Shell Fined $80,000 for 2011 Pulau Bukom Refinery Fire

1. Shell was fined $80,000 for its role in a fire that broke out at its Pulau Bukom Refinery on 28 Sep 2011. Earlier, on 9 Oct 2012, the company had pleaded guilty to failing in its duty as an occupier to take reasonably practicable measures to ensure the safety of persons at its workplace under the Workplace Safety and Health (WSH) Act. This led to the largest refinery fire since 1988.
2. MOM’s Occupational Safety and Health Division’s (OSHD) investigations showed that the fire started in the course of the open de-oiling of naphtha (a highly flammable petroleum product) from a pipeline that ran through a pump house at the refinery. The investigations determined that Shell had not ensured the safety of the open system of de-oiling of naphtha and its process. Please see Annex A for more information on the investigation findings.
3. Emphasising the importance of safety, Mr Go Heng Huat, Deputy Director, OSHD, said, “MOM reminds the industry that they should proactively review their risk assessment and work procedures to ensure the safety of workers, as part of good workplace safety practices. Eliminating hazards should be a priority in ensuring a safe work environment, especially for major installations and industries where process safety incidents could have potential for catastrophic consequences. MOM will continue to engage the industry to help all stakeholders strengthen their workplace safety and health processes. We will also be engaging industry stakeholders to share the lessons learnt from the Bukom fire.”

1. The Ministry of Manpower’s Occupational Safety and Health Division (OSHD) carried out investigations into the cause of the incident. OSHD found that the fire had started in the course of the open de-oiling of naphtha (a highly flammable petroleum product) from a pipeline that ran through a pump house at the refinery.
2. Investigations revealed that there were three main lapses that led to the fire:
   
   (a) Shell had allowed its contractors to drain naphtha from the pipeline by allowing the naphtha to flow out from two open valves and an open flange joint of the pipeline into trays. This open system of de-oiling allowed naphtha vapour to escape into the atmosphere resulting in an accumulation of flammable vapour, which would in turn pose a danger of ignition.
   
   (b) Shell had allowed the use of a plastic tray, which was a non-conductive container, as a receptacle for collection of naphtha. The free fall of naphtha onto the plastic tray would allow accumulation of static charges as a result of the friction caused between them. When the accumulated static charges come into contact with any good conductor, they are instantaneously transferred to the conductor. A spark could be caused as a result of the sudden surge of energy during the transfer, which could be sufficient to ignite the naphtha vapour which is within flammable range in the atmosphere.
   
   (c) Shell failed to deploy portable gas monitors sufficiently close to the open de-oiling area to give the warning when the build-up of the flammable vapour reached an undesirable level.
3. Shell was charged under Section 11(a) of the Workplace Safety and Health Act (Chapter 354A) for having failed in its duty as an occupier to take reasonably practicable measures to ensure the safety of persons at its workplace, and punishable under Section 50 (b) of the said Act (maximum fine of $500,000).