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 Mr Vernon 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 two PSVs (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 Mr Richard replaced Mr Grant as the Phase 1 Operator. Mr Bollands saw Mr Flook 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 Mr Richard 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. Mr Vernon 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 Mr Bollands 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. Mr Vernon 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. Mr Clark 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. Mr Rankin 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 Mr Vernon’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 10 valves. 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 Mr Todd who asked him about his knowledge of the permit to work system. Mr Todd 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 Mr Rankin had suspended permits or had them extended.

Mr Rankin’s shift began about 6 am and was due to run until 6pm. Normally a valve would be completed during the one shift. Once a permit had been issued for Mr Rankin’s work he would be given a copy of the permit. He claimed that he would have kept it on his person which is not exactly how he should have dealt with it.

The defenders argue that the evidence shows that matters involving the extension or suspension of permits would normally be handled by the incoming Lead Production Operator and they are right about this. Of course the practice would assume that there would be an incoming Lead Production Operator recently come on duty when the suspension or extension was required. Thus were it the case that Mr Rankin had brought the permit back to the Control Room at 5pm it would be consistent with the evidence that Mr Flook would have dealt with any suspension required at that time.

There was evidence which was not disputed that it was not unknown for a pump which had been withdrawn for planned maintenance to require to be brought back to service and the defenders found on this as indicating that the Lead Maintenance Operator should have had this in mind when apprising himself of the working conditions on the platform. It was certainly part of his duties to be familiar with the running of the plant during his shift. He controlled it on the floor of the platform. As we were told the tripping of a pump is not unusual and that may have been why Mr Seddon when he telephoned the platform from onshore was rather uneasy about doing the planned maintenance.

In relation to Mr Vernon’s state of mind when he went to restart the pump it is certainly most unfortunate in every sense that he did not live to give his own account of the facts of the night of the accident for which he is being blamed. However Counsel for the defenders maintained that the test of a person’s state of mind would in any event have to be decided on the objective data. He referred me to Walker and Walker "0n Evidence" where at par. 24 the authors say that a party’s state of mind can be proved only by inferences drawn from other facts so that the circumstances associated with these facts are relevant and admissible evidence. I did not understand that this expression of the law was disputed. Of course there may be many cases unlike this one where direct evidence of a state of mind was available but even in such a case the reliability of the witness as to that would have to be assessed by reference to evidence of the other facts and circumstances. Nor do I have any difficulty with Mr Keen’s argument that if the proved facts would have conveyed the necessary knowledge to any reasonable person then the required knowledge will be imputed to the relevant person. I was also referred to some of my own dicta in the wilful fireraising case of John Scott Blane v HMA 1991 S.C.C.R. 576 where I observed:

That quotation deals of course with intention to be attributed to actings and not with state of knowledge. However the problem in this case is not the law on this matter but the difficult "Jury" question of ascertaining what the surrounding facts were and what inferences can be taken from them. Defenders’ counsel’s point was of course that since Mr Vernon must be taken to have been a reasonable man then from the facts known he must be presumed to have been aware that Pump A was lacking its PSV. However the problem is compounded by the fact that the issue is not what Mr Vernon may have known at some time but whether or not he retained that knowledge at a particular time.

The defenders also made a submission that far from being pressed for time Mr Vernon had plenty of time to take alternative measures. He had over an hour before the Suction Condensate Vessel would overflow to flare. The de-isolation of the electricity would involve some time because this involved the identification of the tags and the relevant keys, the retrieval of the keys from the key safe, the removal of padlocks and the return of the racks. This would have to be done not only for the motor but for the lube oil system as well. These would have required about 15 minutes. However the argument was continued by the defenders to the effect that there was not such an emergency that an experienced Operator would have thrown caution to the wind. If the word "deliberately" is added I doubt that the pursuers would disagree with that sentiment. The defenders placed great emphasis on the fact that for Mr Vernon not to be aware of the PSV’s absence he would have to have ignored or not absorbed not one factor but a great many. The Defenders summarised these as being, firstly, that the PSV permit would have been suspended at the end of the day shift and it is clear that it must have been Mr Vernon himself who suspended it. Secondly Mr MacGregor had a permit suspended at about 9.15pm on the evening of the accident. It would have been Mr Vernon’s duty to inspect this worksite at the point of suspension and this site was close to where PSV 504 should have been located. In fact Mr MacGregor’s work had been to fix a plate to the Suction Scrubber near the scaffolding which had been erected for the PSV removal. Thirdly there were many people directly in contact with Vernon who would have known about the PSV maintenance. Fourthly it was said that even if Mr Vernon did not himself suspend the PSV permit at the shift handover he would have known about it assuming that he had followed the other safety procedures. Fifthly the events in the Control Room just before the explosion suggest that Mr Vernon must have known about the position regarding the PSV. I do not think that there is any doubt that it was Mr Vernon’s responsibility to keep himself informed of features of the process which may have affected safety. If anyone in management should have known about the status of the PSV it was he.

The pursuers themselves make averments in their pleadings which the defenders said are important to the resolution of the problem being considered. They aver:

The pursuers argue that the defenders originally denied these averments and only admitted them by amendment at a late stage of the proof. Thus at the relevant time the pursuers had simply not proved these averments which at the time they led relevant evidence were in dispute. It is of course obvious enough why the pursuers made these averments since they were anxious to show that they had little choice but to make compensation payments to the victims. The question remains if they have at the same time established one of the defences to the application of the indemnities by themselves apparently accepting that the accident was caused by an intentional departure from good and prudent practice. This is certainly the defenders’ contention and indeed they say that since they have admitted the averments in question these must be taken as among the established facts in the case. In terms of the permit to work procedures the Lead Production Operator in his capacity as Designated Authority has an obligation to satisfy himself with the job site in the event that he is responsible for the suspension of the permit (paragraph 3.6(a) of the permit to work procedures in the General Safety Procedures Manual number 12/405 of process). However it must be noted that the responsibility on the Designated Authority is not specifically to inspect the site but to "satisfy himself". Whatever the pursuers take to be the import of the rule about the procedure to be followed upon suspension there is little doubt that in practice not all the operatives considered that it was necessary to carry out an actual inspection to satisfy themselves about the worksite. Thus Mr Henderson thought that it was sufficient to satisfy oneself by indirect inquiry and that an inspections would only be necessary if there had been serious work carried out such as breaking into the condensate system. On that view what would be a reasonable procedure to satisfy himself may vary with the particular circumstances. Thus in the case of an absent PSV it may be a sufficient safety check to inquire if blind flanges have been fitted particularly if the pump has already been isolated. In any event it is by no means clear that a Lead Hand who did not carry out a physical inspection would consider that he was violating the safety procedures. Mr Snape thought that upon suspension it was the duty of the Lead Production Operator to inspect the site but he may not have been as familiar with the Rules on this point as the production operators who were following the system from day to day. The matter of the blind flanges seems to have been Mr Smith’s only concern when he spoke to Mr Rankin in the recreation area. In any event whatever the wording of the Safety Procedures the procedure followed on the platform seems to have been that granted that it was often impracticable to inspect a site it sufficed in many cases simply to be satisfied that the site had been left safe. Applications for suspension of permits were likely to be coming in thick and fast at or about the changeover period. In any event there is a fundamental illogicality in the pursuers’ averments on this matter. If Mr Vernon did have a duty to inspect the worksite this could only be because he was aware that the valve work had been proceeding. Since no-one suggests that he had been asked to cancel the permit it is intrinsic to the situation that he knew that the work had not been completed. If he knew this then it is not likely that on inspection he would have discovered anything he did not know before the inspection. In any event in relation to the Court’s attitude towards implied admissions the pursuers referred me to Charles Lee v The National Coal Board 155 S.C. 151 and Wilson v Clyde Rigging and Boiler Sealing Co. &c 1959 S.C. 328. I do not find it necessary to examine the implications of these cases. In any event no attempt was made by the defenders to have excluded evidence that showed that the alleged admission was totally inapplicable to the facts. Even if an admission on Record is to be regarded in the same light as evidence (as Lord Sorn suggests in Lee at page 160) if further evidence is without objection admitted to the proof which contradicts it then the Court must assess the whole evidence. Cancellation of a permit (as distinct from suspension) involves a duty to inspect the worksite but the permit to work relating to PSV 504 would only have been cancelled if the work on the valve had been completed and it is one the uncontested facts in this case that the work had not been completed.

It should perhaps be noted that when Mr Todd the Maintenance Superintendent was asked if it was good practice to run the Condensate Injection Pump with the PSV missing he had no hesitation in saying that it would not be good practice. Mr Clark was somewhat ambivalent about his own knowledge of what would be bad practice on this matter but given Mr Todd’s position I think it can be assumed that Mr Clark as a Lead Maintenance Hand familiar with the equipment would well know that it was not satisfactory to run the pump in the absence of an important safety feature such as the pressure relief valve.

On the matter of signing-off electrical de-isolation tags although Mr Clark was not entirely consistent about this I think it is clear that as Maintenance Lead Hand he had authority to sign these tags albeit that he was not the Designated Authority on the permit. The production of documents relating to such de-isolations establishes this.

One matter that may affect the evidence of Mr Bollands to the effect that on the day of the accident Instrument Technicians had been working on Pump A under the planned maintenance permit is that it seems undisputed that on the day preceding the accident Maintenance Technicians had been working on Pump B. In his memory Mr Bollands could have got the two pumps confused. On the other hand if such technicians had been working at Pump A during the preceding shift Mr Clark would not have had direct knowledge of this since he would not have been on duty.

It should also be noted that extending a permit does not require any inspection. Upon a handover any suspended permits are handed over in a separate pile.

If two permits relating to the same equipment were issued then there was evidence that they would be folded together but this did not necessarily happen if the permits related to work at different platform levels and given the system for grouping the permits this would make sense. Moreover it was not made clear that say a live permit or a permit application would be folded with a suspended permit. Certainly Mr Bollands never referred to seeing two permits in Mr Vernon’s hand at any time. In any event the defenders argued that if there was only one set of electrical isolation tags then this must have related to the PSV permit. This is based on evidence that the planned maintenance permit had not been issued and evidence that electrical isolations would not be carried out until the work is about to begin. The pursuers made the point that it had not been proved that the replacement of the PSV actually required electrical isolation. Certainly the evidence was that only some designated authorities required such isolations for PSV work. Indeed were the position with regard to electrical isolations critical to the defenders’ attempted reliance on the exceptions in the Indemnities it has not been proved that the calibration of the Pressure Safety Valves invariably led to such isolation although I would accept that it often did.

There was evidence that when the air lines to the pump were disconnected a tag saying "do not operate" is attached. It was suggested that if Mr Vernon had attempted to restart the pump he would have seen these tags. However since his objective was to take the pump out of maintenance I am not quite clear how it can be assumed that he would be deflected by the tags.

It was argued by the defenders that the pursuers cannot challenge Mr Clark on the matters contradicted by Mr Bollands because they did not challenge either witness. However the defenders did not object to any evidence from Mr Clark on the basis that it contradicted evidence which the pursuers had led and not challenged. They were prompt to make such challenges on other occasions and if a party has been misled by a pursuer’s approach to a witness this may be a good ground for objecting to an attempt to lead contradictory evidence. This arises on the basis of failure to give fair notice of the case being developed. However in the case of Mr Clark’s evidence far from claiming prejudice the defenders came to adopt and rely upon much of his evidence. In any event where witnesses are giving evidence on relatively small matters of detail where from the circumstances recollections might be expected to be unreliable about such detail I am inclined to think that there is nothing irregular in not challenging all such material. In such a case the integrity of the witness is not being challenged and the point is often not whether a concession might be rung from the witness but whether at the end of the day one version of events more closely fits other evidence than another. Thus for example Mr Clark indicated that the electrical isolations were taken out not for the PSV but for the planned maintenance and the defenders themselves did not appear eager to challenge Mr Clark on this and other aspects of his evidence. Mr Clark could hardly have supposed that the electrical isolation tags had been referable to the PSV contract since he claims that he did not know about this and yet at handover he was obviously told about the electrical isolation. When Mr Vernon telephoned him he did not say "I do not know what you are talking about. The permit application is in the Safety Office and in accordance with practice there would be no red tags attached to it until the work is about to begin". His attitude would only be consistent with a belief that electrical isolation tags were already attached to the permit application since he seems not to have known about any PSV tags. The point made may rise more sharply if one is left only with contradictory evidence from the witnesses whose evidence is under review. Then if neither witness has been cross-examined it may well be inappropriate to prefer one witness to the other if there is no other evidence on which a decision can be based. However I need reach no conclusive view on the technical point made for in my opinion it is misconceived. Mr Bollands not only gave his understanding of the status of the Planned Maintenance permit but actually claimed that he had read it. This is at the core of his evidence and it is true that the pursuers did not challenge him about this. Mr Clark did not for his part say that he had seen an unissued planned maintenance permit in the Safety Office or indeed anywhere else. What he founded his opinion on was the evidence that Mr Smith had told him that the permit was not issued. He came after Mr Bollands (who was not cross-examined by the defenders) and the pursuers at least to a degree challenged Mr Clark’s assertion that the maintenance permit was never live. Unfortunately Mr Smith did not survive the accident so that the account Mr Clark gave of his conversation with Mr Smith could not be challenged nor could the basis for Mr Smith’s information be tested. In these circumstances the pursuers may well have decided that there was little point in challenging Mr Clark’s evidence as to what he had been told. There is of course a division in the evidence as to whether Mr Vernon saw Mr Clark in the Control Room and one or other of the two persons who spoke about this must be mistaken. As I have already indicated it would certainly be difficult to decide between them on this point so that it is fortunate that it does not matter. It may also matter little whether the red tags remained on a permit at the time when Mr Clark signed them or whether they had earlier been detached by Mr Vernon. These incidental details are exactly what one might expect a witness to be mistaken about.

The defenders submit that Mr Bollands must be wrong in suggesting that instrument technicians were working on the pump during his shift because evidence was given by the night technicians that contradicts this. However it would not be at all difficult for Mr Bollands to confuse technicians working towards the end of the day shift with technicians working in the evening. Whatever else is clear it is that Instrument Technicians were not working on planned maintenance of Pump A when Mr Vernon came down to investigate pump B. Certainly Mr Clark said that no work had been done on the pump that night and this therefore could be true in relation to the night shift. On the other hand Mr Bollands is very certain that Mr Vernon took the pink permit with tags on it from the box of active permits for the 68-foot level. Two details are particularly important here. Firstly if the permit to work had related to the PSV it would have been a blue permit. Secondly if the permit had related to the valve maintenance then it would have been kept at the 84-foot level slot and not that for the 68-foot level. It is perhaps unlikely that Mr Bollands would have been in error in respect of both details. Of course he might be mistaken about the detail but if he is right it is difficult to see why a revalidated permit relevant to the situation was in the live permits box unless some work had indeed been proceeding under it. As the timings may help to clarify whether or not Mr Clark saw Mr Vernon in the Control Room I think they would permit the view that an encounter there was perfectly possible. On the other hand as I have said I do not find it critical to reach a concluded view about that fact.

The pursuers referred me to authorities aimed at assisting me to arrive at a solution to the problem of witnesses who may give conflicting evidence about factual questions. The first case they referred to was Keenan v Scottish Co-Operative Society Ltd 1914 S.C. 959. In that case (which was a jury trial) three witnesses had given important evidence for the pursuer but the defenders led conflicting evidence which was not cross-examined. It was held that the pursuer must be held to have conceded the veracity of the account given by the defenders’ witnesses. The pursuers distinguished that case on the basis that on the vital matters they had cross-examined Mr Clark. Moreover, of course, there is the fact that both witnesses were led by the pursuer and in circumstances where it might be conceded that each was trying his best to remember detailed events of some complexity in circumstances where genuine lapses of memory might be expected. The other case cited by the pursuers was Margaret Robertson or Stewart v The Corporation of Glasgow 1958 S.C. 28. This was a reparation case where one expert had examined a pole which had caused the accident and was not cross-examined on his views. The second expert had not examined the pole but on the technical questions agreed with the first expert on the basis that he accepted the results of the latter’s examination of the pole. A question arose as to the corroboration of the condition of the pole and the pursuer sought to corroborate this point from the fact that the first expert had not been challenged. It was held that failure to cross-examine a witness did not supersede the need for corroborative evidence on the point under discussion. It should be noted that the case was concerned with credibility in relation to a critical matter. If one were applying the above cases strictly then the fact is that it was the defenders in the first place who accepted the evidence of Mr Bollands without challenge. The defenders in other words did not challenge Mr Bollands credibility. They accepted that he was trying his best to remember detail of the important events. In cases of this sort one can understand why Counsel may hesitate to suggest to a witness that he is not credible. Counsel for the parties were prepared in general to accept that each witness was doing his best to tell the whole truth and to base any criticism of the accuracy of a witness on other evidence of detail. In any event what the pursuers argued is that the evidence of Mr Bollands and of Mr Clark can largely be reconciled. This is true and even if there is divergence on matters of detail these do not destroy the pursuers’ position in relation to Mr Vernon. On the really essential matters the evidence is sufficiently consistent particularly upon matters that were not challenged with Mr Clark.

One fact beyond doubt is that shortly before the accident occurred Mr Young the instrument technician had been summoned to the 68-foot level. The defenders say this shows that by that stage Mr Vernon’s intention was to restart Pump B. Certainly it can be argued that a Instrument Technician might well be of more service in starting the pump which had tripped rather than the pump to be retrieved from the maintenance programme. On the other hand the fact that Mr Vernon was trying to get Pump A started would not preclude continuing efforts to trace the trouble in pump B and get it in working order again. Further Mr Vernon had expressed the view that the trouble with Pump B was in the Lube Oil system which would not require an Instrument Technician to cure. The fact is that in my view Mr Young’s summons does not advance matters significantly.

There is certainly no evidence that there was any talk of suspending any planned maintenance permit before doing any work restarting Pump A. If Mr Clark had been presented with an issued planned maintenance permit one would have expected that he and Mr Vernon would have suspended this permit when they signed the tags. Neither Mr Bollands nor Mr Clark speak to that happening. Thus either Clark is right when he says he was only given tags or at least he is right when he suggests that the permit had never been issued.

In relation to the question of timings I have already in Chapter 5 discussed these at some length and I have also there elaborated on my views as to whether or not a permit to work for the pump had been issued. The question is difficult and although the evidence that the permit had in fact been issued is marginally stronger as I have already stated I am not sure that the matter is one which impinges critically on Mr Vernon’s state of knowledge.

7.1.3. Mr Rankin’s Part

In relation to the work he had done earlier in the tour Mr Rankin thought that generally he had been working on plant with more than one PSV available to it. The valve fitters could not work on a valve on a line which was in production and accordingly they had to wait until a particular piece of equipment became available. This is what happened with PSV 504. In the morning of 6 July Mr Rankin was told by Mr Smith that PSV 504 would be made available to the valve technicians during the day. It was the last valve they had to attend to before their tour of duty ended. Mr Smith mentioned that there would be further ongoing work on the pump which would allow the removal of the valve for maintenance. The conversation with Mr Smith took place in the Maintenance Lead Hand’s Office which was close to the Maintenance Superintendent’s Office. The timing of the conversation with Mr Smith is not exactly clear but we do know from Mr Lynch that by about 7.15pm Mr Smith knew that he would be getting Pump A for maintenance and that he had applied for the requisite permit. This timing is vouched by the fact that Mr Curtis signed the permit about 7.40 am. Mr Rankin came to the Control Room just after 8 am to inquire if he could get the valve without a separate permit. This fact itself may reflect his relative inexperience. Mr Rankin stated that after he got his intimation from Mr Smith he obtained a permit form for the PSV from his Container Room which he thought had been filled in by Mr Whalley the preceding Score supervisor. He is again vague about the details but seems to remember that some information had already been filled in.

After procuring the permit application Mr Rankin indicated that he took it to Mr Curtis for approval. It is perhaps also a measure of his lack of familiarity with the procedure that he had to consult his check list before taking this step. Mr Rankin was able to confirm that the application was for a cold work permit. Mr Rankin does not remember at any stage going to Mr White to have the permit requested. Of course Mr Smith may have taken this step for him. Mr Curtis is unlikely to have signed the application until Mr White signed it and although the copy permit application which was recovered and produced (number 12/233 of process) does not show any decipherable indication of Mr White’s signature this may be because it had been damaged in the catastrophe. In the case of permit applications the Approval Authority keeps a copy and this is the copy that was produced. It was recovered from the accommodation area of the platform wreck. As Mr Rankin proceeded with his evidence the impression that he had little recollection of certain details was reinforced. Mr Lynch speaks to the fact that Mr Rankin came to see him between 8 and 9 am on the morning of the accident and mentioned that the Condensate Injection Pump would be available that morning so that he wanted permission to do the valve work. Mr Lynch sent him to Mr Smith to get the necessary paper work attended to. Mr Rankin does not remember any visit to the Control Room that morning but I have little doubt that Mr Lynch has a more accurate recollection. He also had Mr Flook there at the time of Mr Rankin’s intervention. One problem however with Mr Lynch’s account is that the copy permit shows a signature of the Approval Authority which purports to have been appended at 7.40 am so that Mr Lynch may not be accurate as to his timings, or as he suggests, Mr Smith may have taken the application for a permit to Mr Curtis at an earlier time. Mr Lynch does not remember seeing the completed application before he withdrew about 9.45 am to leave the platform so that if anyone signed the permit as Designated Authority it must have been Mr Flook who unfortunately did not survive the accident. Even if the permit application had been presented to Mr Lynch he would not have signed and issued it until the isolations were complete. In fact it is unlikely that any permit would have been issued until the pump was ready for handover in the late morning or early afternoon.

Mr Rankin does remember that after he had obtained a signature from Mr Curtis he experienced further delay because he needed to arrange for a scaffold and this may be the sort of detail which stood out sufficiently in his memory to be retained. He did not remember going to the Control Room to have the permit issued but agrees that he must have done this. On the other hand he is not entirely consistent about this because at certain stages of his evidence he claims that he took the permit to the Control Room in the morning. Moreover, however restricted Mr Rankin’s experience may have been he was certainly aware of the need to obtain a permit to work and I think it unlikely that he would have embarked upon the work without such a permit. This view is enhanced by the fact that an application for a permit was signed by Mr Curtis. If he got a permit then a copy of this as a live permit would have been retained in the Control Room and the Lead Operators would have expected some procedure relating to this to be followed at the end of the shift. Thus Mr Vernon would have been expected to know something about the permit when he came on duty supposing of course that the permit was actually issued. Even if Mr Rankin had not been available as a witness I should have been reluctant to believe that he so flagrantly breached his obligations as to carry out work without any permit unless there was at least some evidence to suggest this possibility.

Assuming then that he had his permit Mr Rankin then had to address himself to the removal of the valve. Since the scaffolding permit could be issued before the permit for the valves I think it is reasonable to suppose that Mr Rankin had arranged this at some time during the morning as his vague recollection supports. Mr Grant gave him some help and he remembers Mr Grant closing a valve in Module C which was close to the deck level. This does not make too much sense because the only valve in Module C which Mr Grant may have closed was the Manual Isolation Valve for PSV 504 which was close to the PSV and some height above the deck. Mr Rankin thought that it was about 2pm when he began to remove the valve. He said that it was after lunch, that Peter Grant was available, and the valve was removed. The procedure followed for this is that the nuts would first be open at either side to see if gas is escaping. Once the nuts are loosened the rigging is put on the valve, the bolts are extracted, the valve suspended and then it is lowered to the deck. The blind flanges are then put on and until this is done the pipework is open. The practice seems to have been to release the nuts slowly to ensure that no gas is escaping and this is done in the presence of an OPCAL representative to ensure that there is no sudden escape of gas. Just what the OPCAL representative was supposed to do in the event of an escape was never made clear. Mr Rankin stated that his job in the operation in question was to remove the nuts and bolts and then he could depart. He remembered that a rigger was present and the valve was taken from the module on a small trolley to be carried further by crane. As another illustration of his bad memory Mr Rankin could not remember if he had participated in the removal of the valve outside the module. He remembers the crane coming and lifting the valve to the Score Container. He cannot remember how the services of the crane was secured and indeed his recollection of the valve removal is seriously flawed. However Mr Rankin seems to be certain that he personally had loosened the bolts holding the valve. Then he had gone off leaving Mr Sutton to fit the blind flanges.

Some evidence about the valve removal was given by Mr James McDonald. He was aged 56 years and was a rigger employed by Wood Group. This witness speaks to a fellow rigger Rutherford assisting Mr Sutton with the valve. Unfortunately because he was medically unfit to give evidence Mr Rutherford did not appear at the proof although neither party made any attempt to introduce his recollection by way of hearsay except in one respect. The witness McDonald said that he had discussed with Rutherford the timing of when the work on PSV 504 was carried out and Mr Rutherford’s recollection was that the work had not begun until the afternoon. It was Mr Rutherford and not McDonald who was directly involved in the work. Mr McDonald had himself assisted Mr Sutton on other occasions. Mr McDonald claims that about 8am Mr Sutton came to him in the Gas Module and asked for help in the removal of a valve. This timing must be wrong since the pumps had to be run and Pump A de-pressurised before any work on the valve could proceed. Mr McDonald was not free to assist Mr Sutton at that time but he sent another colleague. When Mr McDonald visited Module C later in the day the valve was already down on the deck and the only persons at the scene were Mr Rutherford and Mr Sutton. That is to say Mr McDonald confirms that at that stage Mr Rankin was not present. Again the timing is doubtful for Mr McDonald claims that his visit to Module C was at "dinner time" which he said was about 12 o’clock. The meal lasts for about an hour and cannot be taken late. The valve was put in a barrow and taken outside the module to be moved further by crane. If Mr McDonald’s recollection is accurate it is perhaps rather surprising that Mr Rankin was not present supervising when the valve was being transported outside but there may of course be some explanation. Mr McDonald was initially adamant that he had only gone for his "dinner" after he had attended to the transport of the valve and he thought that this operation would have taken about 20 minutes. Later however he was prepared to admit the possibility that his timings could be wrong. It would have taken about three hours to calibrate and quality test the valve after it had been taken to the Score Container. The whole job of removing the valve from its initial location on the deck and transporting it to the Container may have taken about half an hour. Mr Rankin states that the work on the valve did not begin until after lunch but he is not a reliable witness on matters of detail. Like Mr McDonald he accepted that he could have been wrong on matters of timing. A starting time after lunch would certainly be more consistent with the time needed to test Pump B and isolate Pump A before work on the valve could commence.

It should be noted that Mr Rankin never returned to the valve site to check the blind flanges after they had been fitted. I do not say he was remiss in this respect for the matter is not raised but of course it does mean that if the flange had been fitted improperly no-one would have noticed. He remembered the OPCAL Quality Assessor coming to the Score Container to check the valve about 5.30pm. If Mr Rankin is more or less right in relation to timings this would mean that the valve was ready for replacement about 6pm whereas with Mr McDonald’s timings it could have been ready by 5 o’clock or earlier.

Mr Rankin claims that when the valve was finished it was quite close to the end of the shift and that may be the sort of detail he would remember. He claims that he remembers that he returned the permit to the Control Room and thought that this happened about 6pm. He had gone there not only to see about the permit but to see if he could get a crane to move the valve that evening. His evidence is that there was only one person in the Control Room but if his timings are accurate it is unlikely there would only be one person there at that particular time. Indeed Mr Clark was in the Control Room for his changeover about 6pm and states that it was busy at the time as was always the case between 6pm and 7pm. Mr Rankin cannot remember whom he saw in the Control Room nor if he had dealt with that person earlier in the day. Of course if he only saw one person it is always possible that the person he saw was not the Lead Production Operator but the Control Room Operator. On the other hand he claims that he was told in specific terms that there would be no crane available that night and it may be unlikely that the Control Room Operator would give him such information. Mr Rankin also says that his not very certain recollection is that the permit was thereafter suspended. The Control Room Operator would not have done that. Accordingly although the evidence is not entirely convincing I think there is at least a fair possibility that Mr Rankin did return a permit to work to the Control Room and there saw Mr Vernon or Mr Flook depending on the time of his visit. After all because Mr Rankin had little experience of being a supervisor he was working off a checklist in the work container and it is unlikely, even were it necessary to remind him, that this would not clearly relate the need to return permits to the Control Room at the end of shifts. If others were present he may simply have forgotten about this. Mr Rankin’s conversation in the Control Room was said just to have lasted a few minutes and he says that thereafter he left the permit on the Control Room desk. Whichever of the two Lead Production Operators Mr Rankin saw would have put a suspended permit among the pile of such permits rather than retaining it as a live permit. Mr Rankin’s evidence is that when he left the Container to visit the Control Room he had left Mr Sutton there talking to two others. After being in the Control Room Mr Rankin returned to the Container and Mr Sutton was still there. I mention this evidence because otherwise it may have been a possibility that when Mr Rankin went to the Control Room hoping to get a crane Mr Sutton had begun to loosen the blind flanges in preparation for the refit. However in relation to this evidence Mr McDonald raises another point about timing. He claims that he had visited the container and been told by Sutton and Rutherford that a crane would not be available. Apart from other considerations Mr McDonald is likely to have finished his shift just before 6pm. Mr McDonald places his visit to the Score Container at about 5pm (although he later modified this to bring his visit nearer to 5.30pm) and he has a point of reference in relation to time in respect of his tea-break which was about 4pm.

Mr Rankin stated that at the time when the valve came to being replaced he and Mr Sutton would have taken off the blind flanges together.

Mr Bollands when asked about his recollection of events in the Control Room at the changeover of shifts on 6 July stated that as from about 5.30pm the Control Room was rather busy as would normally be the case. Mr Bollands said that after he came on duty about 5.15pm he would acquaint himself with what was going on and then retreat to a coffee table in the Control Room to have a cup of coffee. This could put him out of sight of persons coming into the Control Room. Mr Bollands also indicated that the Lead Production Operator would normally carry out his inspection before 6pm. This would mean that if Mr Rankin had come to the Control Room just after 6pm the normal inspection may have finished. Of course if Mr Vernon went to perform his inspection between say 5.45pm and 6pm it is just possible that Mr Flook had delayed to finish his shift and would have dealt with Mr Rankin.

The defenders made the point that it was only in respect of his timings that the pursuers challenged Mr Rankin’s evidence and this was not disputed.

Mr Rankin claimed not to remember the person he had taken the permit to at the end of the shift but the defenders say, as they can, that he had had some previous contact with Mr Flook whereas he may never have met Mr Vernon who had only come on to the platform that day. Another point made by the defenders is that when Rankin went along to the Control Room he did not know if his permit would be suspended or extended. His hope was it would prove possible to extend it and finish the work that evening. Permits were only extended at the end of the shift so that he may not have seen any point in visiting the Control Room before the end of the shift. Thus for example in number 15/4 of process we find a permit to work for a PSV refurbishment that was extended by Mr Rankin on 3 July 1988. This permit was extended at 6pm until 9pm. There is another permit in that bundle of productions which shows another extension of a permit by Mr Rankin. This however is not a conclusive point for if on the day of the accident he had done all he needed to do on the valve rather than waste time he may have tried to get a crane as soon as possible so that he could get on with the work.

Unfortunately Mr Rankin’s evidence is rather indecisive in relation to his return of the permit to the Control Room. He does make it clear that he still had some hope of obtaining a crane so that the work could be finished that night. It is just possible that when he went to the Control Room, if it was a little early, that Mr Bollands was there on his own. He indeed claims that there was only one person in the Control Room. If he had merely seen Mr Bollands he could not have had much success in regard to commandeering a crane. If the person alone in the Control Room was Mr Bollands it is unlikely that he would have given Mr Rankin the negative information about the crane that Rankin reports. Indeed Bawdens were the agency which made cranes available. I suppose it is possible that in the absence of a Lead Operator Mr Rankin took the permit away until he found out what was going to happen in respect of the crane. If Bawden’s had told him no crane was available he may have gone off to find Mr Smith to see if anything more could have been done. Mr Smith may have been one of the few Lead Operators Mr Rankin as an inexperienced supervisor knew. He certainly seems to have sought out Mr Smith. It is plain that Mr Smith was only interested in suspending the permit (if it was not already suspended) since he inquired about the blind flanges. In that kind of situation Mr Rankin may have neglected to return once more to the Control Room with the permit. The possibility I have been discussing is extremely conjectural and is not consistent with Mr Rankin’s recollection that he left the permit in the Control Room. However it was clear from the content of his evidence that whatever the reality he does not have a precise recollection of how he acted at the end of the shift in question. His rather confused version about what took place in the Control Room is not consistent with what might have been expected. The peculiarity of this case is that however possible it seems that there is merit in the defenders’ contention that Mr Vernon should have known of the absence of the PSV there are in my view strong reasons to believe that he did not have this knowledge at least at the time there was pump failure. It follows that the precise cause of his ignorance at the critical time must in fact be at best somewhat conjectural. The high point of Mr Rankin’s position in relation to the suspension of his Permit may be contained in his observation "my understanding is that we suspended the permit". Of course if Mr Rankin did not return the permit to the Control Room then someone should have noticed that the live permit had not been cancelled, extended or suspended. If this situation in fact arose it is difficult to know if there was a deliberate departure from practice or simply an act of inadvertence.

Given the procedure that had been laid down for Mr Rankin and with which he was at least to some degree experienced it remains eminently possible that Mr Rankin returned the permit to work to the Control room for suspension. However doubts about the matter remain. Just what happened to the suspended permit if it was returned to the Control Room is difficult to discover. Unfortunately Mr Rankin (no doubt because of the shock of the accident) was unable to give any convincing account of what he had done with the permit at the end of his shift. If the permit had been left in the Control Room then Mr Vernon must I think be the person who at that stage dealt with it. However some hours later he was not aware of the existence of the permit and although there could be a number of reasons for this, one might be that he had never seen the permit.

7.1.4. The Manual Isolation Valve

It was the procedure that if a Condensate Injection Pump was closed down the Manual Isolation Valve on the relief line was closed as an additional isolating factor. Once closed they would normally be locked and chained (in this connection it is perhaps worth noting that there was no evidence as to who kept the key or as to how long it would have taken to procure this if the valve had to be re-opened). As I have already observed this valve was approximately at the same height as the PSV and about 18 inches away from it. Obviously the isolation valve, if it had been closed, would have to be opened before the pump could be re-started. Failing this the PSV could not function and there would be no pressure relief on the pump. There was evidence of a practice to open the manual valve before jagging to re-pressurise the pump but it was not clear that everyone would have followed, or was expected to follow, this sequence in respect of the valve. If Mr Vernon himself had opened the valve before carrying out the alleged jagging of the pump then he would have seen that the PSV was missing. I would accept that a person manually operating the Manual Valve would be unlikely not to notice the absence of the PSV. Equally if Mr Richard had gone to open the Manual Valve then he to would have seen that the PSV was absent and might have been expected to tell Mr Vernon. However it should be noted that there was no direct evidence to suggest that either Mr Vernon or Mr Richard had in fact opened the Manual Valve at the time of any jagging. There was no evidence of any express direction to open the valve before jagging and there was no evidence that it would have been dangerous to keep the valve closed until after jagging. Indeed the witness Mr Murray an experienced Operator saw no danger in re-pressurising the pump before opening the Manual Valve. The PSV would be set at a much higher pressure than the system pressure which would be achieved at re-pressurisation (the system pressure would be about 650 psi and the PSV would be set at about 1750 psi). Mr Seddon the Operations Superintendent agreed with this. It is only when the pump starts running that pressure could be built up. Because of the circumstances there would have been little time between the tripping of the pump and the alleged jagging. During this time Mr Vernon was also engaged in trying to restart Pump B. The precise order of procedures may have depended on the number of persons available for the re-pressurising process. As it happens if Mr Vernon jagged the pump Mr Richard had already been called away before the vital second jagging procedure. Mr Henderson had said that normally three men were required for a re-pressurising operation and his reference to the practice of opening manual valves possibly related only to an operation with that number of men. Mr Murray said that he would only send someone to open the Manual Valve at an early stage of re-pressurising the pump if he had the men available. Moreover we were not told very clearly how an operator was expected to gain access to the Manual Valve which was about 20 feet above the deck as was the PSV. Perhaps the PSV scaffolding could have been used as an access but this is by no means clear. Possibly a ladder or some other equipment would have to have been arranged. In any event if other factors point to Mr Vernon not knowing or remembering about the PSV I do not think the requirements relating to the Manual Valve can be taken as excluding the other grounds of inference.

The witness Mr Henderson spoke to the fact that there was a practice whereby in re-pressurising the pumps the Manual Valves would be opened as a first step. The defenders objected to any attempt to lead evidence from Mr Murray and Mr Seddon that there was no such practice on the grounds that Mr Henderson had not been challenged on the point. In the interests of fairness I sustained this objection when first made with the result that the pursuers would have been precluded from leading any evidence to the effect that there was any other established practice. Other objections in a similar vein were reserved. There was some discussion as to whether my ruling related to the sequence of de-pressurisation or re-pressurisation or indeed to sequence at all. The pursuers argued that in fact the objections covered the circumstances in which the Manual Isolation Valve would be used rather than precise sequence. However even if the objections can be taken as relating to the sequence of re-pressurisation as I have indicated there was no evidence as to the source or scope of the practice. It may be that the sequence of events spoken to was generally more convenient. As I have said no reason was advanced as to why individual operators could not have deviated from the practice if it were more convenient to do so.

It should be noted that Mr Henderson, a reasonably impressive witness, opined that in the kind of situation where one pump had tripped and there was an emergency attempt to de-isolate a second pump the Lead Production Operator (whom he supposes has two other men available) would be "getting that pump pressured up to run whenever we had electrical power available". This of course is what the pursuers claim that Mr Vernon was doing.

Mr Murray informed us that the Manual Valve is operated by a straight bar handle so that once access was gained the actual opening should take no time at all. However Mr Murray could not say anything very useful about the Manual Isolation Valve since he had never operated it. A fact confirmed by Mr Murray was that Mr Vernon would have about one hour before the Suction Vessel would be liable to overflow if the flow of condensate were not stopped. He also said that the situation confronting Mr Vernon and his response to it was similar to what had happened on a previous occasion. However I do not think in this observation he was including an absent PSV.

Mr Seddon, an Operations Superintendent on Piper Alpha, had considerable hands-on experience of the Production process. He had in particular considerable experience of operating Manual Isolation Valves. In fact from his evidence it appears that the de-pressurisation and re-pressurisation of equipment such as pumps is a very common procedure indeed. He said that invariably if a pump trips it is a "very, very minor fault". An important observation of Mr Seddon is that if he had required to start a pump which had been with maintenance he would ascertain the status of the pump from the Lead Maintenance Technician. He does not suggest for example that he would look through the permits to work. One point he makes is that before starting the work the permit for the maintenance work should be cancelled for it had not been completed. However in relation to the Manual Valve the point he makes is that there is a considerable difference between jagging with the Manual Valve still closed (the pressure in these circumstances being comfortably within the tolerance of the system) and with the pump running where pressure surges beyond the capacity of the Manual valve might be expected.

The Defenders contended that Mr Vernon might well not have arranged to open the Manual valve which of course would be consistent with a position where he had realised that there would be no point in opening the manual valve with the PSV missing. On the other hand if Mr Vernon had discovered through an attempt to open the Manual Valve that PSV 504 was missing (assuming that he had for some reason forgotten this) the knowledge may explain why when Mr Grieve came on the scene he saw that Mr Vernon had apparently switched his attention to Pump B. But as other evidence shows the main effort could always be expected to be to try to re-start the pump which had tripped.

7.1.4. Handover from Flook to Vernon

The defenders are undoubtedly correct to claim that it was the incoming Lead Production Operator’s responsibility to familiarise himself with the state of the plant and of anything in the preceding shift that could affect the safety of the ongoing production process. Thus Mr Vernon should have had a comprehensive handover from Mr Flook and should have also had an opportunity to discuss the state of the platform with the Operations Superintendent. Since neither of the parties who would have been involved in the latter process have survived it is speculative to consider what, if anything passed between Mr Vernon and Mr Curtis. In relation to PSV 504 Mr Curtis may not even have been aware of the up-to-date situation. Thus I doubt if it is fruitful to bring Mr Curtis into the matter. In any event if Mr Vernon was likely to hear about the PSV from anybody one might expect that it would be from Mr Flook. Mr Keen contended that it was the duty of the incoming Lead Production Operator to familiarise himself with permits that had been suspended during the shift and in a general sense this too must be correct. Moreover the defenders pointed out that Vernon had not only come onto a fresh shift but was actually commencing a new tour of duty so that it would have been particularly necessary that he should thoroughly familiarise himself with the state of the operations he was responsible for. It was also to be his first encounter with the switch to Phase 1 and this may have dominated his thoughts. It was said that the late Mr Flook was a conscientious and meticulous workman and I do not doubt that this is true but all the victims including Mr Vernon were given first class "references" from their surviving colleagues and one could hardly expect anything else. Because of the nature of the situation I should not like to make any vital decision on the basis of any such evidence alone. Moreover I can accept that the likelihood is that Mr Flook knew that the PSV work had been going on and at the point he came off shift he may have had no reason to believe that the work had not been completed. To find out about this he may have been awaiting the return to the Control Room of the PSV permit. In any event this may not have worried him if he thought that the pump was going to be immobilised for a number of days. The pursuers in their pleadings "believe and aver" that Mr Flook knew that the PSV had been removed. However knowing about the valve does no necessarily mean the information was thought to be important. Moreover if Mr Flook had been keeping his log with reasonable accuracy the fact that the PSV had been worked on that day should have appeared in his log. Thus Mr Flook is likely to have given Mr Vernon material from which at least it was possible to derive the information that the PSV had been worked on that day. Whether or not Mr Flook specifically discussed the valve work with Mr Vernon is a matter of conjecture. As I have already indicated Mr Flook may well have thought that the work on the valve would not be of great interest to Mr Vernon since it was expected that work on the motor would commence that night and the possibility of the pump being recalled may well have seemed rather remote given its condition. Since there was a live permit for the PSV work Mr Flook may have considered that given that he personally may not have been sure if the work had been completed Mr Vernon would find out about the pump more informatively when the permit was presented to Mr Vernon for extension or whatever. However the pursuers accept that Mr Flook could be expected to have given Mr Vernon some information to the effect that work on the PSV had been proceeding that day. Mr Grant undoubtedly knew about the PSV work since he had participated in it and the defenders founded on the fact that he would have recorded such work in his own log. There was uncontested evidence that he would have done so and it may have been surprising had he not. The pursuers asked for a specific finding in fact that in accordance with normal and proper practice Mr Flook would have handed over to Mr Vernon information that PSV 504 had been worked on that day. The defenders further argued that the removal of the PSV was not simply a matter of a calibration exercise that might have been of little interest to the Lead Production Operator but represented the removal of a major piece of equipment that would have become very significant should the need arise to bring the pump precipitately into commission which was in fact what happened. Indeed the objective of the permit to work system was to make sure that the Lead Production Operator was aware of everything going on at the plant which might affect production. There seems little doubt that if a PSV was removed during a shift and was likely still to be absent at the end of the shift the outgoing Lead Operator would normally tell the incoming Operator or hand him a log containing the information. On the other had as I have said the outgoing Lead Operator might form the view that the up-to-date status of the valve would inevitably be conveyed to the incoming Lead Operator when the Permit was returned to him at the end of the shift (assuming as he would that the permit would be returned). There was certainly uncontradicted evidence that the work on PSV 504 would, if proper practice had been followed, be recorded in the outgoing Lead Production Operator’s log. The defenders also wanted a finding that the removal of the PSV would be recorded in the Phase 1 Operator’s log which would be handed over to the incoming Phase 1 Operator, in this case Mr Richard. Mr Grant had certainly spent time assisting in the removal of the valve so that some reference to this might have been expected although just what would be said is more conjectural. Defenders’ counsel pointed out that the relief pipe beyond the Manual Relief valve was still connected to the Condensate Suction Vessel which remained a significant part of the ongoing production process so that it was important for a Lead Production Operator to be aware if he could safely open the Manual Valve. It was said that one would have expected Mr Vernon to take particular care to ascertain the state of the plant because he was beginning a new tour of duty. Of course this could be a double edged point since to begin a new tour of duty could mean that there was more than normal to remain mindful of. The defenders argued that the visit by Mr Vernon or Mr Richard to unload and recycle the Reciprocating Compressor Pumps would have taken them to Module C and the scaffolding would have been noticed. I do not think that there is much doubt that these pumps had been unloaded and recycled. Mr Vernon said so to Mr Bollands when he last returned to the Control Room and the matter is consistent with Captain Clegg who noticed a sudden increase in flaring minutes before the accident.

There was of course evidence that because the Pressure Control Valves PCV 1000 A and B did not always set effectively it was practice to adjust the larger valve B if recycling. This valve had a tendency to "hunt" which meant that the valve struggled to find its proper setting. The valves allowed the gas released by the unloading to pass through them to flare. The object was to drop the set point of the valve. Such resetting would have taken the person doing it quite close to the absent PSV and on the same gangway. The problem is that although it was obviously quite normal to adjust PCV 1000 B this was only superficially explored. For example it was not discussed in the evidence whether this was a critical requirement or merely a preferred practice. Mr Bollands seemed to suggest that it was a convenience rather than a necessity. The question of course is whether the PCVs would normally be readjusted if the recycling and unloading had to be accomplished in circumstances of some urgency. In addition it is not at all clear how much of the operator’s attention the valve adjustment might have been expected to take. It is not even clear that it was necessary to go to the valve itself to effect any necessary adjustment. Moreover the valve which had to be reset was located much lower than PSV 504. The evidence raised the possibility that in Phase 1 the valve was not operated at all in which case it would not require adjustment. I do not think too much help can be extracted from the demands of the valves in question. For the recycling operation itself 14 switches had to be thrown. For Phase 2 operation it would be necessary to go to both the PCVs and reset them but with Phase1 because some gas is already passing through PCV 1,000 A it would only be necessary to reset B. It should also be noted that Mr Henderson was somewhat tentative in suggesting that in Phase 1 PCV 1000 A could cope with the normal escape to flare alone. He personally had no direct experience of resetting these valves during Phase 1. It is accordingly also not clear that Mr Vernon or Mr Richard would have had experience of what, if anything, was required of these valves during Phase 1 and the same could be said of Mr Bollands.

The defenders strongly maintain that Mr Clark did not know of the valve maintenance work. However Mr Smith had to a degree been involved in the original instructions to the valve technicians to commence the PSV work and in accordance with the normal procedures spoken to by witnesses the valve work was an incident of the day’s work that Mr Smith might have been expected to record in his log. Indeed Mr Rankin thought that Mr Smith was the person to whom he had to report. If the material was in the log then this should have been handed over to Mr Clark at handover. Thus either Mr Smith’s log was not entirely complete, or Mr Clark had not registered all the material in it or had forgotten it. The only significance of this is that it cannot be assumed that the procedural system will always work effectively in every instance.

There was a point made by the defenders that I have to weigh in my mind in deciding this aspect and indeed all aspects of the case. That is that if the pursuers’ case at any point depends on hypothesis and I make one finding in fact that is inconsistent with that hypothesis then the hypothesis fails. In general as a matter of logic as well as law that must be true. However although the rule would normally be applicable in a circumstantial case it is difficult to apply in the abstract. A factual finding which would otherwise be attractive may be displaced as an available possibility because the other evidence in support of a particular hypothesis is so strong that it can only be supposed that the otherwise contradictory fact cannot be justified.

7.1.5. Conclusions on Mr Vernon’s Knowledge

If the position is that the accident was caused by the fact that Mr Vernon was attempting to put Pump A into Production then the defenders would have a good defence to claims under the Indemnities if they could show that he was acting deliberately in the knowledge that at the time PSV 504 was not in place. There are difficult questions as to what he may have known at certain stages of his shift but I think since it is his state of mind at the time he would have been jagging the pump that is critical, it assists to begin at that point. The question of onus of proof could arise but since I see a reasonable way through the difficult tangle that surrounds this matter I do not require to found my determination on onus. Thus onus is a matter I need not at this point decide although my initial impression is that the onus rests on the defenders to prove wilful misconduct. The alternative would be that the pursuers had to prove a negative.

My starting point must be that it would have been surprising if Mr Vernon had been prepared to ignore safety procedures to the extent that he was prepared to run the pump without a relief system to cope with any build up of pressure. Claims by his former workmates that he was exceptionally conscientious must of course be viewed cautiously but there is certainly no indication in the evidence that he might be capable of downright irresponsibility. It is clear from the evidence that all the Lead Production Operators and the ordinary Operators were well aware that it was bad practice to run a pump without a PSV in place. Indeed there was no suggestion from the considerable number of qualified workmen who gave evidence that such a thing has ever been done previously. There is of course always a first time but one would have to ask why Mr Vernon would have taken a risk. Personally he had nothing to gain. He had indeed a lot to lose because the course he is alleged to have followed was very exposed to discovery by his superiors and could have attracted a severe reprimand or worse. If Mr Vernon did consider that the exigencies of the situation he was faced with might justify a departure from reasonably safe procedures then one would at least have expected that he would discuss the problem with his colleagues. He said nothing either to Mr Bollands nor to Mr Clark both of whom he could readily have consulted. Moreover supposing that in fact Mr Clark was unaware that the PSV had been removed equally it would not have been surprising if he had known. He might have noticed the missing PSV while walking around the platform or Mr Smith might have told him at the handover. Thus Mr Vernon would not have known what Mr Clark would have known about the PSVs and yet allegedly he blithely ignored both Mr Clark and Mr Bollands on the matter. Furthermore Mr Richard would have found out that the PSV was missing when he went to release the Manual Valve if he did not know already. The prospect of losing Production was serious but would probably have been confined to the loss of condensate production since condensate would have had to be released to flare if the pumps had continued to remain disabled. However if Mr Vernon was concerned that he would lose production it is remarkable that he did not consult the various superiors in the management line who were on the platform. Mr Lynch indicated that it was acceptable, if necessary, to wake them out of their beds if there were a breakdown. This would have relieved Mr Vernon of the responsibility were indeed anyone likely to take a decision to run the pump without the PSV. Of course it is unlikely that any of his superiors in management would have authorised the use of Pump A so that there was little risk of his being criticised for not putting that pump into production. There were many routes by which senior management could have found out about Mr Vernon’s irregularity. Moreover there is a further consideration. The defenders’ contention is that Mr Vernon would have known that the valve maintenance was incomplete and suspended. If Mr Vernon had restarted the pump A in these circumstances then there was always the prospect that next shift the valve fitters would seek to resume what they were doing. This would mean removing the blind flange with condensate running through the system. Of course if the permit to work system had worked properly the valve permit would not have been renewed but there was clearly an undesirable risk of a mistake or misunderstanding which simply highlights the risk of running the pump with the PSV missing.

The defenders contend that although it was bad practice to run the pump without a PCV it may not have seemed such a great risk to Mr Vernon. The valve is only needed if the pressure builds up and there are additional safety devices including safety trip devices that could have relieved the flow pressure if the pressure began to build up excessively. However the immediate risk of pressurising the pump was not only that when the pump was in use the pressure valve would not be there as a relief. The relief line had been opened up and was only protected by a blind flange. This may have sufficed if the flange had been pressure tested. This was the procedure with flanges in use on an active line. There was no suggestion that Mr Vernon had made any arrangement to have the flange pressure tested and indeed we are not even certain how quickly this could have been done if desired. Of course if the line had been pressure tested any deficiency in the fitting of the flange would have been discovered. As soon as the pump begins to be pressurised one is dependent on an untested flange to contain the condensate.

One question is the origin of the red de-isolation tags which indisputably Mr Vernon released to Mr Clark to sign off. As between Mr Bollands and Mr Clark I formed the view that Mr Bollands had in general been the more accurate observer but it would be remarkable if any witness could be taken as totally reliable in all matters of detail and this must include Mr Bollands. Certainly a point was made that if Mr Clark knew that the PSVs were missing he would have had a lot to answer for because he released the electrical isolations. I have little doubt that he would have known that it was bad procedure to run the pumps without PSVs. It was also argued that Mr Bollands would have had an interest to cover his tracks by denying all knowledge of the PSV maintenance but this is less obviously so since in the presence of Mr Vernon and Mr Clark he could have had little direct responsibility. However although Mr Clark’s evidence has to be read with a certain caution and is not in all respects convincing I am by no means in a position to suggest that he was consciously misleading the Court. Both Mr Clark and Mr Bollands suffered frightening experiences when the accident occurred. Mr Clark got blown across the Control Room and was injured. With such a shock it would perhaps be expecting too much for Mr Clark in particular to have a reliable recollection of detail some years after the accident.

According to Mr Bollands a permit for the planned maintenance work had been issued and it was this pink permit that Mr Vernon took out of the live permit slot to present to Mr Clark for signature. Mr Clark on the other hand states that the permit application and tags were in the Safety Office and the permit had never been completed and issued. I doubt if either witness is entirely accurate. Since the maintenance permit was Mr Clark’s responsibility it would indeed be surprising if he did not know about its issue. The matter would have inevitably been mentioned to him at handover and one would expect that he would have been responsible for having it extended if it were to be a permit in the live permit container. Moreover it would not have been extended unless work was proceeding during the evening shift and it would be surprising if Mr Clark did not know about this since he would have been responsible for it. Mr Clark at least purports to remember that Mr Smith had told him specifically that the Permit had not been issued and this account of what he had been told may well be true. However, whatever Mr Smith said about the whereabouts of the permit application, I doubt if this was in the Safety Office even if the permit was at the stage of only being an application. There are parts of Mr Bollands’ evidence where it is possible his memory is not accurate. However there are certain details which are more likely to be accurate than others. As Control Room Operator Mr Bollands would have required to know the work proceeding during his shift. Thus he may well not have looked at the suspended permits which would have included the one relating to PSV 504. On the other hand he remembers looking at a permit which certainly gave him the impression that the Pump was undergoing planned maintenance and this he remembers was a pink permit (as it would be). I think when he came on duty he must have looked at something which related to planned maintenance. He claims that this was a live permit but if he is wrong about the live permit coming out of the live permit container the reality may be that what he saw was the permit application. I think that despite Mr Clark’s account of what he had been told the permit application (if there were such) was left lying in the Control Room ready for Mr Clark’s immediate attention when he came to proceed with the Voith Coupling work which he hoped to perform during the nightshift. There was evidence that sometimes after the necessary isolations had been carried out a permit was left lying in the Control Room for issue. The situation may be quite different when it is not known precisely when work will proceed but this was work where urgent completion was desired particularly after isolations had been completed. It is possible that Mr Clark had retrieved the permit himself from the Safety Office. He was challenged as to whether or not he had been in the Safety Office after coming on duty and his evidence was rather vague on this. However it got to the Control Room I think it was there when Mr Bollands looked through what he conceived to be permits relevant to his duties and also when Mr Vernon looked for the maintenance electrical tags. It is of course suggested that what Mr Vernon must have done was to take his tags from the PSV permit but I think this unlikely for reasons I shall expand upon shortly. If the permit had not in fact been issued then I would conclude that the permit form with its tags was available at the relevant time in the Control Room. It is strange that Mr Bollands had the impression that instrument work had been carried on at the pump but since no other evidence supports this I cannot exclude the possibility that this is simply some quirk of his memory. That I think must be so since it would be an odd tale to make up.

One circumstance that Mr Clark accepts without hesitation is that the original electrical isolations had been effected for the planned maintenance proposal and had been completed. This would make sense for once the pump had been isolated by de-pressurisation one would not want someone accidentally switching on the pump. The defenders suggested that what Mr Clark was saying is that the permits had been prepared ready for signing but the isolations had not taken place. However this does not at all accord with Mr Clark’s evidence. He claims not to have known about the PSV work or he would not have signed off the tags. Indeed when he signed the red tags he would not according to his evidence have known that they could possibly relate to valve work (since he claims not to have known about this) and must have had grounds for believing that the maintenance isolations had been completed. Otherwise what tags did he think that he was signing. The defenders’ Counsel attempted to draw some particular conclusions from general evidence that the electrical isolations would not be effected until the work was about to start. However in relation to the Maintenance programme all the evidence was to the effect that the electrical isolations necessary for this programme had been completed. The work was not simply a single job but was expected to be extensive and it was anticipated that some might begin during the night shift. In particular it was expected that the Voith Coupling work would be carried out during the night shift and although this on its own may not have required a hot work permit the work was to be carried out under the maintenance programme permit which would have required electrical isolation. Mr Clark was an experienced Maintenance Lead Hand. He claimed that the Maintenance permit had not been issued. Nevertheless he signed off tags which he assumed related to the maintenance permit. This I think shows that any practice of electrically isolating within a very short time of the work beginning was not in all circumstances followed particularly perhaps if it was part of a more substantial isolation process. The position was therefore that under the maintenance application the electrical switches would have been immobilised and sections of the tags attached thereto so that the power could not be restored unless the electricians were presented with discharged isolation tags. This is very important since it means that the electricity could not be restored unless the tags attached to the maintenance permit or application had been signed off by Mr Vernon and Mr Clark. Mr Clark accepts this and goes beyond it for as he claims he would not have signed off tags (which he assumed were Maintenance permit tags relating to the pump) if he had known that PSV tags were in force. Mr Clark would have had no obvious authority to sign off any valve tags since the performing authority for that work was Mr Rankin. There was a preponderance of evidence to the fact that a PSV Maintenance permit would be a blue cold permit and many (though not all of the relevant authorities) would require electrical isolations. The witness Mr Lloyd thought that the normal practice was to have electrical isolations for PSV calibrations. The Safety Procedure Rules specifically provide that each permit will have the tags relevant to it attached to it. This alone makes sense and there was no evidence that the operators ever departed from their prescribed safety rules. For example if only one set of tags were provided for two distinct jobs requiring isolation at the same time then if these were attached to one permit the risk would exist that when work relating to one permit was completed and the permit cancelled the electricity would be restored while the other work is proceeding. This approach can be illustrated in relation to the Planned Maintenance Permit. Although the various items of work were likely to be proceeding at the same time separate tags were required for the pump motor and the lube oil motor. Thus Mr Clark obviously knew what he was talking about when he said that if he had known that a PSV permit with electrical tags were out, there would have been no point in signing off tags for the Planned Maintenance Permit. The same would apply if the PSV permits alone were signed off. The point is that there would be attached to the switch lock two sets of tags, the tags relating to the two pump motors being one set and the tags relating to the PSV being the other. Then electricians could not restore electricity unless they had authority to discharge all the tags attached. I do not think it was suggested that Mr Vernon was proposing to override the whole tags system. The trouble he was taking to get Mr Clark’s signature indicates the opposite.

Everything about Mr Vernon’s communications in the Control Room suggests that he was concentrating on the planned maintenance situation. There is no suggestion that he visited the Safety Office at any time. Even if we suppose that Mr Vernon must have visited the Safety Office then on the basis of the defenders’ submissions he would only have found the maintenance tags there and these alone would not have been effective if he knew that there were two separate sets of isolation tags. When Mr Vernon spoke to Mr Clark on the telephone his first enquiry was about the position of the planned maintenance. He was apparently keen to get the pump back from that. Moreover his question to Mr Clark was somewhat curious if the position were that the maintenance permit had not been issued. He first asked what the status of the pump was and if work had been done on it. This would be an odd approach for a Lead Production Operator if there was no permit issued for he would know that no work at all could proceed without a permit being issued. Thus either there was a live permit or he had forgotten that the permit had not actually been issued. He did not say to Mr Clark that there was a PSV permit outstanding and that he would like these isolations signed-off (assuming indeed that the PSV permit had provided for such isolation). This is what one would have expected if he knew there was no planned maintenance permit and was standing with the PSV tags in his hand. Instead the whole thrust of his short conversation with Mr Clark seemed to be directed at planned maintenance. He seems certainly to have known about the proposed planned maintenance. He would not have asked if work had been done if he had not known about the isolations and this is what one would expect since that must have been an important element in Mr Flook’s handover. The various steps to isolate the pump must have figured prominently in Mr Flook’s log. However if Mr Vernon had it in his mind that the PSV permit was alive (with its isolations in force) he must have realised, just as Mr Clark did, that there was no way the electricity could be restored without releasing both sets of electrical isolations.

The defenders placed great store in the effectiveness of the procedures in insuring that the Lead Production Operator was at all times well aware of the state of the production situation. However at best for the defenders Mr Vernon must have inadvertently forgotten at least one important fact. Either it had escaped his mind that there were planned maintenance isolations or it had slipped his mind that there was a PSV permit. He could hardly have supposed that he could electrically de-isolate both permits unless he had access to all the tags. Moreover as I have said when he spoke to Mr Clark the emphasis in his conversation was on Maintenance and one would have supposed that the conversation about the red tags related to that. This clearly is what Mr Clark thought. There was certainly no evidence that Mr Vernon got hold of all the tags. If he had wanted the PSV tags (assuming there were some) he would have required to retrieve the permit from the suspended permits relating to the 84-foot level. Of course this would not have bothered him if he was not at the time aware that a PSV permit and possibly tags relating to it were in existence. If Mr Clark is right and the maintenance permit application was in the Safety Office he would also have required to visit there to get hold of the Maintenance Tags. Mr Clark would have been presented with more tags than he speaks to. Mr Bollands remembers Mr Vernon having in his hand a permit with tags attached. This seemed a vivid enough recollection to be substantially true. He may be mistaken in thinking that this was a live permit or even that it came from the 68-foot permit container and not simply from the desk nearby but his belief that it was a maintenance permit could only have arisen from it being red (or pink as the colour is sometimes described) and everything points to Mr Vernon being interested in discharging the planned Maintenance and not the PSVs alone as would be the alternative hypothesis. If it is clear that at the relevant time the PSV permit must have slipped Mr Vernon’s mind (assuming that is that he had ever been aware of it) it may not matter what he had known at the earlier stage of the evening. The defenders of course approached the problem from the opposite end and contended (at considerable length) that he must have known in the early evening and possibly later but in any event it must therefore be assumed that he knew when allegedly he went to restart the pump. One problem of course is that at least in one respect the pursuers seem to accept that Mr Vernon suspended the permit. This was originally denied by the defenders and as I have discussed the averment is based on material which is contradicted by the evidence that has been allowed to emerge. However the matter is not critical. First of all if the averments govern the position this means that the pursuers are accepting that there had been a live PSV permit. I do not think that there can be much doubt about this. Mr Rankin may have had his problems as a witness but he was undoubtedly sufficiently experienced to know that he could not calibrate Valves without a permit. If at one stage he may have been confused about this because of the intervention of the planned maintenance isolations he took the trouble to ask about the position and was put right. There was considerable evidence about the timing of his progress but on balance as I have said I prefer the view that he did not finish all he was able to do on the day of the accident until about 6pm and then he took his permit to the Control Room at least for some purpose. If as the defenders contend the pursuers are bound to a position that the permit was properly suspended Mr Vernon was in all probability the person who suspended the permit and this is what the pursuers aver. As I have said the pursuers’ averments on this element of their case seem to me to involve a massive non sequitur. If the pursuers’ averments are to be taken literally the only occasion when the Lead Production Operator could under the alleged safety rules possibly have a duty to inspect a site relating to an uncompleted job would be when a permit is suspended. However this would involve the Lead Operator knowing about the state of the work in the first place for the application to suspend the permit would tell him that. It is therefore difficult to see what the inspection would add to his knowledge. Moreover certainly as far as an operator was concerned he would on the evidence not necessarily be aware that it was a prudent procedure to inspect a site if he could properly be satisfied that the work had been left in safe condition. As I have said in reality there appears to be a doubt as to whether in the early evening of the accident Mr Vernon had the opportunity to discover from a permit to work that the valve was out of position. However it is not necessary for me to rely on my view of the technical arguments relating to the pursuers’ own pleadings. I shall assume that as the pursuers seemed to assert at least at one point of the case that Mr Vernon did suspend the permit. However he derived any information in the permit against a background when he had just begun his tour and may have had many different situations to worry about. We know for example that the process had just switched over to Phase 1 from Phase 2. This was a considerable change in the process and Mr Vernon was about to experience it for the first time at least for some years. He may therefore have paid limited attention to a valve that was missing from a Pump that was in any event to be unavailable for some time. It also seems that the permit if presented to him for suspension was probably presented rather later than normal - perhaps just after six o’clock. When Mr Flook made his handover he may not have realised that the valve work would spill over until the next day. In any event if that were to happen Mr Vernon would be able to ask for the details and he may have thought that little needed to be said about the PSV particularly with the pump in planned maintenance. The same points can be made in relation to Mr Grant’s handover to Mr Richard. Mr Grant may not have appreciated that the PSV job had not finished particularly as there was no indication that Mr Rankin would report to him nor did he have any responsibility. If Mr Grant was concentrating on matters that the incoming Operator would have to involve himself with then there may have seemed little point in making reference to the missing PSV. Indeed Mr Grieve in his evidence said that the Phase I operator would go through with the incoming operator anything which started during the shift which would relate to the work of the operators. This of course would not include work handed into the control of maintenance. Indeed Mr Grieve indicated that the entry in the log would simply record that the machine had been handed over to maintenance. Mr Bollands took a rather different view of what would have been recorded in the log but even if he was right the evidence would simply be recording that the detailed implementation of the practice could vary from operator to operator. In any event we do not know just how studiously Mr Richard required to look at the log if he had an apparently full oral handover. I am not convinced that the manual valve had been opened before any jagging took place and with the switchover to Phase 1 the proper procedure for resetting of the relief valves to flare may have been ignored by say Mr Richard who may not have been familiar with how to cope with that situation. This would also be likely if Mr Vernon was working under pressurised conditions with inadequate manpower.

It was suggested that Mr Vernon may have learned about the missing PSVs after leaving the Control Room - say from attempting to open the Manual Valve or from Mr Richard. The suggestion goes wider than the question of knowledge for it is that he may have decided not to proceed with the re-introduction of Pump A. If that had been the position I should have expected him to radio Mr Clark to cancel the electricians. Mr Vernon would hardly have wanted to de-isolate the pump and then proceed to isolate it again for completion of the valve work. Regarding inspection of the pump it may well be the case that Mr Vernon had completed his normal walkabout before Mr Rankin reported to him that he required the pump suspended. We were not really told what his practice would have been if subsequent inspections were required. This may have depended on the other tasks at hand and the importance of urgency in the inspection. Thus the inspection of a valve site and the nameplate work carried out by Mr MacGregor were hardly likely to cause much danger and may have justified low priority. When Mr Smith heard that the valve work had not been fitted his only concern was that blind flanges had been fitted. In general there was a limit to what a walkabout could reveal. Mr Clark said that he would not have noticed scaffolding. There was a great deal of it about and much was concerned with matters such as painting and other projects that do not involve production. Mr Clark also revealed that PSV 504 is situated in an area where there is a mass of complex piping. There are about 800 valves on the platform and he could not even identify PSV 504 without reference to a drawing. It is perhaps interesting that none of the operators giving evidence who might have been expected to know that PSV 504 was missing seem to have known so. Mr Bollands, Mr Clark, and Mr Grieve claim not to have known. It is unlikely that Mr White, the Maintenance Superintendent knew since he was present when Mr Clark agreed to return the pump to the operating department. If Mr Vernon hoped to restart the pump in the knowledge that the PSV was missing he might have expected some resistance from Mr Richard if he had known but there was no evidence to suggest this. The problem might well have been that no-one was focusing on the pump because it was presumed to be out of commission for maintenance. Mr Vernon for his part, if he had recollected the absence of the PSV valve could not have known that all these persons did not know the position but there is no suggestion that he attempted to conspire with them to breach safety practices.

The situation on the platform could admit of many circumstances which might explain how Mr Vernon came to forget about the PSV or not to know that it was not in position. The problem for the defenders is that there is in my view fairly clear eyewitness evidence from which it can be inferred that in the final period before the accident Mr Vernon was not aware that the PSV was absent. On the other hand the evidence of what might have taken place to produce that situation is vague and leads to no convincing conclusion. Many of the possibilities remain totally speculative and we shall never know what happened at and following on the handover. Among the various possibilities the likeliest is that at some stage in the evening Mr Vernon had suspended or at least seen the PSV permit but that either in the whole circumstances surrounding the planned work on the pump it had failed to register in his mind that the state of the valve had any significance or if it did so register it had slipped his mind later.

In arriving at a view of Mr Vernon’s behaviour I am in no way suggesting that he was not seriously negligent in allowing the PSV permit to escape his mind, or in any event as the Lead Production Operator on duty not having discovered that it was absent.

7.2.1. His Involvement

There was no dispute that in terms of OPCAL’s contract with Score the latter was required to fit blind flanges to all open ended pipework. The fitting of blind flanges was also a condition of the PSV permit to work. Nor was it disputed that such blind flanges ought to have been secured tightly by use of a flogging hammer or by combination spanners. In the case of a PSV being removed the purpose of the blind flange was not only to prevent dirt or other impurities entering the pump but also to prevent any hydrocarbon remaining in the pipe from escaping. These purposes are fairly obvious and should be known to any reasonably experienced valve fitter.

The tests carried out by Mr Stanton showed that if the flange is finger tightened alone it would not withstand the pressure which would be introduced to the valve upon re-pressurisation of the pump. On the other hand if it is tightened by flogging or by use of combination spanners then it should be able to withstand that pressure. A lesser degree of tightening would permit a leak to develop.

It was accepted by the pursuers that their allegation that Mr Sutton had caused the leak by not flogging or using combination spanners on the blind flange depended entirely on inference. No-one observed him when he was actually putting the bolts on the relevant flange. Moreover most unfortunately Mr Sutton did not survive the accident so that we do not have his own testimony.

It is I think obvious that given that a properly fitted flange should not leak then if the flange did leak the probability must be that the flange was not fitted properly. The defenders’ case is that there was no reason why Mr Sutton should not have followed his normal practice and tightened the flange adequately. The pursuers say that there are three reasons why Mr Sutton may not have fitted the flange properly. One is that he expected that the PSV would be replaced that evening and therefore did not expect that tightening the flange would be important. Another possibility that the pursuers advance is that he was working in a restricted space and therefore found it difficult to use tools. The third possibility is that Mr Sutton or Mr Rankin had selected the wrong size of flange for the pipe (a 1500 standard flange for a 900 pipe). It was conceded that this alone would not cause a leak but it was suggested that Mr Sutton had found that he had the wrong size of flange then thinking that the valve would be replaced that day he may not have bothered to tighten the flange properly. In other words it is suggested that the problem with size may have deflected him from tightening the flange as carefully as he might otherwise have done.

The pursuers averred quite plainly that Mr Sutton failed to secure the blind flange securely. The defenders submitted that these were not derivative or inferential averments and that the pursuers had therefore obliged themselves to prove by direct evidence that Mr Sutton had not secured the flange properly. They are correct in stating that there is no direct evidence that Mr Sutton failed to tighten the flange fully. They argue that if the pursuers sought to rely on an inferential case they should have introduced their averment with words such as "believed and averred" to show that their case was based on inference. They should also have set out clearly the circumstances which might permit them to draw any inference they proposed to found on. The only foundation which the pursuers plead in support of their general averment is that the flange leaked so that it must have lacked proper tightening. I think at this stage of the case where the whole factual background has been extensively explored it is a narrow technical point to complain about the pleadings in the manner I have indicated. If the evidence now before me allows for an inference that the blind flange was not properly secured by Mr Sutton I see no pleading difficulty about a finding in these terms. The defenders further argue that the pursuers can only establish their case of incorrect tightening of the flange if the Court first makes a finding that the flange leaked. This point I think has merit. There is no other material from which it could be inferred that the flange was not fixed properly. However it was contended there was no direct evidence that condensate leaked from the flange. Nobody actually saw this happen. I would agree with the defenders to the extent that the position is that there is no evidence about the fitting of the flange that would enable the pursuers to claim that such evidence in itself supports the view that the accident was caused by leakage from the flange. The negligence of Sutton could only arise if it is clear that the tragedy was caused by a leak of condensate from the blind flange.

The defenders develop their argument to the effect that if Mr Sutton did not follow the established practice for the fitting of the blind flange this must have been a deliberate departure from normal and prudent practice. This could of course have implications for the application of the indemnities. I think it would be rather strained to regard a failure by Mr Sutton to tighten the bolts as "wilful misconduct" even as defined by the Contracts. There is always the possibility that any failure to tighten the bolts was simply inadvertence promoted by careless application to the job. Even if he decided not to flog the bolts this may have been due to a misunderstanding as to what was required when the blind flange was thought only to be in place for a short time. He did know the established practice for tightening bolts but may not have realised that it was unsafe to depart from the practice in any circumstances whatsoever. Against the background of the proposed maintenance of the pump it may have been beyond Mr Sutton’s comprehension that circumstances could arise which would necessitate the hurried re-introduction of the pump. He should not have presumed that in the situation he was faced with anything less than a fully tight flange would be safe but his error may have been due to a misunderstanding of the dangers rather than a deliberate ignoring of them. If he was finding it too difficult to flog the bolts or manage the heavy flange in the cramped situation in which he found himself then he had a duty not simply to leave matters but to seek assistance. I think this would be an extension of the case that the pursuers have pleaded. However his conduct in such circumstances would not be deliberate departure from practice. As Mr Sutton was tightening the bolts someone may have arrived and distracted him so that he inadvertently forgot to complete the tightening sequence. In the whole circumstances if Mr Sutton did fail to bolt the flange insecurely I could not proceed to conclude that he did this as an act of wilful misconduct. The defenders seek to extend this argument by saying that if Mr Sutton knew that he had not fitted the flange properly he was also guilty of wilful misconduct by not informing Mr Smith of the position when he met him at the end of the shift. In fact it may never have occurred to him that he was misleading his superiors in any material way. It may be possible to infer that the bolts on the flange were not properly tightened by Mr Sutton. However if this is what happened it is not possible to infer what led him not to do his work properly.

The defenders again referred me to the case of McWilliams v Sir William Arroll 1962 S.C.(H.L.) 70 where it was observed that an inference unfavourable to a deceased should not be drawn except upon a strong balance of probabilities. This of course only creates a presumption and it must yield to the evidence before a Court. The defenders submitted that if it is assumed initially that Mr Sutton was a reasonable man (the appropriate assumption to begin with) then unless it is positively proved that he acted unreasonably it would not be possible to infer that anything happened due to his misconduct. However in my view if other evidence shows that the perceived state of facts could only have arisen if Mr Sutton had not acted unreasonably then I find no difficulty in arriving at that conclusion even in the absence of immediate evidence pointing to the fact that he had acted irregularly. Generally the valve calibration work was completed on the day it began.

Understandably the defenders also submit that Mr Sutton was an experienced valve fitter, he was familiar with the platform and there was no evidence that he or indeed other valve fitters had ever failed to tighten flanges properly. Of course one answer to this may be that it is perhaps unlikely that the very peculiar circumstances which preceded the accident had ever before occurred so that even if a blind flange had in the past not been secured properly the chances are that this would have been noticed.

When Mr Rankin gave his evidence he accepted that the blind flanges had to be fitted securely. He said that "There is, I think, only one way to fit a flange and that is with the correct flange and you tighten up the studs properly." Mr Rankin thought that "the reason for applying these blind flanges to the open pipework was primarily to protect the faces of the flange, to stop any accidental spillage from the system, or to prevent any dirt from entering from outside". These illustrate the experience of a person who until a few weeks earlier had been working as an ordinary valve fitter. Mr Rankin confirmed that he and Sutton had been able to do all the other valves they had dealt with on their tour in one shift (sometimes extended with overtime). Certainly Mr Rankin said that PSV 504 was the last valve he and Sutton had to work on during their tour and that he expected to finish the job on the day he had started it. He confirmed that some flanges for the work were kept in the Score Container and that other flanges could be obtained from a store at a lower level. Mr Rankin did not assist Mr Sutton in the fitting of the blind flanges and it is clear that Mr Sutton fitted them on his own. After the flanges were fitted by Sutton, Mr Rankin, who had left the site did not return to the site to check Mr Sutton’s work. There was no attempt to develop a case that Mr Rankin failed in a duty to inspect the work but his failure to check would ensure that any failure to tighten the bolts would pass unnoticed.

Mr McDonald the rigger who gave evidence had sometimes helped Sutton to remove valves on other jobs. He confirmed that Sutton seemed to be a reasonably competent workman. Mr McDonald said that he had seen Mr Sutton tighten up flange bolts by hand but the matter was not pursued in evidence so that it is not entirely clear if the witness meant that he had seen Sutton tighten bolts with his fingers alone or if he meant tightened by hand with combinations spanners. He affirmed that the blind flanges were heavy and that was obvious from the ones produced in Court. Mr McDonald was able to tell me that Mr Sutton’s worksite had been a very congested area. In fact he thought that given the valves were heavy his view would be that in that constricted site it would require two men to fit the valve properly. On the other hand the witness Bagnall, who seemed to have wider experience of the flanges thought that one man could fit the flange but with difficulty. He thought for example that there might have been difficulty in keeping the mating flanges parallel. He thought that one flange would take from half an hour to three-quarters of an hour with one man but perhaps fifteen to twenty minutes with two men. In fact Mr Bagnall would have put two men on the job. He also expressed the opinion that it could have been difficult to use the combination spanner in the confined space that would have been available to Mr Sutton. If two men had been available then one on either side of the pipe could have wielded a combination spanner. Thus if Mr Sutton had only got combination spanners available to him he may have been faced with the problem of going off to procure a flogging hammer or persuading Mr Rankin to return and help him. It should perhaps be noted that a combination spanner is a spanner which has a round headed spanner at one end and an open-ended spanner at the other end. There is no case against Score for not having enough men on the job but in any event it was Mr Sutton’s duty not to leave the valve in a half tightened state without reporting any difficulty to Mr Rankin. What is significant however is that he is likely to have had some trouble in fitting the valve properly and if he thought that the work was only for a short time he may have had a temptation to do the tightening half-heartedly.

The evidence showed a degree of uncertainty as to the size of the valve unit being serviced. Mr Wylie who was a Quality Assessor who certified re-calibrated valves was shown the certificate which related to the earlier re-calibration of PSV 505 (the valve on Pump B equivalent to PSV 504 and agreed to be the same) and he indicated that on the certificate the valve was shown as having a rating of 1500 lbws on the downstream side and of 600 lbws on the upstream side. However the information on the certificate had been filled in by the valve engineer who was Mr Bruce. There was therefore a suggestion that possibly PSV 504 had a similar rating. However Mr Wottge’s clear view which I have no reason to doubt was that PSV 504 was a 900 lbws rated valve although the defenders challenged him on this point (this may be because the pursuers themselves had raised in their pleadings the possibility that the wrong blind flange size had been chosen). The pressure that the valve was planned to withstand did not require a higher rating than 900 lbws. Moreover a drawing which was part of OPCAL’s records and which purported to be from the manufacturers of the pump (12/170 of process) showed that the flange for the PSVs had a rating of 900 lbws. Other documentation relating to the valve in the pursuers’ possession after the accident were to the effect that originally the valve had a 900 lbws rating. One drawing (12/146) perhaps suggests that the valve may have had a different rating but Mr Wottge did not think this was accurate particularly in the light of the manufacturers’ own drawing. Whether or not the certificate for PSV 505 was accurate need not concern me. Confusion could have arisen because the valve itself was rated at 1500 lbws although the outlet was rated 900 lbws. Mr Standen said that even if a valve had a mismatched size of flange this would not matter provided the flange was effectively tightened. However there was evidence from a Mr Pirie that one could not put a 900 lbws flange on a 1500 lbws pipe because the bolts would not marry up. Mr Bagnall on the other hand indicated that in the opposite case one could put a 1500 lbws flange on a 900 lbws pipe. In any event it was Mr Sutton’s job to see that he was fitting the correct size of blind flange but there was really no evidence that he did not do so. If he was in fact trying to fit a flange which was a higher rating than needed (which I doubt) not only had the fitters selected the wrong flange for the job but he had made the task of fitting the flanges harder since the 1500 lbws flange was much heavier. According to Mr Bagnall a fitter at the valve site would have no difficulty in recognising that he had the wrong size of flange. At the end of the day I did not understand the pursuers to press their case that the wrong size of flange may have been fitted.

Number 12/230 of process was a valve calibration certificate dated 22nd June 1984 relating to PSV 504 and it shows the rating at 4 inch 900 lbws. In the certificate 12/228 the valve size of PSV is shown as 4 inch 1500 lbws. The date of the certificate is October 1985. A certificate of the same date relating to PSV 505 also shows that valve with the higher rating. However Mr Wottge confirmed that there was no change to the relevant line between 1984 and 1985. A question may arise as to whether the fitters may have been confused by looking at earlier certificates and seeing perhaps a certificate that declared the valve to have a 1500 rating. However if the wrong size of flange had been taken to the site as Mr Bagnall said this should immediately become obvious to the fitter and all that was required was to fetch the proper size. There was a store of flanges kept on the platform. Mr Rankin did not suggest that such a problem had arisen. In any event Mr Sutton had worked on PSV 504 not long before so that he should have known the flanges that were fitted to these PSVs notwithstanding that the certificate (which he would not have himself prepared) had been inaccurate. A Mr Reid gave evidence. He was a Production Manager with the Wood Group. In his earlier post as Quality Assessor he had completed the certificate relating to October 1984. He explained that the outlet from the valve was not large and he had rated it at 900 lbws. He thought he may have got the rating from Info