Corus UK Ltd, Port Talbot No 5 Blast Furnace Explosion

Introduction

Port Talbot Number 5 Blast Furnace exploded catastrophically at 5.15pm on 8th November 2001.  The explosion was associated with the failure of two Furnace water cooling pumps on 7th November 2001.  All the water pumps were found to have been endemically unreliable in the weeks before the explosion, and the failures on the 7th November were part of a continuing pattern.  In consequence of the pump failures a number of Furnace coolers failed due to overheating, and there was a prolonged delay in detecting (and isolating) the failed coolers.  About 55 tonnes of water entered the Furnace.  The subsequent attempts to recover the chilled Furnace on 8th November were made more challenging by a further water ingress.  The explosion resulted from a sudden pressure rise caused by the interaction of molten metal and slag, and entrapped water, in the Furnace.

Three men, Stephen Galsworthy, Len Radford and Andrew Hutin were killed in the explosion, and 12 others were seriously injured.

Corus UK Ltd was prosecuted by HSE and the case was heard on 14th and 15th December 2006 at Swansea Crown Court before High Court Judge, Mr Justice Lloyd Jones.  Antony Donne QC and Andrew Langdon QC represented the Crown, and Hugh Carlisle QC appeared for Corus.

Corus pleaded Guilty to breaches of sections 2(1) and 3(1) of the Health and Safety at Work Etc Act 1974, in that it failed, so far as was reasonably practicable, to ensure the safety of employees and contractors at Port Talbot.  Corus claimed that the “explosion of the type and magnitude that occurred was neither foreseen nor foreseeable at that time”, and this was accepted by the Prosecution.

The Judge fined Corus £1,333,000 and ordered the company to pay costs of £1,744,474.  In passing sentence the Judge said “The lamentable catalogue of failures makes clear that this was an accident waiting to happen”.

The Prosecution followed an extensive and meticulous investigation of the causes and circumstances of the disaster mainly carried out by HSE South Wales staff, and by the Health and Safety Laboratory, Buxton.  The latter carried out a detailed analysis of the failed Furnace, and sought to establish the precise mechanism of the explosive event.  HSL and HSE were greatly assisted by an expert witness report on the ‘mechanism’ of the explosion by Professor Venart, a Canadian thermodynamics specialist with extensive experience in process accident investigation.

Richard Booth, Professor of Safety and Health at Aston University, and HASTAM's Chairman also acted as an expert witness in the case.  He prepared a report for the Court on the causes and circumstances that led to the explosion.  His colleagues Mike Thomas and Dr Tony Boyle played a major role in its preparation.  Our involvement in the investigation is outlined at the end of this news item. 

HSE has indicated that it will publish a full report on the explosion in a matter of months as it is now able to put into the public domain much more information than it could before the Court hearing.

Prosecution Statement of Case

Antony Donne QC set out the Prosecution’s case as follows:

“At 5.15 pm on the afternoon of the 8th November 2001 there was a massive explosion within Blast Furnace No. 5 at Port Talbot Steel Works.  The force of the explosion was such that the top part of the whole of the furnace rose about 2ft and shifted sideways about 4 inches before dropping back.  A mass of furnace material and gas was expelled through the gap into the Cast House, the building surrounding the bottom part of the furnace.

Three Corus employees, Stephen Galsworthy, Andrew Hutin and Len Radford were killed and many others were injured - 12 seriously.

The cause of death and injury was exposure to heat, flame and blast impact.  The conditions were such that Andrew Hutin’s body was not recovered until the following day.

The explosion shocked, saddened and angered the Port Talbot community.  It was caused by a chain of events which came about not just from individual errors at lower levels in the Company but by long standing faults in Company procedures, systems, installations and maintenance, including a pattern of failures at management level to act upon reports and recommendations highlighting past and future areas of problems and potential danger.

If it had not been for these management failures, the explosion would not have happened.

It is the Prosecution case that this was a tragedy which was entirely avoidable.

The immediate cause of the explosion was a chain of events as follows:

• On the morning of the 7th November there was a period of time (probably about twelve minutes) when the water supply to the coolers of Blast Furnace No. 5 was reduced by 45%.  This came about because a switch of transformers governing the flow of electricity to one of the two pumps then in use for pumping water to the cooling system caused it to trip.  Within seconds the back-up pump also tripped.          
• The reduction in water supply to the coolers caused a number of them to overheat, burn out and leak substantial quantities of water into the furnace.
• It took a very long time (over ten hours) for the leaking coolers to be detected and isolated.  The switch of transformers took place at 08.45 and the leaking coolers were not detected until about 19.00.  In that time about 50 to 60 tonnes of water, possibly more, leaked into the furnace.
• The water ingress into the furnace caused its cooling.   This led to a solidifying of the molten materials in the furnace, making it difficult to extract more than a very small amount.
• Efforts were made during the night of the 7th/8th and during the day of 8th November to extract molten metal, but with very limited success.
• On 8th November there was a further substantial leak of water into the furnace.
• The interaction of water and hot molten materials in the Furnace caused the explosion.”

The prosecution went on to explain the details of their case under the following headings.

• The workings of a Blast Furnace
• The risks and hazards of water/hot material mix
• The history of Blast Furnace No. 5
• Events prior to the 7th November 2001 in relation to Blast Furnace 5
• The events of 7th November 2001
• The events of 8th November 2001.

Antony Donne read out to the Court harrowing statements by the families of the deceased that had a profound impact on all who heard them.

The Judgement

In reaching his decision on the appropriate level of fine Judge Lloyd Jones accepted that there was no deliberate decision by Corus to breach safety duties, and that profits were not put ahead of safety.  However, he commented that “the warning signs were very clearly there”, that there was an attitude within management which was “casual and sloppy” involving a “lamentable catalogue of failures”.  He emphasised that he placed no blame on any individual and indeed praised the bravery of those involved at the time of the explosion.  In the view of the Judge, the failures lay with management, not individual employees.   In his summing up, the Judge went step-by-step through the prosecution case, indicating his agreement with it - indeed he added a number of criticisms of Corus that were not part of the Crown Statement of Case.  He said that Corus had fallen well short of the duties under sections 2(1) and 3(1) of the Health and Safety at Work Etc Act 1974

The Judge listed a series of previous health and safety prosecutions of Corus and said that he saw these as aggravating features.  He said the company’s health and safety record was “very poor”.  He stated also that the deaths and serious injuries were an aggravating factor in the case.  Other aggravating factors included the failure to implement recommendations from previous internal enquiries, and that the pump failures were part of a continuing pattern, not isolated events.

He cited relevant case law as a foundation for his decision on the size of the penalty.  He noted that a larger fine would have been merited had members of the public also been put at risk.  He emphasised that any fine would seem inadequate compared to the loss of life and that the purpose of the fine was not to provide compensation, nor was it a measure of the value of a life.

He concluded that a fine of £2million was appropriate, but allowed a reduction of one third in recognition of the fact that Corus entered a guilty plea as early as they reasonably could.  He ordered Corus to pay the full Prosecution costs of almost £1.75m.

HSE Press Conference

In a statement at the conclusion of the case, HSE Director for Wales, Terry Rose said:  "Having met with the families of Mr Galsworthy, Mr Hutin and Mr Radford over the last five years I want to pay tribute to them.  I have seen their grief and frustration, and we should all recognise that whatever has happened today cannot bring back their loved ones.  Fines are insignificant alongside that.

“This was systematic corporate management failure at the Port Talbot works. Proper management attention may have broken the chain which led to the explosion. I hope Corus, and indeed the iron and steel industry worldwide, learn from Port Talbot and make sure that those lessons are put into practice in their management systems, and maintained.

“This must be a wake up call for the industry. The process is centuries old but the risks need to be managed to the highest modern standards."

The explosion was caused by water in the furnace coming into sudden contact with hot material.  As water turned into steam it expanded rapidly, creating pressure, which blew a confined vessel apart.

Terry Rose went on to say: "As far as we can establish an explosion of this magnitude is unprecedented in any blast furnace anywhere in the world.  

"The proper design, maintenance and operation of the water cooling system are vital to the safe operation of the furnace and the ability to detect, and stop, water leaking into the furnace in quantity is very important.  Corus failed to do this in relation to Blast Furnace 5.  Those failings were spread over many years, with many different people involved.  That is why HSE prosecuted the company, rather than any individuals.  

"Since the event, HSE has continued to work with Corus to improve its safety management, and will continue to do so but none of this can bring back the men who died, or guarantee that it can never happen again."

HASTAM’s Involvement

Professor Booth was invited by Bond Pearce, Solicitors acting for HSE, to prepare an expert report based on a study of the substantial evidence associated with the case.  The evidence obtained, mainly by HSE, included witness statements, reports prepared by British Steel dating back to 1994, Corus' internal enquiry report on the explosion, Minutes of key meetings, Corus' Energy Department's Power Plant Log, their COMAH Safety Case, and also the transcript of the 17-day Inquest held in July 2005.  His colleagues Mike Thomas and Dr Tony Boyle made a very substantial contribution to the work, for example in the preparation of the Events and Causal Factors and Fault Tree Analyses that were the Report’s foundation.

Both the Prosecution and the Judge quoted extensively from Richard Booth’s Report.  The Judge described the Report as “particularly thorough and helpful”.

The work we carried out for the Court was challenging and of considerable interest.  But in all the circumstances, it was a task that we wished had never been necessary, following as it did the loss of life and very serious injuries.

Events and Causal Factors Analysis (ECFA) and Fault Tree Analysis (FTA) are both techniques widely taught on HASTAM training courses as being the best means of establishing a logical sequence leading to, and root causes of, incidents.  These techniques are equally suited to the investigation of less serious incidents as they are for a major accident of the type described here.

Ironically, Richard Booth was, as part of a 1988 to 1994 HASTAM contract, safety adviser to the company (B-J Construction Ltd) that relined Blast Furnace No 5 for the last time in 1989.