A SHIP'S engineer suffered serious cold burns after Shell UK’s flawed safety procedures led to a violent release of liquid propane at Braefoot Bay.
A Health and Safety Executive (HSE) investigation said the accident happened during loading operations at the Firth of Forth marine terminal, which is on the coast between Dalgety Bay and Aberdour.
Vladimir Volkov, a gas engineer aboard the tanker MV Symi, sustained cold burns to 10 to 13 per cent of his body after liquid propane was released without warning at the Shell site in the early hours of November 1, 2018.
The incident created a rapidly expanding flammable vapour cloud that enveloped workers on both the ship’s deck and the adjacent jetty.
While the Crown agreed the probability of ignition was between one-to-two per cent, the results of such an ignition could have resulted in a "catastrophic explosion".
HSE’s investigation was carried out by inspectors and specialists in its chemical, explosives, and microbiological hazards division – reflecting the large quantities of dangerous substances handled at the site.
Their report said: "The vapour cloud produced by the release extended the full length of the ship and across the jetty, reaching down to the surface of the sea.
"It was registered by gas detection monitors 20 metres away.
"Propane vapour is heavier than air, highly flammable and capable of travelling significant distances to find an ignition source.
"Had the cloud ignited, those in the immediate vicinity would have faced significant risk to their lives."
At Kirkcaldy Sheriff Court yesterday (Tuesday), Shell UK Ltd pleaded guilty to breaching The Control of Major Accident Hazards Regulations 2015, and the Health and Safety at Work etc. Act 1974.
The company was fined £450,000.
HSE principal specialist inspector Euan Ross said: “Shell had adapted procedures from its old equipment and applied them to a new and fundamentally different system, without carrying out adequate safety checks.
“While the injuries sustained were serious enough, this could have been a far more catastrophic event.
“We will not hesitate to take action against companies which fail to do all that they should to keep people safe.”
HSE said the release was triggered when a Shell technician accidentally pressed a button on a remote-control handset, causing a loading arm quick release coupling to disconnect from the ship’s manifold before the arm had been fully cleared of propane.
An estimated 250–300 kilograms of liquid propane was released at pressure in a matter of seconds.
Investigators established that Shell’s own operating procedure — which required a critical safety mechanism known as an emergency release coupling to be disarmed before the arm had been fully purged and drained — directly contradicted the guidance provided by the loading arm manufacturer.
It also contradicted procedures prepared by a third party involved in the installation of the equipment.
The investigation identified "two significant underlying failings".
The report said: "First, Shell’s system of work was unsafe. The operating procedure in place at the time required workers to disarm the emergency release coupling too early in the disconnect sequence — before the loading arm was fully cleared of product.
"This left a dangerous window in which an accidental button press could, and did, cause a sudden propane release.
"Second, Shell’s management of change process was wholly inadequate.
"When the company replaced all four of its marine loading arms in 2018 — upgrading to new equipment from a different manufacturer that operated differently, including via wireless remote control and with a quick release coupling — it treated the project as a straightforward 'like for like replacement'. It was not."
It said that "Shell failed to conduct a full risk assessment of the new loading operation" and added: "No consideration was given to basic protective measures such as fitting interlocks to prevent the coupling from opening while propane was still present, or simply shrouding the buttons to prevent accidental activation.
"Following its own post-incident review - prompted by an Improvement Notice served by HSE - Shell identified that a coupling interlock was both technically feasible and reasonably practicable. That system could have prevented the incident entirely."
Liquid propane (often called LP or LPG) is propane gas that is compressed into a liquid state for easier and transportation. It is a highly flammable, non-toxic hydrocarbon derived from natural gas processing and petroleum refining.
A Shell spokesperson said: “Shell’s focus on safety and care for our people is deeply ingrained in our culture and drives every decision we make.
"In 2018, a release of propane from a newly-installed loading arm caused cold burns to a worker which needed treatment before he could return to work at a later date.
"This happened despite the new equipment being made to industry standards and installed with the help of the manufacturer.
"We investigated the incident fully, introduced stronger safety procedures and worked with the manufacturer to introduce a new fail-safe feature to stop this happening again."
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