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VOLUME 4
CHAPTER SEVEN - CAUSATION 3
7.1.Mr Vernon’s Knowledge of PSV 504
7.1.1.General
A matter that was extensively argued and certainly is an important question in these cases is the state of Mr Vernon’s knowledge about the condition of PSV 504 at the time of the accident. Assuming that Mr Vernon contributed to the cause of the accident by seeking to restart Condensation Injection Pump A at a time when the relief line from the pump was not available because PSV 504 had been removed from the line for service did Mr Vernon know that this was the position. If he knew then this would go towards meeting the pursuers’ need to establish that the accident was caused by Mr Vernon’s negligence. Of course the pursuers’ case is not that Vernon was negligent by attempting to start the pump when the valve was missing but rather that he had no knowledge of the state of the pump and that this was due to his failure to carry out his duty to inspect the worksite. If he had carried out such an inspection, they say, it would have brought home to him that the valve was missing. The pursuers have a delicate balance to achieve on this matter and this is due to the position taken by the defenders. The defenders aver that if the accident happened because Mr Vernon was attempting to start Pump A then he knew that what he was doing was contrary to the Operators’ safety procedures so that his decision to start the pump was a deliberate failure to follow good and prudent work practices and consequentially was “wilful misconduct” as defined in the Indemnities. This would free the defenders from any liability they may otherwise have had under these. Thus this matter while by no means the only point in the defenders’ defence is undoubtedly a pivotal point. Moreover it should be noted that it is not critical to the defenders’ position that Vernon knew that the PSV was missing for if he did not know this they say that his ignorance points to a deliberate failure on the part of the Operators to institute and maintain good and prudent handover and permit to work practices which could also point to “wilful misconduct”. Of course the state of Vernon’s knowledge could have a bearing on the question of whether or not he was attempting to start Pump A about the time the accident happened. The pursuers’ position is not that Mr Vernon never knew about the state of the valve during the evening of the accident but that if he had at some point known then the information had not at the time registered in his mind or that he inadvertently had forgotten about it at the time he made his decision about Pump A. It was said that the thought uppermost in Mr Vernon’s mind towards 10pm on the evening of the accident was that the pump had been handed over to maintenance for a 24-month planned maintenance and his concern was to discover if any maintenance work had been performed on the pump which might preclude taking the pump back into production. In any event since as Lead Production Operator he ought to have known that the valve was absent he was negligent if he began to start the pump and the pursuers have a prima facie right to recover under the indemnities whether or not Vernon had actual knowledge that the valve was absent. Accordingly the pursuers submit that provided that MrVernon pressurised the pump when the valve was missing, if the defenders want to claim that his conduct was wilful misconduct, they have the onus to aver and prove this.
7.1.2.The Relevant Evidence
One fact that was agreed by all the evidence of experienced operators was that it was contrary to prudent and good practice to run a Condensate Injection Pump with the safety PSV missing. Indeed it was accepted that no operator, including Mr Vernon, would ever do such a thing. I think this evidence is soundly based. The safety element in the situation is not difficult to understand. The purpose of the PSV is to open to relieve pressure should there be a surge in pressure above acceptable levels when the pump is running. Such surges occur from time to time and if the PSV is not in place the increased pressure has nowhere to go. The Safety Procedures include a proposed procedure for running a pump in an emergency without its PSV. This would involve a person being posted at the blind flange. None of the witnesses favoured nor indeed could explain the advantage of this procedure and indeed the witness Mr Henderson said that if it was applicable at all it was only applicable to apparatus with twoPSVs (of which Pump A was not one).
The witness Mr Bollands took over his duties as Control Room Operator at about 5.15pm on 6 July 1988 and he replaced Mr Price. It should be noted that all Production Operators rotate so that Mr Bollands was perfectly experienced in the duties of a Production Operator. About the same time MrRichard replaced Mr Grant as the Phase 1 Operator. Mr Bollands saw MrFlook and Mr Vernon conducting their handover which took place at the Lead Production Operator’s desk. He expected that matters of significance would at that time be recorded in the Log kept on the Lead Operator’s desk. This was an A4 notepad. Either the incoming Lead Operator was handed notes on this pad or he took his own notes on the pad. The contents of these notes is not clear and it may well be that each Lead Operator decided what he considered to be important and worth noting. Generally just before the shift turnover on the Day Shift was a busy time in the Control Room because performing authorities would be returning their permits to be cancelled, continued, suspended or whatever. The busy period usually began about 5.30pm. This means that if Mr Rankin followed the usual practice with regard to the valve permit which would have needed to be suspended overnight then the probability is that Mr Vernon would have been asked to suspend it. If on the other hand Mr Rankin had finished what he could do that day to the valve at an early time and had taken his permit say at 5pm to the Control Room then it may have been Mr Flook who suspended his permit.
When just before 9.45pm that evening Mr Vernon was informed that an alarm had gone off which indicated that Pump B had tripped he went to assist MrRichard after having a short conversation with Mr Bollands. Then the JCP Panel Alarm went off and shortly after this Mr Vernon returned to the Control Room. The JCP alarm would be consistent with the tripping of the Condensate Injection Pump and would indicate that the JCP level was increasing unduly. MrVernon was informed that the JCP alarm had gone off and he also informed Mr Bollands that he had unloaded and recycled the Reciprocating Pumps. This procedure would relieve the pressure on the JCP Drum. Mr Vernon informed MrBollands that he had been unable to get Pump B to restart and that he expected that there was trouble with the lube oil system on the pump. MrVernon then indicated that he would try and see if he could get Pump A back from Maintenance and get it running. At this point he said nothing about PSV 504. Indeed Mr Bollands asserts quite categorically that he personally did not at the time of the accident know that PSV 504 was not in place. Mr Bollands said that if Mr Vernon was intending to run Pump A without its safety valve he would have expected him to discuss this. As he put it “it was such a drastic step”. He thought that Mr Vernon would have valued his opinion. Mr Bollands also thought that if such a decision had to be taken Mr Vernon would not have taken it without recourse to his superiors. If Mr Vernon had radioed to his superiors other operators with their radios switched on, like Mr Grieve, would have heard. When Mr Vernon saw Mr Bollands within minutes of the explosion the first thing he did was to ask Mr Bollands what had happened. This may indicate that Mr Vernon himself did not associate the explosion with anything he had been doing to the injection pump. Of course later Mr Vernon was killed. Mr Clark was also adamant that Mr Vernon had not raised with him the matter of PSV 504. MrClark was an experienced Lead Maintenance Hand and if Mr Vernon was about to do something that was irregular and possibly risky one might have expected him to take the opportunity of discussing it with Mr Clark. Equally it can be said that if Mr Clark knew that the PSV was absent it might have been expected that he would have mentioned this to Mr Vernon. Mr Clark also made other significant observations. He declared that if he had known that the PSV was off he and Vernon would never have started the pump and also that if the valves were missing the electricity would have been immobilised from a second source so that he would not have signed the red tags as he had.
The witness Mr Grieve who was down at the 68-foot level at the time of the accident also says that he had no idea that the PSV was missing.
With regard to Mr Vernon’s character the witness Henderson said that he had worked with Vernon for 8 years and found him to be responsible. He accepts that it was very bad practice to run a pump with the safety valve missing and says that if necessary the plant would have been shutdown to prevent that happening. Moreover Mr Vernon was hoping to get promotion and in that situation I would wonder if he would be inclined to take a highly irregular step that almost inevitably would be found out.
The Phase I Operator would normally know the work going on in his Modules during his shift and certainly Mr Grant, the Phase 1 Operator during the day shift on 6 July, would have known since he at one point helped in removing the valve. Of course when he went off duty he may not necessarily have known that the valve had not been replaced since until the last moment the valve fitters were trying to secure a crane to replace the valve. The question, of course, is whether or not he would have communicated the status of the pipe to the incoming Operator, Mr Richard, at handover particularly if no work was to proceed at the valve over the night shift and the valve calibration was being done in conjunction with the planned maintenance. On the other hand the fact that the planned maintenance was proceeding was something that he certainly would have been expected to mention. This does not however mean that he would have thought it necessary to communicate to Mr Richards what was happening to the PSV since the pump had passed out of the control of operations and was with maintenance. Moreover as I have said he may not have known the precise position regarding the PSV.
Mr Rankin gave evidence to the effect that after 6pm he met Mr Smith in the accommodation module. He describes Mr Smith as his Maintenance Supervisor which is incorrect in that he was the Maintenance Lead Hand. MrRankin was right in thinking that as the employee of a specialist contractor he should report to the Maintenance Supervisor but of course he got the wrong man. Mr White was his proper supervisor and from Mr White’s lack of response when Mr Clark got his telephone call shortly before 10pm, it can perhaps be assumed that Mr White did not know the state of the PSV. Mr Rankin was possibly confused in that Mr Smith had assisted him to get started with the valve in the morning and as he had only recently begun to act as a Score Supervisor he may not have been as familiar as some Score employees with the personnel on the platform. Mr Rankin claims to have returned his permit to work to the Control Room (although he is vague about the detail of this) and then to have visited the Score container before proceeding to the Accommodation Module where he met Mr Smith. I have no reason to doubt that the encounter with Mr Smith took place and since the circumstances are such that it can be assumed to have been after 6pm, when Mr Smith was off-duty, we have one time reference that can perhaps be relied on. Indeed another witness Mr Mochan confirms, at least to a degree, the time of the meeting. It would appear that Mr Smith had gone off-duty about 5.45pm and before meeting Mr Rankin in the recreation room would have required time to make a telephone call and to have changed out of his work clothes. Mr Smith asked Mr Rankin if blind flanges had been fitted and the latter confirmed that this was so. It is perhaps unfortunate that Mr Smith did not also ask Rankin if he had reported to Mr White but it would perhaps be understandable if he just assumed that this normal procedure would have been, or would be, carried out. This confusion may also reinforce Mr Clark’s claim that he had no opportunity to find out about the state of the PSV. Also if Mr Smith did not know what had happened to the valve before he went off-duty (he may well not have known that the work had not been completed if indeed he knew that the permit had ever been issued) then it is unlikely he would have mentioned the situation during his handover with Mr Clark. Thus whatever Mr Vernon’s paths to knowledge about the position regarding the PSV it is unlikely he gleaned any information about it from Mr Clark.
The evidence of Mr Rankin may be of crucial importance in relation to MrVernon’s knowledge of the valve work. Mr Rankin was uncertain in some of his evidence and this is perhaps not surprising. He had survived a dreadful accident which had killed his workmate Sutton. Then he finds himself associated with the critical events said to be responsible for the catastrophe. Moreover the accident happened shortly after he had become supervisor which of course must have added to his concern. Prior to the accident Mr Rankin had been employed by Score for about two years as a valve technician and had previously been employed by Otis Pressure Control. Thus in a general sense he had reasonable experience of valve maintenance operations. Before the accident he had worked on valve related work on Piper Alpha and other offshore platforms. He had worked on Piper Alpha for about 6 weeks during March 1988. However during that period he had not been acting as supervisor. He was appointed to that position on the day before returning to the platform for the tour of duty that led to the accident. He had not acted previously as supervisor. Mr Sutton and he began their tour on Piper Alpha about 27 June 1988 and their tour was expected to last about 4 weeks. Before the accident he had on that tour maintained about 10valves. He claimed, and I can accept it, that it was a routine job to fit blind flanges. Yet at one point in his evidence he indicates that he cannot ever remember having been involved in the fitting of valves to open-ended pipework. Before he came to Piper Alpha as supervisor he had no experience of operating the permit to work system on the platform. He realised quite clearly that his function as supervisor included being responsible for following the permit to work procedure, to refurbish and certify the valves, and to oversee the work. In dealing with the permit to work situation he was helped by the fact that in the Score Container a list was posted indicating the various steps which had to be taken to follow the permit to work procedure. There is no doubt that he appreciated that the permit to work procedures were important for the regulation of safety. However it might appear that the specific instructions which his employers gave him about the detail of the permit to work system were fairly skimpy. He was given no specific instructions about the fitting of blind flanges. However he knew that blind flanges always required to be tightened with a flogging hammer or combination spanners. His view of the function of a blind flange was that it was attached to prevent accidental spillage from the system or to prevent dirt getting into the pipes. Since he must largely have acquired this knowledge while working as an ordinary valve technician this is an indication of what such a person might have been expected to appreciate about the fitting and the function of blind flanges.
When Mr Rankin began his tour as supervisor he was introduced to MrTodd who asked him about his knowledge of the permit to work system. MrTodd was presumably satisfied that Mr Rankin knew sufficient about the system. Mr Rankin had informed him that he had no problems with this and that he had run through it with his own supervisor.
Mr Rankin claimed possibly to have had experience in the suspension of permits to work but his evidence in this respect was distinctly vague. However the documentary evidence shows that at least on occasions during the tour MrRankin had suspended permits or had them extended.