The Vest Tank Accident
Experiences gained from the Authorities’ collective handling
of the Vest Tank accident in Gulen Municipality
Rambergveien 9 Postboks 2014 3103 Tønsberg
Experiences gained from the Authorities’
collective handling of the Vest Tank accident
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1 Summary ...5
2 Introduction ... 7
3 Short description of the incident ...9
4 The public authorities’ responsibilities, roles and handling ...11
Gulen Municipality ... 11
Hordaland Police District ...12
The County Governor of Sogn and Fjordane ...13
The Norwegian Coastal Administration ... 14
Norwegian Institute for Public Health ... 14
The Norwegian Food Safety Authority ...15
The Norwegian Pollution Control Authority (SFT) ...15
The Directorate for Civil Protection and Emergency Planning (DSB) ... 17
5 Evaluations and learning points ...19
a) Local and regional authorities handling of the matter ...19
Crisis management and coordination ...19
Environment- related health protection ...19
Access to competence and resources ...20
Municipal risk and vulnerability assessment ...20
b) Central authorities’ handling and the authorities’ interaction ...20
Obscurities in responsibility and task distribution ...20
c) Sharing information and interaction ...21
Information to the public ...22
d) Internal Control ...22
6 Action points for further follow-up ...23
Sharing information and interaction ...23
Obscurity in division of responsibility and tasks ...23
Environment-related health protection ...23
Crisis Management and Coordination ...24
Internal Control ...24
1 Summary
The purpose of this report is to collocate the experiences gained by each of the individually involved competent authorities in connection with the accident at Vest Tank in Gulen Municipality on the 24th May 2007; to ascertain possible unclear lines of responsibility between the various authorities; and to present learning points and improvements in handling should such an incident of this type again occur in Norway.
The following authorities have collaborated on the report: Gulen Municipality, Hordaland Police Dis-trict, the County Governor of Sogn and Fjordane, the Norwegian Coastal Administration, the Norwe-gian Institute for Public Health, the NorweNorwe-gian Food Safety Authority, the NorweNorwe-gian Pollution Con-trol Authority (SFT), the Directorate for Civil Protection and Emergency Planning, Norway (DSB). The report describes the acute and after phases of the incident, the responsibilities and roles of the participating authorities based upon the legislation that they administrate and the subsequent follow-up from the various authorities. Furthermore, important learning points are presented, and finally a number of recommendations for definite improvement measures which the respective authorities wish to work on and develop. The most important follow-up measures are, cf. Chapter 6 in the report:
Municipalities must attend to their coordinating responsibility during crisis situations and requ-•
est professional advice and guidance from regional and state authorities. When this does not take place the regional and state authorities can be more active in offering their competence.
The County Governor of Sogn and Fjordane will strengthen the municipalities’ general emer-•
gency preparedness response and in particular in the health and social services sector. During the autumn the County Governor initiated a survey of the municipalities’ environmental health protection work.
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The Norwegian Coastal Administration will, in cooperation with SFT, contribute to bettering •
society’s understanding of the two autorities’ roles and the distribution of responsibility in acute pollution situations.
The Norwegian Food Safety Authority will, in acute crisis situations where other authorities have •
the main responsibility, evaluate whether its own area of responsibility is touched upon, establish contact with other parties in order to clarify distribution of responsibility and request all neces-sary information concerning the matter.
The Norwegian Institute for Public Health will evaluate if the professional support the institution •
renders to safeguard public health in cases of chemical accidents should be organized in a more formal manner concerning emergency preparedness response - comparable to the arrangement for infectious disease protection. The institute shall also consider introducing a duty to report to the Institute for Public Health from the municipal health services when chemical accidents may represent a threat to the population.
SFT will more often evaluate the need for taking samples and making analyses at an earlier point •
during the course of events. This, in addition to the enterprise’s obligations to disclose the course of events, the cause, danger of pollution and clean-up operation.
DSB will clarify existing expectations to the Directorate regarding its role in coordinating acci-•
dents of this nature.
Regional and central authorities must ensure that necessary information reaches the municipality’s •
administration as quickly as possible when this type of incident occurs. DSB shall ensure that the County Governor contributes to the follow up the above-mentioned conditions.
The report is based upon the experiences gained by the competent authorities that were involved in the handling and follow-up of the accident at Vest Tank in Gulen Municipality on 24th May 2007.
The following authorities have collaborated on the report1: Gulen Municipality
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Hordaland Police District •
The County Governor of Sogn and Fjordane •
The Norwegian Coastal Administration •
The Norwegian Institute for Public Health •
The Norwegian Food Safety Authority •
The Norwegian Pollution Control Authority (SFT •
The Directorate for Civil Protection and Emergency Planning, Norway (DSB). •
The purpose of this report is to collocate the experiences gained by each of the individual authorities involved with the accident at Vest Tank in Gulen Municipality on the 24th May 2007; to ascertain possible unclear lines of responsibility between the various authorities; and additionally to present learning points and improvements for handling any similar incident should it occur sometime in the future in Norway.
DSB and SFT have been the driving forces behind this work based, upon the letter from the Minister of the Environment to the Norwegian Parliament and the Centre Party in which the Minister pledged that DSB shall take the initiative for the compilation of a summary following the Vest Tank acci-dent. DSB commenced the task by calling a preliminary meeting and leading the work of compiling a report with background in the Royal Decree of 24th June 2005 that specifies DSB’s coordinating responsibility in the area of civil protection.
The Royal Decree gives DSB the responsibility for coordinating supervision of activities, objects and enterprises that have the potential for causing major accidents. This coordinating responsibility inclu-des all public sectors, and covers both those that come under DSBs special areas of jurisdiction and those that are covered by other legislation. The coordinating role does not set aside the professional supervision or responsibility that belongs to the respective Ministries and their subordinate depart-ments. By means of its incumbent coordinating responsibility DSB shall, amongst other, make sure that preventive safety measures are attended to in a responsible manner ensuring that surroundings are satisfactorily safeguarded; that defects in preventive safety and emergency preparedness measures spanning both public and private sectors are identified; and that necessary corrective measures are considered. DSB’s co-ordinating role entails that the directorate shall support the Ministry of Justice and the Police in its co-ordinating role within the area of civil protection.
The authorities presented their experiences at an initial meeting held on 5th September 2007. In ad-dition, the working method has included both written and oral input from the respective authorities, correspondence concerning the report’s contents and form and a final meeting held on 7th November 2007.
The report presents some learning points following the accident in Gulen but does not intend to give an exhaustive description of the course of events and problems to be addressed which came up in the aftermath of the explosion at Vest Tank.
2 Introduction
1. The Norwegian Labour Inspection Authority has given written input to the Police in connection with the investigation but has not participated in the public meetings, and was therefore not invited to collaborate on the exchange of experience. Bergen Fire Service has also contributed to the report.
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On 24th May 2007 at 1000 hours a tank exploded at the Vest Tank company in Sløvåg in Gulen Mu-nicipality. Amongst other, the tank contained sulphur components following the desulphurization of oil products. The explosion was violent and resulted in one of the plant’s tanks, which contained oily waste, being lifted from its fundament and thrown into the rock wall behind. The explosion also led to a nearby tank containing oil products (naphta) catching fire. Vest Tank’s office building and several tanker trucks were totally destroyed in the fire that followed. No persons were seriously injured from the explosion and the ensuing fire.
Emergency response personnel from Gulen Fire Service participated in the acute phase. In addition, Bergen Fire Service and Hordaland Civil Defence District were called out.
Following the incident many people living permanently in the near vicinity of the plant have experi-enced illness and unpleasant conditions consisting of nausea, vomiting and sore throats. Uncertainty surrounding the contents in the tanks resulted in the need for public information. At a later stage, information meetings and public meetings have been held to accommodate this aspect of the incident. Uncertainty still exists amongst the public regarding possible long-term effects from the chemicals involved despite documentation of the contents of the tanks.
The incident can be divided into two phases; the acute phase and the after phase. The acute phase consisted, amongst other, of fire extinguishing, the establishment of necessary emergency prepared-ness response at the location in relation to pollution of exterior surroundings, obtaining an overview of the total extent of damages and identifying the cause of the explosion. The after phase is related to complaints of illness, considerable and troublesome odorous smells and other types of unpleasantness experienced by the public. In addition, need for information concerning the contents of the tanks and possible effects on health from these substances. This report relates to both phases of the accident. The accident resulted in vast media coverage. Local and national coverage followed both phases of the accident with increasing focus on the uncertainty connected to the contents of the tanks and the public’s health issues and concerns. In the after phase two public meetings were held in Gulen Municipality, one arranged by Eidsbotn Vel (Eidsbotn Residents Association) and the other arranged by Gulen Municipality. Representatives from local, regional and central authorities participated in the meetings. During the meetings the population of Gulen expressed their lack of confidence in Vest Tank and the authorities.
The case is still under police investigation and the authorities are assisting the police. The GexCon consulting company, who are experts on gas explosions, have been engaged by the police and DSB to clarify the technical cause of the incident. The final investigation report was published on 31st Octo-ber 2007. The police will continue their investigation as to whether legal offences have been commit-ted based upon the cause of events described in GexCon’s report.
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Gulen Municipality
There are several Acts with appurtenant regulations that have requirements regarding municipal pre-ventive work and emergency preparedness and readiness in various specific sectors. For example the Fire and Explosion Act, the Social and Health Hazard Preparedness Act, the Communicable Diseases Act, the Pollution Act, the Planning and Building Act and the Municipal Health Services Act.
In accordance with § 1-3 paragraph 5 of the Municipal Health Services Act a regulation is laid down concerning environmental-related health protection that specifies the municipality’s responsibility for promoting public health and contributing to the protection of the population against factors in the en-vironment that may have a negative effect upon health. This obligation implies that the municipality shall have an overview of environmental-related health threats, and establishes municipal responsibi-lity to conduct supervision in relation to environmental-related health protection.
One of the basic principles in Norway is that the person who has the responsibility in a normal situa-tion also has the responsibility when accidents and excepsitua-tional incidents occur. The principle is estab-lished in a number of Parliamentary White Papers that emphasize that good municipal emergency preparedness and readiness is a fundamental prerequisite for good national emergency preparedness and readiness. (cf White Papers no. 265 (2004-2005) and no. 37 (2004-2005) on the tidal flood cata-strophe in South Asia and central crisis management.)
The emergency response personnel from Gulen Fire Service took part in the acute phase. The munici-pal physician in Gulen vas present and examined the injured and those involved. The municimunici-pal admi-nistration was in meetings in other vicinities when the accident occurred but took immediate contact with the local police. The municipal council considered establishing crisis management but chose to postpone the decision until the extent of the accident was clarified. Later in the day when the rescue work seemed to be successful and no lives had been lost it was not considered necessary to estab-lish formal crisis management in the municipality. Despite the fact that crisis management was not established, close internal contact was maintained at all times between the Mayor, the Chief Officer, the Municipal Physician and various advisers in the municipality. A short time after the explosion the municipality initiated the testing of drinking water and found no alarming results.
On 7th June reports were received of cases of illness caused by stench2. The municipal council con-tacted Vest Tank and requested an accident report as well as testing to establish which substances had been in the tanks. Gulen Municipality did not receive satisfactory documentation from Vest Tank until 4 weeks later. It was therefore difficult for the municipality to issue verified information about the substances that had been in the tanks.
A short time after reports of illness caused by stench were received the County Governor took the initiative to contact Gulen Municipality. The municipality was positive towards being contacted as, apart from awareness of the responsibilities of the Municipal Physician, the municipality was so-mewhat unsure of the extent of its responsibility in such a situation. To obtain a better overview the municipality invited relevant regional and central authorities to a coordination meeting on 4th July. Representatives from Vest Tank participated in parts of the meeting.
4 The public authorities’ responsibilities,
roles and handling
Prior to the accident the surrounding neighbourhood had been bothered by smell from the plant. However, no reports of sickness had been received.
Hordaland Police District
In accordance with §27, paragraph 1 of the Police Act, the police are responsible for initiating and or-ganising rescue efforts when human life or health are threatened and in cases where another authority does not have the obligation. In accordance with the Police Act, Police Instruction and Organization Plan for the rescue service, the police have the responsibility for co-ordinating and leading every kind of rescue effort.
The local police in Gulen received a report of the accident shortly after it occurred. The call-out was undertaken by two servicemen/women and these arrived at the scene of the accident at approx. 1030 hours. The designated leader of the rescue operation was placed in the administration wing of Vest Tank’s neighbouring company, Wergeland-Halsvik AS. Contact was established with ambulance per-sonnel, the fire service and local companies in Sløvåg. At 1100 hours the decision was made to stand up the Crises Support Staff centrally at Hordaland Police District. The Chief Fire Officer in Bergen and the County Physician in Hordaland were amongst the members. The Civil Defence was also noti-fied and contributed at the scene of the accident.
Cooperation between the police authority, other departments and local companies in the vicinity of the place of accident was judged to function well by the police. Various departments were in contact with the police. Both DSB, SFT, the Norwegian Coastal Administration Authority and the Municipal Chief Officer were in contact with the local police in Gulen during the acute phase. It was a challenge to get good enough information about the contents of the tank which had exploded and about the contents of other tanks on the industrial site.
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The leader of the rescue operation considered that it was necessary for the representative from Vest Tank to give information in direct line of contact with the Crises Support Staff in Hordaland Police District. The General Manager of Vest Tank spoke directly with the Chief Fire Officer in Bergen to ensure that correct information should reach the Emergency Management Staff and the various pro-fessional departments.
With respect to judgment of any impending danger to health during the acute phase, the skadestedsle-der related to information received from the Emergency Management Staff. The Police conducted gas measurements by using a borrowed “Gas Alert” gas measurement instrument. Measurements were taken of the amount of hydrogen-disulphide, carbon monoxide and oxygen in the areas of Sløvåg, Steine, Dalsøyra and Nordgulen. Gas measurements were taken to check if there were health dama-ging or explosive concentrations in the air. The results of the gas measurements showed that they were under the specified marginal values for such substances. With respect to the further follow-up of injured and involved persons the leader of the rescue operation was in contact with the Municipal Physician in Gulen who confirmed that he would follow up those concerned.
On 25th May the police established an investigation team to find the cause of the explosion. The in-vestigation team received assistance from Kripos (criminal inin-vestigation unit), several administrative units in Hordaland Police District, DSB and SFT in relation to tactical investigation and professional technical support. In accordance with a recommendation from DSB the police have engaged the Gex-Con consulting company to assist in finding the technical cause of the explosion.
The County Governor of Sogn and Fjordane
In accordance with the Instruction for the County Governors’ emergency preparedness and response efforts of 21st September 1979, the County Governor is, amongst other, given the task of coordinating and conducting supervision of all civil emergency planning in the county, as well as the obligation to give advice and guidance to the municipalities in the area of civil protection. This is further explained in Chapters 53-55.4 of the Government Commission 2007 from the Ministry of Justice and the Police. This coordinating role is practised by the County Governor himself/herself or by the Deputy County Governor, and gives the County Governor the authority to call in parties to a meeting but not the aut-hority to instruct them.
The County Governor had direct contact with the police during the acute phase but did not have a role beyond ensuring reciprocal information in relation to the police.
In the after phase the County Governor had several roles, amongst other, advisory and guidance service within own areas of formal competence. In this case, advice in the areas of environmental-related health protection and crisis management was most relevant. In the area of environmental health protection advice was given in form of interpretation of legislation and professional guidance. The County Governor’s environmental protection department has a professional working cooperation with SFT in that both issue permits and conduct supervision with, amongst other, industrial enterpri-ses. Vest Tank is within SFT’s area of responsibility. The County Governor’s environment protection department also has an advisory function for the Norwegian Coastal Administration when national operations are undertaken. The County Governor is the complaints authority in cases of decisions made in accordance with Chapter 4a in the Municipal Health Act. The County Governor is therefore somewhat reserved in giving concrete advice with regard as to which decisions should be taken by the municipal health service.
Through the media the County Governor became aware that several persons in the Sløvåg area had symptoms of illness considered related to emissions following the explosion and contacted the Nor-wegian Institute for Public Health on 8th June requesting them to give professional advice to the municipal council. The Mayor in Gulen was subsequently contacted and made aware of the municipal council’s responsibility and use of policy instruments in accordance with the Municipal Health Act and Regulation concerning Evironmental Health Protection. In addition, a specific contact person in the Public Health Institute was allocated who could assist the municipal council with professional advice. The Mayor was also informed of how the County Governor could contribute.
The County Governor had to evaluate which role profile should be chosen, and how the tasks within the chosen role profile should be undertaken. Initially, a profile of advice and guidance was chosen even though this may have led to incompetence in the event of possible complaints at a later date. The County Governor was later in contact with the municipal council on a number of occasions (mostly with the responsible case-officer in the Chief Officer’s staff), and also participated in the pu-blic meetings in the municipality as well as a meeting with other pupu-blic authorities on 4th July. As to whether the County Governor should practise the coordinating role was a subject of discussion but the County Governor understood that the municipal council wished to handle the situation and therefore decided to await further development.
The Norwegian Coastal Administration
The Norwegian Coastal Administration is assigned responsibility pursuant to the Pollution Act, and attends to the national commitment for emergency preparedness and readiness related to acute pol-lution. The department has round-the-clock watch in order to register incidents, give guidance and undertake supervision of the polluter’s handling of acute pollution in accordance with the Pollution Act. When large-scale pollution occurs that is not covered by either private or municipal emergency preparedness, the Norwegian Coastal Administration shall take action on behalf of the State. Cases of large-scale pollution mostly concern oil spills from vessels and shipwrecks or unknown sources. The Norwegian Coastal Administration’s emergency preparedness watch team received notifica-tion of the incident at Vest Tank three minutes after the explosion occurred. The incident was fol-lowed up continuously during the acute phase in accordance with the supervision part of the Coast Administration’s own emergency plan. The Coastal Administration took immediate contact with Vest Tank, the Joint Rescue Coordination Centre (HRS), the Coast Guard, Gulen Municipality and the emergency preparedness division at Statoil Mongstad. Statoil Mongstad implemented response measures in accordance with the cooperative plan entered into with the Coastal Administration and contributed, together with the Coast Guard with supplies of substantial materials and personnel to handle the acute phase. The Coastal Administration’s emergency preparedness watch completed an inspection of the plant the same day they received notification of the incident.
The day after the incident occurred, the Coastal Administration contacted Vest Tank requesting a de-scription of the course of events and which measures Vest Tank intended to implement. The Coastal Administration was in satisfactory dialogue with Vest Tank. The company met with the request and sent a preliminary report on 31st May. A copy of the report was also sent to SFT, DSB and the Police. The municipal physician was sent the same information on 8th June. The Coastal Administration, SFT, DSB, the Police and Gulen Municipality have later received two updated reports from Vest Tank.
Norwegian Institute for Public Health
The Norwegian Institute for Public Health is the administrative body under the Ministry of Health and Care. The Institute shall be a driving force in bettering general public health and quality of life amongst other by researching factors that affect health and by monitoring the state of health in Nor-way.
The Institute has no formal responsibility defined by law in connection with chemical accidents of the type that occurred in Gulen. The Institute has professional competence in evaluating health risks in connection with exposure to chemicals in the air, water or food, and in this connection gives profes-sional support and advice to administrative bodies at all levels.
The Institute first became involved on 8th June when the County Governor, in the capacity of the County Physician, approached the Institute and asked what it could contribute with in this particular case3. On 20th June Gulen Municipality made contact and asked if the Institute could give its view on the probable cause of the health problems and the extent to which these problems were dangerous. The Institute requested analyses of the sludge following the explosion and that the council make further contact when the test results were available. The Institute received the test results on 3rd July and sent the health risk evaluation back to the municipality the following day. On 5th July the Institute made
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direct contact with the Municipal Physician to establish a good dialogue for the further follow-up. Representatives from the Institute had the first meeting with the municipality on 11th July and visi-ted Vest Tank prior to the meeting to gain an overview of the course of events and also to get further information about the chemicals that were involved in the explosion. At the meeting with the muni-cipality the Council Physician’s finds concerning health worries were discussed. The Institute parti-cipated in the public meeting on 23rd July and also on this occasion paid a visit to Vest Tank together with SFT. At the public meeting the population was informed about the health consequences connec-ted with the incident.
The Norwegian Food Safety Authority
The Norwegian Food Safety Authority is a national, nationwide supervisory authority within the area of plants, fish, animals (meat), drinking water and articles of food. In cases of acute pollution the Food Safety Authority, in accordance with the Food Act and the Animal Protection Act, must evaluate the possibility of an increased risk of danger in drinking water, farming products, seafood and also danger to fish and animal health and to animal wellbeing.
The Food Safety Authority was not actively involved at an early stage in this case as other authorities had the administrative responsibility for Vest Tank. The Food Safety Authority later gained an insight into the extensive environment analyses that were completed by fish farms in the near vicinity and the Food Safety Authority took such tests to a lesser extent. The tests proved that there were findings of PAH, PCB, dioxides and heavy metals in the area surrounding Vest Tank. Health damaging levels were not found in any of these analyses. The Food Safety Authority also took direct contact with farmers and the owners of local waterworks and requested that the situation be monitored and that they be contacted in the event of any observations that could be related to the incident in Gulen. In the early stages of the case the Food Safety Authority was not aware of which authority had the main responsibility to co-ordinate the work. The Food Safety Authority did not receive any pro-active general information from Gulen Municipality, the County Governor, the Coastal Administration or SFT during the first month. The Food Safety Authority assumed that other authorities would alert them if their area of responsibility should be involved. During this period, the Food Safety Authority received a number of public enquiries that were sometimes difficult to answer as they were not aware of actions taken by other authorities in this matter.
The Norwegian Pollution Control Authority (SFT)
SFT administrates the Pollution Act that primarily regulates enterprises with the potential for pol-lution or enterprises that represent danger of polpol-lution. SFT or the County Governor issues permits to this type of enterprise which stipulate specific terms for, amongst other, emissions, emergency preparedness, etc. Vest Tank has a permit from SFT issued 5th December 2001 for the receipt, storage and handling of oily flushing water and sludge water. Vest Tank sends annual internal control reports to SFT relating how the enterprise is administrated in relation to demands in the permit. Vest Tank has not informed SFT about the activity connected to desulphurization of naphta. SFT has requested a report from the company in order to evaluate the need for a permit for this activity.
SFT conducts risk-based supervision with, amongst other industrial enterprises, in order to inspect whether the enterprises are complying with demands in permits and also other rules in the Pollu-tion Act and the Product Control Act. Since 2003 SFT has conducted 3 supervisions at Vest Tank (13.11.02, 06.12.05 and 20.09.06) and had regular contact with the enterprise. All the inspections have revealed breaches in regulations and the most important findings were connected to operation, dis-charge control and documentation for the enterprise’s water purifying plant and in one case deficient documentation on received waste. The inspection reports are public and are available on request from SFT.
The Department for Poisons Information (subordinate to the Norwegian Directorate for Health and Social Affairs) was involved in the acute phase of the accident giving advice and guidance on the treatment of acute poisonings. 3.
If any acute discharge occurs at an enterprise which has a discharge permit from SFT, SFT has the responsibility of following up the breach in the permit including breach of any requirements for prepa-redness and response measures decided by SFT. Otherwise, SFT is available in the capacity of advi-ser for the Norwegian Coastal Administration in an acute phase. When the acute phase is over SFT follows up the case further with the enterprise and other authorities. Both the Coastal Administration and SFT have competence in the environmental effects of chemicals which can be communicated to municipal authorities and local preparedness and response units. The day following the accident at Vest Tank SFT made an inspection of the enterprise to collect first hand information on the pollution situation. Much of the documentation that was requested during the inspection was lost in the fire. SFT have had regular contact with the enterprise in order to ensure that the ongoing work to avoid the further spread of pollution and to secure the clear-up was satisfactorily completed. In the period following the accident, SFT had contact with the police, the municipal health service, the County Physician, the Food Safety Authority, DSB and the Coastal Administration.
SFT is also the supervisory authority for the export and import of dangerous waste. The Waste Re-gulations require the approval of the export and import country for the export and import of waste, and also lays down strict rules related to the handling of hazardous waste. Following the explosion questions were asked as to whether Vest Tank had received waste, especially connected to the port call by the vessel “Probo Emu”, and if the enterprise had received waste which needed an import permit. Vest Tank presented documentation at the beginning of July which showed that they had not received waste from Probo Emu that needed an import permit. Furthermore, the documentation showed that it concerned oily wash water from the cleaning of the vessel’s tanks, and that this waste was not invol-ved in the explosion.
After the accident SFT received several enquiries concerning consequences to health in addition to questions about pollution. SFT has the necessary competence concerning the substances’ chemical and physical properties and possible effects on the outer environment, but not to possible health effects as the result of discharge of the substances. SFT therefore referred enquirers to the health authorities and in particular to the municipal health service as the appropriate authority to clarify such questions.
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The Directorate for Civil Protection and Emergency Planning (DSB)
DSB is the supervisory authority that administers the Fire and Explosion Act which purpose is to protect human life, health, the environment and material values against fire and explosion and also accidents involving hazardous substances. DSB has issued 2 storage permits in connection with the operation at the plant in Sløvåg. These permits apply to the storage of flammable goods and are gran-ted respectively on 27 July 2005 and 20 December 2004. DSB has not conducgran-ted supervision at Vest Tank but has visited the company in connection with handling applications for permits.
DSB’s general coordinating role implies that the directorate shall have an overview of risk and vulne-rability in society, take initiatives to strengthen society’s ability to handle accidents, crises and other types of undesired incidents and also ensure good preparedness and response and accident and crisis management related to major accidents. With this backdrop DSB works to encourage the establish-ment of natural arenas for cooperation in various fields. Such an area is hazardous chemical sub-stances. The arena for cooperation shall provide an interdisciplinary meeting place for its members, composed of representatives from various authorities and interested parties with a stake in the field of hazardous substances.
DSB is the coordinating authority for the Major Hazards Regulation and follow-up of the Seveso II Directive, and in this capacity has exchanged correspondence with Vest Tank when clarifying the enterprise’s situation in regards to the regulation. It was established that the enterprise would be covered by the regulation if the upper tank area were taken into use in connection with flammable goods. Under such circumstances the company should inform DSB and submit the safety report when this became relevant. According to Vest Tank the upper tank area was not taken into use for flamma-ble goods and was not involved in the incident.
When DSB received notification of the explosion a short time after it occurred, DSB contacted the local police in Gulen, the Norwegian Coastal Administration and the Bergen Fire Services that was on stand by with personnel, leadership resources, boat and the organising of extinguishing. DSB alerted the Ministry of Justice and the Police about the incident, and sent a situation report. The Civil De-fence was alerted by the police and contributed at the place of accident with personnel, pumps, hoses and sanitation equipment. Following the effort a report of concern has been received from the Civil Defence (in compliance with DSB’s own internal control system) brought about by uncertainty regar-ding which chemicals were involved. The follow-up of this report is ongoing.
The day after the explosion representatives from DSB visited the place of damage. DSB decided after the inspection that the permits should be withdrawn until future notice. DSB informed the owners of the company that operation could not recommence before safe operation could be documented in ac-cordance with the Fire and Explosion Act and pertinent regulations.
Following the incident DSB decided that the directorate should not conduct its own enquiry but instead chose to establish a close cooperation with the police. DSB has, amongst other, assisted the police with professional technical advice, participated in interviews and also meetings with GexCon. DSB shall, with basis in GexCon’s report and the police investigation, draw up its own report on the incident and possible technical and organisational learning points. In accordance with the obligations in the EEC-agreement the report shall be sent to EU’s Major Accidents Hazards Bureau.
In September DSB conducted a survey of the affected families living in the immediate vicinity to Vest Tank. The results of the survey will be published separately on DSBs website www.dsb.no.
There are several deciding factors that affect the degree of satisfactory execution of tasks in an inci-dent such as the Vest Tank acciinci-dent. These include, amongst other, appropriate knowledge, securing access to resources, training and experience, well-functioning crisis management and clarity regar-ding lines of responsibility and task solving issues. These are important factors that contribute to ensure suitable interaction, coordination and exchange of information between the different bodies.
a) Local and regional authorities handling of the matter
Crisis management and coordination
The municipality is, in accordance with established principles of responsibility, responsible for taking on a coordinating leadership role when handling an accident. Based upon this it is important that the municipality themselves has adequate general crisis management competence and access to necessary external professional competence for the crisis in question. In its capacity of coordinating authority the municipality has a special responsibility for establishing, as early as possible, communication channels. It also has the responsibility to clarify conditions of responsibility towards, and work-sha-ring with, other involved authorities in the incident in question. Furthermore, the municipality must gather all information and actively collect all necessary data that can contribute to good crisis mana-gement. This particular case has shown how important it is that local authorities seek professional support from the health authorities, especially the Norwegian Institute for Public Health.
Upon reflection Gule Municipality perceive that in such cases it is important that local authorities contact central authorities as soon as possible for professional support in whichever area necessary. The municipality’s main responsibility should not, however, prevent national authorities from contac-ting local authorities on their own initiative.
As to whether the County Governor should employ its coordinating role was a point of discussion but the County Governor understood that Gulen Municipality wished to handle the situation itself and the County Governor awaited further development. The County Governor’s coordinating role is entered into first and foremost when several municipalities are involved or when there is an actual need for coordination at local level.
Environment- related health protection
Environment-related health protection covers factors in the environment that at any time directly or indirectly may have negative effects upon health. These cover, amongst other, biological, chemical, physical and social environment factors. The municipality is obliged to have an overview of condi-tions that comprise environment-related threats against health and environment, and shall make super-visions in the area of environment-related health protection.
The incident revealed that work connected to environment-related health protection appeared to have low priority. At a local level this may be due to the fact that there is no tradition in municipalities/mu-nicipal health services regarding pollution of the outer atmosphere causing health hazards. Through its summary following the incident it became apparent that Gulen Municipality had not included environment-related health protection in the preparedness and readiness plan. Questions have been raised as to whether legislation in this area has unrealistic expectations regarding small municipali-ties’ resources and professional competence.
Access to competence and resources
In this case Gulen Municipality itself determined that it lacked both competence and the resources to deal with the complexity of the matter. Especially in the area of competence connected to environ-ment-related health protection. The municipality therefore wanted more assistance and advice from regional and central authorities, for example from a resource team or explicit guidance and assistance from the County Governor. In the situation Gulen Municipality should to a greater extent have
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ested support and competence on environment-related health protection both from the County Go-vernor and the Institute for Public Health.
The County Governor has several roles and in this situation the choice of role profile was difficult. The challenges lay in the borderline between guidance, supervision and the fact that the County Governor is the appeals authority. In retrospect the County Governor considers that it should have been more vigorous in offering process assistance to Gulen Municipality in addition to requests from the municipality, amongst other that the County Governor should have visited the municipality at an earlier point in time.
Municipal risk and vulnerability assessment
By undertaking a thorough assessment of its risk and vulnerability the municipality would realize which crisis and information preparedness and response measures it should have in place. Gulen Mu-nicipality acknowledges that it was probably too concerned with the acute phase and did not consider a “worst case” scenario with regards to the after-effects of the explosion.
Such incidents as the Vest Tank accident can be difficult to handle for a small municipality. It is the-refore important that municipalities regularly develop and update their risk and vulnerability assess-ments in order to establish which preparedness and readiness challenges they may meet, and ensure that the preparedness and readiness plans can cope with these challenges in a good manner. Likewise, it is important that the municipalities exercise crisis management in accordance with these plans.
b) Central authorities’ handling and the authorities’ interaction
Obscurities in responsibility and task distribution
The incident has shown the significance of involved authorities knowing each others’ areas of respon-sibility. Also that routines for notification are established which clearly safeguard necessary commu-nication between the authorities.
SFT note the need for specification and clarification concerning the health authorities preparedness and readiness in case of acute pollution. SFT have previously raised this question with the Ministry of Environment (cf correspondence between SFT, the Ministry of Environment and the Ministry of Justice in 2000 – 2001.)
The incident has revealed lack of knowledge in other authorities and the public concerning interface of authority between the Norwegian Coastal Administration and SFT in the event of acute pollution. It is therefore necessary with better information regarding this picture of responsibility.
DSB had its main focus on its supervisory role pursuant to the Fire and Explosion Act and the coor-dination responsibility in accordance with the Major Accident Regulation (Seveso II Directive). In retrospect DSB has acknowledged that the directorate should have taken an initiative to bring about a dialogue between the relevant authorities, possibly request the municipality to take such an initiative, cf. DSBs coordinating role.
In the early stage, the Norwegian Food Safety Authority was not aware of where the main respon-sibility lay for coordinating the work regarding this case and took it for granted that they would be notified by other authorities if their area of responsibility was involved. In retrospect the Food Safety Authority acknowledge that in cases of acute crisis where other authorities have the main responsibi-lity the Food Safety Authority must evaluate as quickly as possible if its own area of responsibiresponsibi-lity is involved. It should thereafter contact the other authorities in order to clarify conditions of responsibi-lity and request to be presented with all necessary information.
c) Sharing information and interaction
Sharing information (reports, test results etc.) is important in every incident and involved public bodies must be better in communication and exchange of information. To improve this it is neces-sary to lower the threshold for making contact and asking for or offering help. It is decisive that the coordinating responsibility is clearly placed and attended to. This responsibility today lies with the municipalities.
The accident has shown us that such incidents demand a good flow of information internally in the municipalities and between involved authorities in regard to following interaction. There is agreement that the central authorities should have contacted the municipality’s leaders when they visited the place of damage on 24th and 25th May to ensure that necessary contact was established.
The day after the accident the central authorities knew that the tanks contained sulphur mixtures. This information should have been immediately shared with Gulen Municipality and the Norwegian Institute for Public Health. The preliminary report from Vest Tank dated 31st May should have been sent to all the involved authorities with the intention of safeguarding public health.
The municipality experienced that Vest Tank dealt mainly with central authorities in preference to the municipality. This in turn caused problems for the municipality in obtaining necessary information from the company.
Information to the public
In cases where several authorities are involved it is of the utmost importance that the information gi-ven to the public both from local and central authorities is clear about what has happened and how the matter shall be further dealt with. It is paramount that unnecessary insecurity amongst the inhabitants
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is avoided.
Based upon the facts that emerged during the meeting at DSB on 5th September 2007 information was already available on the day of the accident which could have enabled the Norwegian Institute for Public Health to comment on expected health worries at an earlier stage. There have been cases earlier where sulphur mixtures (mercaptans) have caused health afflictions similar to those experienced by the inhabitants of Gulen Municipality. The public’s insecurity could therefore have been reduced if it had received information about which substances were in the sludge following the explosion and that these substances could lead to extremely unpleasant sensations connected to smell, a feeling of illness and discomfort.
Had Vest Tank at this point been subject to the Major Accident Regulation (Seveso II Directive) the population would most probably have received better information on how they should act in the case of a possible incident as the regulation sets requirements regarding information from the enterprise to the general public. This had also involved that Gulen Municipality would have had greater obligations in relation to preparedness and readiness as the Seveso-II Directive makes such demands to authori-ties in areas where enterprises that have the potential for causing major accidents are localized.
d) Internal Control
In accordance with the Internal Control Regulation the individual enterprise has the responsibility to ensure that the enterprise’s health, environment and safety work is conducted in accordance with le-gislation and permits issued by the authorities. Amongst other, this involves that the enterprises shall have routines that cover the demands for mapping risk conditions and measures for reducing risk. The authorities follow up how the enterprises meet with the legislation by conducting risk based supervision and inspection. This involves that inspection activities are given priority based upon the risk posed by individual enterprise or branches. The choice in subject of inspection is made with background in knowledge and experience of the enterprise’s risk, potential for major accidents and accidents that may have occurred.
Based upon the principles of the Internal Control Regulation it is the enterprise itself that is responsi-ble for procuring sufficient documentation following an incident. The Pollution Act imposes the one responsible for damage to undertake necessary consequence assessments for damage to the environ-ment following incidents of acute pollution. This involves, amongst other, an obligation to ensure necessary testing. The authorities conduct supervision to ensure that this is satisfactorily undertaken. Even though the responsibility lies with the enterprise, the authorities could, in Vest Tank’s case, have been more active because it took too long before necessary documentation was produced regarding contents in the tank and the sludge following the explosion, and also because the population did not have confidence in the enterprise’s documentation.
In cases where they are the appropriate authority SFT will more often consider taking tests and com-pleting analyses at an early stage in the course of events, in addition to the obligations of the enterpri-se to state how things happened, the cauenterpri-ses, danger of pollution and clearing up measures. This will contribute to the population receiving necessary information at an earlier stage.
There is agreement that the incident has revealed a potential for improvement in relation to the aut-horities ability to interact, the sharing of information and application of the professional bodies’ knowledge and competence. The involved authorities shall ensure that these follow-up measures are introduced to enable better handling of future incidents.
Sharing information and interaction
The municipalities must attend to their coordinating responsibility in crisis situations, and request professional advice and guidance from regional and national authorities in situations where the muni-cipality does not have the necessary professional competence. Regional and national authorities must be prepared to give and be able to give such professional support.
Regional and central authorities must, when this type of request is received, ensure that necessary information is given to the leadership of the municipality as soon as possible.
DSB shall ensure that the County Governor contributes in following up the above-mentioned condi-tions.
DSB shall evaluate the possibility of introducing a general requirement to enterprises that handle dangerous substances to inform the population and other enterprises in the vicinity about which type of risk the enterprise represents, and how they shall act in the event of an incident.
Obscurity in division of responsibility and tasks
The Norwegian Coastal Administration shall, in cooperation with SFT, contribute to improving society’s understanding of the authorities’ roles and division of responsibility in situations of acute pollution.
DSB has a general coordinating role in the area of safety in society and based upon this shall clarify which specific expectations exist regarding the directorate’s role in coordinating this type of incident. In retrospect the Norwegian Food Safety Authority acknowledge that in acute crisis situations where other authorities have the main responsibility it must, as soon as possible, evaluate whether its own area of responsibility is involved, make contact with other parties to clarify conditions of responsibi-lity and request all necessary information about the case in question.
Environment-related health protection
The incident has revealed that work with environment-related health protection appears to have too low priority. The situation regarding environment-related health protection in municipalities should be surveyed, and it should be evaluated whether society’s expectations through legislation to small municipalities competence in this particular area are too high. The involved authorities request that the Ministry of Health and Care and/or the Directorate of Social Services and Health take an initiative in this work. The health preparedness and response connected to environment-related health protec-tion in cases of acute polluprotec-tion is an important aspect.
The County Governor of Sogn and Fjordane shall continue efforts to improve the municipalities’ general capability in preparedness and readiness and in the health and social affairs sector in particu-lar. In the autumn of 2007 the County Governor has initiated a survey of environment-related health protection in the municipalities and the results will be available at the turn of the year.
Crisis Management and Coordination
It is important that the municipality exercises regularly in handling possible incidents which are identified in the municipality’s risk and vulnerability analysis in the municipal crisis preparedness and readiness plan.
The municipalities must be made aware of their own responsibility for handling, issuing information and following up in connection with major industrial accidents.
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DSB shall ensure that the County Governor contributes to following up the above-mentioned condi-tions.
The Norwegian Institute for Public Health shall also evaluate if a recommendation for introducing an obligation for the Municipal Health Service to notify the Institute for Public Health should be introdu-ced for cases where chemical accidents that may represent a threat to the population.
SFT shall, in similar cases, evaluate more often testing and analyses at an early stage in the course of events in addition to the enterprise’s obligations to find out how things happened, the causes, danger of pollution and clearing up measures. This will contribute to the public receiving necessary informa-tion at an earlier point in time.
Internal Control
The explosion at Vest Tank in May 2007 has shown that it is important to control the branch’s syste-matic (HES) health, environment and safety work. Based upon this conclusion SFT and DSB have agreed upon a joint supervision project in 2008 where supervision shall be held at plants receiving waste from oil related activities.
HR-2157 ISBN 978-82-7768-209-9 November 2007 Rambergveien 9 Postboks 2014 3103 Tønsberg Tlf.: 33 41 25 00 Fax: 33 31 06 60 postmottak@dsb.no www.dsb.no
