LETTER FROM BILL CAMPBELL TO SENIOR PROCURATOR FISCAL DEPUTE (also copied to Sheriff Harris, and the Lord Advocate): 24 February 2007
24th February, 2007
Mr E Barbour
Senior Procurator Fiscal Depute
Atholl House
84-88 Guild Street
Aberdeen
AB11 6QA
Dear Sir
Fatal Accident Brent Bravo and subsequent Inquiry - without prejudice
I wrote to you on 8th November 2005 providing you with evidence that I wished presented at the Fatal Accident Inquiry. That evidence was not presented as I understand it you thought it to be quote unsolicited, the ranting and ravings of a disgruntled ex Shell employee unquote, or at least that is what you are alleged to have said.
I took this allegation to the Lord Advocate in December 2005, and have discussed indirectly with the then Solicitor General and must say to you that your employers have never, in any direct correspondence to me, disputed the allegation. Anyway, I wish you to know that this allegation has been well circulated, to the BBC and various London newspapers. They have never published anything but nevertheless you should be aware that your character and your motivation in the handling of the evidence have been questioned in the public domain. All independent persons, lawyers and non-lawyers when presented with the evidence consider it incredulous that you did not view it as relevant to
The Fatal Accident Inquiry
Previous public inquiries into major accident events in the North Sea have been open and objective, for example, the Inquiry into the helicopter accident at Cormorant Alpha heard by Sheriff Scott in 1992/3 drew forth many recommendations to reduce risks in flying operations. That is what the public wants, not to apportion blame so much as to stop similar accidents happening again. And this of course is enshrined in the 1976 Act that the underlying causes of death should be established and importantly what steps might have been reasonably taken prevent the deaths and importantly to prevent similar accidents in the future. This can only be done if the root causes of the accident are determined, without such accurate diagnosis, no effective prognosis can be established. In the attachment Progress with Safety is made a case via a comparative analysis that the common failure modes present on that fatal day had persisted for 4 years and ironically you support this. In a note from the LA to my MSP in July last year she states quote the PF has assured me that throughout proceedings there was evidence led to suggest that the deaths had occurred as a result of failures over a long period of time, not failures that had arisen just prior to the deaths unquote. There is not much evidence of the leading of that evidence in the transcripts, and the Sheriffs determination doesn't look further back in time than the 17th August 2003.
If these failures had developed a long time ago and were allowed to persist for this period, any Inquiry would have attempted to ask the basic question of why this had been allowed? This being particularly relevant in an area of the world, the North Sea where the residual risks are higher perhaps than anywhere else in the world. And in an industry served by the best, and most sophisticated legislative regime to be found. A regime founded on the recommendations of the esteemed Lord Cullen with the purpose to prevent or reduce as far as is reasonably practicable, such major accidents.
When asked in 1995 as part of research for the Scottish Crown Office, 11 out of 49 procurator fiscal and 2 advocates depute described what they wanted from a FAI. This was that it should be quote a public ventilation of all the facts unquote. Well it seems that you and Sheriff Harris put paid to all that stuff and nonsense and are reported to have held the most restrictive public inquiry ever held under Scottish law. Solicitors complained about evidence not being put forward, of resigning, even the Counsel for Shell at one point was to join in and complain to the Sheriff. It was all a bit of a shambles and I painted this picture to the Solicitor General last year and she did not reply to refute this description.
Both the Crown Agent in January 2006, and the Solicitor General in discussions with my MSP place credence on a Report you have allegedly sent into Chambers Street explaining how you handled the evidence. It is generally explained as 'we have viewed the Report from Mr Barbour and consider that your evidence was handled appropriately by him', or words to that effect. What I say to this is prove it by disclosing the Report. I doubt if the Report exists. Certainly under the Freedom of Information Act I cannot obtain it, it has been denied, and my appeal, which has gone well beyond the mandatory 40 days, is unanswered. If the Report exists, and if it is credible, why can't it be brought forward? I even offered to read the Report in camera at Chambers Street. This is all covered in the submission to get access to your Report.
In discussions with the HSE, as enforcing authority, they say that the decision in 2005 on possible prosecution of Shell for alleged wrongdoings in 1999, and as to whether the evidence should be led at a future Inquiry was all yours, and yours alone. After a period of several iterations, and the bringing forth of evidence from the files of the HSE under the Freedom of Information Act, the HSE admitted on 31st August last year, at a meeting in Aberdeen that my evidence was not handled via the formal complaint process.
This is recognised to be a serious admission because their official who discussed the evidence with you, in a meeting reputedly of short duration, could not on his own assess the worth of the evidence. The evidence was technically complex and the process calls for a multi-disciplined team approach including legal input before a report is eventually passed to the CPS. Such a report was never handed to you. Further the CEO of the HSE in the UK wrote to me to explain that at the meeting of short duration no evidence was ever physically handed over to you so your only grasp of the import or efficacy of the evidence must have been established at the short duration meeting alone. It is also established I think as fact unless you disagree, that you are no doubt a Solicitor of some worth, with an acute understanding of the Law, but you are not a technical specialist and ipso facto could not, even if you had wished to, make any comment of any worth about the evidence without competent input from the enforcing authority.
So then, all that said, what could you possibly cover in your Report. I note that a Report is by general definition a work of substance, not a briefing note, or a letter, or a memorandum, but a Report, with introduction, analysis and summary. Given the way the evidence was apparently handled I would love to see the Report, but the CPS are so confident in its worth that it is buried in some deep hole in Chambers Street, that's if it even exists.
These allegations will be made public in due course and if you have any reason in Law for me not so doing then please raise it with me formally or forever hold your peace. If you wish to look through the electronic attachment Progress with Safety you will see that endemic weaknesses existed in the Brent field for at least 48 months before the accident. Directors of Shell Expro were aware of these weaknesses and took no reasonable action to eradicate them. That was the root cause of the deaths. Sadly the trauma of the deaths has not changed things, rather the situation now is worse, much worse. In the attachment you witness an increase of almost 300% in enforcement actions post the fatalities with no change in the negative safety culture so apparent in 1999 and 2003.
Your actions, and a Determination by the Sheriff of little worth since the Sheriff did not hear the appropriate evidence, contributed to the continuance of a negative safety culture from 2003 and beyond up to late 2006 according to the data available to the public. I consider it a reasonable assertion that if Sheriff Harris had heard the full evidence then his recommendations forthcoming from the Inquiry would have reinforced a damaged and ineffective offshore safety regime. The full evidence would have assisted the Sheriff in getting to the root cause of why these conditions relevant to the deaths persisted for such a long period.
• The Sheriff did not hear that in 1999 Directors of Shell were informed that the Brent Bravo was being operated at high risk levels and immediate actions recommended to reduce these risks were never undertaken. He did not hear that an internal investigation undertaken by Shell International in 2005 confirmed the above and as importantly that longer term actions to reverse the negative safety culture through correcting the bad behaviour witnessed both in 1999 and 2003 were truncated when only 20% complete
• The comparative analysis in the attachment viewgraphs 67 through 88 show that the common failures resulting in the deaths on that day. These relate to the purposefully operating plant and equipment when it was in an unsafe condition due to neglect of maintenance, to carrying out unauthorised design changes on process plant, equipment and pipes, to operating with ESD and other control valves in a failed or functionally impaired state, and to accepting known failures through deviation and violation of the permit to work and other essential control procedures.
All of these four failure modes were witnessed and verified unanimously and by consensus by the 1999 Shell Expro internal audit team. A team that I coincidentally led on behalf of Shell International. All the above you have described in November 2005 as the ranting and ravings of a disgruntled ex employee, even discounting the fact that up till May 2006, I was still employed by Shell on a part-time basis as a highly valued Consultant.
In answer to Morag McLaughlin in her letter refusing access by me to your Report, a letter dated 19th October, 2006, she alludes that my evidence would have entailed a systematic examination of the safety processes offshore and therefore this would be beyond the scope of the Brent Bravo FAI. But the comparative analysis is about endemic weaknesses in the safety processes offshore yes, but offshore on Brent Bravo and that made the evidence entirely relevant to deaths on that specific offshore installation.. It is also just co-incidental, but very important, that there were, from the data in the attachment, endemic weaknesses in essential controls on all the other 17 installations subject to the Shell post fatality technical integrity review in September 2003.
The situation in 2003 was appallingly bad, just look for example at how the maintenance of principal ESD valves was being neglected across the North Sea.
The Sheriff in his determination suggests that the accident could have been prevented if a robust risk assessment had been carried into the consequences of starting up with valve EZV 44715 in a failed state. As a former Shell International technical expert I can assure the Sheriff there is by engineering convention, and by reference to Shell internal guidance, no methodology for carrying out such a risk assessment. Certainly the use of Quantitative Risk Analysis is disallowed by Shell in any attempt to justify operating in breach of internal Codes of Practice or UK legal requirements. Under the various provisions of the Safety Case Regulations and the Installations Safety Case it is simply unlawful to operate knowingly with an ESD valve in a failed state.
The 2003 data shows a state of procedural anarchy and endemic non-compliance.
Even if Shell had got around to writing a risk assessment it would have been entirely subjective, done on the back of a fag packet, and would not have recommended anything other than that start-up was permissible with this valve and others, either in a failed or functionally degraded state. After all that is what was going on for 4 years or so before the accident not only on Brent Bravo but also on all the other 17 installations covered in the 2003 data.
In summary I consider that in your mishandling of the evidence, in that you ostensibly ignored it, did great disservice to the future health and safety of persons offshore, something for which you should be thoroughly ashamed. It made the FAI of little worth and sadly a missed opportunity to force improvements on the Duty Holder, enforcing authority and industry per se. I sincerely hope you do not live to regret it, but I fear you might, if things don't improve, and improve significantly. I would welcome any comments, or criticism of the contents of this Note, as previously stated it will be published in some form or another in due course.
Sincerely, Bill Campbell DMS. B.Sc. MET C.Eng.
PS: This note has been copied to Sheriff Harris ,and the Lord Advocate