page 1 1 Thursday, 10th July 2008 2 (10.45 am) 3 ALAN TYLDESLEY (continued) 4 THE CHAIRMAN: I am sorry there is a delay in starting this 5 morning. There were traffic problems. 6 MR MARTIN: Thank you, my Lord. 7 Examined by MR MARTIN (continued) 8 Q. Good morning, Mr Tyldesley. Could you return Inquiry 9 statement, please, at page 21. I am about to move on to 10 the final section on your evidence on guidance and 11 previous incidents but I wonder if I could, just before 12 I do that, refer you to your exchange with his Lordship 13 yesterday and to the logic of your position, as it was 14 put to you, that the only way you will ever know the 15 condition of a buried pipe is to excavate along the 16 whole length of the pipe because it may be that the part 17 you excavate may not be the part that contains the 18 corroded section, if there is one. 19 That is the logic of your position, is it not? 20 A. If you give me a few minutes to explain I have thought 21 about this overnight and I would be grateful if you give 22 me a chance to explain it in my own words. 23 I think first you need to look at the way HSE 24 inspects small companies and large. Small companies 25 often have little expertise, they are prone to ask the page 2 1 inspector, "Just tell us what you want to do and let's 2 get on with it". 3 Large companies, the Shells, the BPs, the Rolls 4 Royces of this world are more likely to say they've got 5 the competence, they understand their business, they've 6 got the people, "Tell us what the objective is and we 7 will find a way of making that safe". 8 With that background in mind, and bearing in mind 9 that ICL is a relatively small company and Calor is 10 a relatively large one, I think we can reconstruct the 11 letter that I would have hoped to have seen from 12 a competent person who had received the advice from my 13 report. 14 It would read as follows, "Dear Mr Stott, we visited 15 your premises on 14th February 1989 and we excavated 16 a short section of the pipe close to the tank down to 17 the first elbow. We have found there that the pipework 18 is made of the same material above ground that appears 19 to be galvanised steel or wrought iron. It is suffering 20 from superficial corrosion. We cannot tell -- we have 21 asked you about the age of the pipe and understand it 22 probably dates from 1969 or thereabouts. We have 23 examined the recent Codes of Practice and understand for 24 at least the last 10 years these are recommending that 25 all underground pipes carrying liquefied petroleum gas page 3 1 should be protected by a corrosion tape, such as Denso 2 tape. In our opinion it would be possible to excavate 3 the remainder of this pipe, to clean it thoroughly, to 4 dry it, to inspect it and if it was found to be in good 5 condition wrap it and rebury it. But with a pipe that 6 is already 20 years old that inevitably will have had 7 some exposure to water and air in that period, our 8 professional expertise suggests it would be much cheaper 9 and safer to replace this pipe at an early date." 10 That's the letter I expected and hoped would have 11 been written by someone to Mr Stott. You don't need to 12 dig it all up, you dig a small amount, it is obviously 13 not up to current standards and it's very old. 14 Q. Mr Tyldesley, you may not have understood my question. 15 I wasn't asking about any letter that either was or 16 might have been written, I was asking about your 17 position as somebody with the expertise that you have 18 and the logic of your position as it was put to you by 19 his Lordship, which was in accordance with what was put 20 to you that only if you excavate all of a potentially 21 corroded pipe, the whole length of that pipe, only in 22 that situation can you be sure that there is no 23 significant corrosion because if you excavate only part 24 of the pipe, in fact you may be leaving in the ground 25 the part that is significantly corroded. page 4 1 Is that your position? 2 A. No, you have misunderstood this and we will have to go 3 round this again. British Gas have faced this problem 4 for many decades. There are many thousands of 5 kilometres of pipeline we cannot dig up at a regular 6 interval that are put into a standard that allows them 7 to survive a very long time and we have been using that 8 standard for a very long time. 9 During the 1970s -- and I understand this from 10 Calor's evidence last week -- that Calor recognised that 11 they had been putting in pipe that was not corrosion 12 protected and they changed their standards. So, in 13 1988/89 we find the pipe that we know has been put in to 14 standards which are no longer acceptable that is already 15 20 years old and if Calor had recognised this, their 16 advice should have been this pipe is not fit for further 17 purpose, it should be replaced. That's the logic of it. 18 Now I couldn't say that because I couldn't be sure 19 what the pipe was made of underground. I could guess 20 but I didn't have the evidence to say, "You have to 21 replace this pipe". 22 Q. Again, Mr Tyldesley, I am not sure that you have 23 addressed yourself to my question, but can we agree that 24 at the very least a significant part of the pipe ought 25 to have been excavated so at the least to identify the page 5 1 condition of that part of the pipe? 2 A. That is exactly what I expected to happen. Now let us 3 have a look at the letter Calor might have written if 4 they had been there and not excavated the pipe. It 5 might have gone as follows, "Dear Mr Stott, we have 6 looked at section of pipe that is above ground. It has 7 minimal corrosion but nothing to worry about. We 8 suggest you paint it annually and do nothing further 9 until HSE suggests that further work is required". That 10 is what Calor could have written if they had looked at 11 the pipework above ground and that alone. 12 Q. That is what might have been written, Mr Tyldesley, but 13 we know what was written because if you look, please, at 14 11479 -- and we looked at this letter yesterday -- what 15 Calor said, as we have agreed yesterday, made no 16 reference to any excavation of any part of the pipe. 17 Is that right? 18 A. This comes back to the point I tried to make at the 19 beginning of this morning that it's whether you are 20 treating Calor as a competent person here or not. 21 I don't know whether they are treating themselves as 22 a competent person but I do know that they were putting 23 themselves up by making recommendations about that pipe 24 that led me to believe they might have been a competent 25 person who would know about the cause of pipework page 6 1 failure who would know about the consequences of that 2 failure, who would understand the standards. 3 That letter from Mr Coville is ambiguous but 4 I perhaps believe that Calor were competent, taking the 5 role of a competent person, and would understand the 6 relevant codes and standards, the problems and the 7 foreseeable hazards. 8 Q. Can we agree a step at a time, please, Mr Tyldesley. 9 The letter says nothing about excavation of any part 10 of the pipe, does it? 11 A. We have been round this and you know my view. 12 Q. No, Mr Tyldesley, I would appreciate it if you would 13 address yourself to my questions and do me the courtesy, 14 and do the Inquiry the courtesy, of answering those 15 questions. 16 Can we agree that Mr Coville's letter and the 17 critical sentence does not say anything about excavation 18 of any part of the pipe? 19 A. It doesn't say it isn't going to excavate either, but 20 your premise is correct. 21 Q. What it does say is that there would be examination of 22 the riser pipe at the vessel. 23 A. That's right. 24 Q. There is nothing ambiguous about that, is there, in the 25 sense that the riser pipe at the vessel is above ground page 7 1 and, therefore, does not imply any excavation does it? 2 A. I think there is some ambiguity there. It is perfectly 3 reasonable to assume that the riser pipe was the 4 vertical section of the pipework which disappears into 5 the ground. That is what I can honestly take that 6 sentence to mean, that "We will look at the vertical 7 section". That is a logical place to dig because it's 8 not concreted over there. That's the logical place to 9 dig because that's where they are working at and it 10 wouldn't disrupt progress in the factory. That's where 11 you start. 12 Q. So if there was an ambiguity in the letter (that is to 13 say, it was not clear whether Mr Coville was proposing 14 excavation or not), could you look, please, at 11481, in 15 particular the last part of the third paragraph numbered 16 3. 17 A. It is clear there that I -- 18 Q. Forgive me, Mr Tyldesley, I just want it up on the 19 screen. 20 A. Yes, it is on the screen. 21 Q. Can we agree that you have not drawn to Mr Ives' 22 attention any potential ambiguity in what Mr Coville 23 said? 24 A. That's correct. 25 Q. Thank you. page 8 1 Can we agree that Mr Ives was relying upon your 2 specialist expertise, you having been called in from the 3 Field Consultants Group to give advice on the LPG 4 installation? 5 A. I believe Mr Ives would have relied both on my expertise 6 and on that of Calor. 7 Q. So can we agree that having asked for your contribution 8 and having received your initial recommendation and 9 having received your response to Mr Coville's letter, it 10 was not unreasonable for Mr Ives to assume -- I am 11 sorry, it was not unreasonable for Mr Ives not to expect 12 excavation to take place? 13 A. Double negatives obscure the meaning of the sentence 14 but -- 15 Q. Will you -- 16 A. Double negatives obscure the meaning of the sentence but 17 Mr Ives lost the word "underground" when he relayed that 18 advice on to Calor. But I still think if Calor put 19 themselves up as a competent person then they carry some 20 of the responsibility for what they do. 21 Q. Why did you not ask either through Mr Ives or however 22 for clarification of precisely what Calor, as 23 a competent person, was intending? 24 A. I don't think it's normally necessary to stand over 25 a competent person to redo their job for them. If we page 9 1 did that, HSE would never get anything finished. We 2 actually have sometimes to trust people to get on with 3 it. 4 Q. What is the answer to my question, Mr Tyldesley? 5 A. Would you like to repeat the question. I'm sorry, I ... 6 Q. Yes. Why did you not ask, either through Mr Ives or 7 otherwise, for clarification of what exactly it was that 8 Calor were proposing? 9 A. Because Calor had seen the earlier correspondence from 10 us which set out in detail the four steps that we went 11 through yesterday: excavate, inspect, write a report, 12 and implement the conclusions of that report. Calor had 13 seen that. They knew what was wanted. 14 Q. But they had also responded in the way that Mr Coville 15 responded and he did not say, "We accept the 16 recommendation and will carry out it", did he? 17 A. That is Mr Coville's brief clarification of how he 18 proposed to start the job. I think that's how it should 19 be seen. It's very easy now to pick over one sentence 20 from 20 years ago, but we have a lot of issues here and 21 this was just one. I think I had made it abundantly 22 clear what was needed. 23 Q. Mr Tyldesley, what other issues do we have? This pipe 24 ultimately failed as a result of corrosion underground 25 in the length which was the subject of your page 10 1 recommendation. What other clarification or what other 2 issues were relevant other than the need for that pipe 3 to have been examined so as to find out if it was prone 4 to any significant corrosion? 5 A. There is the issue of what it was actually made of. 6 It's not terribly easy to tell just looking at something 7 whether it is wrought iron or steel or mild steel. 8 There is a significance in that. 9 Q. Let me move on for the moment. 10 Could you return to your Inquiry statement, please, 11 and under the heading of HS(G)34, would you please begin 12 reading at paragraph 95 and could I have 1272 on screen, 13 please. 14 A. "All Fire and Explosion Specialists have training in 15 Health and Safety Executive Booklet HS(G)34 'The storage 16 of LPG at fixed installations' at the time it was put 17 there in 1987. It superseded previous guidance, 18 including CS5. It represented a new agreement between 19 the HSE and the LPG ITA (the LPG Industry Trade 20 Association). 21 "I would have read and thought about HS(G)34 at the 22 time of my visit to ICL. 23 "The guidance in HS(G)34 does not give specific 24 advice in relation to the maintenance of underground 25 pipeline carrying gas." page 11 1 Q. Just stop there, please. Could I have page 01306. Is 2 that a page from HS(G)34 which began on page 1272? 3 A. It is. 4 Q. Do we see towards the second part of the first column 5 the heading "Maintenance and examination". 6 A. Indeed. 7 Q. In 182 it says: 8 "The installation should be properly maintained to 9 acceptable standards determined and overseen by 10 a competent engineer of appropriate discipline with the 11 objective of maintaining the established safe operating 12 limits. Emphasis should be placed on features affecting 13 the integrity of the installation or the ability to take 14 emergency action. For installations rented from the gas 15 suppliers this work may be carried out by the company 16 owning the vessel." 17 In general terms, can we agree that that is what you 18 and your colleagues were directing yourselves to in 19 looking at the LPG installation at Grovepark Mills? 20 A. There was maintenance aspects in the pipeline as well as 21 those. I wouldn't perhaps class maintenance as, "Have 22 we got a fire extinguisher and have we piled a pile of 23 rubbish next it". That isn't really maintenance in my 24 book. 25 Q. That paragraph was at least part of what you and your page 12 1 colleagues were addressing yourselves to. Is that 2 right? 3 A. I think that was probably true on 95 per cent of visits 4 that HSE specialists made, "Is this actually maintained 5 properly". 6 Q. 183: 7 "A maintenance scheme should be prepared which 8 includes protective devices and instruments the form and 9 detail of which reflect the needs of the particular 10 installation. Servicing and maintenance handbooks may 11 be adequate for simple installations." 12 Is that requiring the keeping of records by either 13 the occupier or by the gas supplier or perhaps by 14 a combination of the two? 15 A. It's instructions for what needs to be done and records 16 of what has been done. 17 Q. 184 reads: 18 "Suitable records should be kept so that all 19 maintenance schemes are properly monitored. All 20 significant repairs or replacements should be recorded." 21 Did you ask for and receive records from ICL which 22 were sufficient to satisfy you that that paragraph was 23 being complied with? 24 A. That, I believe, is why I asked them to dig the pipework 25 up. I probably asked -- I don't like speculating but page 13 1 I must have asked some questions about that pipeline. 2 I got inadequate answers and, therefore, we have to do 3 something to establish its baseline: is this safe for 4 continued further use or is it not? 5 Q. Did you see, did you ask for and did you see, suitable 6 records within the meaning of paragraph 184? 7 A. At an interval of just short of 20 years I don't know 8 what questions I asked Mr Stott. 9 Q. So can we agree by reference to the documents we have 10 already looked at there is no reference either in your 11 notebook or in the written memos which you prepared of 12 your having seen at the time and having noted any 13 written records which might be said to have complied 14 with paragraph 184; is that correct? 15 A. Indeed. 16 Q. 185: 17 "Scheme for examining the installation should be 18 drawn up by or be endorsed by a competent person and 19 reviewed after each examination. Vessels should be 20 examined at intervals as required by a competent person. 21 Direct heated vapourisers should be thoroughly examined 22 at intervals not exceeding one year." 23 As far as vessels are concerned did you ask for and 24 receive any written evidence of the scheme for regular 25 examination which was suggested by that paragraph? page 14 1 A. The vessels were commented on by Alistair Gunn in 1982 2 as I recall. Calor as an owner of a very large number 3 of tanks would have a database of where those tanks 4 were, when they were last inspected and when they were 5 next due for inspection. 6 In terms of vessels, I think we probably trusted 7 them to get on with that. There would be a tag on most 8 vessels which they could probably read to tell us when 9 it was last tested. 10 Q. What about the other aspects of the installation? 11 A. It's clear that those who deal with pressure systems, 12 and that's not me particularly, always put high 13 importance on inspecting pressure equipment with the 14 expectation that suitable inspection allows something 15 that is about to fail to be taken out of service or 16 repaired before it fails. That's the objective -- 17 nothing new about that. 18 Q. Paragraph 188, please: 19 "Underground piping carrying liquid which is laid in 20 a back filled trench should be examined for corrosion, 21 or tested in such a way as to establish continuing 22 integrity, at least once every 10 years." 23 Was that a paragraph which applied to the 24 underground pipework at Grovepark Mills? 25 A. Most certainly not. The pipe at Grovepark Mills did not page 15 1 carry liquid. 2 Q. So was there no regime or suggested period for 3 examination of such underground pipe carrying vapour? 4 A. I don't know what was in the LPG ITA codes in 1988 and 5 I haven't got a copy of this. 6 Q. Could you explain to me as a layman, please, 7 Mr Tyldesley, why is it that given that the pipe, which 8 is presumably steel, has the potential to corrode from 9 the outside (that is to say, by the action of soil or 10 surrounding conditions, moisture and so on), why does it 11 make any difference that the pipe is carrying liquid as 12 opposed to carrying vapour? 13 A. For a hole of the given size the amount of gas and the 14 amount of material that escapes when it is a liquid is 15 greater than when it is a gas. But really I think you 16 should be asking an expert witness these questions. 17 I have been told I'm not an expert witness today. 18 Q. I can go back to your qualifications if you wish, 19 Mr Tyldesley, but I am certainly treating you as 20 somebody who is competent and experienced to answer the 21 sort of questions that I'm asking. 22 Should the Chairman regard you as not competent and 23 experienced, such as you have said at the beginning of 24 your Inquiry statement, to answer such questions? 25 A. I was told I was here as a witness of fact today. We page 16 1 have had this debate with Gillian Glass. 2 Q. If you forgive me, Mr Tyldesley, I am asking you 3 questions based on the evidence you put before the 4 Inquiry and according to paragraph 4 and after reference 5 to your academic qualifications, including an honours 6 degree in chemistry and nine years' experience in 7 research and development in the chemical industry, you 8 have indicated that you were one of a group of around 12 9 specialists within the Health & Safety Executive who 10 covered the whole of Scotland and you were in the post 11 of specialist inspector. 12 Did that not give you experience and training in 13 matters such as HS(G)34, the storage, the installation 14 relating to LPG? 15 A. I won't labour this point much further. The point is 16 that you're asking me to do my professional job as an 17 expert witness when you've asked me to come here as 18 a witness of fact. That I don't think is very fair. 19 Q. I am sure the Chairman is more than capable of 20 addressing himself to the fairness of the Inquiry to 21 witnesses, Mr Tyldesley. But if I ask you a question 22 such as related to paragraph 188 about the potential for 23 corrosion of a steel or iron pipe in the ground and the 24 distinction between its carrying vapour LPG or liquid 25 LPG, do you feel qualified to give me the answer that page 17 1 I think you gave me a few moments ago, which is that the 2 difference is in the event of a leak, LPG which has been 3 liquid within the pipe can of course create a much 4 greater quantity of gas or vapour. Is that right? 5 A. It's partially that. Its partially also it will be 6 a higher pressure if it's going to remain liquid the 7 pressure inside the pipeline will be higher. 8 Q. Thank you, I understand that. 9 Can you then return to your Inquiry statement, 10 please, under the heading of "FICs" at paragraph 98. 11 Perhaps we could have up 1040, please. If you read from 12 98 please. 13 A. "Factory Inspectorate Circulars (FICs) were issued on 14 various topics. Their purpose was to alert specialists 15 to relatively specific issues. 16 "They were internal circulars and so were not 17 normally available to industry. 18 "FIC28643 was a circular dated 10th November 1980 19 which recommended standards of installation, 20 commissioning and inspection of underground pipes 21 conveying LPG, primarily in liquid form, although it 22 stated that similar standards could be applied with 23 advantage to underground pipes conveying LPG vapour. 24 The pipeline at ICL conveyed vapour rather than liquid. 25 This circular was important at the time it was issued in page 18 1 1980 because it identified a problem that needed to be 2 bought to the attention of other inspectors. 3 "At paragraph 7 this FIC suggests an inspection of 4 the underground pipework after 10 years. In my opinion 5 the word 'uncovered' requires excavation. The author 6 leaves inspectors with little help in deciding what 7 should be done about pipes carrying gas rather than 8 liquid. 9 "Paragraph 8 states: 10 "'If for any reason leak or severe corrosion is 11 suspected then the line should be taken out of use and 12 pressure tested without delay.'. 13 "At ICL, I had no reason to suspect a leak or severe 14 corrosion -- there was no evidence of a leak. 15 "Paragraph 9 states that firms with 16 inaccessible pipes or pipes that are not installed to 17 good modern standards should be advised of the danger 18 from leaks and encouraged to install the pipes to a good 19 modern standard. At ICL, we had no evidence of the 20 standard that the pipeline was constructed to, which is 21 why I would have recommended that ICL excavate to check 22 the condition of the pipes. 23 "The 1983" -- 24 Q. I am sorry may I just ask you to pause there, if you 25 would, and have before you page 1040 which should be on page 19 1 the screen. 2 Was this a circular at least at the time that it was 3 in force that applied directly to a situation where 4 underground pipes were carrying liquid LPG? 5 A. To me as a specialist that circular says no more than, 6 "We at headquarters, Factory Inspectorate FIA 7 headquarters, have identified a problem, please go and 8 look out for it". That's all it says in truth. 9 Q. My question, Mr Tyldesley, was: did that circular whilst 10 it was in force apply directly to underground pipes 11 carrying liquid LPG? 12 A. It is vague on that point. If you look at the 13 first sentence "primarily liquid form although similar 14 standards could be applied with advantage". That is 15 deliberately vague. The problem was there with both of 16 them. 17 Q. I was asking about LPG within pipework in liquid form. 18 Does the circular apply directly, whilst it was in 19 force, to a situation where LPG was being conveyed in 20 pipework in liquid form? 21 A. I don't like the word "enforce" there. This can't be 22 enforced in the sense it was not public document, it 23 does not tell individual inspectors precisely what do. 24 It gives information. I don't think it's enforcement 25 instructions but it is intended to apply to liquid page 20 1 carrying pipelines and with advantage to others. 2 Q. It could be applied with advantage to underground pipes 3 conveying LPG in vapour form; is that right? 4 A. I hope that the inspectors who wrote that and the 5 inspector who wrote that knew perfectly well that a leak 6 of gas or liquid LPG underground was a problem, but this 7 is 1980. I can't speak for them. 8 Q. But you have referred to this circular in your evidence, 9 Mr Tyldesley, and I infer from that that you regarded 10 it, whilst it -- I use the words "in force" -- while it 11 was valid as having some application to the situation 12 before the Inquiry? 13 A. No, it's in my evidence because it was in the evidence 14 that the Fiscal took off me in 2005. At the time that 15 we reworked that to present to this Inquiry it was felt 16 we shouldn't chop it out entirely. But it's history, 17 it's ancient history and it says nothing knew. 18 Q. It is ancient history but it was applicable at least for 19 a period between 1969 when this installation at 20 Grovepark Mills was created and the late 1980s when you 21 were involved in your examination -- sorry, early 1980s. 22 Is that right? 23 A. That's right. It was an internal circular for HSE staff 24 but it is quite likely that the contents were discussed 25 with the major players in the LPG industry by whoever page 21 1 had the topic lead for HSE on LPG at that time. Such 2 circulars would probably discuss with the major players 3 in the LPG ITA. 4 MR MARTIN: I am sorry, my Lord, if I may just have 5 a moment. (Pause) 6 If we look at the paragraphs which you have in your 7 evidence referred to, Mr Tyldesley, and bearing in mind 8 that the standards referred to may be applied in 9 advantage to underground pipes conveying LPG vapour, can 10 we agree that in paragraph 7 it says: 11 "After 10 years all pipes carrying LPG, in 12 particular those not installed to current standards, 13 should, if reasonably practicable, be uncovered and 14 physically examined." 15 A. You have read that correctly but the words "reasonably 16 practicable" allow every individual inspector to take 17 a judgment as to what that means. So it's as vague as 18 can be. 19 Q. You, in effect, were fulfilling that in your 20 recommendation to Mr Ives, were you not, because you 21 said that, at least in part, the pipe should be 22 excavated, uncovered. 23 A. Right the world had moved in by 1988. This circular and 24 the subsequent one had been cancelled. HS(G)34 had 25 taken over the standard. So this is ancient history. page 22 1 Q. Why do you say that, Mr Tyldesley? It is something that 2 was in existence during the period that this 3 installation was in existence. If cancelled or 4 superseded in 1983, it was some six years before the 5 events with which your evidence is directly concerned. 6 Why do you describe it as ancient history? 7 A. I described it as ancient history because HSE took on 8 new responsibilities in 1985 and we're jumping around my 9 statement but in 1985 HSE took on responsibility for the 10 mains gas industry and in the first year they got two 11 substantial explosions which I think I refer to and our 12 understanding and our knowledge of the dangers from 13 underground pipe moved forward a very sudden step. 14 Suddenly we were faced with incidents that were 15 happening at depressing frequency concerning underground 16 gas pipe and much more attention was given to it by some 17 of our 5 explosion specialists. 18 Q. Paragraph 7 refers to steps to be taken in relation to 19 pipes which are over 10 years old and as we have already 20 discussed in HS(G)34, which did apply, paragraph 118 21 also refers to steps which should be taken in relation 22 to underground piping, albeit carrying liquid LPG, at 23 least once every 10 years. So the period of 10 years is 24 a consistent theme between 1980 and at least 1989, is it 25 not? page 23 1 A. It is indeed. 2 Q. You knew from Mr Gunn's earlier report in 1982 that at 3 that time the tank at least was reckoned to be at least 4 10 years old, did you not? 5 A. That's right, though it's not necessarily the case that 6 the tank was new at the time it was installed. These 7 things can be shuffled around. It might have had 2 8 years' service somewhere else and then shuffled round to 9 ICL's premises. 10 What we do know is it had been inspected, last 11 inspected, at whatever Mr Gunn gave us. 12 Q. Could I ask you to go to page 1232, please. Perhaps 13 first we could have 1215. This is the LPG ITA Code of 14 Practice first printed 1986. 15 Was that a document with which you were familiar at 16 the time, Mr Tyldesley? 17 A. My Principal Inspector in Edinburgh had quite a lot of 18 the codes of practice from the LPG ITA. I don't think 19 we have a full set. I don't know that they are all the 20 most recent copies. I don't know whether there was 21 a copy of that document in the Edinburgh office in 22 1988/89. I just don't know. 23 Q. Could you go, please -- could I have page 1232. 24 Highlight 6.2, which is the second part under the 25 heading of "Underground pipework". page 24 1 In 6.2.1 it states: 2 "Pipelines conveying vapour below 5-bar should be 3 surveyed for leakage at a frequency dictated by the 4 risks associated with their location, pressure of 5 operation and aggressiveness of their environment." 6 So again can we agree that in this guidance -- and 7 I accept that you may not directly have seen it -- was 8 consistent with the need for a regime of surveying or 9 examination of underground pipework? 10 A. You are asking me technical questions about a document 11 I certainly haven't seen for 19 years and may never have 12 seen before then I would request some time to formulate 13 an answer to that. 14 I don't think it's fair on an expert witness, which 15 you now appear to want me to be, to throw from out of 16 the sky something like that. I have not seen that 17 document since 1990 and I may well have never seen it. 18 Q. I accept, Mr Tyldesley, you may not have seen it and my 19 question proceeded upon that hypothesis. I am simply 20 asking you by reference to the words which are being 21 used in the passage that I have just read whether you 22 would agree or not that again at the material time (that 23 is to say, after 1986) in this document there was also 24 provision for surveying of pipelines by reference to the 25 location, pressure of operation and aggressiveness of page 25 1 the environment which is consistent with what was said 2 in FIC286/43 and in HS(G)34? 3 A. Your reading is correct. Perhaps to put more 4 information on that perhaps we can see a distinction 5 there between something which is highly specific, 6 a 10-year inspection interval, which is convenient for 7 those small organisations who don't want to think about 8 these issues and something that's a bit more 9 sophisticated for the bigger companies who might say, 10 "In this location we think it's vulnerable. It needs 11 inspecting every 2 years or 5 years or in some other 12 location because it's particularly dry we think the 13 inspections can be increased". So you have there the 14 dichotomy of goal setting legislation, which is, "We 15 want this pipe to remain intact", or very targeted 16 instructions, "You will inspect this at 10-year 17 intervals regardless of the fact it might fail in 5". 18 That's what you can see there, the distinction between 19 two types of guidance. 20 Q. Could I ask you to return to your Inquiry statement, 21 please, and begin reading at paragraph 105. 22 A. "In 1983, FIC286/43 was cancelled and a revised document 23 FIC286/43 revised had been issued." 24 Q. Could I have page 1041, please. 25 A. "This circular is headed up as 'Underground steel pipes page 26 1 conveying LPG as a liquid'. However, it states: 2 "'The standards recommended here are good practice 3 and are suggested for all underground pipes conveying 4 LPG, which would include gas.' 5 "Paragraph 16 recommends that pipelines should be 6 inspected at intervals of not more than 5 years. You 7 cannot inspect something you cannot see so I take this 8 as requiring at least some excavation. 9 "Paragraph 19 states that when an underground pipe 10 is installed to a low standard (this includes the 11 standing being unknown, as was the case at ICL), it 12 should also be inspected. 13 "These two FICs were issued before I joined. 14 I believe I would have read them because I was 15 reasonably diligent at making sure I had access to all 16 advice on my topic. However, by the time I visited the 17 ICL premises in 1988 it appears that FIC286/43 revised 18 had also been cancelled (the copy circulated has 19 a handwritten note saying 'Cancelled by F/FIM1987/48' 20 and by this stage the main guidance was HS(G)34). These 21 two FICs show that the HSE were considering the issue of 22 underground pipework in the early 1980s. The 23 identification of sites to which these circulars applied 24 was left to local factory inspectors. Advice about the 25 extent of circumstances in which enforcement action was page 27 1 appropriate could be provided by one of the regionally 2 based specialists. The decision whether to take 3 enforcement action on the issues covered by these 4 circulars would ultimately be made by the factory 5 inspector." 6 Q. Just before you move on can I, for the benefit of the 7 Inquiry, indicate that the document referred to there 8 F/FIM1987/48 is to be found at pages 3827 to 3833. I do 9 not think I need to ask Mr Tyldesley to look at them. 10 That document confirms or intimates that HS(G)34 had 11 been issued and intimated the cancellation of 12 FIC286/43REV and as I understand it that is your belief, 13 Mr Tyldesley, of the sequence of events, that in 14 effect HS(G)34 replaced the FIC286/43 sequence? 15 A. That's clearly the intention since you have told me the 16 substance of the FIM. These are now history. HS(G)34 17 is the document you work to. 18 Q. Could I have up, please, 11510. If you put that to one 19 side of the page, could I have 9409. Could I also have 20 9410 and 11 underneath. 21 Perhaps, if I just -- 22 A. It will be illegible if you put too many pages up, I 23 think. 24 Q. I was hoping to help you and then you can look at the 25 specific page, Mr Tyldesley, because you are now going page 28 1 on in paragraph 110 to refer to report of an injury or 2 dangerous occurrence and we have this in two places in 3 the Inquiry documentation, one beginning at 11510 and 4 one beginning at 9409, the difference being that in the 5 case of 9409 and the sheet afterwards there are two 6 cover sheets which do not occur or do not appear on the 7 other version. But thereafter the first page, which is 8 headed "Summary sheet of FCG inspector's report" is the 9 same as are the subsequent pages. 10 Could we go please then to 9409 if you could 11 highlight that. Why would that page appear, as it were, 12 before the summary sheet which is the third sheet in 13 that run of the documents and is the first sheet in the 14 other run of the documents? What is the significance of 15 that sheet "Report of an injury of dangerous 16 occurrence"? 17 A. The top sheet report of injury or dangerous occurrence 18 is the report on behalf of whoever was responsible for 19 the premises, the occupier, to HSE, of an injury or 20 dangerous occurrence as required under the RIDOR regs. 21 So that top sheet has come from the occupier. 22 Q. So could we see 9410, please. That is headed "Marcode 23 incident summary form". What is the significance of 24 that document? 25 A. You really are asking the wrong person about this. page 29 1 A specialist didn't use the marcode system. 2 Q. It has been signed by Mr Powell and he is a witness so 3 I will be asking him but it is in fairness to you, 4 Mr Tyldesley, so that you are aware that there is this 5 extra page that is not entirely clear to those of us who 6 are not ourselves familiar with the system. 7 A. The system is that somebody would enter the incoming 8 RDOR reports, the report of accidents to HSE on to a 9 computer database which at that time was called marcode 10 beyond that I can't give you any information because the 11 specialists didn't use it. 12 Q. If we then have 9411 and 11510, can we agree that these 13 appear to be the same first pages and my understanding 14 is that the subsequent pages are the supporting pages to 15 that summary sheet. They are the same concerning an 16 incident on 15th December 1987 and a report, which 17 I think, it is a little unclear, is dated 13th January 18 1988. It is in a box under the heading "FCG file 19 number" towards the middle of the page on the right-hand 20 side. 21 A. I believe that there is only one version of that 22 specialist report. You can see it is written by an FCG 23 Specialist Inspector. Gordon Harding did effectively 24 the same job as I did from the Birmingham office but 25 at Principal Specialist Inspector grade, as you can see page 30 1 from the bottom of the top page. 2 Q. Could you then begin reading from the second sentence at 3 paragraph 110, please. 4 A. "I was shown a Report of an Injury or Dangerous 5 Occurrence. This is the Health & Safety Executive 6 report about an occurrence on 14/12/1987 at LBA Limited, 7 Hinton House, Daventry, North Hants, and the report was 8 prepared by Inspector GT Harding and dated 13th January 9 1988. The incident which was reported was a major LPG 10 explosion in an underground firing range causing 11 structural collapse. I am sure I was not aware of this 12 report at the time of my visit to ICL. The specialist 13 who looked at this did not appear to send any report to 14 the Fire and Explosion Specialist Group in HSE's Bootle 15 Headquarters so there was no obvious route for it to 16 reach me. I did not routinely see reports from my 17 specialist colleagues in England and Wales. 18 Headquarters would raise common patterns but would not 19 circulate all reports. The headquarters staff looked 20 for new and interesting reports to circulate. I already 21 knew that if there was an LPG leak into a basement, it 22 could cause an explosion." 23 Q. Just pausing there, please, is there anything on the 24 document itself which indicates that the specialist 25 inspector who prepared it did not appear to have sent it page 31 1 to the Fire and Explosion Specialist Group? Is there 2 a box that might have been ticked or something of that 3 sort? 4 A. No, it's normally clear who it was sent to, copies to: 5 AD, Area Director, that's the Area Director in whose 6 area the factory was situated; PI that's the Principal 7 Inspector of the group who was responsible for the 8 premises; file, that's the FCG file; Mr P Sumption, 9 Public Utilities NIG. 10 Public Utilities NIG was not a headquarters 11 specialist function. That was the group of factory 12 inspectors who collectively would liaise and co-ordinate 13 our response to, as it says, public utilities, the gas 14 industry, major electric suppliers, the water industry. 15 They would head up a UK-wide -- I hesitate to say 16 UK-wide because Northern Ireland isn't in, but an HSE 17 collective response to those big industries. So that's 18 where it went to. If it had been sent to the specialist 19 group in headquarters it would have said there. Gordon 20 didn't send it to the specialist headquarters. 21 Q. Paragraph 111 of your statement, please. 22 A. "At the time of my visit to the ICL premises, I was 23 aware of the need to consider underground pipework. 24 "At the start of 1985 the HSE took on responsibility 25 for mains gas safety. It started enforcing the Health page 32 1 and Safety at Work Act 1974 against the mains gas 2 industry. We were all on a learning curve. 3 "Just after taking on responsibility for mains gas 4 safety, in January 1985, a block of flats exploded in 5 Putney, London, killing eight people. In November 6 1985, in the same year, five residents were killed in an 7 explosion at flats in Rutherglen Glasgow. This informed 8 the HSE's perspective at the time. The HSE started to 9 look at the codes and standards that the nationalised 10 gas industry had used over a long period (the gas boards 11 had standards which required routine corrosion 12 protection of all low pressure pipework and medium 13 pressure pipework), the types of failures and the 14 consequences of those failures. Mains gas was 15 traditionally laid in wrought iron pipe. Steel pipe, 16 which is recommended for use with LPG, is normally more 17 vulnerable to corrosion. 18 "I knew of the history of problems of gas leaks in 19 the mains gas industry. The Putney report records that 20 in 1984/85 in England, Wales and Scotland there were 16 21 gas explosions of which 8 resulted in severe damage. 22 I had knowledge of the reports into the explosions at 23 Putney and Rutherglen which highlight the ease with 24 which gas escaping from pipes outside a property leaks 25 into the property, even from a low pressure source. page 33 1 I knew corrosion was possible. I knew the mains gas 2 industry wrapped pipe with corrosion protective tape. 3 Taken together, I could evidently not satisfy myself 4 during the site visit to ICL's premises that this 5 pipeline was safe. I did the only thing open to me at 6 the time, which was to recommend to John Ives that he 7 required that the company did more to establish whether 8 the pipeline created a risk. 9 "From reading my initial report I would say that the 10 recommendations which I have listed were made up from my 11 knowledge taken from the HS(G)34, earlier guidance on 12 LPG and my knowledge of incidents involving mains gas. 13 "With regards to my chain of command, if I ever had 14 to obtain any advice from any other person in most 15 direct contact would have been Keith Wilson." 16 Q. You can confirm that the -- 17 A. "I confirm that the contents of this statement are 18 true." 19 MR MARTIN: Thank you very much, Mr Tyldesley. Please 20 remain there. There may be further questions for you. 21 THE CHAIRMAN: Mr Tyldesley, I wonder if you could just help 22 me on a couple of points. I can understand that codes 23 of practice and FICs and so on are always open to 24 interpretation, but just standing back for a moment from 25 the detail of all these codes and just looking at this page 34 1 as, I suppose, a commonsense proposition it was obvious 2 to you at the time that you made your report to Mr Ives 3 that this was a buried pipe that did require some form 4 of investigation. Leaving to one side the issue of how 5 much investigation was required, it was plainly a matter 6 that you regarded as requiring some form of 7 investigation because there was a question as to the 8 integrity of the pipe. 9 Would that be a fair statement? 10 A. That's clearly the case. 11 THE CHAIRMAN: So the recommendation goes up to Mr Ives. 12 Then there is the counter-proposal from Mr Coville and 13 then Mr Coville's counter-proposal is accepted. Your 14 position is this: bearing in mind Calor's expertise, you 15 took it for granted that Coville's counter-proposal 16 would involve some form of investigation below the 17 surface of the ground. Is that fair? 18 A. Bearing in mind Calor's reputation as a large company -- 19 well, not reputation, the fact of a large company -- 20 yes, I expected them to do that. 21 THE CHAIRMAN: So what then did you do to -- or did you do 22 anything after that to check that they actually had 23 carried out some underground investigation of the pipe? 24 A. That was not the role. We went to premises if we were 25 invited. We commented on documents that came from the page 35 1 Factory Inspectorate if we were invited. Proactive work 2 was not the way it operated, certainly not in my time in 3 Scotland. 4 THE CHAIRMAN: So we are looking here then at a system 5 problem, are we, that the system did not countenance the 6 idea that you would follow-up the recommendations to be 7 sure that they had been carried out? Is that right? 8 A. I hesitate to say this but it was a constant source of 9 annoyance, if you like, that too many specialists didn't 10 know what became of their recommendations. 11 THE CHAIRMAN: So, in other words, if you had followed-up 12 Coville's counter-proposals with a subsequent letter to 13 ask what they had actually done and what they had found, 14 that would, in fact, have been contrary to practice 15 within your department; is that right? 16 A. The specialists would never write directly to the 17 factory occupier, ICL, and you could see we didn't write 18 directly to Calor. We wrote through John Ives. That 19 was the system. 20 THE CHAIRMAN: I understand that. So I will revise the 21 question and put it this way: if you had to put up 22 a memo to Mr Ives saying to him, "I think you should 23 follow-up with Mr Coville the question whether they 24 actually did examine the pipe underground and if so what 25 he found", then you say that would have been contrary to page 36 1 practice within the department. 2 A. I've been told once enforcement was not my business. I 3 think you can find that in one of the notes from John 4 Ives. I don't really think it was likely that I was 5 going to bother him on this particular occasion to say 6 some months down the line, "What's happened? What's 7 happened?" That was never likely to get written. 8 THE CHAIRMAN: You see, if there was no system for 9 follow-ups to be sure that Calor or whoever had actually 10 done what they said they would do, then that would 11 suggest, would it not, that there was a gap in the 12 system? 13 A. If we spent a lot of time chasing up every 14 recommendation, then we would get round far fewer 15 premises. I think others in HSE would be better to 16 comment on this but it isn't practical to divert our 17 time into -- "our" ... I don't work for HSE. It was not 18 practical at the time I was in Scotland to devote our 19 time into chasing up every specialist recommendation 20 I ever wrote. 21 THE CHAIRMAN: So that would suggest then that there was 22 a resource problem perhaps as well? 23 A. It's always possible to use more resources. I think 24 that is inevitable. 25 THE CHAIRMAN: So really you've just got to take a practical page 37 1 decision as to where your resources are best deployed -- 2 A. That is certainly part of the issue. You also have to 3 take a judgment on whether you trust people to actually 4 implement what you say. I think you can see from the 5 tone of my first report that my trust in ICL 6 was ... well, suspect. 7 THE CHAIRMAN: Well, that was exactly what had occurred to 8 me. Without going to the documents, there is a letter 9 there that does indicate that you had no great faith in 10 ICL to do what was asked of them. 11 That led me to wonder whether that would not also 12 have been a reason for ensuring that there was 13 a follow-up. 14 A. Every inspector has to take judgments on what they think 15 of the people they speak to. My judgment and John's may 16 have been different. He met Mr Stott more often than 17 I did. I think I only met him the once. That is 18 a judgment call and you will get different answers from 19 different people on different occasions. 20 THE CHAIRMAN: Thank you for that, Mr Tyldesley. 21 There are some questions for you from Mrs Smith, 22 first of all. Mr McBrearty will ask it. 23 Examined by MR McBREARTY (on behalf of Mrs Smith) 24 Q. Mr Tyldesley, you obviously gave evidence that the LPG 25 pipe at ICL's premises passed through the basement area. page 38 1 In that kind of situation in general, where there is LPG 2 pipework in a basement, would you ever have considered 3 recommending that gas detection equipment of some form 4 should be fitted in the basement? 5 A. I don't think gas detection equipment is the best answer 6 there. Rerouting the pipework would be the preferable 7 arrangement and, secondly, I suggested a rather unusual 8 suggestion that the gas supply was turned off whenever 9 it wasn't being used. Gas detection equipment requires 10 maintenance, it requires calibration, it's possible to 11 go wrong. Gas detection equipment is not a normal 12 arrangement for this sort of facility. 13 Q. Appreciating that, Mr Tyldesley, in a situation where it 14 was not possible to reroute the pipework, such as ICL, 15 would you nevertheless have considered gas detection 16 equipment as an alternative? 17 A. I remain to be convinced that it wasn't possible to 18 reroute the pipework. I'm not familiar with where it 19 went within the building. 20 Q. Just to be clear, Mr Tyldesley, at the time of your 21 report you made no recommendation that the pipework 22 should be rerouted. 23 A. Well, I made a rather strange but clearly intending to 24 address a similar issue, turn the gas off whenever it's 25 not being used. It limits the chances of it escaping page 39 1 over the weekend and somebody coming in on Monday 2 morning and blowing the place up. That isn't a normal 3 arrangement but it is something that I recommended, but 4 it required daily and weekly ongoing work from ICL. 5 Simple work but something that they would have to do. 6 Q. Did you consider that that was an appropriate 7 alternative to rerouting the pipework? 8 A. You're asking me to speculate but I think what I would 9 have hoped was that the time the pipe was replaced, 10 because it was defective in 1989, it didn't meet the 11 current standards, that whoever advised them on 12 replacing that pipe would also have advised them to 13 route it somewhere that didn't run through the basement. 14 Q. But that played no part in the recommendations which you 15 made? 16 A. You can see I made recommendations that were intended to 17 reduce the chance of the gas building up in the 18 basement, a situation which I found unsatisfactory. 19 Your proposed suggestion of a gas detector is an option 20 but it's not the best. 21 MR McBREARTY: Thank you. 22 THE CHAIRMAN: Mr McBride? 23 Examined by MR McBRIDE 24 Q. Extremely briefly, my Lord, thank you. 25 I know you have been asked a number of questions page 40 1 about this but just for my own purposes, please. 2 Do we understand from your exchanges both with his 3 Lordship and with Counsel to the Inquiry that the 4 inescapable conclusion relating to the proposals by 5 Mr Coville are that in the absence by him of an explicit 6 suggestion of excavation you made an assumption about 7 partial excavation based on the fact he was a competent 8 person? 9 A. I really don't want to comment on individuals, 10 remembering I know nothing about Maurice Coville except 11 his job title at that time. 12 Q. Based on the fact that you thought a competent person or 13 organisation was being involved did you make an 14 assumption about partial excavation? 15 A. I made an assumption that Calor would understand the 16 problem and understand the consequences and how that 17 could be resolved. 18 Q. And in relation to the assumption you made you never at 19 any stage sought to clarify that position; is that 20 right? 21 A. That's right. 22 Q. In relation to the assumption you made, we know now the 23 assumption was wrong. Is that right? 24 A. I don't know what work was done after January 1989. You 25 tell me. page 41 1 Q. We know that Mr Coville did not go and excavate the 2 pipe. So insofar as you had made the assumption he 3 would, your assumption was wrong. 4 A. Evidently so. 5 Q. Had you sought from him through Mr Ives an explicit 6 assurance that he would excavate the pipe, the position 7 might have been quite different subsequently; is that 8 right? 9 A. A very hypothetical question now but, yes, if I had 10 written back saying, "Please, assure me you really do 11 intend to excavate this pipe as my original 12 recommendation", goodness knows what answer I would have 13 got back. 14 MR MCBRIDE: I am very grateful. Thank you very much. 15 THE CHAIRMAN: Mr Ellis, please. 16 MR ELLIS: Obliged, my Lord. I would like with your 17 Lordship's permission to expand the questions I have 18 somewhat from those in the original written application 19 given the evidence that has emerged in the course of 20 yesterday and today? 21 THE CHAIRMAN: It seems to me, Mr Ellis, that there are 22 a number of the questions that you have proposed that, 23 in the event, have been covered but then there may be 24 new issues that you feel obliged to pursue. 25 MR ELLIS: That is exactly the position, my Lord, yes. page 42 1 THE CHAIRMAN: I will leave it to your judgment, Mr Ellis. 2 MR ELLIS: Thank you, my Lord. 3 Examined by MR ELLIS 4 Q. Mr Tyldesley, I am going to ask you some questions for 5 Calor Gas Limited. 6 Could I start, please, by asking you to look at 7 paragraph 71 of your statement and in that paragraph you 8 explain what you meant by the phrase "competent person" 9 when you used it in your recommendation 6.11. 10 You also in that paragraph refer to "current 11 guidelines". 12 Can I ask is that a reference to published 13 guidelines? 14 A. Not necessarily. What's in the public domain was not 15 necessarily the same as what bigger companies would have 16 in-house as standards. It was not unusual, for 17 instance -- well, it was the normal practice that we had 18 the gas industry in 1970s that British Gas had large 19 numbers of their own codes they worked to and they were 20 good. These tended to leak out into the public domain 21 but they were not public documents. Calor may have had 22 something similar. 23 Q. So perhaps Calor may have had their own guidelines but 24 apart from Calor's own guidelines were you intending to 25 refer to published guidelines? page 43 1 A. I was intending to refer to published guidelines but as 2 I also said, the FICs that we also see were 3 in-house documents but almost certainly had been shared 4 at some stage with the LPG ITA. 5 Q. I was just speaking of the published guidelines. Would 6 you accept that your recommendation of excavation went 7 somewhat beyond what was envisaged in the then current 8 published guidelines? 9 A. Inspector's judgment as to what is guidance and what is 10 the law. That is what I was being paid for, to make 11 a judgment call on what was the minimum required to meet 12 the standard of the Health and Safety at Work Act 13 sections 2 and 3. 14 Q. Just thinking what you did actually choose to recommend 15 for whatever reason would you accept it went beyond what 16 was envisaged in the then current published guidelines? 17 A. Guidelines never give you answers to all of the 18 questions. If that was the case, I wouldn't have a job 19 and I still wouldn't have a job. 20 Q. Well, I am going to ask you to look, please, at what 21 I understand to be the then current published 22 guidelines. 23 Could I ask you, please, to have in front of you 24 page 01306 which is part of HS(G)34. Now you have 25 already looked at this this morning so I think I can page 44 1 take briefly. 2 In the left-hand column there is the heading 3 "Maintenance and examination". Is that right? 4 A. That's right. 5 Q. Then the one part of the section that is relevant to 6 underground piping is paragraph 188. Is that right? 7 A. That's right. 8 Q. Am I right in understanding -- we have seen it before -- 9 but essentially it provides that: 10 "Underground piping which carries liquid and which 11 is laid in a back filled trench should be examined for 12 corrosion or tested in such a way as to establish 13 continuing integrity, at least once every 10 years." 14 Would I be right in understanding that therefore 15 this standard prescribes a 10-year examination only for 16 pipes carrying liquid? 17 A. I wouldn't agree with that for a moment. It doesn't 18 prescribe anything it's guidance. 19 Q. All right, recommends? 20 A. Recommends. 21 Q. And only for pipes carrying liquid? 22 A. That's what it says. 23 Q. Even then would I be right in understanding that by 24 reference to testing in such a way as to establish 25 continuing integrity, that may not exclude testing by page 45 1 pressure tests? 2 A. I'm not quite sure what was meant there. I think that's 3 a deliberate obfuscation. 4 Q. So one reading of it may be that a pressure test may be 5 a method of establishing continuing integrity? 6 A. That's speculation and I don't like speculating in this 7 position, but HS(G)34 would have been written in HSE. 8 It would have been shared with the LPG ITA and the 9 outcome of that would have been what was published. You 10 can ask Brian Fulham(?) who still works for with HSE 11 about it. You can ask Martin Anthony who went with 12 Brian, I believe, on the last meeting -- certainly you 13 will find the documentation here -- and I believe they 14 managed to write in some deliberately, very slightly 15 vaguer wording than perhaps I would have chosen. 16 Q. This is guidance published by the Health & Safety 17 Executive in 1987; is that right? 18 A. Right. 19 Q. And in relation even to pipes carrying liquid, which is 20 the only recommendation that relates to the inspection 21 of pipes, it uses words which could incorporate doing 22 the testing by a pressure test. 23 A. I really don't now what was in the mind of the writer 24 then. You had better ask Brian Fulham. 25 Q. Thank you. page 46 1 Just thinking of HS(G)34 then, would you accept the 2 proposition that in your paragraph 6.11 you were 3 recommending something which met or perhaps exceeded 4 what HS(G)34 recommended only in relation to pipes 5 carrying liquids? 6 A. HS(G)34 does not give you the answer to the question 7 that was facing me at the time. 8 Q. So is your position that although HS(G)34 makes 9 recommendations for pipes carrying liquids, it does not 10 make recommendations for pipes carrying vapour? 11 A. Guidance doesn't give you the answer to every question. 12 There was a question that faced me and I gave my 13 judgment call as to what was needed. 14 Q. As I understand your position you do not know the answer 15 whether even if this pipe carried liquid a pressure test 16 would have come within the recommendation of paragraph 17 188? 18 A. Whatever paragraph 188 says, in my professional opinion, 19 pressure testing pipework at 10-year intervals without 20 some greater certainty that that was adequate is not 21 a very satisfactory standard. 22 Q. That is your professional opinion but if we just think 23 of the guidance, do you think the guidance may envisage 24 such pressure testing as the means of inspection? 25 A. I really don't know. You had better ask Brian Fulham page 47 1 what is meant by the obfuscation in that paragraph. 2 Q. I wonder then if I could ask you to look at the other 3 piece of published guidance which I understand then was 4 current and that is the then current LPG ITA code of 5 practice. You have already looked at this this morning. 6 Could I please ask you to have in front of you page 7 001232. Again, you looked at the relevant parts of this 8 this morning. Could I ask you, please, to look at 9 paragraph 6.2. 6.2 1(a) makes provision for pipelines 10 conveying vapour below 5-bar. 11 In this case, do I understand that we are now 12 talking about a pipe in which the pressure was below 13 5-bar? 14 A. Pressure was certainly below 5-bar; that's correct. 15 Q. It doesn't recommend any particular precautions for 16 a pipe carrying vapour at a pressure below 5-bar but if 17 we look at the next paragraph (b) do we see there the 18 recommendations for a pipeline carrying liquid or vapour 19 operating at pressures of 5-bar or above. 20 Pausing there, am I right in understanding that 21 pipes carrying liquid or high pressure gas are thought 22 to require even more stringent safety standards? 23 A. That's the implication of the text there; that's right. 24 Q. If we look at the text, it goes on: 25 "The interval between surveys for leakage should not page 48 1 exceed 10 years." 2 A. Right. 3 Q. Does it then say: 4 "Where practicable this survey may be a repeat of 5 the pressure test carried out upon installation." 6 A. Right. 7 Q. Would I be right in understanding that that guidance, 8 even in relation to pipes of higher pressure and pipes 9 carrying liquid, says that a continuing inspection may 10 be done by a repeat of the pressure test? 11 A. That too has the reasonable words "where practicable". 12 That's trying to escape the responsibility of digging 13 the pipework up where people didn't want to. That's 14 a deliberate obfuscation again. 15 Q. With respect, is that really the way it can be read 16 because it says you do the pressure test where the 17 pressure test is practicable. Isn't that what it says? 18 A. You are asking me to comment on a technical document 19 from 20 years ago I may never have seen before. It 20 really is a little unfair. 21 Q. I am asking you, with respect, to simply read one 22 sentence and you made a point about practicability. 23 Is not the point of that sentence that you do the 24 pressure test when it is practicable? 25 A. That is the implication of that. page 49 1 Q. So this Code of Practice which makes a recommendation in 2 relation to pipes carrying liquid or gas at higher 3 pressure, it seems to envisage that a pressure test 4 could be the means of carrying out the test of the pipe 5 at 10-year intervals? 6 A. I believe it comes to that assumption, yes. 7 Q. Is it fair to say that in relation to this Code of 8 Practice what you recommended in paragraph 6.11 of your 9 report went beyond what this Code of Practice 10 recommended for pipes, even where the vapour pressure 11 was over 5-bar? 12 A. The LPG ITA codes had no legal status. I was giving my 13 own professional judgment as to what I thought was 14 appropriate at ICL for that pipe on that day. 15 THE CHAIRMAN: Mr Tyldesley, just answer the question and we 16 will get on very much quicker that way. All that has 17 been put to you is that on a reading of this document, 18 which I accept you may never have seen before, your 19 recommendation went beyond what that would have 20 suggested was necessary even for a line with more than 21 5-bar. That's the simple point. 22 A. Look at 6.2.1(a). It has this judgment call depending 23 on the location operation, pressure operation, 24 aggressiveness of the environment. That's the starting. 25 6.2. 1(a) we have to take a judgment of what is page 50 1 appropriate. For every pipeline that may be different. 2 That's the conclusion of 2.2. 1(a). 3 MR ELLIS: If I may, 6.2.1 (b) sets out recommendations for 4 a situation which is thought to be even more hazardous 5 than a pipe with lower pressure and in that more 6 hazardous situation it envisages a pressure test. 7 Do you accept that? 8 A. Yes. 9 Q. What I wanted to just confirm with you, although I think 10 you may already have done it, is that FIC286/43 and its 11 revised version were internal documents within the 12 Health & Safety Executive. 13 A. That's right but they were usually technical ones like 14 this would usually have been shared with the major 15 players outside before they were published, but I can't 16 speak for the author in 1980. 17 Q. Can I perhaps simply confirm with you that if you could 18 have page 001308 in front of you, this is the 19 bibliography for HS(G)34 and we can see it refers to 20 quite a number of documents. If one looks at the 21 Health & Safety Executive guidance that are referred to, 22 is there any reference there to FIC286/43 of its revised 23 version? 24 A. You wouldn't expect to find it there, firstly, because 25 it would not be obtainable by people who bought HS(G)34, page 51 1 it wasn't a public document and, secondly, we were about 2 to cancel it, as we have seen. 3 Q. Thank you. 4 Moving on slightly, at the time of your 5 recommendation in paragraph 6.11, am I right in 6 understanding there had been no report of any leak or 7 leakage problem in the relevant pipework? 8 A. That's right. 9 Q. Would you accept that Mr Coville's proposed courses of 10 action to ascertain the condition of the relevant 11 pipework were within courses that the published 12 guidelines at that time envisaged as being appropriate 13 to check the condition of underground pipes carrying LPG 14 vapour? 15 A. I'm not sure what Mr Coville intended by what he wrote 16 to John Ives. 17 Q. If he proposed to carry out a pressure test would you 18 accept that that came within the courses that were 19 envisaged by the then published guidelines? 20 A. Yes. 21 Q. Thank you. 22 Moving on a little bit you explained the thinking of 23 paragraph 71 and what you meant by a competent person 24 but in seeking to explain your own actions in your 25 evidence, you have used phrases such as ones you have page 52 1 brought in a competent person or another example is 2 taking on the responsibility of a competent person. 3 Now in using phrases like that, are you envisaging 4 that a competent person has undertaken to carry out 5 a risk assessment of the pipe? 6 A. Can we go through that sentence again, sorry -- your 7 question again? 8 Q. If you understood the reference to the phrases, it was 9 phrases such as taking on the responsibility of 10 a competent person which you used yesterday and I was 11 wondering if, in using phrases such as that, you were 12 envisaging that a competent person would undertake to 13 carry out a risk assessment of the pipeline? 14 A. I think the competent person should advise the factory 15 occupier what needed to be done. Whether that's 16 strictly a risk assessment or whether it's simply to say 17 this pipe needs replacing, that's a bit dubious whether 18 you will call that a risk assessment. 19 Q. So you are envisaging that a competent person has 20 undertaken the responsibility of advising on the safety 21 of the pipeline? 22 A. That's right. 23 Q. Now I wonder if I could then ask you, please, to look at 24 Mr Coville's letter which is 011479 and, in particular, 25 could we highlight the second part, the second page 53 1 paragraph. 2 Now I would like to ask you if there is anything in 3 the words used in that part of the paragraph of 4 Mr Coville's letter, or indeed in the other documents 5 you refer to in your evidence, which says that Calor has 6 undertaken to do anything to ascertain the condition of 7 the pipe beyond the two proposed actions? 8 A. That's part of the core of the problem here, that it's 9 not clear who's going to do anything. 10 Q. I wonder would you accept that the letter which appears 11 to be proposed on behalf of ICL offered only that two 12 specific actions would be taken in relation to paragraph 13 11? 14 A. That's right. 15 Q. And those actions are said, would you agree, to be 16 actions which would be for the purpose of ascertaining 17 the condition of the vapour offtake pipe? 18 A. There are the hope that action 3 was implied, that 19 having inspected this pipe they would have actually 20 given some written advice. It's not a lot of use if 21 somebody from Calor went along, dug up the pipe and 22 walked off again and did nothing else. That's not very 23 helpful. So action 3 is implied there, that they should 24 have given some written advice to ICL but it doesn't say 25 that. I assume -- I'm taking that as obvious really. page 54 1 Q. Would you accept just looking at the words of the letter 2 that it does not say that Calor had already carried out 3 an assessment of the pipe? 4 A. It didn't say that Calor had carried out an assessment 5 of the pipe; that's right. 6 Q. Would you also accept that the letter does not say that 7 Calor had, as yet, done anything to ascertain the 8 condition of the pipe? 9 A. It doesn't say who is going to do anything. 10 Q. Well, whoever -- 11 A. It really doesn't say -- and that is part of the core of 12 the problem, that Calor appear to be making suggestions 13 about what should be done without being very clear who 14 actually was going to do this. 15 Q. Well, where is there anything in the words used to say 16 that Calor or anyone undertakes to do anything more than 17 the two actions specified? 18 A. There isn't but there is no -- it's a passive tense 19 there. It would be ascertained. It didn't say by whom. 20 That could be anybody. That could be just about 21 anybody. Calor could have advised ICL to get somebody 22 else in if they didn't want responsibility for this. 23 That's fine. 24 Q. Thank you. 25 Perhaps I could approach it this way. Would you page 55 1 accept that in the letter Calor let you know precisely 2 what they proposed someone would do in order to 3 ascertain the condition of the pipe? 4 A. I don't think the word precisely is an acceptable 5 adjective there at all. 6 Q. They gave notice of two specific proposed actions; is 7 that right? 8 A. That's right. It's not precise. 9 Q. Would you accept that you had the chance to consider 10 their two proposed actions? 11 A. I obviously had a chance to consider how much time was 12 spent pouring over this I suspect rather less than we 13 spent today. 14 Q. Would you accept that you had the expertise to assess 15 the merits of the proposed course? 16 A. I'd set out in my original report what needed to be 17 doing. That advice I still think is sound. 18 Q. Yes, but -- 19 A. My interpretation of what is there is a matter of 20 speculation and I don't really like speculating in this 21 forum. 22 Q. I think, as you may be aware, the question may be not so 23 much what you originally recommended but the fact you 24 accepted a counter-proposal from Calor? 25 A. I wouldn't use "counter-proposal" either. I think page 56 1 that's a wrong term. I think that's an explanation of 2 what somebody, goodness knows who, might actually do. 3 An explanation, a preliminary explanation of what might 4 be done. 5 Q. It's an explanation of what might be done, however, for 6 a particular purpose that of ascertaining the condition 7 of the offtake pipe, wasn't it? 8 A. The intention, yes. 9 Q. You are not saying I assume that you accepted what was 10 being proposed just because it was proposed by someone 11 such as Calor? 12 A. I think I am saying that actually. I think I am saying 13 that I perhaps trusted that Calor had understood the 14 problem and understood the hazard and that they would do 15 the necessary to ensure that ICL were given sound 16 advice. 17 Q. But surely the situation here was that you were getting 18 a number of proposals in relation to your original 19 report and you had the ability to look at them and to 20 say yes or no to them. 21 A. But you can see that so many of the proposals with 22 Maurice Coville's drawing actually is not clear who is 23 going to do those at all. Who is going to knock bricks 24 out of the wall? I don't know who was going to do that. 25 Who is going to put up a armoured barrier around the page 57 1 tank? I don't know. Who was going to examine this 2 pipe? I don't know. I have to say that that letter is 3 vague on many of the who is going to do things. 4 Q. With respect, it may be -- 5 THE CHAIRMAN: Mr Tyldesley, the second paragraph of this 6 letter begins with the words, "On behalf of ICL 7 Technical Plastics Limited". 8 Do you see that? 9 A. I see that but I actually don't think they could have 10 felt responsible for doing all of these things. There 11 are things in there that clearly we wouldn't expect to 12 be done by Calor staff. 13 THE CHAIRMAN: What they say is that the planned outline 14 suggested suitable remedial action to be taken by Calor 15 Gas Limited. That reads to me as if what they are 16 saying is they will do the work. 17 A. Can we remind what 1, 2, 3 and 4 were but I suspect that 18 includes part of knocking bricks out of the wall. 19 I would be interested to know whether Calor were 20 expected to provide a labourer to do that. 21 THE CHAIRMAN: Mr Ellis, I think we have been all round the 22 houses on this. I have got the picture and can draw my 23 own conclusions from Mr Tyldesley's answers. 24 MR ELLIS: Thank you, my Lord. 25 Lastly then on paragraph 71 I wanted to ask you page 58 1 this. 2 Mr Tyldesley, do you accept that the phrase 3 "competent person" acquired greater importance and 4 perhaps with more onerous duties associated with it in 5 later regulations such as the management of Health and 6 Safety at Work Regulations 1992? 7 A. I really think you should ask others in HSE on that 8 question. I was from 1990 the Technical Specialist 9 dealing with technical issues and fire and explosion 10 hazards. Discussions concerning the interpretation of 11 the words "competent person" doubtless took place in 12 many places in HSE but they would not be ones that came 13 across my desk. 14 Q. Finally, on your view at least, in respect of your views 15 of Calor as a competent person, you seemed to suggest 16 this morning that Calor knew that the installation had 17 not been to standards of adequate protection against 18 corrosion. 19 A. I don't know what Calor knew about that pipework. I've 20 no evidence of that. 21 Q. I was just going to ask you then -- I am having a little 22 technical difficulty which may be my own -- do you know 23 whether Calor actually installed the pipework? 24 A. I have heard since 2004 that Calor did not install 25 pipework. page 59 1 Q. And insofar as corrosion protection was concerned, would 2 I be right in understanding that ICL is a company, part 3 of whose business was the business of corrosion 4 protection? 5 A. I understand that ICL's business involved coating metal 6 articles with plastic but I really didn't inspect the 7 factory operations that day and have extremely little 8 knowledge of their actual operation. 9 Q. Thank you. 10 If I could move on, please, to paragraph 84 of your 11 statement and in that paragraph you give the explanation 12 that we have discussed a lot about Mr Coville's 13 proposal. He would carry out some excavation and I just 14 wanted to ask a couple of things more about that. 15 First of all, would it be fair to say that the 16 Health & Safety Executive's main priority at the time 17 and the problem with which it was mainly concerned in 18 respect of LPG at ICL was the size and position of the 19 tanks? 20 A. I think my main concern, if you look at what I wrote, 21 was that we should get ICL to do anything, frankly. 22 I wasn't terribly confident that they were going to 23 co-operate. But I think you misunderstand the nature of 24 the advice I gave. I listed a whole string of 25 recommendations. They were not intended to be a menu page 60 1 from which somebody pick and chose, "We will do 1, 2, 3 2 but not 4, 5 and 6". 3 I would like to draw an analogy here. If 4 a policeman pulled me up for speeding and walked round 5 the car, as they tend to, and found two flat tyres, seat 6 belts that didn't work, a dud light and no tax disk, 7 what do you think his reaction would be if I said, "All 8 right, I'll buy a tax disk and sort out the lights and 9 I'll put the seat belts on next time, Guv, but please 10 I don't want to do the tyres because it's a bit 11 expensive"? 12 Q. I asked you that question for a particular purpose 13 because I want to put a suggestion to you, that your 14 acceptance of Mr Coville's proposal would be adequately 15 explained by your understanding that there was to be no 16 excavation but that the state of the pipework was not 17 the HSE's main priority and what you have recommended 18 were in the then current guidelines? 19 A. I think looking at this at a distance of 20 years and 20 having said our main priority was to get anything done, 21 that I was glad really to see that at least ICL had 22 somebody in the company I thought was competent and 23 would be able to give them good advice as to what to do 24 next. 25 Q. Would you accept that really the two reasons I suggested page 61 1 might be sufficient to lead you to accept Mr Coville's 2 proposal? 3 A. I don't imagine it was given a great deal of thought at 4 the time I wrote that. I have to believe that it was 5 not something that we would have poured over for 6 half-an-hour wondering precisely what he meant, 7 precisely what he didn't mean. I would just be grateful 8 that we seemed to be getting some progress. 9 Q. Thank you. 10 Now I wonder if I could ask you to move on to 11 paragraph 90 of your statement and in paragraph 90 you 12 quote what is said by Mr Ives in his memorandum dated 13 20th January. Could you have before you, please, page 14 011482 which is that memorandum. 15 You will see in that memorandum in the second 16 paragraph Mr Ives refers to the problem that has arisen. 17 Could I just clarify: would I be right in 18 understanding that the problem referred to was that if 19 there was enforcement action over the size and position 20 of the tank there was no completely satisfactory place 21 for the tank to go? 22 A. Within the confines of the land owned by ICL at that 23 time, that's right. I gave a detailed analysis in the 24 original report. 25 Q. Did you understand Mr Ives' concern about enforcement page 62 1 action to be that if he were to insist upon a completely 2 satisfactory position for the tank, ICL might have to 3 stop using LPG? 4 A. Mr Ives might have been concerned about that. You had 5 a chance to quiz him yesterday. Frankly, it's not my 6 concern if there isn't room for 2 tonnes of gas or 7 1-tonne of gas. We cannot tell people that, "You can 8 have a tonne of gas on your premises regardless of the 9 size and the location of the facilities available". 10 Q. With respect I was just asking you about what you 11 understood to be Mr Ives' concern at the time. 12 A. I think we were bending over backwards to try and keep 13 some sort of LPG facility here and some sort of facility 14 that would allow Calor still to be the supplier. 15 Q. Finally then, would you agree that if, for example, it 16 had been decided to insist upon a new supply pipe 17 between the tank and the factory, that would only have 18 involved a relatively moderate cost and would have been 19 unlikely to have had the result of forcing ICL to stop 20 using LPG? 21 A. No, I think you've got a slightly wrong premise there. 22 I can't cost out replacing the pipe, I can't cost out 23 the labour work and I certainly can't have any 24 information about the profitability of the process that 25 they were operating. It is possible that the process page 63 1 they were operating was already running at a loss and 2 that any maintenance cost would be deemed such that it 3 would push it over the edge and to shut this. 4 On the other hand, if it may have been a more 5 profitable process, they would happily spend 6 considerable amounts of money to maintain their 7 pipework. I can't make that judgment. I do have to 8 make a judgment as an inspector as to what are 9 acceptable standards and they don't vary depending on 10 the profitability of the plant. 11 Q. The point is if the HSE had insisted that a new pipe be 12 installed, we have heard that the cost would be 13 relatively modest and would you accept that insisting on 14 a new pipe was less likely to lead to the factory having 15 to stop using LPG than insisting on full separation 16 distances for the tank? 17 A. You are trying to do a pick and choose again. It's not 18 a case of either/or. I saw at the time of the trial 19 last year a cost given out as to replacement for that 20 pipework. I think that confirmed my opinion that the 21 reasonable practicability balance was clearly such that 22 it would have been reasonably practicable to replace 23 that pipe in 1988 just as it was in the beginning of 24 2004. Separation distances we tend to treat with -- 25 they were agreed in the industry and we tend to want to page 64 1 push them, but I cannot give you any clever detailed 2 scientific or engineering justification for why a tank 3 with 2 tonnes of gas is safe 7.5 metres from 4 the boundary but not safe 7 metres from the boundary. 5 It isn't a sharp dividing line, but it is a dividing 6 line between a pipe that is protected and a pipe that's 7 not. 8 MR ELLIS: My Lord, thank you for that opportunity. I have 9 no further questions. 10 THE CHAIRMAN: Mrs Stacey, do you wish to ask any questions? 11 MRS STACEY: Yes, my Lord. I have one question only. 12 Examined by MRS STACEY 13 Q. Mr Tyldesley, could you tell me please -- and I think we 14 will get this from the first paragraph of your 15 statement, which I think you still have in front of 16 you -- you are now self-employed? 17 A. That is correct. 18 Q. When did you leave the employment of HSE? 19 A. At the end of July 2005. 20 MRS STACEY: That is all I wish to ask, my Lord, thank you. 21 THE CHAIRMAN: Thank you, Mrs Stacey. 22 MR MARTIN: I wonder, my Lord, if I might just follow up on 23 three matters arising from the questions that have been 24 asked. 25 Further examined by MR MARTIN page 65 1 Q. Mr Tyldesley, could you go back to document 11481, 2 please. In answer to questions from his Lordship, you 3 explained that there was system whereby a specialist 4 inspector such as yourself would take any steps to 5 ensure in due course that a particular course of action 6 was followed, such as the excavating of the pipe. 7 When you wrote this memo to Mr Ives and you were 8 responding to Mr Coville's response to your original 9 recommendation 11, when you wrote the last sentence of 10 paragraph number 3, is there any reason why in that 11 sentence you could not have recommended that whatever 12 you expected was to be done by Calor was actually 13 followed up? 14 A. The exchange of documents shows that twice I had a go at 15 saying, "Let's sort this one out once and for all". 16 I obviously could have laid the line even more firmly 17 and I certainly could have explained in greater detail 18 the consequences of a leak and it soaking into the 19 ground and out of the building. So there is no reason 20 why I could not have spelled out in greater detail quite 21 why I was determined to improve this situation. 22 Q. I take it then that you are answering my question in the 23 affirmative. There was no reason why you could not have 24 recommended to Mr Ives, as part of your acceptance of 25 what Mr Coville said, that in due course a check should page 66 1 be made to ensure that whatever you expected was going 2 to be done had in fact been done? 3 A. I can't quite remember the sequence of documents but 4 I was ticked off for -- rather abruptly -- enforcement 5 decisions and my responsibility. I wasn't going to 6 repeat that. 7 Q. That was the subsequent document which is 11482? 8 A. Sorry, I've got the sequence wrong there. 9 Q. I am not asking about your recommending enforcement 10 action. I am simply asking whether or not you could 11 have recommended to Mr Ives that steps were taken in the 12 future to follow-up in order to ascertain what had been 13 done? 14 A. I obviously could have done that but the style of formal 15 reports that usually went from the specialist to the 16 factory inspector were really quite formal and I had 17 gone beyond what was perhaps the normal at the time in 18 making any comment about how this was going to be 19 progressed. 20 Q. The second matter I want to explore with you is that you 21 had recommended switching off the supply when it was not 22 being used and I understand that of course has the 23 effect of preventing a build-up of gas during nonworking 24 hours. 25 What difference would that course of action have page 67 1 made when the gas was in use and supply was being used 2 for the appliance in the factory? 3 A. If the corroded pipework was leaking gas outside while 4 it was being used, then we would still have had the 5 danger of gas leaking in the basement. You can see in 6 hindsight that recommendation is not really a very 7 satisfactory solution but it was one that was seen as 8 simple to implement. 9 Q. Lastly, I understood you to in answer to questions from 10 my learned friend, Mr Ellis, about whether or not there 11 could be some choice amongst the recommendations that 12 you made and you gave the analogy of the policeman 13 stopping you and finding other transgressions after 14 having done so. 15 Is it not fair, Mr Tyldesley, quite clearly to 16 describe the ultimate arrangement as a compromise; that 17 is to say, not a fulfilment of all of your original 12 18 recommendations? 19 A. I really do not like the word "compromise" and I'm not 20 going to accept that. I think there is room for 21 discussion over whether a 1-tonne tank instead of three 22 by 250s is a compromise but I don't think that term 23 applies in any shape or form to anything else. 24 Q. Could you look, please, at 11479. This again was 25 Mr Coville's letter and after he had responded in the page 68 1 second paragraph to your recommendations 1, 2, 3 and 4 2 and your recommendation 11, it was he in the beginning 3 of the third paragraph who said that the above measures 4 formed an acceptable compromise, did he not? 5 A. Mr Coville can write the word "compromise". I don't 6 think you will find the same word in what I wrote back. 7 Q. No, but you saw that he was referring to what was being 8 proposed as a compromise, did you not? 9 A. We can see lots of ambiguities in that letter. It is 10 very easy 20 years on to realise that that letter is not 11 as clear as one might have wished. 12 Q. Forgive me, a compromise was something that he was 13 suggesting. 14 Could you look, please, at 11482 which is Mr Ives' 15 response to your response to a letter from Mr Coville. 16 This is the one in which at this stage he emphasises 17 that enforcement policy is a matter for him but in the 18 fourth last line of the end of the memo, Mr Ives states: 19 "I deem it better that we try and reach a reasonable 20 compromise and solution than rush into enforcement 21 action ..." 22 A. He is there referring to one specific problem, and that 23 is the size of the tank. As I tried to explain a little 24 earlier just now, there is no very sharp and clear line 25 between saying that the tank just with slightly greater page 69 1 separation distances than those in HS(G)34 is entirely 2 safe, than those with marginally less separation 3 distances than you will find in the table is somehow 4 completely unacceptable. 5 That isn't a sharp line and no technical 6 justification could be given for it if people chose to 7 argue in the courts or more likely an improvement notice 8 appeal. So John there was referring to 1-tonne of gas 9 and three by 250s. 10 Q. But both Mr Coville, perhaps to a greater extent, and 11 Mr Ives, perhaps to that limited extent, each saw what 12 was being achieved to some extent as a compromise, did 13 they not? 14 A. They did: I don't. 15 MR MARTIN: Thank you very much, Mr Tyldesley. 16 Thank you, my Lord. 17 THE CHAIRMAN: Thank you for your evidence, Mr Tyldesley. 18 THE WITNESS: I've got just a few comments I would like to 19 say on my own, please. 20 THE CHAIRMAN: Just a minute, Mr Tyldesley. 21 THE WITNESS: It will only take a minute. 22 THE CHAIRMAN: Mr Tyldesley, just a moment. 23 What is it you want to talk about? 24 THE WITNESS: It relates to some words I'd like to say to 25 the families. page 70 1 THE CHAIRMAN: I'm sorry? 2 THE WITNESS: Some words I'd like to say to the families. 3 Am I allowed to proceed? 4 Last September after the prosecution was complete 5 but before this Inquiry was announced -- 6 THE CHAIRMAN: Mr Tyldesley, please, just a moment. (Pause) 7 Mr Tyldesley, it is obvious you feel strongly about 8 certain things in this case. If you wish to say 9 something to the relatives, then I am not going to stop 10 you. Please continue. 11 THE WITNESS: It will only take a minute. 12 Last September after the prosecution was complete 13 but before this Inquiry was announced, I put on my 14 website some comments about ICL. These include an 15 apology. I was, and still am, sorry that this disaster 16 wasn't averted. Towards the end of the year (inaudible) 17 Oates, who acted at that time for HSE staff, told me to 18 remove this web page. Somewhat reluctantly I did. 19 During May, when my statement to this Inquiry was 20 being prepared with the help of Pinsent Masons, I wanted 21 again to find a way of saying sorry. We explored 22 various forms of words but could not find any that did 23 not either imply, however obliquely, that anyone else 24 might have anything to say sorry for or appear to take 25 on my own shoulders responsibility for matters over page 71 1 which I did not feel 100 per cent responsible. So these 2 paragraphs were left out. 3 It seems that once the legal processes start, the 4 word "sorry" becomes very difficult to say. Despite 5 that, I just want the families to know where my 6 sympathies lie. 7 THE CHAIRMAN: Thank you very much, Mr Tyldesley. Thank you 8 for your evidence. 9 (The witness withdrew) 10 THE CHAIRMAN: This being a rather arduous morning and the 11 LiveNote writers having been fully stretched, I think we 12 will just stop now and resume about 1.50 if that would 13 be convenient. 14 (12.35 pm) 15 (Luncheon Adjournment) 16 (1.50 pm) 17 ALISTAIR DOUGLAS MCNAB (called) 18 Examined by MR MARTIN 19 Q. Mr McNab, I think you have a copy of the final version 20 of your Inquiry statement and you would prefer to read 21 it rather than my reading it; is that correct? 22 A. Yes, subject to my throat not playing up. 23 Q. We are more than happy to make allowances for that if it 24 becomes necessary. 25 It is also of some assistance that, as previously page 72 1 intimated, only a part of your Inquiry statement is 2 relevant to the issues which are to be covered in Phase 3 1 of the Inquiry. The other matters are more 4 appropriate in Phase 2. I think it was noted that it 5 would be paragraphs 5 to 64 I think in the current 6 version logical conclusion of the Phase 1 aspects of the 7 evidence are at paragraph 66. 8 I wonder if I might begin then and will seek to 9 assist you with your difficulty if I can, insofar as 10 paragraph 1 is concerned you were discussing your role 11 in this matter as one of Her Majesty's Inspectors of 12 Health and Safety in 1992. 13 In paragraph 2 you give reference to your extensive 14 experience by reference to an appendix and in paragraph 15 3 you state that you are currently employed by the 16 Health and Safety Executive as Head of Operations for 17 the Field Operations Division (that is FOD) based in 18 Glasgow. 19 At the time of the explosion you were her Majesty's 20 Principal Inspector in the Hazardous Installations 21 Directorate, Chemical Industries Division in Edinburgh 22 having moved there in 1999. 23 Can I just ask what actually was your position in 24 1992 when you visited the premises as you are about to 25 tell us? page 73 1 A. I was an HM inspector working for John Ives. I had 2 moved into his team after coming back from secondment to 3 Greater Glasgow Health Board, I think, in September 4 1991. 5 Q. I was going to ask you that. So your direct line 6 manager was Mr Ives; is that right? 7 A. That's correct. 8 Q. Yes, obviously we know that Mr Tyldesley was 9 a specialist inspector who was simply called in as 10 a member of the Field Consultants Group so he did not 11 fall within that line management; is that correct? 12 A. That's correct. 13 Q. In paragraphs 4 through to 10 you give reference to 14 various documents and background material which I do not 15 think I need to take up time actually looking at. 16 In paragraph 5 you refer to the HSE guidance CS5 and 17 also HS(G)34 which we have looked at otherwise and we 18 will look at again. 19 In paragraph 6 you refer to HS(G)34. 20 In paragraph 7 you refer to your general awareness 21 from your degree and postgraduate diploma about 22 potential incidents with LPG and you also refer to the 23 expression we have heard previously, which is BLEVE 24 (boiling liquid expanding vapour explosion). 25 A. Yes. May I add something that I have mistakenly put in page 74 1 my CV and I think would help the Inquiry with my 2 knowledge on LPG? 3 Q. May I ask if you could pull the microphone -- 4 A. I will move forward. 5 Q. Not least the transcriber has to hear your evidence 6 clearly, as do the rest of the room. 7 Please carry on. 8 A. In terms of paragraph 5, in 1983 I investigated a major 9 incident with LPG cylinders about 70 cylinders LPG plus 10 oxygen in a demolition yard in Johnston which involved 11 oxygen cylinders flying off site and firefighters being 12 injured. So I had a lot of knowledge of the danger of 13 LPG in general terms. 14 Q. In paragraph 7 you also refer -- 15 A. Sorry, I beg your pardon, I also reported that with the 16 Procurator Fiscal, a guilty plea and maximum fine. 17 Q. Paragraph 8, again as part of your experience you were 18 aware of major incidents in Mexico City and Feysin as 19 well as smaller scale incidents with smaller tanks. 20 I am assuming that would include the one in Johnston you 21 just referred to? 22 A. Yes, I think Mexico City as I recall was refinery scale. 23 It was spheres, thousands of tonnes, not 1 tonne/2 24 tonnes. 25 Q. In paragraph 9 you say you: page 75 1 "... do not recall being aware of any ban on 2 pipework, either natural gas or LPG, in lower than 3 ground floor rooms. I was generally aware that HS(G)34 4 suggested preferable routing other than through 5 buildings, specifying pressures above 37 millibars 6 gauge." 7 You then talk about the fact that gas LPG is 8 normally odourised or stenched so that any leaks can be 9 detected by smell and action taken. 10 Is that because if it is in its natural state as 11 such, in its manufactured state, LPG has no odour so the 12 stenching agent, as it is called, is obviously added as 13 a safety feature so people can smell it? 14 A. That's correct. I think it's probably unstenched in 15 specialist applications, probably aerosol filling. 16 Q. Then in paragraph 10 you speak of experience via your 17 diploma and HSE inspectors obtaining on-the-job 18 training. 19 You were made aware of the main causes of loss of 20 containment of LPG, such as cold catastrophic failure of 21 a tank. 22 Do I take it that is because the cold makes the 23 metal more brittle and it may fracture? 24 A. I think that references more to instances not involving 25 a fire. There is not a fire engulfing the tank. It is page 76 1 what we would call a latent defect, 2 a manufacturing design defect, where perhaps a weld 3 hasn't been done properly and the tank fails because of 4 that. I have to say I'm not aware of any or many of 5 those but it theoretically would be a concern obviously 6 if a tank is not robust enough. 7 Q. Then I think we can take other possibilities as read. 8 I wonder whether I could ask you to begin reading at 9 paragraph 11, please? 10 A. "The file history shows that HSE saw ICL as having one 11 of the worst factory LPG tank positions. Although not 12 stated explicitly, this was the concern that an adjacent 13 fire could overheat the tanks causing a BLEVE. If ICL 14 fire precautions and procedures were not able to control 15 escalation BLEVE had the potential to seriously damage 16 people and structures and potentially seriously injure 17 or kill offsite population via missiles or fire ball. 18 That is why inspectors concentrated on the tanks as the 19 priority rather than the pipework." 20 Q. I am sorry, Mr McNab I am not sure we are hearing you 21 particularly well. I can only just hear you. It may be 22 my fault but I wonder if you could pull the microphone 23 a bit closer. I know it is awkward. 24 A. Is that better? 25 Q. I think it is. It is no criticism. It is easy to move page 77 1 back a little bit and I am afraid the microphones seem 2 to be pretty sensitive to the closeness of the speaker. 3 So please bear that in mind, if you carry on that 4 paragraph 12. 5 A. "At all sites with bulk LPG, I inspected in line with 6 this priority order as the custom