Introduction
1 Following the explosion and fire at Buncefield in December 2005 the Health and
Safety Commission set up an independently chaired Major Incident Investigation
Board (MIIB) led by Lord Newton of Braintree. The Board was given a wide-ranging
set of objectives within its terms of reference and published a series of eight reports
before its final report in 2008. Details of the Board’s work and its recommendations
can be found at www.buncefieldinvestigation.gov.uk.
2 Legal constraints prevented the Board from publishing certain information about
the root causes of the incident while criminal proceedings were in progress. These
proceedings have now concluded and this document fills that gap. It addresses the
root causes behind the loss of containment of fuel on 11 December 2005. It draws
out the key lessons for those managing high-hazard industries.
3 This publication is based on the work of the COMAH Competent Authority
Investigation Team – over four years of investigation – and is a summary of the
conclusions. It would be impracticable to repeat all the painstaking work upon
which the conclusions are based, much of which formed the evidence in the
criminal trial.