- the Inquiry has identified serious weaknesses in the existing health & safety regime arising from the complexity of the legislation and a lack of effective communication between HSE, UKLPG, suppliers and users on safety issues
- deficiencies in HSE’s oversight of ICL in failing to appreciate the significance of buried pipework, failing to pursue follow up visits promptly and lacking caution in the acceptance of a compromise put forward in respect of a recommendation it made that the buried pipework be excavated to ascertain its condition.
"I would like to thank Lord Gill and the ICL Inquiry Team for the manner in which they handled this first joint Inquiry and for fulfilling the Terms of Reference so efficiently. A key message of the report is that this was an avoidable disaster and that its causes are clear. I therefore welcome the findings and recommendations in the report."