A scathing report by the government's health and safety watchdog into a fire which broke out at Britain's nuclear weapons factory has concluded that it was fortunate that the incident did not lead to “numerous fatalities.”
The report prepared by the Health and Safety Executive (HSE) following an investigation into the fire, which broke out at the Atomic Weapons Establishment (AWE) Aldermaston in August 2010, exposes a wide range of serious and systematic failures by managers responsible for explosives safety at the factory.
The investigation identified a swathe of failures by AWE management which led to the fire, including inadequate risk assessments, poorly trained staff, and failure of safety systems – including systems to ensure that emergency response teams were aware of the presence of explosives. Concerns about explosives safety standards had been reported to AWE management, who had not acted on them.
Despite claims by AWE that the incident was “a relatively small fire”, the HSE report states that the company were fortunate that it did not result in “numerous fatalities”. An internal report into the incident published by AWE “played down” the seriousness of the incident.
The fire occurred on the night of 3 August 2010 when AWE employees were manufacturing a batch of nitrocellulose lacquer, which is used in the manufacture of explosives. The incident left a member of AWE staff with burns to his face and arm and required the evacuation of a number of local residents and the closure of roads around the site as safety precautions.
AWE plc, which operates the Atomic Weapons Establishment, pleaded guilty at Reading Crown Court on 16 May to failing to ensure the safety of its employees in breach of the Health and Safety at Work Act 1974. The company was fined £200,000 by Judge Richard Parkes QC, and was also ordered to pay over £80,000 in legal costs and £2,500 in compensation to the employee who was injured during the fire.
A copy of the HSE report with the findings of the investigation into the fire at AWE has been released to Nuclear Information Service following a request under the Freedom of Information Act (available to download at the bottom of this article). The investigation concluded that AWE's failings were “comprehensive and basic, particularly when compared with arrangements in place elsewhere in the company. The company did not pay sufficient attention to non-nuclear high hazard activities on site which it considered low risk”.
The incident itself resulted in one building being damaged and one employee suffering burn injuries. However, the report found that the consequences “could have been far more severe” if the fire had ignited explosives which were being unlawfully held within the building. Firefighters at the incident “were put at risk because they attended the building without knowing that explosives were present in the building”.
The report found that AWE's actions leading up to and on the night of the incident “fell far below the standard expected in an explosives manufacturing company”. The HSE case officer who led the investigation concluded that prosecution was warranted “as this was an incident waiting to happen and the company were fortunate that the consequences did not lead to numerous fatalities”.
Risk assessments for the explosives preparation process were prepared by “an assessor who by his own admission had only undergone in-house training and did not feel fully competent to conduct a process assessment”. The risk assessment was “last minute and mainly cut and paste rather than a considered assessment”. AWE had been made aware of the shortfalls in risk assessments by a Health and Safety assessor working in the explosives area who had raised “numerous concerns” in November 2009. These concerns had not been addressed by AWE by the time of the fire and there was “little evidence of management acting on the issues brought to their attention”.
The investigation concluded that personnel working in the building where the fire broke out had not been adequately trained to undertake their duties. The HSE report reveals that one employee believed he was not competent to undertake the manufacturing process; another could only conduct the activity under supervision and a third had not conducted the process for some time and had to read the operating instructions on the night of the incident. At the time of the incident all those present had worked their normal shift and were into their fifth hour of overtime. Very few breaks had been taken.
Explosives were being held in the building while the preparation process was under way, in contravention to an explosives safety order The close proximity of explosive materials to workers was described as “extremely poor explosive practice” and safety measures during the process “were well below the standards you would have expected in the explosive industry in general. The report judged that generally “there was a lack of understanding by employees with regard to the hazards” and that “the management of competence failed significantly in this incident”.
The report gives an account of the views of the member of AWE staff who was injured during the fire. The employee felt “upset that he was not made aware of all the risks when handling explosives” and “believes the company misled him with their attitude that nothing would happen. He cannot understand why he did not have the same rigorous training and protection as he did for his normal day job”. After leaving the building where the fire broke out, he was attended by a first aider but a burns pack was not available in the first aid satchel and he had to wait for paramedics to arrive and the key to a gate in a security fence to be found before receiving professional treatment for his injuries. The injured employee told HSE that he “no longer has faith in AWE plc to look after his well being” and that “it appears to him that the company is only interested in saving money”.
In October 2010 AWE's then Chief Executive Officer, Robin McGill, said that a building suffered “minor damage in what was a relatively small fire” while taking members of the AWE Local Liaison Committee on a tour of the site of the incident. “There have been some inaccurate reports about the scale of the incident and it is important that LLC members are in a position to reassure local people”, he said.
An internal investigation was conducted by AWE soon after the fire and chaired by Peter McIntyre, a member of the AWE Nuclear Safety Committee. However, HSE's investigation found that “the company's own investigation report states that it was a solvent fire and has played down the potential consequences”.
Following their investigation, HSE decided to prosecute AWE on three charges of breaching safety laws, but concluded that “the extent of the weaknesses found in AWE's arrangements in the explosives area was such that a string of alternative charges could be laid. The HSE investigator concluded that “there were so many management failings on the night of the incident” that prosecution was the “only realistic course of action.”
However, he went on to add: “What is more disturbing are the catalogue of other failures and erosion of the controls adopted for handling explosives that have been brought to light by the investigation.” AWE's managers failed to identify that these conditions existed, and the indications were “that this was not a one-off occurrence”.