for 2 putting in these notices in the case of your clients to 3 the (inaudible) and still the questions keep coming in. 4 MR MACAULEY: I accept that, my Lord. It is a question of 5 getting grips to the material as one is going along. 6 THE CHAIRMAN: Then it would be an enormous courtesy if you 7 could give us better notice of this. We are already way 8 past the time. 9 You want to ask about the tightness test. Is that 10 right? 11 MR MACAULEY: Yes, my Lord. I think in large measure the 12 points I have raised have been covered. 13 THE CHAIRMAN: Just carry on. 14 Examined by MR MACAULEY 15 Q. In paragraph 51 of your precognition, Mr Inglis, you 16 indicate that the tightness test is normally done at 17 working pressure. Is that correct? 18 A. Yes. 19 Q. I think you also have said in your evidence that with 20 a new system you test in excess of working pressure? 21 A. Yes. 22 Q. Any reason you don't test in excess of working pressure 23 on an old system? 24 A. It's purely to check the fittings and pipework. It's 25 just to give it an extra test. I don't know why they page 58 1 did it. They just brought it in and it's 1.5 times 2 working pressure. 3 Q. When you are testing a new system? 4 A. A new system, yes. 5 Q. In paragraph 34 of your precognition you indicate that 6 you are not aware the pipework went into the basement of 7 the factory; is that correct? Were you aware there was 8 an isolation valve in the basement? 9 A. No. 10 Q. Had you been aware of that, would you have used that 11 isolation valve when testing the pipework? 12 A. Yes. 13 Q. In paragraph 85 of your precognition, you make some 14 reference to Denso tape and the use of Denso tape to 15 protect pipework. 16 A. Yes. 17 Q. In relation to the pipework that was visible to you at 18 the installation was there any evidence of Denso tape on 19 the pipe? 20 A. Not that I can recall. 21 MR MACAULEY: Thank you. 22 THE CHAIRMAN: Mr Gray, there are some points you wish to 23 raise; is that right? 24 MR GRAY: No, my Lord, there are no matters that I would 25 wish to clarify, thank you. page 59 1 THE CHAIRMAN: Mrs Stacey? 2 MRS STACEY: I am sorry, my Lord, the questions I had 3 prepared have been asked. There is nothing I need to 4 ask, thank you. 5 THE CHAIRMAN: Mr Ellis, is there you want to mention? 6 MR ELLIS: No, thank you, my Lord. Likewise, what I wanted 7 to clarify has already been clarified. 8 THE CHAIRMAN: Mr McBride? 9 MR MCBRIDE: My Lord, I am in a similar position. I have no 10 questions of this witness. 11 THE CHAIRMAN: I think that covers everybody. That would 12 mean then that anyone who has given notice of questions, 13 apart from Mrs Ferguson, has been covered; is that 14 right? 15 Mrs Ferguson, is there some point you would like? 16 MR MARTIN: Forgive me in the normal way my learned junior 17 would ask if Mrs Ferguson would like to ask 18 a question -- 19 THE CHAIRMAN: Sorry, Mrs Ferguson. 20 Examined by MR McBREARTY (on behalf of Mrs Ferguson) 21 Q. Thank you, my Lord. 22 Mr Inglis, one matter briefly. If you could look, 23 please, to paragraph 63 of your statement you say there 24 that at this point I think you were talking about the 25 fitting of the first Johnston Oils tank in 1998 and you page 60 1 say there you think you disconnected the previous tank 2 and you go on to say it was a normal routine 3 like-for-like tank exchange. 4 A. Yes. 5 Q. So I take it from that what you recall is disconnecting 6 one previous tank? 7 A. (Nodded) 8 Q. We have heard evidence from witnesses from Calor Gas who 9 owned the previous tanks, Mr Inglis, and their evidence 10 was in or about April 1998, in fact, two tanks were 11 removed, two Calor tanks, which would suggest there had, 12 in fact, been two tanks previously on site which would 13 have been exchanged for the one tank that you put in. 14 Do you have any recollection of that? 15 A. No. 16 Q. Is it possible there were two tanks and you have simply 17 forgotten? 18 A. There could indeed but I just can't remember that. 19 THE CHAIRMAN: Could I just raise this with you, if I may: 20 in relation to the cause of the explosion, you have 21 expressed surprise, I think, that if there was this 22 accumulation of LPG in the basement that no-one smelt 23 it. 24 A. Yes. 25 THE CHAIRMAN: Is that just as far as you are going? You page 61 1 are not saying that was not the cause of the accident? 2 A. At the time that I made my statement I didn't know about 3 the pipework. I didn't know about the corroded 4 pipework. 5 THE CHAIRMAN: So obviously when you first gave a statement, 6 I presume that would be to the police? 7 A. Yes. 8 THE CHAIRMAN: People were talking then about the idea that 9 there had been an accumulation of LPG. It would be 10 perfectly natural, I suppose, that you would say, "Well, 11 why did nobody smell it if there was so much". 12 A. Yes. 13 THE CHAIRMAN: But of course there has been a lot more 14 investigation since then so I take it you are not saying 15 that in your view that the fracture of the pipe and the 16 accumulation of gas was not the cause of the explosion? 17 A. I don't know. I don't know what happened. I'm just 18 saying that if there was an accumulation of gas, 19 somebody, I would have thought, would have smelt gas. 20 THE CHAIRMAN: Thank you very much for your evidence. I do 21 not think it will be necessary to recall you to the 22 Inquiry. 23 (The witness withdrew) 24 MR MARTIN: That concludes the evidence from witnesses from 25 J Gas. The next group of witnesses are those who are page 62 1 giving evidence concerning the Health & Safety Executive 2 visit to the site. 3 The first, because it had been intended to call 4 these witnesses in chronological order, the first would 5 have been Mr John Powell but he is not available this 6 week my Lord. So the first witness is Miss Sue Ann 7 Johnston. 8 SUE ANN JOHNSTON (called) 9 Examined by MR MARTIN 10 Q. Miss Johnston, I understand that you would prefer to 11 read your own witness statement. I shall interrupt you 12 from time to time if I may and I shall also ask that 13 documents that you refer to are put up on the screen. 14 So if you just read your evidence, please, and bear in 15 mind that that will happen. 16 A. Okay. Thank you. 17 "I was employed by the Health & Safety Executive in 18 Glasgow from October 1979 until April 2006. In autumn 19 1996, I took a promoted post to Principal Inspector. In 20 September 2002, I became Principal Inspector in HM 21 Railway Inspectorate. At this time, HMRI was still with 22 HSE. In April 2006, HMRI left HSE and merged with the 23 Office of Rail Regulation. 24 "I started work with the HSE on 1st October 1979. 25 "I started as a class 2 trainee inspector within page 63 1 Glasgow North General Manufacturing Division. My 2 Principal Inspector was Norman Swain, he's now retired. 3 "My qualifications are as follows: 4 "A BSc honours in geography, an MSc in personnel 5 management and industrial relations and a post graduate 6 diploma in Health and Safety. 7 "When I star with HSE I did a two year training 8 period followed by a further one year qualifying year. 9 "I have no recollection of ever visiting the ICL 10 site in Maryhill until after the incident. My statement 11 is based on information in the Health and Safety files." 12 Q. Could I ask at this point that document 011418 be put 13 up, please, and when it is up if you would read on, 14 please, Miss Johnston. 15 A. "From this file, I see the first time I visited the site 16 was on 11th June 1981. I visited the site with training 17 inspector John Ives. This was a check visit regarding 18 the circular saws, in particular the guards were not 19 being used." 20 Q. If may ask you to pause there, please, I think 21 unfortunately the images in respect of certain of these 22 documents are not quite complete, not least that the 23 left-hand margin tends to be cut off and what we have on 24 the screen in front of us -- and it is perhaps just 25 worth pausing because a number of these examples will page 64 1 feature in the evidence from now on -- this is a report 2 on visits form which is a standard form completed by 3 officers of the Health & Safety Executive in respect of 4 visits to particular premises. 5 A. That's right, yes. 6 Q. May we take it that by reference to the entry at the 7 top, the name of the occupier and the address of the 8 premises, what forms such as this do is to create 9 a running record of visits over a period of time and 10 certain details in respect of these visits. 11 A. That's correct. 12 Q. If we look at the nature of the form, in the left-hand 13 column there is date and type of visit, in the major 14 part in the centre there is reason for visit and 15 a number of details specified, then there are two 16 sub-columns, as it were, headed "action proposed" and 17 then a final column which is "items changed on" and the 18 form is referred to with the clerk's initials and date. 19 If we go through these in order, the first is the 20 date and type of visit and this is unfortunately where 21 the imaging system has not been completed. 22 The second on this particular form is a reference to 23 your visit on 11th June 1981 and, unfortunately, that 24 date is not quite all visible in the form, but that is 25 what the date is on the original. Is that correct? page 65 1 A. That's correct, yes. 2 Q. Then the type of visit. Is that a form of code that is 3 clear to an officer who is familiar with the completing 4 of these report on report on visits forms? 5 A. Underneath the date, which as you rightly pointed out is 6 not very clear, there's two letters "CV". To an 7 inspector that would mean a check visit. 8 If you look at the previous entry, the one that sits 9 above it you will see in column 4 check visit 6/8/81 and 10 so the purpose of my visit when I went in June 1981 was 11 to carry out the check visit which had been put on the 12 file in February 1981 by the previous inspector, 13 Mr Smith. 14 Q. So there ought in a sense to be a chronology running 15 through from one entry to the next such as that, that in 16 February 1981 a check visit was proposed for June 1981 17 and then if you look down the form there is then such 18 a check visit? 19 A. That's right, yes. 20 Q. Could you just perhaps explain what the two columns 21 under "action proposed" mean in general terms? 22 Obviously, the entries in any particular case will have 23 to be identified, but what would an HSE officer put 24 under the first column, that is to say the one headed 25 "LFI40" and so on if there was something appropriate to page 66 1 enter? 2 A. Well, from my recollection -- it's a long time ago since 3 we used these forms -- but the column 3 would be the 4 action that you had generated following the visit that 5 you made. "L" would stand for letter and that might be 6 a letter to the company, it might be a letter to 7 employer representatives. We had internal systems for 8 getting help, for example, from specialist inspectors. 9 We had forms that we would have to fill in to get that 10 help. If you filled in that kind of form, that would be 11 generated there. So any administrative actions that you 12 as an inspector had initiated following the visit would 13 be recorded in column 3. 14 Q. If we look again just to take an example and it is not 15 one that we are looking at, the one on the upper part of 16 this particular page underneath column 3, we have F587 17 which is presumably a coded reference to a particular 18 form, is it? 19 A. It is but I can't remember what F587 is I'm afraid or I 20 can't remember what F19 is either. 21 Q. I am certainly not attempting to draw you on detail but 22 just so that, for the purposes of the Inquiry, we can 23 understand how these forms work. 24 A. Yes. 25 Q. Then F590, the same thing. Then "L", that would be page 67 1 a letter, would it? 2 A. That would mean letter and then the "CC" would be copy 3 to the employees because under the requirements of the 4 Health and Safety at Work Act we have a statutory duty 5 to keep employees informed on matters affecting their 6 Health and Safety at Work. 7 Q. Then in column 4 under the heading "Assessment" you have 8 already explained CV681 is a recommendation of a check 9 visit in June 1981. Then presumably under that "GDG of 10 circ saws" is guarding of circular saws. That is the 11 topic with which the particular assessment was 12 concerned? 13 A. Yes, that is the previous inspector who visited, 14 Mr Smith, thought what he found was worth going back to 15 have another look at, a check visit. It was in 6/81 16 that he wanted that paid. He had probably given advice 17 to the company previously and was giving them some time 18 to put things right before we went back and he has coded 19 there and I would interpret that, as I read that now, as 20 regarding the circular saws. 21 Q. Then the final column which is "Items changed on form", 22 I will not read it all out, clerk's initials and date. 23 The only thing I can see in this particular example is 24 FI83. Is that another form? 25 A. Yes and I can remember what that is. page 68 1 Q. What is that? 2 A. An FI83 was a system that we used for recording our 3 assessment of the company against the risks and hazards 4 that were in the company, how we thought management was 5 going to respond, those sorts of things, and it was 6 a form which was filled in numerically and a total would 7 come from the numbers against the heading and for every 8 year that past more numbers would be added. It was a 9 system that we used to generate visits for our 10 inspections. So if we had a poorly performing company 11 with high hazards we would ensure they would be visited 12 more often than a better performing company with less 13 hazard, for example. So it was our way of, if you like, 14 ranking the Health and Safety performance of the company 15 and the hazards and risks associated with that company. 16 Q. The prefix "FI" appears to be something which is applied 17 to certain forms; that is an FI83. The form that we are 18 actually looking at, the report on visits form at the 19 bottom left-hand corner, has the code FI42 and we can 20 also see reference to an FI40. These are all standard 21 forms that were used in the appropriate circumstances; 22 is that right? 23 A. That's absolutely right. I think FI might have meant 24 Factory Inspectorate but I couldn't be sure about that. 25 Q. Which would be the previous title of the organisation page 69 1 for this purpose? 2 A. Before HSE, yes. 3 Q. Thank you very much. 4 If you would then go to paragraph 8 of your Inquiry 5 statement, please. 6 A. Would you like me to keep reading? 7 Q. Please, thank you. 8 A. "During the visit I have noted that LPG (probably 2 9 tonnes) had material and equipment being stored next to 10 it. I also noted that there were smaller LPG cylinders 11 also near the tank." 12 Q. If we identify the particular reference because we can 13 see for ourselves the reference to the guards on 14 machines, if we go to the second page which is 011419, 15 the last large paragraph in the continuation of the 16 entry for the amendment of June 1991 reads: 17 "Also during the visit a tank containing propane 18 (probably 2 tonnes) was seen within the premises. 19 Material and equipment including smaller LPG cylinders 20 were seen being stored too close to the larger tank. 21 The company were advised on this." 22 That is the entry to which you referred; is that 23 right? 24 A. That's right. 25 Q. Then we see, just as a matter of interest, referring page 70 1 again to the forms underneath that "no further action 2 proposed, no change to the FI83". May I take it that 3 that is your signature and the date 6/7/81? 4 A. That's my signature and my date and, yes, that's what it 5 says: no further action proposed in relation to the 6 FI83. 7 Q. We can read the other elements on the form for ourselves 8 but in general terms, and again I am just looking for 9 the practice, under the column "assessment" there were 10 three words. The first I cannot read but then "when 11 due" but these have been scored out and then underneath 12 that there is something written in handwriting. Is that 13 your handwriting? 14 A. It is. 15 Q. As a matter of interest, why would you insert on a form 16 such as this something in handwriting, other than your 17 signature, rather than having it typed? 18 A. Well, that's quite a difficult question to answer in the 19 sense that if you -- because it was a typing pool that 20 we had at the time, rather than the computer systems 21 that we might generate nowadays, these forms were all 22 generated as pieces of paper and then they were put 23 through the typing system. To get it typed, I would 24 have had to send that back to the typing pool. So quite 25 often when we are making minor amendments as inspectors, page 71 1 and you will see further on in the file there are 2 handwritten entries -- it just depended on, you know, 3 how significant or what a major change -- not 4 necessarily how significant but the sort of change that 5 you were going to make, if it was a just a minor 6 correction or a minor alteration to the file, instead of 7 sending it to the typing pool to get that done, as was 8 common practice, I would just make that amendment 9 myself. It isn't significant that it is in handwriting. 10 Q. The other thing that we can see on this entry, and it is 11 obvious on the other ones, is that there is a rubber 12 stamp -- I am assuming it is a rubber stamp -- which has 13 been applied towards the bottom right-hand corner of the 14 entries that we see on these documents and it is a box 15 with three parts. The first is the word "shield", the 16 second is a date and the third is the word "input". It 17 is clearer on some than on others. 18 What is the significance of that? 19 A. This was an administrative function. That was put on by 20 administrative staff. Now, I can't actually remember 21 what process they would have followed to stamp the piece 22 of paper, so I can't remember at what stage in the 23 process they would have put that on, but we had a system 24 in place called Shield which was a system that we used 25 for recording the visits that we made, et cetera, and as page 72 1 far as I remember, the shield file would be stamped when 2 the admin support staff had finished inputting and 3 finished all the administrative actions that were 4 associated with that visit. 5 So if you take the visit that is partially 6 highlighted on the screen at the moment, my 7 recollection -- and we are going back to 1982, I think, 8 at the moment -- is that they would stamp that file once 9 the letters had been sent out to the company and the 10 letters had been sent out to the employees. We also had 11 a system to make sure that if I made a record or anybody 12 else made a record on the file to say they wanted the 13 file brought forward or you wanted a check visit made, 14 it was an administrative function to keep a note when 15 they were coming up in the diary. So we had a diary 16 system so that these files would be brought forward for 17 us as inspectors and we weren't expected to remember, in 18 the many, many premises that we were dealing with, 19 exactly when check visits were due. 20 Q. Could I ask for 110978 to be put up, please. Can you 21 read paragraph 9 of your statement Miss Johnston. Just 22 carry on, please? 23 A. "I then in turn after my visit sent a letter to ICL 24 Plastics about a number of items including point 25 a number 3 storage of LPG. I mention about scraps of page 73 1 wood and small LPG 97ders being stored within close 2 proximity of the tank. 3 "In my letter I state these should be moved 4 immediately and stored outwith minimum separation 5 distances. I also mention about the separation distance 6 between the main tank and the boundary wall. I also 7 enclosed HSE guidance note CS5 (storage of LPG at fixed 8 installations)." 9 Q. Could I have 001168 up, please. No, I beg your pardon, 10 it is 1168. That is obviously just the first page, 11 Miss Johnston, but is that the document or leaflet or 12 guidance note that you are talking about? 13 A. It is a version of the guidance note I am talking about. 14 Here I can't be certain. But you can see on that 15 guidance note it is dated May 1981. I visited in June 16 1981 and I can't be sure whether I would have used the 17 May 1981 guidance note or the one that was in previous 18 circulation before then, because that was updated. 19 Q. Thank you very much. Could I have 11419, please. Just 20 read on paragraph 11 of your statement. 21 A. "This letter was approved by Monica Finnan. I mention 22 in the margin that there should be a bring forward with 23 reply in October 1981 and a check visit regarding 24 material at the LPG tank in September 1981." 25 Q. Just carry on, please. page 74 1 A. "The next time I visited the company was on 10th October 2 1981. I visited the site alone." 3 Q. Is that the entry shown on 11491 on the screen at the 4 moment? Sorry, 11419. 5 A. I can't see the date but I'm assuming if that is 6 the ... 10th October 1981 date. 7 Q. What we do have are the two Shield stamps and at least 8 the second one is clear. It is dated 13th November 9 1981. So without directly referring to the date of the 10 visit, it is in the appropriate time period; is that 11 fair? 12 A. Yes, and I've signed it off on 9/11/1981 which you see 13 at the bottom. I'm sorry, I can't read that on the 14 left-hand side there, but I think that must be referring 15 to the visit I paid on 10th October. 16 Q. Just carry on reading paragraph 13, please. 17 A. "I mention that the combustible materials have been 18 moved from around the tank. 19 "I am still showing concerns with regards to the 20 tank. By this, I mean the proximity of the tank to the 21 boundary wall and also the filling of the tank from bulk 22 road tankers. 23 "I mention raising a form FI86. This is an internal 24 request form looking for some help and advice. This was 25 directed towards the FCG (Field Consultancy Group in page 75 1 Edinburgh)." 2 Q. Can we see in the entry, which is the second one on the 3 page, by reference to your signature and the date 4 9/11/81, most of it, if not all of it, is actually 5 referring to the tank and the various features of the 6 tank which you have mentioned in your evidence. 7 I see towards the bottom of the narrative it says: 8 "Proposed to raise an FI87 ..." it is difficult for 9 me to read. 10 Then in column 4 under the assessment there is BF, 11 which is presumably brought forward, with FI and it may 12 have been 87 changed to 86. Which is the form that you 13 were actually referring to? 14 A. I can't remember the number because it's so many years 15 ago but there was a form. Whether it was the FI87 or 16 the FI86 I don't remember, but it was the form that we 17 used to request advice from our Field Consultancy Group. 18 Q. Could I have 1193, please. Is that the form that you 19 are referring to? 20 A. Yes. 21 Q. I think we can see from the bottom -- which is just 22 obscured on the screen, I am afraid -- is an FI86? 23 A. It is, yes. 24 Q. In paragraph 15 of your statement you say that you 25 mentioned raising a form FI86. This is an internal page 76 1 request for looking for some help and advice. This was 2 directed towards the Field Consultancy Group in 3 Edinburgh. 4 Can we just see where in the form it actually says 5 that you are seeking the specified advice. Is it under 6 the item 3 "help needed"? Is that where the advice is 7 specified? 8 A. Yes. I'm sorry, I haven't seen that form for -- 9 Q. You haven't seen it before? 10 A. Well, I've obviously seen it the day I signed it but 11 I haven't seen it since. 12 Q. Just take your time, Miss Johnston. If you need any 13 more time, then I am certainly happy to do that. 14 Could I ask for 11420, please. Could you read from 15 paragraph 16. 16 A. "I then returned to the factory on 20th January 1982 17 with Alistair Gunn (FCG) Fire and Explosion. We met with 18 a Mr Stott, managing director." 19 Q. Just to explain the reference to Mr Gunn, "FCG" is 20 presumably Field Consultancy Group in Edinburgh which 21 you mentioned in paragraph 15. May we take it Fire and 22 explosion was a division or a part of that group? 23 A. Mr Gunn was the fire and explosion expert, yes. 24 Q. You met with a Mr Stott and that is referred to on the 25 second line of the visit. Again, I am afraid the day is page 77 1 not clear but it is obviously January 1982? 2 A. I have seen that previously. I have seen that copy that 3 and it is 20th January 1982. 4 Q. It is another check, CV, and there is a Shield stamp at 5 the right-hand side. Unfortunately the month, as far as 6 I can see, is completely unclear. Your signature is at 7 28/1/82. There is also a Shield stamp to the left which 8 says 2nd October 1981. Is there any reason for that 9 that you can explain at this stage? 10 A. I can't I'm afraid, no. 11 Q. Could you return to paragraph 17 of your statement, 12 please, and just read on. 13 A. "This inspection would have been carried out by Alistair 14 Gunn who would have been looking at all aspects of the 15 tank with a view to compiling a report. Following this 16 visit, I made a note in the file quoting something 17 Mr Gunn said, 'This is probably one of the worst sitings 18 of an LPG that he had ever seen'. 19 "I mentioned that the company had changed the way 20 they filled the tank. For example, the bulk delivery 21 tankers now parked outside the yard and the driver uses 22 an extra length of hose. 23 "If Mr Gunn had thought there was imminent danger of 24 any kind, he would have told me at the visit which in 25 turn would have allowed me to consider formal page 78 1 enforcement action. 2 "Mr Gunn on writing his report became aware that 3 some of the recommendations he was making quite