Office for Nuclear Regulation

Devonshire Dock Complex (Barrow) – Inspection ID: 52440

Executive summary

Date(s) of inspection:

  • June 2023

Aim of inspection

This was a planned intervention to evaluate the adequacy of the implementation arrangements for licence condition 7 (incidents on the site) at BAE Systems Marine Limited (BAESML).  The purpose of LC7 is to ensure that licensees have made and implemented adequate arrangements for the notification, recording, investigation and reporting of incidents on the site.

A key contribution to the continual improvement of any effective safety regime is the learning taken from incidents that occur on the site.  LC7 arrangements typically provide for a scheme of categorisation of events, providing a threshold for reporting (to ONR) and investigation.

The intervention was conducted on-site by the ONR nominated site inspector for BAESML, utilising relevant good practice from ONR-INSP-GD-007 revision 6.1.

Subject(s) of inspection

  • LC7 – Incidents on the site – Rating: Green

Key findings, inspector’s opinions and reasons for judgement made

The inspection focused on LC7 implementation, including process improvements and investigation effectiveness.  No significant issues were found when sampling three investigations; actions were appropriate and evidence was associated with closed actions, providing a clear auditable trail.  The investigations selected for sample showed good investigatory craft, including root cause analysis – though the most common ‘top issues’ identified in events (through causal trends) were not necessarily true root causes themselves.  BAESML is undertaking work to understand the reasons behind the identified top issues.

The improvement plan for LC7 has taken a step forward in detail since the last inspection, but is still not fully underpinned; however as the plan is not driven by compliance requirements this does not present an issue at this time.  There are some outstanding improvement actions identified by the Internal Nuclear Assurance team; these are held in BAESML’s action tracking system.

There remains a differing approach between the conventional health & safety (SHE) and the nuclear safety (Quality) sides of the business for sentencing and reporting, and thus the increased complexity because of these differing approaches could lead to missed learning opportunities.  Quality and SHE should engage positively to have a common approach that benefits the organisation.

The use of cause codes/trends to drive improvements through investigation was positive.  BAESML could benefit from setting clear guidelines within the arrangements for the use of effectiveness reviews to confirm that actions are completed, embedded, and effective in preventing reoccurrence.


Based on the sample inspected, I rate the LC7 intervention as Green – ‘No Formal Action’.  This rating is in line with the established ONR guidance.

  • “Relevant good practice generally met, or minor shortfalls identified, when compared with appropriate benchmarks.”
  • “No significant shortfalls identified in the delivery of safety, safeguards or security functions.”

None of the findings in the inspection presented an immediate or direct risk to nuclear safety.