page 1 1 Wednesday, 9th July 2008 2 (10.36 am) 3 MR MARTIN: My Lord, the next witness is Mr John Keith Ives. 4 JOHN KEITH IVES (called) 5 THE CHAIRMAN: Mr Ives, you will be asked questions by 6 Mr Martin and then there may be some other questions 7 from other parties. 8 Examined by MR MARTIN 9 Q. Thank you, my Lord. 10 Mr Ives, I think you are content to read your 11 Inquiry statement and I shall certainly indicate where 12 I wish to ask you additional questions and call for the 13 documents which need to be produced. 14 If you are happy to do that, I think you perhaps can 15 take the initial part as read. You were formerly an 16 employee of the Health & Safety Executive but retired in 17 September 2004. 18 In paragraphs 2 to 6 you set out your employment 19 history, originally with the Factory Inspectorate and 20 thereafter with the Health & Safety Executive and in 21 1999 you concluded your career as Health and Safety 22 Adviser to the Executive advising on internal safety 23 arrangements. 24 In paragraphs 7 to 20 you refer to the background to 25 training and the training which was received. page 2 1 In paragraph 12 in particular you indicate that 2 there was a recognition that LPG was an issue you needed 3 to pay attention to in relation to bulk storage 4 installations and small operation cylinder and aerosol 5 filling and you refer to various courses. 6 In paragraph 19 you say: 7 "As far as training provided to inspectors on LPG is 8 concerned, certainly there was training on fire and 9 explosion as part of their course." 10 Beginning at paragraph 21 you begin your substantive 11 evidence by referring to your involvement with the 12 premises and I wonder if I could ask you to begin 13 reading there, please? 14 A. At paragraph 21? 15 Q. 21. 16 A. "When the explosion at the ICL premises occurred on 11th 17 May 2004, I thought from the TV pictures that it was at 18 the premises I knew as ICL although it was being called 19 Stockline. 20 "I think someone in Glasgow called me within a day 21 or so and told me it was the premises at ICL. I knew 22 that I had visited the premises a long time ago. 23 "I think Bill Reilly of HSE and I discussed this on 24 the phone. He had worked for me a long time ago in 25 Glasgow as part of my team. I think Bill was working page 3 1 with me at the time I dealt with ICL. 2 "I came to Glasgow around July 2004 for a retirement 3 do and Stewart Campbell (Director of HSE for Scotland) 4 asked me to see him. He advised me I apparently had had 5 a key part in the premises and he believed the police 6 would be looking for a statement. He asked me if I had 7 a problem with that but I didn't. I was thereafter 8 interviewed by police officers. 9 "When I attended for interview with the Procurator 10 Fiscal on 15th August 2005, I was shown" -- 11 Q. Forgive me if I interrupt. 12 I think we can take that in passing because we will 13 look at specific pages in a moment but you saw the 14 Health & Safety Executive report on inspection file 15 together with other HSE files. So you had access to 16 these when you were interviewed by or on behalf of the 17 Procurator Fiscal. 18 A. That's correct, yes. 19 Q. Carry on, please. 20 A. I think I'm on paragraph 26 then: 21 "I have remembered when the story broke that my 22 involvement had been to do with the LPG tank. 23 "Only when I actually saw the file, however, did 24 I realise that I had actually gone on an earlier visit 25 to the premises prior to my involvement with the LPG." page 4 1 Q. Could I have up 011418, please. 2 If you just carry on, Mr Ives, when it appears, 3 thank you. 4 A. "The PF directed my attention to the entry dated 5 11/6/81. That entry shows there was a visit to the 6 premises of ICL Plastics Limited at Grovepark Mills, 7 Hopehill Road, Glasgow on that date by Sue Johnston 8 along with me. It noted that I was the training 9 officer. The persons seen at that time were Mr Stott, 10 Managing Director and a Mr Ian McAlpine, Production 11 Manager. I have no recollection of that visit. 12 "Sue would be the trainee inspector and I would have 13 been with her to observe and assess her performance. 14 "I was a Principal Inspector covering all of 15 Scotland for training purposes. My job was to work with 16 trainees and to run a training programme. 17 "At the time of our visit the tank was noted. The 18 penultimate paragraph of the entry refers also during 19 the visit a tank containing propane (probably 2 tonnes) 20 was seen within the premises. Material and equipment, 21 including smaller LPG cylinders were being stored too 22 close to the larger tank. The company were advised on 23 this. 24 "The last paragraph of Sue's entry was to the effect 25 that no further action was proposed and no change to the page 5 1 FI83. The FI83 was a risk assessment form which would 2 be marked. Sue has marked that there was no change to 3 it, which I had agreed. The FI83 dealt with the rating 4 of the business which could be altered at the end of 5 a general inspection, ie a look round the whole 6 premises. An example of this is shown at page 71 at the 7 end of the file." 8 Q. Could you please put up page 011419 which is the next 9 page. 10 I think that is the continuation entry from the one 11 that began on 11th June 1981 and it is the final 12 paragraph to which you are referring. 13 A. Yes. 14 Q. Above Miss Johnston's name and signature and the date, 15 there is a reference to the LPG tank or the propane tank 16 and no further action proposed, as you have just 17 indicated. 18 A. That's correct. 19 Q. Miss Johnston explained to the inquiry yesterday the 20 nature of these reports on visit forms, Mr Ives. I do 21 not want to take up your time doing that, but if we look 22 at column 4 of this particular entry, we can see that 23 there were three words in typescript which have been 24 scored out and then words handwritten which Miss 25 Johnston confirmed was her handwriting. page 6 1 Is there anything unusual about handwritten entries 2 appearing alongside typescript entries in these reports 3 on visits forms? 4 A. Not at all. The typing procedures were quite slow and 5 laborious. Things had to be dictated and then sent to 6 a typing pool and then returned and it was very common 7 where just small alterations or quick notes had to be 8 made to do it in hand. 9 Q. Thank you. 10 Paragraph 33 of your witness statement and could 11 I have up 11462 and 3, please. 12 A. "The entry shows that Sue sent a letter to the company 13 which was copied to the employees and the papers were 14 marked to be brought forward with a reply or by October 15 1981. The annotation is 'bring forward with reply or 16 10/81' and she has marked underneath 'CV' (that means 17 check visit) material at LPG tank 9/81'. 18 "Sue's letter was a letter dated 16th July 1981 19 (report on inspection file) page 83 to 67." 20 Q. Are these the pages on the screen? 21 A. Yes. 22 "Monica Finan, the Principal Inspector, would have 23 endorsed the letter going out. 24 "In that letter Sue raised the separation distances 25 regarding the LPG tank. page 7 1 "She was pointing out on page 2, second paragraph, 2 that the company should calculate the separation 3 distances for the LPG tank on the premises and that this 4 should be compared against the appropriate separation 5 distances given in a table which she was enclosing -- 6 guidance note CS5 (storage of LPG at fixed 7 installations) -- referred to in the second last 8 paragraph of the letter. She advised the company that 9 if they found that the tank was sited too close to any 10 boundary, building or property line, et cetera, then if 11 at all possible it should be moved and re-sited so that 12 correct separation distances may be obtained. 13 "In essence, minimum separation distances to 14 boundaries, buildings and properties were to ensure that 15 ignition sources were kept away from the tank. 16 "Sue advised that if the premises were too small 17 and, therefore, proved impossible to re-site the tank 18 then the company was to contact her at the office for 19 further information and advice and to advise her within 20 two months of the action they proposed to take on the 21 matter. According to the letter, she enclosed a copy of 22 guidance note CS5 (storage of LPG at fixed 23 installations) for their information." 24 Q. Could I ask for 001168, please. That is obviously just 25 the first page, Mr Ives, but I think we can see that at page 8 1 the top left-hand corner, under the title, it states: 2 "Chemical safety 5 May 1981", which would appear to 3 be the addition that was in existence as at June 1981. 4 Is that your recollection? 5 A. That is my recollection, yes. 6 Q. Thank you. 7 Could I have page 011419, please. Read on at 8 paragraph 41, please? 9 A. "On 14th October 1981 Sue Johnston, again visited to 10 carry out the check visit. The relevant entry is file 11 entry 14/10/81. Either Monica Finan or I may have told 12 her to go back. It looks as if she has gone back alone. 13 Her entry shows that she proposed to raise an FI87 to 14 advise on the matter of the LPG tank and to see whether 15 anything could be done to improve the location of the 16 tank. Again in that entry Sue Johnston has expressed 17 her concern that the yard is cramped and the separation 18 distances between the tank and the boundary walls were 19 nowhere near that required by CS5 and the Code of 20 Practice." 21 Q. Could I have the following page, 11420, please. 22 Read on paragraph 44, please. 23 A. "On 21/1/82 Sue Johnston returned to the premises with 24 Alistair Gunn of the Field Consultant Group (fire and 25 explosion). It is Mr Gunn who would have been brought page 9 1 in by the raising of the FI87. The FI87 is a form 2 whereby an inspector can request specialist input from 3 the Field Consultant Group or FCG. The entry shows that 4 this is the check visit on the siting of the bulk 5 storage tank in the company's yard, the tank being owned 6 by Calor and having a capacity of 2 tonnes. 7 "Miss Johnston noted Mr Gunn agreed that this was 8 probably one of the worst sitings of an LPG tank that he 9 had ever seen. She proposed to write to the company 10 with any recommendations made in Mr Gunn's report." 11 Q. Could I have 11089, please, and I think the subsequent 12 two pages, 090 and 091. 13 Read on, please, paragraph 46, Mr Ives. 14 A. "When I attended the PF for interview I was shown 15 a Health & Safety Executive correspondence file, being 16 Alistair Gunn's report dated 8th February 1982." 17 Q. Is that what is currently on the screen? 18 A. That's correct. 19 Q. Could we expand it? There we are. That is the first 20 page. 21 Read on, please. 22 A. 47: 23 "I have no specific recollection of having seen 24 Alistair Gunn's report but I would normally have read 25 such a report prior to the visit which I later carried page 10 1 out, given the subject matter. 2 "If carrying out a visit on a specific topic or even 3 more so on a general inspection, you should go through 4 the file to identify the specific areas which have been 5 issued in the past, for example, specific 6 problems/niggles, et cetera. 7 "On looking at Alistair Gunn's report it is about 8 the separation distances/siting of the bulk tank, the 9 filling operation for it and a drench system. 10 I would have thought it was not normal practice to 11 have a drench system on a small tank (I would expect 12 such a system to be suggested for a tank perhaps 100 13 tonnes not 2 tonnes). My reaction on seeing that 14 recommendation for a drench system would have been to 15 have asked why Alistair Gunn made that recommendation. 16 Where I thought an organisation needed advice on LPG 17 I would send them a copy of the guidance note CS5. 18 I would normally only send a copy where there was an 19 issue to be to be addressed. 20 "I was fully familiar with the terms of CS5." 21 Q. We know from the earlier correspondence that 22 Miss Johnston had sent to the company a copy of the 23 guidance note CS5. 24 A. Yes. 25 Q. So far as Mr Gunn's position is concerned, as you have page 11 1 indicated and he gave evidence yesterday, he was called 2 in as a result of the FI87 to give specialist input. 3 Where does his position lie in terms of the 4 hierarchy of responsibility? Does he have 5 a responsibility above that of Sue Johnston or above 6 that of you or how does the responsibility and the 7 reporting between the various positions operate or at 8 least how did it operate at the time? 9 A. At that time -- and I think still today as far as I'm 10 aware -- the responsibility of the specialist 11 inspectors, someone like Alistair Gunn, was to report to 12 the inspector dealing with the premises who would then 13 take what action they thought was necessary in the light 14 of that report. 15 Q. Thank you. 16 Could I have 11070, please. I think again the two 17 subsequent pages. 18 Paragraph 52, Mr Ives. 19 A. "The PF referred me to a letter dated 13/01/86 but 20 I cannot recall having seen the letter from Mr Scott, 21 Managing Director of ICL, to Sue Johnston." 22 Q. Is that letter on screen now that you cannot recall 23 seeing it? 24 A. That's correct, yes. 25 Q. Can I go back to 11426, please. page 12 1 A. Paragraph 53? 2 Q. Perhaps 54. 3 A. "That entry shows that Alex Keddie carried out a general 4 inspection. 5 "In this entry he notes that the check visit marked 6 by Sue Johnston, following a visit on 13/11/85 the 7 purpose of which was regarding guarding/LPG storage and 8 spray booths) had never been carried out. 9 "Mr Keddie referred to a letter received by the 10 Health & Safety Executive on 13th January 1986 11 confirming that a water drench was never fitted at the 12 LPG tank. Mr Keddie had noted that the bund wall was 13 now damaged and he would visit with an FCG 'ASAP' for 14 enforcement. 15 "He has marked other matters as having received 16 attention." 17 Q. Does it appear that the letter of 13th January is that 18 from Mr Stott to Miss Johnston that you do not recall 19 seeing but it is dated 13th January 1986? If it can be 20 put back up, it is 11070. 21 A. Yes, that is it. 22 Q. I think it is the third page which refers to the LPG. 23 58 and we are there referring to the entry on page 24 11426 again. 25 A. "In his entry 7th April 1986, Alex Keddie shows that the page 13 1 items had not been covered. He refers in particular to 2 spraying the tank -- the drench system. 3 "A drench system is either an automatic system 4 detecting heat (like a sprinkler system) or manually 5 operated system. Alistair Gunn recommended a manual 6 system. A high risk operation involving the tank is 7 when a road tanker is offloading and, for example, the 8 hose burns by being ignited by a fire. The 9 Health & Safety Executive were very concerned with 10 BLEVEs (boiling liquid expanding vapour explosions). 11 Alex Keddie then put in place a request in April 1988 12 for an urgent visit." 13 Q. If I may, Mr Ives, a BLEVE is where not only is the gas 14 igniting but it is also because it is being heated up 15 turning from liquid into vapour at a significant rate 16 which increases the ferocity of the burning or 17 explosion; is that right? 18 A. Yes, a particularly serious incident. 19 Q. 60, please. 20 A. "I would have had access to Alex Keddie's letter and 21 I was concerned standing the input ICL had had from HSE, 22 about ICL's ability to deliver on the issues HSE had 23 raised with them. 24 "For whatever reason, possibly short staffing, that 25 did not happen until 9th August 1988. When I carried page 14 1 out the visit requested by Alex, Alan Tyldesley, who had 2 recently recruited to HSE working with the FCG Fire and 3 Explosion as a specialist inspector. My recollection is 4 that I went within a day of Alan calling me to state he 5 was available to attend at premises and we went the next 6 day. It was all organised in a bit of a rush. I don't, 7 however remember much of the detail of the visit. 8 "I found Mr Stott of ICL pleasant and amenable to 9 deal with." 10 Q. Could I have entry 011427, please. 11 Just read on, please. 12 A. "Alan attended with me on 9th August 1988 following upon 13 which I made the file entry for that date. When 14 I attended the PF for interview my attention was drawn 15 to file entry dated 9/8/88 (report on inspection file) 16 page 28." 17 Q. I think this is an entry, in fact, which you have 18 signed? 19 A. Yes. 20 Q. It obviously has typescript in the normal way and then 21 in particular in "Action proposed", column 4, there is 22 handwriting. It looks like the letters "BF988". Do you 23 recognise that handwriting? 24 A. Yes, that's mine. I wrote that. 25 Q. So that is a part of your entry? page 15 1 A. Yes, I must have forgotten to dictate that and added it 2 in when the file came back from the typist. 3 Q. Presumably BF means -- 4 A. Bring forward. So the file didn't get lost, hopefully. 5 Q. Do we see that in the entry you have said: 6 "Visit with Mr Tyldesley", is it "FCG Mr Stott -- 7 A. Yes. 8 Q. -- "Managing Director, see visit to see the 9 unsatisfactory LPG installation. Mr Stott was advised 10 to take immediate action to remove all materials stored 11 within the separation distance. This tank is one of the 12 worst sited I have ever seen and it is difficult to know 13 what to do with it. I propose to await Mr Tyldesley's 14 report and perhaps discuss the matter further with him 15 before taking action." 16 Then your name and signature and the date 16/8/88, 17 which is presumably when you signed off that entry. 18 A. Yes. 19 Q. We know from a previous entry, Mr Ives, that Mr Gunn was 20 recorded by Miss Johnston as having commented that the 21 installation was one of the worst sited that he had ever 22 seen. 23 Do I take it you agreed with that because this was 24 your entry? 25 A. Yes. page 16 1 Q. If we look at the left-hand column under the heading of 2 "date and type of visit" and under the date 09/08/88 are 3 the letters "MISC". 4 What does that indicate about the type of the visit? 5 A. Well, this was a miscellaneous visit. This didn't 6 really fit into any of our other categories. I can't 7 just remember what Alex had marked it, whether it was 8 for a follow-up visit of some kind. But it wasn't 9 specifically a check visit, it wasn't a general 10 inspection so I called it MISC. 11 Q. 64, I think we can take as read but I wonder if I could 12 just ask you about the comment you made. What were the 13 unsatisfactory elements of the LPG installation, as far 14 as you were concerned? 15 A. Basically that the tank was far too close to the 16 boundary wall of the site, which in that sense it didn't 17 meet the required separation distances to boundaries, 18 buildings and property lines required by the code which 19 meant there was very poor ventilation if there was 20 a spillage of LPG in the yard for any reason and it 21 would be very difficult for that LPG to disperse. 22 Q. So were the concerns about location or the siting, as 23 the word is used elsewhere, of the tank itself? 24 A. Very much so, yes. 25 Q. Were there any other concerns about other aspects of the page 17 1 LPG installation at ICL? 2 A. At that time, no. Sorry, if I could just correct my 3 answer there, we were also concerned about the amount of 4 clutter and rubbish that had been allowed to accumulate 5 round the tank. 6 Q. Thank you very much. 7 Am I right, Mr Ives, that the close proximity of the 8 wall as such was not a problem, it was the fact that, on 9 the face of it, ICL did not control the land beyond the 10 wall which meant that activities could take place 11 immediately beyond the wall which could pose a risk to 12 the tank? 13 A. Yes and the wall -- where you couldn't meet the 14 separation distances, there was the possibility of 15 building what is called a radiation wall between the 16 tank and the boundary and the wall that did exist didn't 17 meet the standards for a radiation wall. 18 Q. What was the purpose of a radiation wall in such 19 a situation? 20 A. It would be to protect the tank from fires outside the 21 site. 22 Q. So the risk is a heat source which is too close to the 23 tank? 24 A. Yes. 25 Q. And you can devise, if it cannot be avoided, what is page 18 1 called a radiation wall which presumably provides 2 a degree of insulation over and above a normal wall? 3 A. That's correct, yes. 4 Q. The second aspect so far as the wall is concerned is if 5 there is an absence of ventilation at a low level, then 6 if gas were to leak or to be spilled it can accumulate, 7 as it were, in the trough around the bottom of the tank 8 and thus be a hazard if it came to be ignited. 9 Is that something which can be addressed, for 10 example, by having mesh fence rather than a solid wall 11 or by having gaps at a low level in the wall? 12 A. A mesh fence is preferable, provided you've got the 13 separation distance and the mesh fence is the separation 14 distance from the tank, yes. 15 Q. Because obviously the mesh fence could not perform the 16 function of the radiation wall if you needed to have 17 that. 18 A. Yes. 19 Q. I understand, thank you. 20 If you could go then to paragraph 65 of your 21 statement, please. 22 A. "As I recall it, it was the way the tank was jammed in 23 giving poor ventilation. There was a wall on two sides 24 and a fairly congested yard on the other two sides. 25 "It was clear that the siting of the tank did not page 19 1 comply with the separation distances." 2 Q. Could I have page 1272, please. 3 Just read on while we are getting it, please, 4 Mr Ives. 5 A. "I had received HS(G)34, which was the Health & Safety 6 Executive's booklet on the storage of LPG at fixed 7 installations, on 6/8/87. This was a publication which 8 people could buy and it was our working guidelines for 9 bulk storage. It replaced the guidance note CS5 and 10 I considered it to be a vast improvement thereon. 11 I thought it was a lot clearer. The old CS5 was not 12 a very clear document. HS(G)34 was much more detailed 13 and clearer in my view." 14 Q. It is the page on the screen, that is to say 01272, the 15 front page of the HS(G)34? 16 A. Yes. 17 Q. Could I ask for page 1281, please. 18 Is that the table within HS(G)34 which sets out the 19 separation distances? 20 A. Yes. 21 Q. And other details? 22 A. Yes. 23 Q. Thank you. 24 Paragraph 68 of your statement, please. 25 A. "I could tell immediately from attending at Grovepark page 20 1 Mills that the boundary wall on two sites was far too 2 close to the tank. If any spillage/leakage of gas 3 occurred it couldn't be dispersed effectively if trapped 4 in by the walls as they were too close. It was patently 5 obvious that that was the case. 6 "To work out what separation distances were 7 appropriate, I would have had to consult HS(G)34. 8 I didn't note the size of the tank but Alan Tyldesley 9 then noted in his report that it was a 2-tonne tank." 10 Q. Clearly table 2 which is on the screen does have 11 specific distances but it has been said elsewhere, 12 Mr Ives, that it was obvious that this tank was too 13 close, simply on observation without detailed 14 measurement. 15 Was that your impression? 16 A. That's my impression, yes. 17 Q. Thank you very much. Paragraph 70, please. 18 A. "My recollection is that Alan was new to the job. He 19 wanted to check some of the facts and policies and to 20 speak to a more senior person. He had only recently 21 joining HSE, although he came from a background of 22 process and fire and explosion." 23 Q. Could I have, please, 011446. 24 Is that Mr Tyldesley's report or at least the first 25 sheet of it, dated 22nd August 1988? page 21 1 A. Yes, that's the front summary of report, yes. 2 Q. Is it possible to have the succeeding three pages also 3 up, please. 4 If you just read on paragraph 71, please. 5 A. "When I considered Alan Tyldesley's report nothing in 6 that report surprised me. On going through the report, 7 the separation distances are still a significant 8 concern. Alan Tyldesley was supporting an improvement 9 notice requiring LPG storage to be reduced to a maximum 10 of 3 times 250-kilogram tanks along with various 11 associated improvements to ventilation, first aid, 12 firefighting and other matters. The benefit of having 3 13 times 250-kilogram tanks rather than a 2-tonne tank 14 which was in place is that you would have less of 15 a volume of gas to expand if there was a BLEVE and could 16 meet the separation distances much more easily. 17 I considered the whole report. 18 "Under heading 3 of Alan's report (progress with 19 regard to recommendations made in 1982) no fixed drench 20 system had been installed and there was no water supply 21 immediately by the installation. We noted of course 22 that previous advice given to ICL by HSE on these 23 matters had not been acted on. 24 "It was remarked upon that road tankers did stand 25 outside the yard during tank filling which took place at page 22 1 about four weekly intervals but that an unsealed drain 2 cover was located at the new stance. The significance 3 of this is that if filling is taking place near an open 4 drain, it is extremely dangerous if there is a leak as 5 this could lead to an explosion if the gas enters and 6 gathers there." 7 Q. If I may just stop you at that point, leaving aside the 8 potential hazard of a drain at the place where the 9 vehicle was standing -- and I assume that is because the 10 LPG is heavier than air and could sink into the drain 11 and then accumulate if there happens to be a leak -- 12 leaving that aside, what was the significance of the 13 potential for the tanker to be inside the yard and why 14 was it more acceptable that it would be outside the yard 15 during filling? 16 A. Well, the yard was extremely congested and the filling 17 operation is a high risk operation because you use 18 a flexible hose between the tanker and the bulk tank and 19 you are making/breaking connections and therefore there 20 is the possibility of a leak. 21 In a congested yard that would have been a more 22 serious matter than if the tanker was further away 23 outside the yard and not close to the tank in a better 24 ventilated area. 25 Q. So is it simply that if the tanker is close to the tank page 23 1 that is being filled, particularly if it is a confined 2 space such as the yard in question, then there is a risk 3 of a greater hazard, if you like, if something goes 4 wrong such as a rupture in the pipe or ignition of 5 leaking gas or whatever; whereas if the tanker is in 6 effect further away outside, then the consequences ought 7 to be somewhat less? Is that the theory? 8 A. That is the thinking, yes. You would have both the bulk 9 tank and the road tanker involved in the resulting fire. 10 Q. Paragraph 74, please. 11 A. "Mention of an earthing pin is made. It would imagine 12 that would be for the tanker but the report is slightly 13 ambiguous." 14 Q. That would be to draw any static electricity from the 15 tanker presumably such as could cause a spark? 16 A. That's correct, yes. 17 Q. 75. 18 A. "The clutter in the yard close to the tank was 19 considerable and is remarked upon by my colleague." 20 Q. Could I have photograph 012429, please. I think this is 21 one of a series of photographs, Mr Ives, but it is the 22 first one that you actually refer to. 23 If you could read 76, please, and stop when you get 24 to the end of the paragraph. 25 A. "Colour photos. This can be seen the colour photos page 24 1 contained in HSE's complaints file. When I attended the 2 PF's office I was shown colour photos. I did not take 3 these photos. On the back they are dated June '88 but 4 I cannot remember when they were taken. The photos show 5 the cramped conditions of the tank." 6 Q. They are obviously not coloured. I am not quite sure 7 why our versions are not coloured but otherwise can we 8 see in the photograph on the screen, which is 12429, the 9 acute angle formed by the wall, the tank really almost 10 into the corner which is formed? To the left between 11 the tank and the camera is that something lying, if not 12 against the tank, quite a large item lying against the 13 wall beside the tank? 14 A. Well, I can only work from the photographs. It 15 certainly looks like that. 16 Q. Then to the right of the tank up close to the other 17 angle of the wall, the other line of the wall, there 18 appear to be loose items lying curled up on the ground 19 and that is what your recollection is, roughly speaking, 20 is it? 21 A. Roughly speaking, yes. I don't recall the precise 22 details. 23 Q. Could you then please put up the subsequent photographs. 24 If we could just go through them, that is 430, 431, 432, 25 433, 434, 435 and 436. page 25 1 Insofar as certain of these shots showed the tank 2 itself from different angles, again Mr Ives did we see 3 items lying against the wall between the tank and the 4 gate and in the other photographs can we see, one way or 5 another, through the gate opening? In particular, if 6 one looks at 12436 does there appear to be other items 7 piled up in the yard, presumably with the tank obscured 8 behind the gate to the right of the photograph? 9 A. Yes, that's correct. 10 THE CHAIRMAN: Can you explain the date, Mr Ives, on these 11 photographs? I think you said it was in June; is that 12 right? That would be two months before you and 13 Mr Tyldesley visited the site. 14 A. Yes. I don't know the history of these photographs, I'm 15 afraid. I didn't take any and, to be honest, I don't 16 recall Alan Tyldesley taking any but he may say 17 otherwise in his evidence. I am puzzled by that date 18 and have been puzzled by that date. I'm sorry, I can't 19 be more helpful. 20 MR MARTIN: Unfortunately, we don't have the originals to 21 see the date but his Lordship is right because if we go 22 back to page 11426 of the report on visits file, the 23 previous visit appears to have been the one by Mr Keddie 24 on 7th April. Is that right? 25 A. Yes. page 26 1 Q. So there is no record at least in the report on visits 2 sheets of anyone from the HSE having been at the 3 premises in June, if that is the date when the 4 photographs were taken. Is that right? 5 A. That is correct and that's why, like I say, I'm puzzled. 6 I mean, I could speculate that Alex took the photos and 7 didn't get them developed until June but I am 8 speculating and I wouldn't like to say that's what 9 happened. 10 Q. Thank you very much. 11 Could you return to your statement, paragraph 77, 12 please. 13 A. "There has always been a concern regarding ventilation 14 and items close to the tank which were combustible and 15 that is not a situation you want close to something that 16 could explode." 17 Q. Could I have page 11447, please. Could we have item 4 18 under the heading of "Comments" expanded, please. Could 19 we have 11448 also. Just to get the final part of 20 section 4, thank you. 21 Can you read 78, please, Mr Ives. 22 A. "Turning to part 4 'comments' of Alan Tyldesley's report 23 it was so obvious that the separation distances were 24 inadequate. Alan Tyldesley may have measured them. 25 I did not, but the disparity between what was required page 27 1 and the actual siting of the tank was blatant. 2 "The recommendation was that either the total 3 inventory and the maximum size of an individual tank 4 required to be reduced, or the occupier could try 5 converting LPG fired equipment to burn natural gas or 6 lastly, attempting to lease some of the wasteland nearby 7 for the siting of an LPG tank. This might have achieved 8 the separation distances required. 9 "Alan goes on to make further recommendations 10 regarding ventilation, firefighting equipment to deal 11 with either a rubbish fire or a small escape of LPG and 12 to minimise the likelihood of an escape of LPG from the 13 LPG vapour line (which he stated to be operating at 14 5psi -- especially where it runs through the factory 15 basement. I cannot myself say what the operating 16 pressure was." 17 Q. Could I ask for 11448, the whole page, to be brought 18 back up on to the screen, thank you, and 11449. 19 Read on, please, Mr Ives. 20 A. "With regard to recommendation 6.11 (page 50) Alan 21 writes part of the underground pipework carrying LPG 22 vapour into the building should be excavated. The state 23 of the pipework and any corrosive protective coating 24 should be examined by a competent person, and any 25 recommendations made as a result of this inspection page 28 1 should be carried out. A pressure test of the pipework 2 should also be carried out." 3 Q. We can see that in 6.11. It is in handwriting, the 4 final sentence of that paragraph. 5 A. Yes. 6 Q. Just as a matter of interest, Mr Ives, if we look at the 7 very bottom of the last page of the report underneath 8 Mr Tyldesley's name and signature, do we see reference 9 to a copy of the photograph of the tank -- 10 A. We do, yes. 11 Q. Saying a visit would be appreciated. 12 A. Yes, I have just noticed that. 13 Q. Which would suggest at least one photograph was taken. 14 A. Yes. It also suggests I took them but I have to say I'm 15 not a competent photographer and rarely did so. That 16 surprises me. 17 Q. Is that your handwriting? 18 A. No, that's Alan's. It's certainly not mine. 19 Q. But it would suggest that a photograph was taken during 20 the visit when you were there? 21 A. It appears so, yes. 22 Q. Which of course would not be consistent with 23 a photograph taken in June 1988? 24 A. It would not. 25 Q. Carry on please. I think paragraph 82. page 29 1 A. 82: 2 "I accepted this as Alan Tyldesley's advice. 3 However in 1988 when I was involved LPG pipework was not 4 at that time highlighted as an issue in that regard. We 5 saw the filling and storage of LPG as a key issue as for 6 us that would lead to the big bang. 7 "I was generally aware of the standards for 8 pipework. I can't say what they were but I would have 9 consulted the standards where I saw pipework as being an 10 issue. It has to be said for HSE generally as an 11 organisation, pipework was not an issue." 12 Q. Just before I ask you some questions about that, could 13 we have up, please, 001041. Could we leave that up and 14 have 1040 first, please. 15 Mr Ives, it is my understanding that the first of 16 these documents (that is to say, 01040) is a document 17 entitled "FIC" which I believe is Factory Inspectorate, 18 Circular 20, 286/43. It was issued, according to the 19 date at the top, on 5th December 1980 and the printed 20 date at the bottom approximately corresponds to 10th 21 November 1980 and it was issued to HM Inspectors of 22 Factories and was on the subject of underground pipes 23 conveying LPG. 24 Were you familiar with this document whilst it was 25 in force between what would appear to be 1980 and 1983? page 30 1 A. I do not recall that document. 2 Q. Can we see that in this document, in particular in 3 paragraph 3, it is said: 4 "For convenience, LPG is often supplied to the 5 relevant process via underground pipes. These pipes 6 have often been laid in an earth trench not always 7 protected by lagging and or wrapping tape and covered 8 with sand. At last four such installations are known to 9 have failed, resulting in the release of substantial 10 quantities of gas. In one case, an explosive 11 concentration was created in a cellar 400 metres from 12 the leak and such concentrations have also occurred in 13 cellars, drains, wells, electrical main conduits and 14 other underground cavities." 15 Were you aware of that as a matter of history at any 16 stage, Mr Ives? 17 A. All I can say now is that I do not recall seeing or 18 remember seeing that circular or knowing of those 19 incidents. 20 Q. Then further down the document under the heading of 21 "Commissioning and inspection", paragraph 7 states: 22 "After 10 years, all pipes carrying LPG, and 23 particularly those not installed to current standards 24 should, if reasonably practicable, be uncovered and 25 physically examined. If this is not reasonably page 31 1 practicable, then a survey, including pressure testing, 2 should be carried out annually." 3 Were you aware of that in the FIC document as at 4 1980? 5 A. In the FIC document, no. In terms of general concerns 6 about underground pipelines carrying dangerous 7 substances, I was aware of concerns about underground 8 pipelines and the need for inspection, including 9 pressure testing. 10 Q. Paragraph 9 states: 11 "Firms with inaccessible pipes or pipes that are not 12 installed to good modern standards should be advised of 13 the danger from leaks and encouraged to install the 14 pipes to a good modern standard." 15 Again is your position the same? 16 A. I just do not recall that circular. 17 Q. That circular appears to have been superseded by the 18 circular beginning on the following page 01041 which has 19 the same number FIC286/43 REV. In this case it is dated 20 27th September 1983. 21 I think we can see on the earlier page somebody has 22 written in the top right-hand corner it looks like 23 "FIC286/43 REV November 83" and a line has been put 24 diagonally through the document. Is that right? 25 A. Mm-hm. page 32 1 Q. That would suggest somebody is noting that it was 2 superseded. 3 A. Mm-hm. 4 Q. If we could go, please, to pages 01041 which you have, 5 and the subsequent two pages, this would appear to be 6 the FIC which was in force from September 1983 because 7 that is the date at the bottom left-hand corner of the 8 third page and indeed above that it states that the 9 previous "FIC286/43 cancel and destroy". 10 If we look at paragraph 15, which I think is on the 11 second page, again this is under the general heading 12 "Commissioning and inspection" states: 13 "Underground pipework should be surveyed for leaks 14 at least every three months depending on their location 15 and environment. The survey mentioned above should 16 include a visual inspection of the run of the line and 17 a method to detect flammable gases in the soil above the 18 pipe. Gas detectors with remote sensing head or 19 detectors with mechanical attachments can be used for 20 this purpose." 21 Then the following paragraph, please, which is on 22 the next page, 16: 23 "Pipelines should be inspected by a competent person 24 at intervals not exceeding 5 years. After inspection 25 the competent person should set the date of the next page 33 1 periodic inspection and any improvements which may have 2 to be carried out on the pipeline." 3 Then underneath paragraph 19 under the heading 4 "Existing installations": 5 "Where an underground pipe has been installed to 6 a low standard (design standard of pipework unknown, 7 absence of concrete lined trench, unsuitable back-fill 8 material, high loading due to vehicular traffic, history 9 of leaks, et cetera) inspectors should press for the 10 pipeline to be inspected by a competent person to 11 confirm that it is suitable for it's intended service. 12 FI8 [which I assume is a form] should be consulted by 13 the FCG [Field Consultancy Group] where enforcement 14 action is being considered." 15 A. Can I just say FI8 was the headquarters section dealing 16 with LPG and fire and explosion. 17 Q. Again as at 1988, Mr Ives, were you familiar with these 18 statements in the revised FIC286/43? 19 A. I honestly cannot say 20 years ago whether I was aware 20 or not. At this moment I do not recall seeing them nor 21 do I recall much of the action that is said in those 22 circulars ever been implemented in practice in the 23 industry, and it may be just my experience that that is 24 so, but that is the fact. But, you know, now I cannot 25 say whether I saw them or not. page 34 1 Q. I think we should also note that there is a similar 2 notation on the first page of that document with a line 3 through diagonally and according to the letter towards 4 the bottom left-hand corner that one was cancelled by 5 F/FIM1987/48, somebody has written on that. So, again, 6 it would suggest that that was cancelled. 7 Is it fair to say, Mr Ives, that what Mr Tyldesley 8 had recommended was consistent with the guidance which 9 was contained in these two documents about an 10 underground LPG pipe of unknown provenance? 11 A. Oh, yes, yes. I had no problem with Alan Tyldesley's 12 advice. 13 Q. In particular, if you look at the later version which in 14 paragraph 19 states: 15 "Inspectors should press for a pipeline to be 16 inspected by a competent person, confirm that it is 17 suitable for the intended service", why do you then say 18 in paragraph 83 that as for HSE generally pipework was 19 not an issue? 20 A. I, in my 34 years in HSE, attended a number of training 21 courses on LPG. I never recall there being any 22 discussion of the issues involving LPG pipelines, 23 I never recall there being information circulated of any 24 specific incidents on LPG pipelines and, indeed, I do 25 not recall really it being raised as an inspection page 35 1 priority along with other issues in those years. I 2 mean, I'm not saying it was discarded. What I was 3 perhaps trying to say was that the location of the bulk 4 tank was seen as the far more important issue than the 5 pipework. 6 Q. Would it be fair to say, Mr Ives, no doubt with the 7 benefit of hindsight, but not entirely so given the 8 recognition in 1980 of the danger of corrosion to 9 underground pipes and as a result a potential leak of 10 LPG, that there is no reason why inspectors of the 11 Health & Safety Executive should not have been paying 12 attention to pipelines as well as or pipework as well as 13 to tanks? 14 A. I think the issue there is where HSE placed its 15 priorities. As far as I was aware and the information 16 that came through training courses and other events, was 17 that the main issue was around tanks, siting of tanks, 18 failure of tanks and also in the use of LPG, for 19 example, in aerosol filling where there were a number of 20 serious incidents. 21 I'm not saying that the pipework was ignored but I'm 22 saying in terms of relative priorities at that time the 23 siting of the tanks seemed to be the more important in 24 HSE's priorities. 25 Q. We will move on at the moment. page 36 1 Could I ask you to return to your Inquiry statement 2 paragraph 84, please? 3 A. "We wouldn't, as a matter of course, have asked anything 4 about pipework unless there was a reason to raise it. I 5 cannot think of any examples of situations where I would 6 have made enquiries dealing with pipework. Enquiry 7 would only be being made where there was a problem, for 8 example, a forklift truck hitting above ground pipework. 9 "If someone had come along and wanted to install 10 a tank the advice we would have given would be to work 11 above ground as it is easier to maintain there. As an 12 organisation we would have recommended above ground. 13 "As an organisation also we were aware of the 14 necessity of being able to inspect and maintain 15 pipework. Above ground this is clearly easier. 16 "At that time, I don't think any of us would have 17 seen underground pipes as creating an undue risk. 18 "My main concern was the siting of the tank and the 19 pipework was not viewed as presenting the same level of 20 risk. 21 "I don't remember if we discussed how long the LPG 22 installation/pipeline was in place. 23 "I wouldn't have thought the length of the time the 24 pipework was in the ground was particularly relevant at 25 my visit. I was concerned about the siting of the tank. page 37 1 "I don't remember the pipework being discussed as 2 a major concern, even when it was raised by Alan it did 3 not became more relevant for me. My concern was still 4 the siting. There was no evidence of a problem with the 5 pipework, whereas the problems with the siting of the 6 tank were blatant. 7 "Alan Tyldesley's recommendation at 6.11 was 8 reasonable advice. 9 "As regards recommendation 6.11 where the last line 10 was added in Mr Tyldesley's handwriting was that 11 a pressure test of the pipework should also be carried 12 out, a pressure test would've detected if there were any 13 leaks. It wouldn't tell you anything of the condition 14 of the pipe, only that on that day it was sound. A pipe 15 could be corroding but just not leaking at that time. 16 "I am not competent to say if the pressure test is 17 an adequate way of checking the pipe. I would refer 18 such a question to mechanical engineers or the Field 19 Consulting Group but my understanding is that it only 20 checks the pipe at the point of testing by putting 21 pressure into the pipe and then finding out if it drops. 22 "I do not recall at all going into the basement and 23 have no recollection accurately of what we did at the 24 premises. Alan may have gone into the basement and 25 I did not." page 38 1 Q. If I may ask you to stop there and just ask for your 2 comment on this, Mr Ives, at paragraph 87 you say: 3 "At that time I don't think any of us would have 4 seen underground pipes as creating an undue risk." 5 We do know that Mr Tyldesley paid attention to them 6 and in particular he made his recommendation in 7 paragraph 6.11. Could I have page 11448 up, please. 8 How do you reconcile what you have said in your 9 evidence with what we know was Mr Tyldesley's interest? 10 11 A. I think what I'm trying to say, and as usual in 12 retrospect the wording might not be the best, is that in 13 terms of seriousness of risk I regarded the siting of 14 the bulk tank to be the major risk we were dealing with. 15 I am not discounting the pipework and that was discussed 16 and copied to ICL but in terms of what I was faced with 17 at that site, in my judgment at that time, 1988, the 18 main issue we were concerned with was the bulk tank and 19 the pipework was a secondary issue. 20 Q. As far as paragraph 87 of your Inquiry statement is 21 concerned, Mr Tyldesley can speak for himself as to what 22 he regarded an undue risk, but he clearly recognised the 23 existence of the underground pipework and its potential 24 condition as an issue which was within the 25 responsibility of the Health & Safety Executive, did he page 39 1 not? 2 A. Yes. 3 Q. If we look at paragraph 6.11 which is on the screen, 4 what he is recommending is that part of the underground 5 pipework should be excavated and the state of the 6 pipework and any corrosion protective coating examined 7 by a competent person and any recommendations made as 8 a result should be carried out. 9 That was clearly a physical course of action, if you 10 like, which at the very least would have identified the 11 condition of such pipework as was excavated, would it 12 not? 13 A. Oh, yes, yes. 14 Q. We also know from the later version of FIC286/43 that 15 there are potentially other methods of investigating 16 underground pipework, for example, by the use of 17 detectors to see if there is some sort of leak showing 18 on the ground. 19 Do you consider that what Mr Tyldesley was 20 requesting was reasonable in a situation where the 21 history and condition of the underground pipework was 22 unknown? 23 A. I am not competent to comment on that. Alan was the 24 fire and explosion expert. He gave his judgments and 25 recommendations based on that and on the policies, as he page 40 1 understood them, of HSE and I was happy to accept them. 2 Q. So you do not regard what he recommended as in any way 3 being unjustified or unreasonable, do you? 4 A. Oh definitely not, no, no, entirely reasonable. 5 Q. So far as the separate requirement in his handwriting of 6 a pressure test to be carried out, again that is 7 something you cannot give any technical explanation for 8 why it would have been appropriate as well as the 9 excavation and investigation of the pipework? 10 A. No. No I wouldn't wish to comment on the value of that. 11 That's an engineering decision. 12 Q. Could you return to your Inquiry statement at paragraph 13 98, please, and could we have back page 11427. 14 If you read on, please? 15 A. In 97 I received Alan's report and I decided to go back 16 to see Mr Stott. At 98: 17 "When we attended the premises we saw Mr Stott who 18 opened the meeting by saying to us that he was going to 19 do away with the whole installation. The gist was it 20 was causing more trouble than it was worth. By that 21 I think he meant the HSE. 22 "My view was that it was very difficult to resolve 23 the problems with the tank and, given the history of the 24 clutter round it, the best solution might be to do away 25 with it altogether. page 41 1 "He said he was keeping a small quantity of LPG and 2 I asked him to send details of what tank arrangements he 3 proposed as it was going to be smaller. 4 "I have noted in the file letter and CV proposed to 5 ensure Mr Stott keeps his word. The reason I wanted to 6 ensure that Mr Stott kept his word was that he did not 7 have a good track record of delivering. We had to keep 8 the pressure on him, although he did appear to accept 9 advice. 10 "I had gone through the recommendations with him. 11 When we discussed the pipework he didn't feel that 12 excavating it was a practical option as it would have 13 meant digging up his yard. I didn't discuss any 14 alternatives with him. The alternative, I suppose, was 15 to do away with the LPG. My recollection is that he was 16 going to discuss the whole issue with Calor and would 17 approach them for a new proposal. The tank was a Calor 18 tank. I thought Calor had put the pipework in but 19 I don't know why. I have no recollection of Mr Stott 20 saying that this was the case. The matter was left 21 slightly in abeyance until Mr Stott had discussed the 22 position with Calor. If Mr Stott had put forward any 23 alternative proposal then I would have needed to check 24 the alternative was acceptable. For that I would 25 probably have gone to Alan Tyldesley or FCG in general." page 42 1 Q. May I ask you to pause there, please, Mr Ives. 2 In paragraph 102, you have said that you went 3 through the recommendations with Mr Stott: 4 "When we discussed pipework he didn't feel that 5 excavating it was a practical option as it would have 6 meant digging up his yard." 7 I do not mean to be flippant but that is blindingly 8 obvious because the pipework was underneath the yard. 9 A. Yes. 10 Q. Why was that a reason for the HSE not to maintain 11 Mr Tyldesley's recommendation, not least because of 12 course Mr Tyldesley had only suggested digging up at 13 least a part of the pipework rather than the whole 14 thing? 15 A. It didn't affect the recommendation. The recommendation 16 stood. As I recall it, and it is a long time ago, it 17 would have interfered with the operation of his factory 18 and therefore he wasn't keen to dig it up. We did not 19 withdraw that recommendation. 20 Q. Yes, but clearly any such recommendation -- and 21 I suspect the HSE must make many recommendations on 22 a daily basis which have the potential to interfere with 23 or interrupt the carrying out of an industrial 24 process -- why should that in itself be a reason to 25 depart from the recommendation that Mr Tyldesley had page 43 1 made? 2 A. We weren't departing from the recommendation. That is 3 an observation of the response I got from Mr Stott. 4 I said to -- pointed out what Alan had said in his 5 report. That was his response. 6 Q. Do you recall, Mr Ives, if to some extent your reaction 7 to the situation that you were faced with was influenced 8 by the fact Mr Stott was also suggesting the possibility 9 that the whole LPG installation might be done away with 10 and presumably natural gas or some alternative 11 introduced in its place? 12 A. Well, that would have been the best solution to the 13 problem had he gone ahead with that proposal because he 14 could then have done away with the tank and the pipework 15 and so I wouldn't say my view was influenced, though 16 I was certainly interested to know that he was 17 considering that. Had he gone ahead, that would have 18 been a very satisfactory solution. 19 Q. Of course at the stage of the meeting, Mr Tilsley's 20 recommendation of excavation and examination still 21 stood, Mr Stott had not said or certainly give any 22 details of an alternative to LPG so the LPG on the face 23 of it was going to remain. 24 Was your attitude to whether or not the pipework 25 should be excavated, do you think now, influenced by the page 44 1 fact that Mr Stott was giving an indication that he 2 might be doing away with the LPG and thus it might not 3 be necessary to insist on the excavation? 4 A. No. My view of the excavation of the pipeline stood 5 until Calor returned with an alternative proposal which 6 I put to Alan Tyldesley and which he accepted and at 7 that stage I accepted that Calor's alternative proposal 8 was the one that we should go with. 9 Q. Could I have up pages 11444 and 11445, please. Is this 10 the letter that you sent to ICL following your visit? 11 It is dated 8th September 1988. 12 A. It is, yes. 13 Q. Could you just read on from paragraph 104, please. 14 A. "The terms of the letter simply reiterate Alan 15 Tyldesley's recommendation. In paragraph 2 I have 16 written: 17 "'I understand you are in the process of 18 endeavouring to reduce the quantities of LPG required in 19 your factory. I set out below HSE's recommendations to 20 bring the storage of LPG within the current standard. 21 Could you please advise me in due course of the final 22 action that you propose to take.' 23 "By current standard I meant HS(G)34. I was trying 24 to cover either what they had then or if there was 25 a reduction in their inventory. page 45 1 "Paragraph 11 of my letter covered recommendation 2 6.11 in Alan Tyldesley's report. 3 "I considered that if Mr Stott kept the same 4 pipework (even if reducing the quantity of LPG on site), 5 that this recommendation still applied. In response to 6 my letter of 8th September I received a letter dated 1st 7 December 1988" -- 8 Q. If I may just ask you to pause there, please, Mr Ives, 9 could I have 011476, please. 10 THE CHAIRMAN: Sorry, Mr Martin, may I have the number 11 for -- 12 MR MARTIN: 11476. 13 THE CHAIRMAN: No, the number of Mr Ives' letter to ICL in 14 September. 15 MR MARTIN: That is 011444 and 011445. 16 THE CHAIRMAN: Thank you. 17 MR MARTIN: There is an error in 107 because 18 011444 reappears, at least in my version. It should be 19 011476. 20 Is that the letter to which you are referring, 1st 21 December 1988? 22 A. Yes. I was just checking what I had said, yes. That's 23 about the filled of the tank, yes. 24 Q. If you could read on after your reference to the letter 25 in paragraph 107 of your Inquiry statement, please. page 46 1 A. "I received a letter from Mr Stott enclosing a copy of 2 his letter of the same date to Calor Gas Limited and an 3 appendix in relation to the safety procedure during the 4 filling of the Calor Gas tank. Basically, all that is 5 covered by this letter was the fact that Mr Stott was 6 advising that he had issued instructions to their 7 employees regarding the procedure to be followed when 8 their gas tank was being filled and that they had 9 accordingly written to Calor per the attached copy 10 letter. 11 "I think I phoned Maurice Coville, whom I knew well 12 through work. I understood Maurice to be an employee of 13 the Calor Gas Group in Scotland, to give independent 14 health and safety advice to Calor Gas staff and their 15 customers. I understood him to be a fairly senior 16 manager or adviser in Calor's structure. Maurice and 17 I would have regular contact re issues that persons 18 having installations sought guidance on and trying to 19 resolve difficulties regarding LPG installations. We 20 had come up against all sorts of problems, principally 21 siting. Now and, again, incidents would happen and we 22 would try to improve practices. From time to time 23 Maurice would make complaints to us about competitors." 24 Q. What sort of the complaints were these? 25 A. Well, the specific issue that I recall was there was page 47 1 a small company then in Glasgow which was causing a fair 2 bit of difficulty, had very low standards and was 3 filling other people's cylinders. The industry is very 4 careful about only filling their own cylinders. Other 5 company's cylinders have to be returned to that 6 particular company and there was a small business in 7 Glasgow, who I eventually prosecuted, who was filling 8 all sorts of cylinders in a rather unsatisfactory 9 manner. That is the one issue I actually recall. 10 Q. Obviously, you were by this stage having communication 11 with Mr Coville, who you knew was from Calor Gas. 12 You indicated in paragraph 102 of your Inquiry 13 statement that you thought Calor had put in the 14 pipework. You said: 15 "I thought Calor had put the pipework in but I don't 16 know why." 17 A. Yes. 18 Q. Why did you think Calor had installed the pipework? Was 19 it something that Mr Coville said subsequently? Was it 20 something that Mr Stott had said or why was it? 21 A. I really don't remember after all this time but that was 22 an impression I had. 23 Q. Did you know how long the pipework had been in place? 24 A. I really don't recall now. 25 Q. We do know from Mr Gunn's evidence that he had recorded page 48 1 that he knew the tank had been in place for at least 10 2 years. 3 A. Yes. 4 Q. He did not refer to the pipework, but were you aware of 5 that history of the tank? 6 A. Yes. My assumption would be that the pipework had been 7 there since the tank was installed. 8 Q. Was it normal for Calor to have installed pipework when 9 they were installing a tank? 10 A. I really don't know. It's only an impression I have. 11 I don't know whether it is a correct impression or not. 12 Q. So, for the purposes of the Inquiry, you had the 13 impression that Calor had been responsible for the 14 pipework as well as the tank. It was simply an 15 impression and, of course, by this stage you were in 16 communication with Mr Coville about Mr Tyldesley's 17 recommendations, which included a recommendation 18 relating to the pipework? 19 A. Yes. 20 Q. Thank you very much. Could you then return to paragraph 21 109, please. 22 A. "Maurice Coville and I had an amicable working 23 relationship. Following upon receipt of Mr Stott's 24 letter 1st December 1988, I received a letter from Calor 25 Gas Group PLC dated 4th January 1989." page 49 1 Q. Could I have 011479, please. Is that the letter, 2 Mr Ives? 3 A. Yes, that's correct. 4 Q. Carry on, please, 110. 5 A. "The author of the letter was Maurice Coville who 6 referred to my letter of 8th September '88 to ICL 7 Technical Plastics Limited. The letter from Maurice 8 stated that he was writing on behalf of ICL Technical 9 Plastics Limited and it states that it followed his 10 telephone call to me on 23rd December 1988. He stated 11 he was attaching a sketch plan outlining suggested 12 suitable remedial action to be taken by Calor Gas 13 Limited in order to meet the recommendations which I had 14 made in my letter at paragraphs 1 to 4. These 15 clearly ..." 16 Q. I am sorry, could I have the following page along with 17 the letter which is 480 which is the sketch plan. Could 18 they both be put up together, please. 19 Read on please, Mr Ives. 20 A. "These clearly involved: the quantity of LPG stored 21 within the factory yard (the overall inventory); the 22 sizes of tank(s) within the yard; the issue of 23 separation distances -- I had recommended that the wall 24 separating the factory yard from the open land outside 25 should be removed from the existing gateway to the page 50 1 corner by the adjoining premises and replaced by 2 a substantial wire mesh fence or metal paling type fence 3 at least 1.8 metres high. 4 "The proposal on the appended plan was for a 1-tonne 5 bulk tank and the plan sets out how Calor proposed to 6 deal with the siting of the vessel. 7 "Basically there would be a continuance of the 8 property boundary and that there would be a staggered 9 removal of some bricks along the full length of the wall 10 (to increase ventilation). 11 "There would be vehicular impact protective barrier 12 around the tank, either of steel 'motorway' type or 13 strategically placed concrete bollards. 14 "The existing height of the wall which is referred 15 to by Maurice as a 'radiation wall' would be increased 16 from 1.8 metres to 2.6 metres and the area surrounding 17 the tank to the extent of 3 metres should be clearly 18 defined, eg by painting as a guide to the prohibition on 19 building, combustible materials, non-flame proof 20 electrics, or car parking within that line." 21 Q. May I ask you to pause there, please. If we look at the 22 sketch plan -- if that can be expanded on the screen, 23 please -- I think the diagrammatic outline is pretty 24 clear in relation to the site. Towards the top can we 25 see that there is an arrow pointing to the wall which page 51 1 says "wall to be suitably vented at floor level"? 2 A. Yes. 3 Q. Then there is a little note 1 and underneath towards the 4 bottom left-hand corner, note to captions 1: 5 "The staggered removal of some bricks is suggested 6 along full length." 7 A. Yes. 8 Q. Is that right? 9 A. Yes. 10 Q. That was along the wall which was in line with the gate. 11 Is that the wall that you were expecting to be vented? 12 A. Sorry, I'm struggling slightly to see with my varifocal 13 glasses. 14 Q. It is not easy. Could I ask, please, that the top 15 one-third -- that is better thank you -- 16 A. Sorry, notes 1: 17 "Staggered removal of some bricks ..." 18 Q. Click that off, please. If you look at the form, it is 19 obviously printed at the top "Calor Approved LPG 20 Storage" and then handwritten details. Just beneath the 21 "P" in the word "plastics", there is a hatched line 22 which has the legend: 23 "Continuance of property boundary." 24 Can you see that? 25 A. Yes. page 52 1 Q. I am very sympathetic, Mr Ives, of the difficulty in 2 seeing this. Underneath that, the next parable down on 3 the page is pointing to the wall which is horizontal on 4 the drawing. 5 A. Yes, that's right. 6 Q. And the legend is: 7 "Wall to be suitably vented at floor level" and then 8 there's a (i) in a circle and if you look at the bottom 9 left-hand corner, underneath the diagram there is 10 a section headed "notes to captions" and 1 states: 11 "The staggered removal of some bricks is suggested 12 along full length." 13 A. That's correct, yes. Sorry, I'm having slight 14 difficulty with my spectacles. 15 Q. I sympathise. 16 The venting at floor level by the staggered removal 17 of the bricks that was being indicated on this drawing, 18 was that along the wall which is in line with the gate 19 opening; that is to say, the one where the arrow points 20 to -- 21 A. Yes. 22 Q. -- or did you also expect it to be along the wall that 23 is an acute angle, that is the one described as 24 a radiation wall? 25 A. No, I expected it to be along the horizontal wall at the page 53 1 top of this sketch. 2 Q. If we then look at the wall which is running at an angle 3 from top to bottom (that is to say, the other side of 4 the angle), it is identified by an arrow with the legend 5 "radiation wall"? 6 A. Yes. 7 Q. Then, I think it is 4 and at note 4 it says: 8 "Existing height of wall 1.8 metres to 2.6 metres." 9 A. Yes. 10 Q. That is what you mentioned in paragraph 114 of your 11 Inquiry statement? 12 A. Yes. 13 Q. Having regard to the construction of that wall and we 14 saw it in the photographs which appear to have been 15 taken at about the same time, would you regard that 16 construction as a radiation wall? 17 If you wish, we can go back to the photographs which 18 probably the best one ... 19 A. What I would need to do is refresh my memory really on 20 the standards for radiation walls, which I'm afraid 21 I don't remember after being out of this kind of thing 22 for many years. 23 However, without wanting to pass the buck, I did 24 pass the whole thing to Alan Tyldesley who agreed that 25 this was a satisfactory solution to the problem. page 54 1 Q. Could you keep these documents on standby, please, and 2 could I have up photograph 012429. 3 I think we can see that is just one of the examples, 4 Mr Ives, that the wall clearly appears to be 5 a straightforward brick and mortar construction wall? 6 A. Yes. 7 Q. Without confirming any technical application, is it 8 conceivable that such a wall, if properly constructed, 9 could fulfil the purpose of a radiation wall for the 10 purposes which we are discussing? 11 A. If the tank is far enough away from it. There would 12 have been to be a separation distance between the tank 13 and the wall and providing it was a suitable height and 14 Calor were proposing that the wall should be raised, 15 just off the top of my head I don't see why not. 16 THE CHAIRMAN: We will stop there, Mr Martin, for ten 17 minutes. 18 MR MARTIN: Thank you, my Lord. 19 (12.02 pm) 20 (A short break) 21 (12.16 pm) 22 MR MARTIN: Thank you, Mr Ives. 23 Could I have back on screen, please, 11479. 24 Read on from paragraph 115 of your Inquiry 25 statement. page 55 1 A. "With regard to paragraph 11 of my letter of 8th 2 September 1988, Maurice Coville's proposal was that: 3 'The condition of the attendant vapour offtake pipe 4 would be ascertained, during vessel exchange, by 5 examination of the "riser pipe" at the vessel and by 6 a pressure test on the pipeline.' 7 "My understanding would be that when Calor took out 8 the larger 2-tonne tank and replaced it with the smaller 9 tank they would carry out an examination of the pipe 10 from the tank before it disappeared underground and also 11 would pressure test the pipeline. I took it to be that 12 they would look at the part of the pipe which anyone 13 could see above ground anyway without a vessel change 14 (maybe a competent engineer would carry this out?) and 15 that there would be a pressure test (ie what's going on 16 at that point). 17 "Maurice Coville's suggestion did not address the 18 question of the underground pipework other than to test 19 that it was keeping pressure on the day of the test." 20 Q. Mr Ives, clearly as you have indicated in paragraph 116 21 it was not even clear that the proposal regarding 22 paragraph 11, which was Mr Tyldesley's original 23 recommendation that the pipework be excavated and 24 examined to ascertain its condition, it was not even 25 clear from what Mr Coville said that the examination of page 56 1 the visible pipework would be carried out by a competent 2 engineer, simply that it would be an examination of the 3 riser pipe of the vessel. 4 Why then might it have been appropriate to accept 5 this response to the recommendation when there was not 6 even a certainty about how the examination would be 7 carried out and by whom? 8 A. All I can say to that is that I passed this to the FCG 9 who accepted that as an acceptable standard of 10 examination of the pipeline. 11 Q. The paragraph does not either confirm whether or not the 12 pipework was regarded by Calor as their responsibility, 13 does it? 14 A. No, it doesn't. 15 Q. Although there is an implication that if they are 16 recommending or if they are responding to the 17 recommendation by some sort of examination, that they 18 are taking some responsibility for that on behalf of 19 ICL; is that fair? 20 A. That is correct, yes. 21 Q. Having regard to the fact that, as you said in paragraph 22 117 and indeed elsewhere, that a pressure test simply 23 confirms that the pipework is not apparently leaking on 24 the day of the test, was that an appropriate response in 25 your opinion to the recommendation which Mr Tyldesley page 57 1 had made that the pipework be excavated and actually 2 examined? 3 A. I was not sure and that's the reason I passed it back to 4 Alan Tyldesley for comment. 5 Q. Would you carry on with paragraph 118, please? 6 A. "At paragraph 3 Maurice Coville stated, 'I trust that 7 you will consider the above measures form an acceptable 8 compromise to your recommendations and they meet the 9 spirit of the guidance note HS(G)34 (the storage of LPG 10 at fixed installations) whilst maintaining security of 11 the installation and the premises it is served in an 12 area with reputedly high incidence of unauthorised entry 13 to property.' 14 I understood from that that they needed walls to 15 keep out vandals, et cetera. Whereas Alan Tyldesley had 16 recommended a wire mesh fence (recommendation 6.3 of his 17 report), I took it to mean that the wall would be 18 retained but holes would be knocked through to provide 19 ventilation." 20 Q. So the implementation of what Mr Tyldesley had 21 recommended and what Mr Coville had proposed in 22 response, the implementation, if that is the nature of 23 what came to be the compromise as he suggested, included 24 the knocking through of the ventilation holes or 25 ventilation spaces in the wall beside the tank and page 58 1 towards the gate. Is that right? 2 A. That's correct, yes. 3 Q. Paragraph 120? 4 A. "I was asked by the PF at interview about the position 5 outlined in the letter by the use of the phrase, 'On 6 behalf of ICL Technical Plastics Limited', ie Maurice 7 Coville apparently had been authorised to make 8 the proposal. I found this acceptable as Calor owned 9 the tank and, in a sense, held the whip hand in that, if 10 the installation wasn't to their standards, ie the 11 standards that they felt acceptable, they could refuse 12 to supply the customer. After all, they wrote most of 13 the guidance and were the major players in the industry. 14 They had actually recruited our top LPG specialist, 15 Dr Roy Foster, as their Safety Director. Dr Foster was 16 instrumental in developing guidance and being the top 17 expert in HSE in the field of LPG. He had been 18 a specialist inspector based in London. 19 "I was very conscious that if you went for an 20 argument with Calor, you had to be sure of your facts. 21 They weren't slow to criticise our advice. I just 22 couldn't understand why they had never changed this 23 installation. In essence what HSE were putting forward 24 as being required (based on Alan Tyldesley's specialist 25 input) had to be both deliverable on a practical basis page 59 1 and had to be robust so that it was not vulnerable to 2 criticism by Calor. If, for instance, I had proceeded 3 to take enforcement action and was then appealed, then I 4 had to be sure I was on certain ground otherwise it 5 would be difficult in making enforcement action stick 6 otherwise." 7 Q. If you stop there, please, Mr Ives, may I take it that 8 just because an occupier or employer might be resistant 9 to a course of action proposed by the HSE was not 10 a reason for the HSE to withdraw, was it? 11 A. Certainly not and I am not suggesting that. 12 Q. What was it about Mr Tyldesley's advice that might have 13 been said not to be on certain ground, as you have put 14 it? 15 A. It was the problem of the tank sizes he was 16 recommending. It was argued by Calor that they couldn't 17 supply these and it was not something that they could 18 achieve. 19 Q. Did you have any anxiety that you might not be on 20 certain ground or that the HSE might not be on certain 21 ground in relation to the recommendation to excavate and 22 examine the state of the pipework? 23 A. No. No, that wasn't an issue. 24 Q. If you applied your mind at the time, did you believe 25 that the HSE and the recommendation of Mr Tyldesley was page 60 1 on certain ground on that point? 2 A. Yes, on that point, yes. 3 Q. Read on 122, please. 4 A. "What was being suggested in the letter appeared to form 5 a reasonable solution to a difficult problem from 6 a siting point of view. A small tank was being 7 suggested. They had tried by their suggestion to 8 improve ventilation. They had tried to take action to 9 avoid clutter. 10 "Their proposal was not perfect but it was a major 11 step forward." 12 Q. If I can just stop you there, that of course is all 13 about issues related to the siting of the tank? 14 A. Yes. 15 Q. And a judgment was made about that. 16 A. "As far as the suggestion re the pipework was concerned, 17 I didn't feel competent to decide if that was 18 a reasonable compromise. The letter from Maurice 19 Coville was copied and sent to Alan Tyldesley." 20 Q. Could I have 11481, please. 21 Is that Mr Tyldesley's response? 22 A. Yes. 23 Q. Thank you. Read on 126, please? 24 A. "Alan addressed the siting of the tank and the 25 separation distance and made it clear that if the page 61 1 occupier could fulfil what was set out in his report, 2 then he stood by his earlier recommendations and would 3 be prepared to support enforcement action in respect of 4 them. 5 "With regard to recommendation 11 -- the examination 6 of the underground pipework from the installation -- 7 Alan Tyldesley responded by saying that the proposals by 8 Mr Coville were acceptable. 9 "I had no reason to question his judgment on that 10 particular point. I didn't disagree with any of his 11 comments re the Coville letter. 12 "He emphasised in the report that it was 13 a particularly poor LPG installation which had been in 14 existence for an excessive time and that he hoped that 15 appropriate enforcement action would now be taken to 16 ensure that the installation was improved without 17 delay." 18 Q. Again, if I could ask you to stop, Mr Ives. 19 Mr Tyldesley in his response -- which I assume was 20 addressed to you; is that right? 21 A. That's correct, yes. 22 Q. -- says at the end of paragraph 3: 23 "In respect of recommendation 11, regarding 24 examination of the underground pipework from the 25 installation, then the proposals by Mr Coville are page 62 1 acceptable". 2 A. That's correct. 3 Q. He does not give any explanation of why the proposal was 4 acceptable, does he? 5 A. No. 6 Q. He, of course, was the specialist inspector called in on 7 behalf of or as part of the Field Consultant Group; is 8 that right? 9 A. That's correct, yes. 10 Q. Whose decision ultimately was it that Mr Coville's 11 response to recommendation 11 was acceptable? 12 A. On technical matters the responsibility really lay with 13 the FCG, with Alan Tyldesley. 14 Q. I may have misunderstood you, Mr Ives, but I thought you 15 said earlier in answer to questions from me that the FCG 16 came in as consultants and made recommendations but the 17 responsibility was ultimately that of the Field 18 Inspector. 19 Did I misunderstand that? 20 A. No. I did have the power, I suppose, to disagree with 21 an FCG inspector and on rare occasions I have done so, 22 but what I would normally do is go back to them and 23 question them if I have reason to doubt that the advice 24 made sense. Otherwise, if it was a technical matter and 25 there was no particular reason why not to, I would just page 63 1 accept their advice. They were the experts on process 2 safety. 3 Q. But as we agreed a moment ago, Mr Ives, Mr Tyldesley did 4 not give any explanation or justification for his 5 acceptance of Mr Coville's response. 6 Is it fair to say, therefore, that you simply 7 accepted his judgment without further consideration in 8 relation to recommendation 11? 9 A. Yes, that's true. 10 Q. Could we keep that page up, please, and could I have 11 011482, the next page. 12 Could you read paragraph 130 of your Inquiry 13 statement and after, the subsequent paragraphs. 14 A. "I responded to Alan's report by my memo of 20th January 15 1989, page A11: 16 "'I would remind you that enforcement policy in this 17 matter rests with myself and I will take appropriate 18 action as I see fit to deal with this matter.' 19 "I had to weigh up taking enforcement action in the 20 form of an improvement notice when in fact a reasonable 21 solution was almost in reach for the best things to do 22 with this installation. 23 "I felt that if an appeal was to go before 24 a tribunal in relation to any the improvement notice 25 served I might well fail before that tribunal if it came page 64 1 down to any arguments on the detail the notice required. 2 By agreeing to a reasonable solution that possibility 3 could be avoided. 4 "In my note I was telling Alan Tyldesley that the 5 question of enforcement was one for me and not him (as 6 a specialist inspector)." 7 Q. Could you pause there, please. If we look at 8 Mr Tyldesley's report which is 11481, item 4 at the 9 bottom says: 10 "This is a particularly poor LPG installation which 11 has been in existence for an excessive time. I hope 12 that appropriate enforcement action will now be taken to 13 ensure that the installation is improved without delay." 14 Was your statement in the first paragraph of 11482 15 that you would remind him that enforcement policy in 16 this matter rests with you and that you would take 17 appropriate action as you saw fit to deal with this 18 matter a response to that final sentence in 19 Mr Tyldesley's report? 20 A. Yes, it was, yes. 21 Q. In 132 of your Inquiry statement, you said that if an 22 appeal was to go before a tribunal in relation to an 23 improvement notice, then you might well fail if it came 24 down to an argument on the detail of what the notice 25 required and that by agreeing a reasonable solution that page 65 1 possibility could be avoided. 2 You have agreed with me a moment or so go, Mr Ives, 3 that anxiety about whether or not enforcement actually 4 could be sustained was in connection with issues 5 relating to the siting of the tank and not in relation 6 to the underground pipework. 7 Was it not possible for you to recommend enforcement 8 action or to initiate enforcement action in respect of 9 the underground pipework only and reach a compromise on 10 the issues surrounding the siting of the tank? 11 A. It would have been possible. It didn't strike me as the 12 best way forward at the time. So far as I recall 13 I wanted to try and wrap everything up together. 14 Q. Perhaps you could read 134 of your Inquiry statement. 15 A. "I set out my reasoning in the second paragraph of the 16 memo and asked Alan to confirm it would be possible for 17 Calor to supply tanks of a volume no greater than 250 18 kilograms as they were claiming this couldn't be done." 19 Q. Does that confirm that again when you were accepting the 20 reasonableness of the compromise you were again focusing 21 on issues relating to the tanks rather than on the 22 pipework? 23 A. Oh, yes, yes. 24 Q. So if I understand the position, Mr Ives, it is that, as 25 far as the pipework is concerned, a recommendation was page 66 1 made by Mr Tyldesley (that is to say, to excavate and 2 examine), Mr Coville responded by suggesting that 3 examination of the riser pipe where visible and pressure 4 testing would be an acceptable alternative, Mr Tyldesley 5 recommended to you that that was acceptable as far as 6 the pipework was concerned but gave no explanation or 7 justification of why that was so and you then accepted 8 that without any further consideration and, in 9 particular, did not initiate enforcement action in 10 respect of any matter, including the potential 11 excavation of the pipework. 12 Is that a fair summary of what happened? 13 A. It's a summary of what happened, yes. 14 Q. Well, is it a fair summary, Mr Ives? I am not trying to 15 be unfair, I am -- 16 A. I was just trying to work out the various things you 17 said. I think it's fair. 18 Q. Ultimately, as the senior field officer to whom 19 Mr Tyldesley was making his recommendations and giving 20 his reports, was it your responsibility that no 21 enforcement action was taken in respect of the 22 underground pipework? 23 A. Yes. 24 Q. Could I ask you to resume at 135, please. 25 Perhaps I could have 011484 on the screen, please. page 67 1 A. "Following the exchange between Alan Tyldesley and 2 myself I wrote to Maurice Coville in a letter of 23rd 3 January 1989 in which I set out certain comments 4 regarding the proposals in his plan and emphasising that 5 the proposal was only acceptable provided the occupier 6 could somehow gain control of extra land outside his 7 existing premises so that he had full control of all 8 land within 3 metres of the proposed tank. I advised 9 that if this could not be achieved then I regretted that 10 the proposals were not acceptable and we returned to the 11 requirements of my letter of 8th September. This 12 related to the siting of the tank and how it would 13 ventilated and the separation distances dealt with." 14 Q. Could I then have 01485, please. 15 Carry on, please, Mr Ives. Paragraph 136? 16 A. "In response to the letter which I sent to Maurice 17 Coville, I received a letter of 25th January from 18 Mr Stott referring to my letter of 23rd January 1989 and 19 confirming that the company was in control of land 20 outwith the main factory gate and that they had already 21 moved the car parking facility to the far side of the 22 gate which would be in excess of 20 metres from the 23 proposed site of the tank. 24 "He further confirmed there was no reason why bricks 25 should not be removed from the wall and that a no page 68 1 parking sign would be put up to prevent other people 2 from using this site as a parking spot. He assured me 3 that if this proved ineffective, the company would find 4 some other form of preventative in the matter. 5 "He concluded by stating: 6 "'I trust that the above information will allow you 7 to accept the Calor proposals, which we will implement 8 with Calor as soon as possible.'. 9 "Following upon receipt of that letter, Alan 10 Tyldesley prepared another note, (no indication on the 11 file that I had sent a copy of Mr Stott's letter to him 12 but he refers to my having heard that the company 13 proposed to purchase or obtain control of a small area 14 of extra land close to their LPG tank)." 15 Q. Just before we go to that memo, Mr Ives, I take it that 16 the ability of the company to control the additional 17 land which was being referred to was at least a solution 18 to part of the problem because you can then ensure that 19 nothing happened on that area of land that was 20 a potential risk of ignition too close to the tank? 21 A. It was a major step forward actually because we could 22 now achieve separation distances which were not possible 23 previously. 24 Q. I understand. Thank you. 139, please, and could I have 25 011486? page 69 1 A. "Alan Tyldesley then prepared memo dated 2nd February 2 1989. His view was that, having purchased or obtained 3 control of a small area of extra land close to the LPG 4 tank, this would allow the company to obtain a greatly 5 improved arrangement around the tank. 6 "He recommended that the tall brick wall adjacent to 7 the gates giving access to the factory yard should be 8 removed and a robust non-combustible open mesh fence or 9 similar security arrangement should be installed at the 10 appropriate separation distance for whatever size of 11 tank is required. 12 "He noted that Calor were unable to supply a tank of 13 capacity less than 1-tonne. He was somewhat surprised 14 by this as his telephone enquiries to other gas 15 suppliers indicated that tanks of capacity of 200 or 600 16 kilograms were available elsewhere. He closed by 17 offering his further assistance in the matter if 18 required. 19 "I must have phoned or told Alan about the proposal 20 to acquire the land which enabled him to respond in this 21 memo." 22 Q. Could I then ask for 011427 to be put back on the 23 screen, please. 24 Carry on, please, Mr Ives. 25 A. "On looking at file entry dated 11/9/88 I can see that page 70 1 after the visit on 1st September 1988 to the premises, 2 I had marked the file for a check visit in November 3 1988. I had then marked for that to be cancelled 4 because negotiations regarding the LPG were underway. 5 I don't know what date I cancelled it but it was not 6 marked up again at that point for a later check visit." 7 Q. May I just understand where we see that. Is this on 8 page 11427? On the left-hand side there is an entry 9 which I think is dated 11/9/88, although it is slightly 10 obscured. Again, the legend "MISC" which is 11 a miscellaneous as you explained earlier? 12 A. Mm-hm. 13 Q. The reference, the reason for visit you have already 14 discussed and then in the assessment column, 4, there is 15 written "CV", which is check visit, and there's a line 16 through what is below and I can't actually -- I am not 17 going to try and make out what it should be but what do 18 you think is written? 19 A. It says "cancelled", I would say. 20 Q. Yes, but forgive me what is actually typed underneath 21 the diagonal line? 22 A. Oh underneath the line? 11/88. 23 Q. So that is the reference to a check visit in November 24 1988? 25 A. Yes. page 71 1 Q. A line was then put through it and to the right of that 2 something is written in handwriting and you think that 3 is what? 4 A. That's my scrawl for "Cancelled". 5 Q. So that is the reference which you are making in 6 paragraph 148 of your Inquiry statement. 7 Carry on with 144, please. 8 A. "The file entry dated 17th January 1990 I recorded in 9 a handwritten note, 'Visit by Mr Coville, Calor Gas 10 Safety Adviser, to say work was not yet carried [unclear 11 believed to be] out but provided new drawing of 12 a proposal seems satisfactory." 13 Q. Is that your handwriting? 14 A. It is, yes. 15 Q. Carry on, please? 16 A. "The new drawing which I was providing and have referred 17 to is sketch plan dated 19th December 1989." 18 Q. Just pause there, please. Could I have 011487. 19 This is a similar sketch plan to the previous one 20 but clearly different not least because it has two 21 tanks. 22 A. Yes, indeed. 23 Q. Just read on in paragraph 145, please. 24 A. "In it is shown 2 x 2,000 litre vessels with a proposal 25 to ventilate the wall adjacent to the sliding gate page 72 1 (vehicular impact protective barrier) to be erected 2 around the two tanks, the continuation of the property 3 boundary line, prohibition on the building, combustible 4 materials, non-flame proof electrical equipment or car 5 parking within 3 metres from the vessel to be suitably 6 extended beyond the ventilation gate wall and that the 7 area for separation be clearly defined by, for example, 8 painted lines on the floor. 9 "It was suggested that the staggered removal of wall 10 bricks at floor level would achieve the ventilation." 11 Q. If we stop there, please, and we look at the drawing it 12 is similar to the previous one but the various 13 annotations are in typescript. We can see to the left 14 again an arrow pointing at the wall towards the top of 15 the drawing and it says, "Wall to be ventilated at floor 16 level". 17 It then references to item 1 which is right at the 18 bottom of the page: 19 "Notes to captions, ventilation suggests a staggered 20 removal of wall bricks at floor level." 21 It is clearly along the wall which is in line with 22 the gate. 23 A. Yes. 24 Q. Does that suggest the removal of bricks from the 25 existing wall? page 73 1 A. Yes. 2 Q. Then if we look at the other wall, that is to say the 3 one to the left of the tanks at an angle, the legend is 4 "Property boundary, radiation wall" and item 2 in the 5 note is: 6 "Height of wall exists at between 1.8 metres and 2.6 7 metres." 8 A. Yes. 9 Q. Does that suggest that what was proposed was, in effect, 10 simply the retention of the existing wall because we 11 know that is what the heights were? 12 A. Yes, it is. 13 Q. In the situation would that reasonably be described as 14 a radiation wall? 15 A. Yes. 16 Q. Why is that? Why did it satisfy what reasonably would 17 be required of a radiation wall? 18 A. Because if there was a fire on the outside of the wall 19 it would protect the tanks from radiated heat. 20 Q. Is that because the tanks were now two small tanks 21 rather than a large one, potentially slightly further 22 away from the wall and of course control of land 23 outside -- 24 A. Yes because they have now managed to achieve the various 25 separation distances and have the radiation wall. page 74 1 Q. Thank you very much. Just referring again back to the 2 entry which is 11427, paragraph 147, please. 3 A. "At the time of Maurice Coville's visit I marked the 4 file for a check visit in 30/90 (sic) ie March 1990." 5 Q. I think it is 3/90. 6 A. So it is, yes. My apologies. 7 Q. Carry on. 8 A. "When I marked the papers for that check visit it should 9 have gone on our computer system. The procedure would 10 be that it was brought forward to the inspector who put 11 it out for a check visit, ie me. SHIELD was the filing 12 system which we used at that time but you can see from 13 the page that the SHIELD stamp, which appears after 14 other instructions, was not under my entry. It looks as 15 if it was possible that it didn't go into the system and 16 with the pressure of other things, it had been 17 forgotten." 18 Q. Just to understand this, Mr Ives, could we have 11428 19 also, please, if the two can be up together. If we 20 simply take the entries in chronological order as they 21 appear on these two pages, the top left-hand corner is 22 9th August 1998 and we see towards the right-hand side 23 a stamp with the word "SHIELD 16AUG1986 input"? 24 A. That's correct. 25 Q. What does that actually indicate? page 75 1 A. It means that the administrative staff have entered that 2 visit and the action on to the SHIELD computer system 3 and when they got their monthly printout of actions, it 4 would show up that, for example, on the first entry of 5 9/8/88 that you bring forward for September and they 6 would get the file out and pass it to the appropriate 7 inspector. 8 Q. So it is simply -- was it a computer? 9 A. It was a computer, yes. 10 Q. A computer program. It is a system which ought to bring 11 to the attention of those responsible that file needs to 12 be looked at again, in this case in September 1988? 13 A. It brings to the attention of the administrative staff. 14 What they would do is get a printout and attach the 15 files appropriate to it and then pass it to the 16 appropriate inspector. 17 Q. In that particular case the SHIELD stamp has got a -- if 18 I can use this word -- a squiggle towards the bottom 19 right-hand corner. What is that likely to be? 20 A. That is the initial of the person who input the data on 21 to the computer. I'm not sure who it was. 22 Q. But presumably the system was that you dictated the 23 entry, sent off the report on visit form to the typing 24 pool? 25 A. That's correct. page 76 1 Q. Got it back with the entry completed. If you were 2 satisfied, you signed it, you might have to add 3 something in manuscript, as you have described, and then 4 what did you pass the file to the SHIELD operators? 5 A. Yes, yes. 6 Q. Could we then look at the entry for 1st September 1988. 7 Again, it is the same, there is a SHIELD stamp -- 8 A. Yes. 9 Q. The point you were making about the entry on 17th 10 January 1990 is that there is no SHIELD stamp or 11 initial. 12 A. No. 13 Q. Then if we go to the next page which is a date in 14 January 1992 -- we will hear about this from another 15 witness -- but on this occasion there is a stamp with 16 the word "FOCUS", similar to the SHIELD, in fact it is 17 identical to the SHIELD type stamp otherwise with 18 initials and then the one below again has a similar 19 stamp. 20 A. That's correct. FOCUS replaced SHIELD at some stage -- 21 Q. It is another computer system with the same purpose? 22 A. Yes, it's supposed to be bigger and better. 23 Q. I think if you return you were at 149, please, Mr Ives? 24 A. "The check visit was not carried out in March 1990 as 25 you can see on the file at entry dated 9/1/92. This page 77 1 shows that the next visit was on 9/1/92, almost two 2 years after the date I had marked for the check visit 3 when in fact I had intended that after Mr Coville's 4 visit to me the premises would be checked in two 5 months." 6 Q. Is that to be explained by the fact that because the 7 entry was not entered in the SHIELD system as it was the 8 appropriate mechanism probably didn't operate so the 9 file wasn't brought back to you or whoever is 10 responsible at the appropriate time? 11 A. Yes. 12 Q. Is that an administrative -- 13 A. It's an administrative error by somebody and I can't 14 explain how it happened and memory failed me to remember 15 to go and get it out. 16 Q. How then would the file have come to the attention of 17 either Mr McNab or somebody who passed it to Mr McNab in 18 January 1992, two years later? 19 A. As far as I know, he would have picked it up on the 20 basic priority inspection list as having an FI83 rating 21 of more than 43, which brought it up for inspection that 22 year. 23 Q. I am sorry, Mr Ives, could you just explain what you 24 mean by what you just said about an FI83 -- 25 A. The FI83 was a risk assessment form that was completed page 78 1 following a general inspection or -- I mean, the name of 2 that inspection varied over the years, general 3 inspection or priority inspection, and you completed it. 4 It was a numerical form that gave an indication of the 5 risk and competence of the management of that particular 6 site. Alex Keddie would have been the last one to 7 complete it. There was three added to the sum total 8 every year, if I remember rightly. 9 I'm sorry, my memory may be slightly askew here but 10 I think that's the system. When it reached 43, as 11 I recall, it then became due for a priority inspection. 12 It was a system of bringing up files for inspection -- 13 premises for inspection. I don't think I explained that 14 very well. I'm sorry. 15 Q. Not at all. In a sense it was, if you like, a parallel 16 but separate system to the SHIELD system that meant that 17 files would come back to somebody's attention? 18 A. It was put on to SHIELD. The figure that the inspector 19 had rated it as was put on to SHIELD and then, as far as 20 I recall, SHIELD automatically added three for every 21 year since the last inspection and at the start of the 22 year, the work year, the admin staff would get 23 a printout giving all those premises where the 24 inspection rating was above, I think it was 43 although 25 it could have been varied from year to year. Then the page 79 1 inspectors work through that list. 2 Q. So perhaps I am reading too much into this, Mr Ives, but 3 was it a system which took account of the possibility 4 that an individual entry would be omitted from SHIELD, 5 such as this one may have been, because sooner or later 6 it would bring that file back to the attention o