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Executive summary
Introduction On 11 May 2004, nine workers were killed and more than thirty-three injured in an explosion at the ICL Plastics plant of Grovepark Mills in Maryhill, Glasgow, This was the worst health and safety incident in Scotland since Piper Alpha in 1988 when 167 lives were lost, and the worst on mainland Scotland since the 1960s. This report has been produced by a multi-disciplinary team of academics and experts with specialist knowledge in the fields of occupational health and safety, finance, employment rights, architecture, corporate accountability and industrial relations. Their intention was not to duplicate or mirror the official investigation but to examine issues and raise questions that might be neglected or under-explored by that investigation. The principal aims of the research team and their report were as follows:
• One recent estimate suggests that globally as many as 5,000 people die daily from work-related injuries and illnesses. The Health and Safety Executive’s (HSE’s) figures – an underestimate – reported 593 UK work-related deaths for 2004-5. • Despite these statistics little importance is often attached to this serious social problem of industrial illness and injury. Explanations for this include legislative and regulatory weakness and a health and safety deficit in workplaces where workers lack collective empowerment through trade unions. • Contributing to this health and safety deficit has been the reluctance to criminalise employers who commit safety offences. • The very language (and concepts) used is part of the problem. Terms such as ‘human error’ or ‘normal accidents’ suggest wrongly that industrial accidents are either normal and unavoidable occurrences, or attributable to the actions of individual workers, thereby masking broader realities such as employer-driven cost cutting, lack of worker representation and consultation and/or regulatory failure. • Over many years the HSE has recorded significantly higher rates of fatal and major injuries for Scotland as compared to the UK as a whole. For example, between 1996/7 and 2005/6 Scottish employees have averaged 58% higher rates of fatality than the UK overall. Scottish workers are thus at greater risk. • HSE’s attempts to explain this ‘Scottish anomaly’ have produced unsatisfactory conclusions. Alternative explanations include weaknesses in the inspection and prosecution of safety offenders. To illustrate this – at the time of the Stockline disaster the HSE reportedly had only 68 inspectors to police 600,000 out of about 3 million workplaces, in a UK-wide context where inspection has been de-prioritised. • In Scotland, the impact of the de-emphasis of enforcement has been aggravated by lower levels of fines on safety offenders, of prosecutions resulting from workplace deaths/serious injuries and of investigations resulting from work-related illness. While in England and Wales, eight company directors and five companies have been convicted of manslaughter, no director or company has ever been convicted of a homicide offence following a work-related death in Scotland. • The Research Team used ‘action research’ methods, based on the participation of a group of seven ICL Stockline workers and ex-workers representative of different sections/functions in the plant. Both ‘risk mapping’ and ‘body mapping’ exercises were used whereby workers provided unrivalled evidence of working conditions, potential hazards and symptoms of ill-health. In-depth worker interviews provided further invaluable data. • Ethical research protocols - including written consent, confidentiality and the anonymisation of contributions - were adhered to throughout the research process. The one exception to the anonymised interviews was that freely given by Laurence Connolly Snr who wished to make public his experiences, particularly in his dealings with the Health and Safety Executive. • The worker-centred research approaches were combined with methods used by academics drawing on their areas of expertise, including finance and accounting, industrial relations, the built environment, regulation and health and safety.
• As the parent company, ICL Plastics has control over all six companies within the group, including ICL Tech. ICL Plastics and ICL Tech were the two companies named in the criminal charges. • Scrutiny of the accounts registered at Companies House suggests that Campbell Downie, as the majority shareholder of the entire group and a Director of five of the six companies, was the dominant controlling figure for the whole group. • There is little doubt that the parent company (ICL Plastics) was cash rich as can be seen from the following table.
• At the global policy and financial levels Campbell Downie appeared to exercise total control. At an operational level authority for the day-to-day running of the factory was delegated to the Managing Director, although even here Downie was heavily involved in operational matters. The evidence from workers’ testimonies suggests that Downie attended the premises on a daily basis, walked through the workshops regularly and took most operational decisions. Ultimately, the style and substance of decision making and the exercise of authority appears to have rested with the Downie family. • Workers report an authoritarian style of management from the top down and a long-standing and overt hostility to trade unionism. The following quotes relate to reported attempts to establish a trade union in the plant.
• More broadly, employment relations were characterised by an absence of consultation with the workforce on either a formal or informal basis.
• Grovepark Mills was a four-storey building. Beneath the ground floor was a basement which contained a large number of steel supports (ACRO props). The ground floor and its annex contained many processes and much machinery, including the fabrication sections, coating shop, compressor room, shot blasters, electric and gas ovens, pallet and powder storage, gas tanks, heaters and despatch. The first floor contained various store rooms, racks, pallets, lockers, tools, forklift trucks, CNC milling machines, ovens and a canteen. The second floor contained the general offices of ICL and Stockline. The third floor housed more storage areas containing inter alia paper records, exhibition stands and a boiler. Above this floor was a flat roof. • Fabrication consisted of batch production of variable volume. Orders could be repeats or could consist of one-off products. Consistent with these jobbing production methods production seemed to involve taking all the work that was offered, irrespective of whether the productive resources could cope with the demands. Around a dozen employees worked in the main fabrication area with a couple more working in an outbuilding. Plastic sheets would be cut to size or were pre-cut and then worked upon in various ways – sawed, placed in the oven for formatting or finishing, machined, cemented or welded together. • Six workers were employed in the coating department where incoming parts would be blasted with fine aluminium powder, de-greased using Genklene, coated and then cooked in gas ovens to harden. • Two workers were employed in despatch and the remainder of 50+ workforce were employed in various ancillary and managerial roles and in the offices. • Cost-minimisation was a central imperative linking production, market niche, managerial style, employment relations and labour utilisation. Workers reported increasing pressure to improve productivity through intensified monitoring. • Symptomatic of the company’s preoccupation with minimising costs was the decision taken to reduce some workers’ holiday entitlement, triggered ironically by a mistaken interpretation of the European Working Time Directive at the time of its introduction in 1998, as this worker reported.
• The health hazards facing plastics workers, recognised for several decades, include skin, neurological and respiratory problems and these are documented in the full report. In addition to diverse chemical hazards, plastic workers often face other dust hazards, noise and vibration hazards, hot and cold working conditions, manual handling and machinery hazards and poor welfare arrangements. • By 1997 occupational health professionals had documented a wide range of chemical and physical hazards attached to materials, processes and machinery in the plastics industry, leading to recommendations that proper medical surveillance and workplace controls (including adequate ventilation and exhaust systems, regular air monitoring and properly fitted personal protective equipment - PPE) be put in place. From worker accounts and the evidence encapsulated in HSE correspondence and statutory notices, it is difficult to identify such effective measures in place in the plant. • The unavailability of records and data on what substances were used at ICL Stockline, on engineering controls and personal protective equipment, despite requests by the Research Team to the HSE, means that it is not possible for us to ascertain with certainty exactly what levels of exposure to what substances occurred at the plant. Nevertheless, as we document, worker accounts provide factual insight. • Many of the chemicals used at ICL Stockline presented potentially serious threats to human health, e.g. methylene chloride, dichloromethane, styrene, trichloroethylene. Worker testimonies indicate that, in many different respects, such substances were not controlled at various times at all by engineering methods. In several instances there were no extraction or proper local ventilation systems available. Workers report that initially they were provided with no protective equipment and then later only with masks or gloves but with no information, instruction, training or supervision regarding their appropriate use. • The Research Team did access a report by Glasgow Technical Services produced immediately after the disaster which listed the chemicals and materials they could identify on the site. These include hazardous substances which could present a range of acute and chronic, short-term and long-term adverse effects to those exposed. • Most significantly, we have an extensive set of accounts by workers who list a wide range of symptoms they experienced when carrying out various production processes and when exposed to dusts and fumes in hot and poorly ventilated workrooms. Workers even reported the presence of asbestos. • The risk mapping exercise enabled us to build up a physical and organisational picture of a workplace, processes and material to identify where hazards existed, what risks were attached to those hazards and the impact of those hazards on workers. • Workers identified risks throughout the building. For example -
• The lack of effective extraction appeared to have been a particularly serious problem in the fabrication and coating sections and was related to the presence of dust (from plastics or MDF) and fumes (including those from solvents or cleaning agents).
• Other related risk relate to potential exposure to hazardous chemicals and to fumes burnt off during the curing process from the ovens.
• The ovens themselves were regarded by workers as hazards. One had been fabricated from parts of a bin lorry but even this was regarded as less of a problem than the condition of another oven.
• Workers described signs and symptoms consistent with exposure to some of the substances listed above and the known adverse effects. The most commonly cited were effects on the respiratory system, but these were often experienced in combination with a range of other complaints/symptoms.
• Workers’ testimonies constitute a powerful indictment of the general approach to health and safety management taken by management at ICL Stockline. They reveal the routine disregard of health and safety legislation and statutory regulations, including serious breaches of COSHH regulations. There are many graphic examples of this negligence, of which the following complaint following exposure to chemicals is quite typical.
• Working with some of the machinery proved quite dangerous.
• Presaging the now identified cause of the disaster, workers reported that they were aware of serious problems that had emerged with regard to the gas pipes.
• Apparently belated attempts were made with regard to health and safety practice, but these did not lead to action over vapours gasses, dust, temperature extremes or the effects of chemical hazards. In the words of one worker, they amounted to instructions such as, ‘Keep the place tidy! Get things up on the walls!’.
• Employers have legal responsibilities to ensure the provision and exchange of information and information and instructions that enable employees to be properly informed about risks and health hazards and to provide appropriate training. For example, under the Health and Safety (Consultation of Employees) Regulations, in circumstances where there is no trade union recognition, employers must ensure that a system for consulting workers on health and safety is in place. The regulations allow for the company to choose between a system of consultation through safety reps elected by the workforce or a system of direct consultation. • Given that there were no elected safety reps at ICL Stockline, it was incumbent on management to directly inform the workforce on information from the accident books and any assessments made under COSHH regulations. Workers’ testimonies provide clear evidence that ICL Stockline’s organisation of H&S representation and consultation fell well short of legal compliance. For example, contrary to the minimal legal requirement, management apparently failed to provide its workers with a prepared statement of general policy.
• The health and safety training, instruction, supervision and communication systems and practices appear to have been seriously deficient. • Contrary to the Management of Health and Safety at Work Regulations (1999) and the COSHH regulations, no risk assessment was undertaken by management during the years of employment according to the knowledge and recollection of the workers’ interviewed. No workers were recalled ever having been involved in the specific process of risk assessment. On at least one occasion employees put specific requests to management under the regulations.
• The key piece of legislation in relation to the use of protective equipment in the workplace is the Personal Protective Equipment at Work Regulations (1992). PPE should be appropriate for the task and for the substances to which it is applied. Yet, notwithstanding the obvious hazards, all the workers interviewed insisted that management for many years had neglected to provide important items of protective equipment. Telling evidence comes from Laurence Connolly.
• The equipment that was latterly provided often proved to be inadequate.
• Perhaps the most telling observation regarding the lack of protective equipment is provided by one of the workers interviewed.
• The HSE failed to recognise the nature of industrial relations at the plant and the potential problems that employees might face if management discovered that they had approached HSE with complaints about health and safety. This failure is summed up by the readiness with which HSE inspectors revealed the identity of a worker in full view of the very same managers he had complained about. This episode revealed at best a staggering naivety on the part of HSE and, at worst, collusion with management that risked compromising workers’ employment status. • HSE failed to recognise the importance of keeping lines of communication open with workers as well as with management. Laurence Connolly’s testimony demonstrates HSE’s failure to have communicated with workers either before or after regulatory contacts with ICL/Stockline. This failure meant that workers were denied important information gathered by HSE relating to their employers’ compliance with the law and relating to the risks to which they were being exposed. HSE’s abject failure in this respect therefore disempowered workers in their efforts to improve health and safety conditions at the plant. • HSE inspections seemed, according to this testimony, unable to comprehend the complexity and gravity of the hazards that workers were exposed to in the plant. Thus, it appears that key features of the risks that workers were exposed to (air quality and the integrity of purpose built equipment in the plant) were barely investigated. The need for a more comprehensive approach to the ongoing inspection of safety critical features of safety management and the management of hazards is supported by the evidence provided by workers in this report. Only comprehensive testing of known process hazards and full communication with workers would have improved HSE’s ability to identify the key problems at the plant. • The ability to identify health and safety problems during HSE ‘walk-through’ inspections would certainly have been limited by the advance warning that pre-ceded visits and afforded management the opportunity to carry out a quick health and safety make over. • All those features of HSE’s approach to regulating safety at ICL/Stockline stem from the ‘compliance’ regulatory philosophy adopted by HSE outlined in the introduction to section 6 below in which the trust and co-operation of managements is the primary aim of the regulatory process. This brief exploration of the regulatory issues relating to ICL/Stockline reveals the fundamental contradiction that exist in system of regulation that is heavily biased towards the protection of managements’ right to manage, even where this involves a serious compromise of workers’ safety and health.
• The question remains as to why such a factory - which was clearly demonstrating symptoms of structural stress under increasing live loading conditions - was allowed to accommodate a variety of hazardous processes with a high explosion risk? • The anecdotal evidence from the workforce points to the management adopting a "running repairs" strategy to floor joist deflections and cracking brickwork, rather than undertaking a detailed structural assessment of the buildings capability to support live loads from material storage. The reports that the ground floor had been "held up" with temporary ACRO props (scaffolding poles) for many years, provides further proof of this somewhat haphazard approach to structural safety’. • Where there is a risk of explosion a framed structure is now required to ensure that in the event of such, the removal or displacement of an external brickwork panel will not result in similar progressive structural collapse. • If relatively major structural works have in the recent past been carried out to the factory, why is there no evidence of a Building Warrant? • Did the management carry out any risk assessments as to whether the building structure could support the additional loadings from palletised materials and new processes? • Why were the repairs to the areas of the building that were clearly showing structural stress (floor deflections) of a makeshift nature? • Given that these structural problems were evident to many of the workforce why did the management not engage a structural engineer to undertake a use and condition survey? • Why was a factory, which was clearly demonstrating symptoms of structural stress, allowed to accommodate a variety of hazardous processes with a high risk of explosion? • Who was primarily responsible for ensuring that the structural integrity of the factory was regularly assessed and what statutory/executive agency is responsible for ensuring such inspections occur? • Dr Stirling Howieson reported, ‘After further investigations it appears that in 1993 an application for a Building Warrant (no. 1993.1310) was submitted to cover "storm damage" to the ICL factory. It does not appear that any warrant was however either issued or discharged (normally signifying completion of the works to the agreed standard). There is reportedly a file note saying that storm repairs do not require a warrant. I have requested that Building Control confirm that this is the case, in writing. No drawings can be found either at Building Control or at the Mitchell Library’. Building Control have no records of any warrant applications and thus any significant alterations to the factory (slappings for fork lifts etc) undertaken over the last 25 years, as reported by the workers would have been "illegal". If this work had been done properly and professionals employed to undertake calculations it would have increased the likelihood of an Architect or Structural Engineer being allowed the opportunity to view the building and identify any shortcomings in the structural integrity re: the imposed loadings/ beam deflections and 'Akro' props in the basement. Any alterations appear to have been done without any specialist engineering input that would have calculated the loads on the new steel/concrete RSJs/lintels. |