A ship’s engineer sustained cold burns to 10–13% of his body surface after liquid propane was released without warning in the early hours of 1 November 2018 during loading operations. A flammable gas cloud could have resulted in a catastrophic explosion if ignited. The worker was treated at the hospital and subsequently repatriated to Russia, where he received further treatment. He is understood to have returned to work.
The incident, which created a rapidly expanding flammable gas cloud that enveloped workers on both the ship’s deck and the adjacent jetty, could have resulted in a catastrophic explosion if the cloud had found an ignition source.
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.
How it happened
The release was triggered when a 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 300 kilograms (661 pounds) of liquid propane was released at pressure in a matter of seconds.
HSE investigators established that the company’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 HSE investigation identified two (2) significant underlying failings.
First, the company’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, the company’s management of change process was wholly inadequate.
When the company replaced all four (4) 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.
The company failed to conduct a full risk assessment of the new loading operation. The new arms introduced a remote-control handset with exposed coupling buttons on its side, a feature that had not existed on the previous equipment. 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 — the company identified that a coupling interlock was both technically feasible and reasonably practicable. That system could have prevented the incident entirely.
The broader risk
The gas 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 meters (65 feet) away. Propane gas is heavier than air, highly flammable, and capable of traveling significant distances to find an ignition source. Had the cloud ignited, those in the immediate vicinity would have faced a significant risk to their lives.
The company 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.