A HSE investigation has found that a ship’s engineer suffered serious cold burns after Shell UK safety failures led to a violent release of liquid propane during loading operations at a Firth of Forth marine terminal
Gas engineer Vladimir Volkov sustained liquid propane burns to 10–13% of his body after it was released without warning at Shell’s Braefoot Bay Marine Terminal near Dalgety Bay, Fife, in the early hours of 1 November 2018.
The incident created a rapidly expanding flammable vapour cloud that enveloped workers on both the ship’s deck and the adjacent jetty.
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.
Shell safety failures led to the catastrophe
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.
HSE 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 equipment installation.
“Shell had adapted procedures from its old equipment and applied them to a new and fundamentally different system, without carrying out adequate safety checks,” stated HSE principal specialist inspector Euan Ross.
“While the injuries sustained were serious enough, this could have been a far more catastrophic event.”
The broader risks of liquid propane release
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.
Propane vapour is heavier than air, highly flammable, and capable of travelling significant distances to find an ignition source. If the cloud had ignited, those in the immediate vicinity would have faced significant risk to their lives.
HSE investigation found Shell should have caught two significant failings
The HSE investigation identified two significant underlying safety failures.
Firstly, Shell’s work system 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.
Secondly, 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.”
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.
Conclusion of the investigation
Shell UK Limited pleaded guilty to breaching The Control of Major Accident Hazards Regulations 2015, Regulation 5(1) and the Health and Safety at Work etc. Act 1974, Section 33(1)(c).
The company was fined £450,000 at Kirkcaldy Sheriff Court on 26 May 2026.
Ross concluded: “We will not hesitate to take action against companies which fail to do all that they should to keep people safe.”
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