§ Sir George Young
In my statement to the House on 6 June, I said that I had ordered a full investigation into the matter, and that I would publish the report. I also assured the House that the lessons learnt from this unfortunate incident will be vigorously pursued.707W
The investigation was carried out by Mr. M. J. Dudding, a Principal in the Parliamentary Works Office, assisted at relevant times by one of Her Majesty's Inspectors of Factories of the Health and Safety Executive, a member of the staff of the Serjeant at Arms' Department or a safety officer of the Property Services Agency's London region. His report has been completed and a copy has today been placed in the Libraries of both Houses. Copies have also been sent to the appropriate trade unions and staff associations; and to all occupants of the Norman Shaw south building.
I am satisfied that Mr. Dudding's investigation has been detailed, thorough and impartial. His report was prepared in full consultation with the authorities of the two Houses, and with the Health and Safety Executive. Each of these bodies has expressed itself satisfied with the investigation and the findings of the report.
The investigation has established that anti-corrosion chemicals were accidentally poured into the wrong tank in Norman Shaw south on two occasions, on 4 May 1985 and 4 June 1985. The report reveals weaknesses in the management of the Parliamentary Works Office, and in communications within both that office and the Serjeant at Arms' Department, and between these two bodies.
The main recommendations are that:
- (a) improvements should be made in the Parliamentary Works Office relating to records and instructions to staff;
- (b) in both the Parliamentary Works Office and the Serjeant at Arms' Department formal training should be given so that all staff understand the relevant procedures. and can pass on and record messages accurately;
- (c) the Parliamentary Works Office and the Serjeant at Arms' Department (together with Black Rod's Office in the House of Lords) should jointly consider ways in which communications could be passed through defined focal points in each body, and should redraft the material about services in the two Houses which is made available to Peers, Members and their staff to include reference to building services and the channel for dealing with complaints;
- (d) chemical dosing equipment, which would obviate the need to pour chemicals into the water tank, should be fitted to the Norman Shaw south boilers as a matter of urgency.
I accept these recommendations as far as the Parliamentary Works Office is concerned, and I shall be in touch with my right hon. Friends the Lord Privy Seal and the Lord President of the Council about those recommendations which relate to the Serjeant at Arms' Department and the Black Rod's Office respectively.
The following measures have already been taken in Norman Shaw south:
- (a) chemical dosing equipment for the boilers has been ordered, and will be fitted as soon as possible;
- (b) all down-service supply tanks have been clearly marked as such;
- (d) all taps marked "Drinking Water" have been checked to ensure that they are supplied from a rising main, and all drinking water taps have been clearly marked;
- (d)all tanks are being numbered, and instructions have been issued that the number and description of the appropriate tank is to be quoted on the order form when a tank is to be dosed; and also that the Technical Officer must show the operative which tank is concerned and explain what is required;
- (e)permanent labels marked "Not for drinking" are being made to taps at wash basins which are not supplied directly from a rising main.
Similar measures are also being implemented in other Parliamentary buildings. Additional drinking water taps 708W are being installed during the recess in Norman Shaw south. Management and control procedures in the Parliamentary Works Office will be urgently reviewed in the light of both this report and a district management review of the office which was carried out in May as part of PSA's planned programme of checks to ensure the proper maintenance of the estate and the effectiveness of its district works offices.
The question of possible disciplinary action against any of the PSA's staff concerned in this case, which is a matter for the agency's management, is being considered in the light of the report.
I can assure you that the recommendations of this report will be vigorously pursued.