Opinion: No one has time to read any more

More Buncefields unless we start reading? See the scene of the latest disaster below.

The Explosion Mechanism Technical Group of the Buncefield Major Incident Investigation Board (MIIB) recently presented the results of its investigations at a meeting of explosion specialists. The slow unravelling of the mechanism highlights our apparent general inability to read, digest and retain crucial information.

It’s embarrassing enough that the Buncefield explosion took us all by surprise: regulator, industry and fire & explosion community (including ASK). True, there did not seem to be a plausible explanation for it: when ignited, the cloud of petrol vapour should have burned without any blast or any appreciable off-site impact. Vapour cloud explosions (VCEs) had been understood to require partial confinement of the flammable cloud by buildings and/or congestion by process units, criss-crossing pipework bundles etc, but such features appeared to be almost totally lacking at Buncefield. The explosion appeared to have taken place in a large open space.

At the time of the incident, it was widely held to be unprecedented. The MIIB stated that it “would not have been anticipated in any major hazard assessment of the oil storage depot prior to the incident”.

However, literature searches quickly revealed several unnervingly similar precedents, for example in Newark, New Jersey (1983), in Naples (1985) and in Saint Herblain, near Nantes (1991). Each of these had been reported in detail in high impact journals, one as recently as 1999.

The MIIB Technical Group has finally pinned the blame for the explosion upon the congestion offered by branches, twigs and foliage of the trees bordering the Buncefield site. They might have spared themselves much labour – and an illusory eureka moment – had they been aware of modelling results, published the year before Buncefield, which set out in detail the explosion mechanism now proposed. Neither the journal (Journal of Loss Prevention in the Process Industries) nor the title of the paper (“Do tree belts increase risk of explosion for LPG spheres?”) is in the least obscure. Yet no one at the meeting recalled having seen it when it was mentioned by an ASK consultant [1].

How could it have been forgotten so quickly – and then overlooked by the MIIB Technical Group?

Prof Trevor Kletz, that oracle of process safety and loss prevention, has coined the phrase “corporate forgettory” to explain how the same accidents keep happening again and again, sometimes even within the same company. “In medieval England”, he muses, “there were officials called Remembrancers whose job was to remind the king’s courts of matters that they might otherwise forget.”

From the above, it seems that many reports relevant to the understanding of major accidents never even get a chance to be forgotten about – because they are not read in the first place. Are we too busy with our own publications? Is it the distraction of email, or do we drink too much coffee? No one these days, it seems, can find the time to read, or at least to digest what they do read. The irony, of course, is that it would save an awful lot of time (among other things) in the long run if they could.

[1] We had cited the paper when arriving at similar conclusions to those of the MIIB Technical Group as early as 2006, following our investigation on behalf of Hertfordshire Oil Storage Ltd. Despite having limited access to the physical evidence, we identified the same ignition source and pointed out the trees as being potentially responsible for the blast.

STOP PRESS: Buncefields are becoming more frequent. On 23 October 2009, at the Gulf Petroleum site, San Juan, Puerto Rico, a spill from an overfilled petrol storage tank generated a vapour cloud which exploded on ignition. Did the trees play a part?

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