Lessons and challenges in major hazards leadership: a personal perspective
18 July 2019
Jo Nettleton is Deputy Director and Head of Radioactive Substances and Installations Regulation at the UK Environment Agency. In this article, based on her presentation at the Hazardex 2019 Conference, she looks at some of the high hazard incidents that have occurred during her wide-ranging career and reflects on the importance of leadership and collaboration in preventing these incidents. Jo also considers some of the main challenges for the future.
Over the past 30 years, I have been lucky to have had a varied career as a medical physicist and regulator across many sectors (including industrial, public services, biological agents, nuclear, chemical and energy sectors). However, throughout that time, I have dealt with the aftermath of many major accidents across all those sectors – that have resulted in catastrophic impacts for individuals, communities and the environment, sometimes on a global scale.
As I reflect back, I am struck by the depressingly similar learning that arose from incidents across very different sectors and I question how well we are all taking on board those lessons – particularly those around leadership and collaboration. We face some very significant challenges in coming months and years, such as the need for clean energy, to improve the air we breathe and perhaps most significant of all – to mitigate and adapt to a changing climate. I believe it is vital that key players build on our collective efforts, or we will not be ready for those challenges.
The list of major accidents and the range of industries and services affected by those would of course fill many pages; examples include the Barrow Legionnaires’ Disease outbreak, Stockline explosion, Windscale fire, Piper Alpha, Chernobyl, Marley Farm fireworks explosion and fire, Chevron refinery explosion, Zaragosa radiotherapy overexposures… the list goes on! In preparing this article, I have considered four seemingly very different accidents as examples; the Devon and Exeter radiotherapy incident in 1988, the Pirbright Foot and Mouth virus release in 2007, Buncefield explosion and fire in 2005 and the Fukushima Daiichi Nuclear Power Plant explosion and fire following the Tsunami in Japan in 2011.
The Devon and Exeter Hospital radiotherapy incident happened at the very start of my career in 1988 and involved the repeated incorrect calibration of a cobalt teletherapy unit, used to treat cancer. It resulted in around 200 patients being given large overexposures to high energy gamma radiation. Looking back at the investigation findings – now more than 30 years ago, I am struck by two things; the first is that the investigation focused on the technical aspects, rather than looking for wider lessons around leadership and culture. The recognition of the importance of these in managing major hazard risks has certainly increased over the intervening period. However, the report did highlight the need for improved collaboration across the UK (and wider) medical physics community to ensure robust and consistent standards when calibrating such potentially lethal radiotherapy machines. Sadly, the learning was not sufficiently embedded to prevent further similar events – Zaragosa (Spain) in 1990 and Stoke in 1993 being further examples.
The Pirbright Foot and Mouth Disease (FMD) virus release in 2007 took place at the Institute for Animal Health in Surrey – a government-funded, world recognised centre of excellence in research. Whilst FMD is an animal pathogen and does not affect humans, the impacts of the accidental release of the virus from the lab into the local environment were devastating on the local farming community and have been estimated to have cost the UK around £150 million. The Health and Safety Executive-led investigation found a shocking catalogue of errors – many of which may have arisen out of the complacency due to FMD being an animal rather than human pathogen. These included site-specific issues around biosecurity, equipment maintenance, etc. – but also highlighted issues around leadership, both at the site and across the whole sector.
In fact, the biological agents community struggled to recognise that it was a major hazards sector – working with human and animal pathogens that if released from the lab could cause multiple deaths, environmental damage and financial consequences. The incident and investigation also highlighted the need for much greater leadership and collaboration – to identify and find solutions to sector wide issues that threatened continued control and containment.
The Buncefield and Fukushima Daiichi events have been the subject of volumes and I doubt there can be any member of the major hazards community who is not familiar with the vapour cloud explosion at the Hemel Hempstead fuel depot or the Japanese nuclear power plant explosions.
Buncefield injured 40 people (it could have been so much worse), resulted in a fire lasting 5 days, the prosecution of 5 companies by HSE and EA and is estimated to have cost the UK around £1billion. As well as technical and equipment failures, the investigations found multiple problems associated with leadership in managing the hazards at Buncefield. The industry-wide lessons were taken forward by the Buncefield Standards Task Group and subsequently, the Process Safety Leadership Group, focusing on the need to demonstrate effective leadership and the need to share and learn across the sector.
The Fukushima explosions resulted from the failure of electrical supply to reactor cooling systems, when the earthquake knocked out the off-site supply and the ensuing tsunami wave submerged the on-site back-up supply. The explosions led to widespread radioactive contamination and the decision was made to evacuate more than 100,000 people from a 20km radius. The impacts are still being felt. Whilst there have been very few (single figures) radiation casualties recorded to date, many deaths and injuries occurred due to the decision to evacuate so many people, massive amounts of radioactive waste were generated (still awaiting treatment and disposal), whole communities were displaced, and the impacts (mainly economic) have been felt around the world. To date costs are estimated at around £150 billion. Lessons have been learned at a global level, including the key role of well-informed leaders and the need for shared learning.
A common thread through all this learning – achieved at such massive cost, is the absolutely vital need for leadership and collaboration across the major hazards community – in its widest sense; within sectors, across industry, with government, regulators, NGOs and the public.
How well are we doing?
So as we navigate the choppy waters ahead of us, I think it is good for us to ask ourselves: Have we got this? Are we up to the job of managing the major hazards associated with our work, meeting the challenges ahead and maximising the opportunities that are presented?
On leadership – there is definitely a wealth of excellent resources available to show us the way; for example, PSLG Principles of Process Safety Leadership (1), COMAH (Control of Major Accident Hazards) Delivery Guides, and the range of industry specific regulator, professional body and trade association good practice guidance. The question is whether those who need to use that guidance are actually doing so and improving? Given the fact that so many accidents and incidents still happen and that failures of leadership are identified as key contributing factors, I’d say we have a way to go.
And so to collaboration. I hope it is beyond argument that open, honest and constructive collaboration is the most effective way to spot problems ahead, work up realistic solutions and then share that learning and help embed the resulting improvements across industry. There are certainly many groups that exist to do just that; COMAH Strategic Forum, Nuclear Safety Directors Forum, Joint Competent Authority Groups etc. I have the pleasure of working on and with a number of such groups and am often impressed by the energy and knowledge shown by many of those involved.
But I am struck by some questions we may all wish to reflect upon:
• Why, when some of the sectors represented are so large, does it seem to be the same few faces at each group?
• How truly open are discussions?
• How aligned are the priorities of the group members (and the organisations they represent)?
Until we can give resoundingly positive answers to these questions, our progress will be limited.
Future challenges and opportunities
As we look to the future, not only do we need to continue to improve major hazards management and leadership, we need to do this at a time when faced with the global challenges that come from a changing climate, our ever increasing waste imprint, the need for clean and sustainable growth, low carbon energy and the need to improve the air we all breathe. Of course, many of these bring their own opportunities, such as those captured within the government’s Industrial Strategy (2), Clean Growth Strategy (3), Clean Air Strategy (4) and 25 Year Environment Plan (5). Each of these is worthy of a paper, but I will look at climate change as an example.
Climate change is the biggest threat we face. We are already experiencing impacts from rising sea levels and extreme weather. But there is much worse to come and particularly for the world’s most vulnerable societies and precious environments. The scale and pace of change demand that we think and work in radically different ways in order to minimise our own impact on the planet and to be better prepared for the inevitable impacts. We also know that tackling climate change in the right way will be positive for sustaining economic growth.
In November 2018, new Met Office-led climate change projections for the UK were launched (6). Commissioned by Government ministries DEFRA and BEIS, these new projections provide the most up to date and authoritative assessment of climate change for the UK (UKCP18). They do not make happy reading.
The UKCP18 shows us that:
• The UK’s climate is continuing to warm and sea levels continue to rise
• All areas of the UK are projected to be warmer in future, more so in summer than in winter. Hot summers are expected to become more common
• Summers are expected to become drier, particularly so in southeast England; winters are projected to become wetter, particularly in northern UK
• Sea levels are projected to rise by around 1metre by 2100, and possibly by around 4 metres by 2300, with regional variations.
The Future Impacts diagram below gives an indication of the impacts on UK society associated with the predictions. The increased droughts, heatwaves and flood events will affect people and animals, the environment we live in and society as a whole.
They also mean that managing major hazards will become more difficult, whether as a result of increased flood risk, restrictions in water and energy supply, or health impacts on the workforce. As an example, there are currently 1,640 key infrastructure sites located within extreme flood areas in England alone (including those designated as critical to UK resilience). The need to properly assess the potential risks, plan and put in place mitigation and continually review their adequacy has never been more important. Fukushima is a salutary reminder of how badly things can go if we don’t get this right.
Future Impacts - IPCC
There has already been some great collaborative work across industry, government and regulators. The Chemical and Downstream Oil Industry Forum Best Practice Guidance for Flood (7), the COMAH Competent Authority Flood Delivery Guide (8) and the joint ONR (Office for Nuclear Regulation), EA (Environment Agency), NRW (Natural Resources Wales) position statement on UKCP18 are all excellent starting places (9). The COMAH Strategic Forum (CSF) has designated 2019 as the Year of Leadership in Managing Major Hazard Risks and there is a great resource for learning and getting more involved (for COMAH) at the CSF web community (10).
However, I still see reticence across industry; to have open and sometimes difficult discussions, to agree which priorities on which we must work together (sometimes accepting that our own top priority may need to wait a while, for the greater good) and to commit real resource to the work set in train.
We need to do so much more and show great leadership if we are to mitigate and adapt to the coming changes to our climate and other global challenges. We will only be able to do this if we work together.
About the author
Following a career in medical physics and radiation research, Jo Nettleton joined UK HSE as a radiation specialist inspector, regulating the use of ionising radiations across medicine, research, education and industry and working on related strategy and policy.
Jo moved to join the Nuclear Installations Inspectorate, leading teams to regulate nuclear decommissioning (including environmental impact assessment), conventional health and safety and nuclear safeguards, before joining HSE's Hazardous Installations Inspectorate, leading regulation of biological agents, explosives and chemical industries.
She joined the Environment Agency in 2015 and is now Deputy Director and Head of Radioactive Substances and Installations Regulation.