Incomplete unloading of EO rail tank car

CH/2010/AW/02 Chemicals FIM #: 471454 Feb. 2010

Target audience for this alert A potentially hazardous situation existed, not
EO rail tank car customers only because EO was standing in an
unmonitored container but also because there
What happened
was a risk of overfilling during the subsequent
A rail tank container (RTC) loaded with 55
loading.
tonnes of ethylene oxide (EO) was
incompletely unloaded at a customer site.
Approximately 7 tonnes of product remained
in the container. This was discovered some
weeks later when the RTC was returned to
Moerdijk to be re-loaded. During this period
the RTC was assumed to be empty.
The RTC was fitted with a track-and-trace
system, which monitors the RTC position and
the temperature and pressure of the product.
This system has two different alarm settings:
25 °C when full and 45 °C when empty.
The full/empty mode is determined by the Full/empty switch
manual full/empty indicator of the braking
system.
Why it happened
There were no independent checks of the product weight differences before and after the unloading
operation and there was no checklist in place to confirm that the weight difference was within an
acceptable range.
Lessons learned:
• Existing site controls may not always be effective in ensuring that RTCs are empty after
unloading.
Recommendations:
• Customers should review their unloading procedures and systems to ensure that effective
controls are in place to confirm that EO rail tank cars are fully empty before leaving the site.

Goal Zero: Zero injuries, Zero fatalities

Disclaimer: This document is made available for information only and on the condition that (i) it may not be relied upon by anyone, in the conduct of their own
operations or otherwise; (ii) neither the [Shell] company issuing this document nor any other person or company concerned with furnishing information or data
used herein (A) is liable for its accuracy or completeness, or for any advice given in or any omission from this document, or for any consequences whatsoever
resulting directly or indirectly from any use made of this document by any person, even if there was a failure to exercise reasonable care on the part of the
issuing company or any other person or company as aforesaid; or (B) make any claim, representation or warranty, express or implied, that acting in accordance
with this document will produce any particular results with regard to the subject matter contained herein or satisfy the requirements of any applicable federal,
state or local laws and regulations; and (iii) nothing in this document constitutes technical advice, if such advice is required it should be sought from a qualified
professional adviser.
 Incomplete unloading of EO rail tank car
• An independent check (i.e. by two different persons) using a checklist should be carried out
before the RTC leaves the site to ensure that any product weight difference is within an
acceptable range (e.g. < 1000 kg).
• If any significant discrepancy is detected, customers should immediately notify Shell.

More information: Please contact: Riccardo Magliocchi or Peter Roest

Goal Zero: Zero injuries, Zero fatalities

Disclaimer: This document is made available for information only and on the condition that (i) it may not be relied upon by anyone, in the conduct of their own
operations or otherwise; (ii) neither the [Shell] company issuing this document nor any other person or company concerned with furnishing information or data
used herein (A) is liable for its accuracy or completeness, or for any advice given in or any omission from this document, or for any consequences whatsoever
resulting directly or indirectly from any use made of this document by any person, even if there was a failure to exercise reasonable care on the part of the
issuing company or any other person or company as aforesaid; or (B) make any claim, representation or warranty, express or implied, that acting in accordance
with this document will produce any particular results with regard to the subject matter contained herein or satisfy the requirements of any applicable federal,
state or local laws and regulations; and (iii) nothing in this document constitutes technical advice, if such advice is required it should be sought from a qualified
professional adviser.