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LESSONS LEARNED

Environmental Incidents 2010

Jerry Crooks Marine Technical Advisor, HSSE/Incidents

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LEGAL 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.

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INTRODUCTION

This Lessons Learned focuses on the learnings from Losses of Primary Containment (LOPC) and spills experienced in 2010. The marine incidents discussed in this document involved Shellchartered vessels, which were not under Shell's operational control, and/or Shell terminals in North America. A summary of each incident, redacted to protect the identities of the parties, accompanies this presentation.

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WHAT HAPPENED: 2009 VS. 2010

LOPCs increased while the number of transfers/barrels transported has not.

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Source: STUSCO North America Incident Spreadsheet RESTRICTED

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WHAT HAPPENED: 2009 VS. 2010

Spills-to-water decreased, demonstrating the value of full perimeter spill rails. There were 17 spills to water in 2009 with a total volume spilled of 154 gallons. There were eight spills in 2010 with a total volume spilled of less than six gallons.

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Source: Carrier Photograph

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FINDINGS

2009 Root Cause LOPC Spills Communication 1 1 Design 3 0 Error Enforcing Conditions 1 0 Equipment Factors 36 3 Human Factors 14 6 Housekeeping 1 1 Procedures 5 6 Weather 1 0 Total 62 17

2010 LOPC Spills 1 0 8 0 0 0 38 0 16 6 0 0 4 2 3 0 70 8

Total 3 11 1 77 42 2 17 4 157

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Source: STUSCO North America Incident Spreadsheet

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FINDINGS

Equipment factors contributed to a high percentage of incidents.

Valve 17% Cargo Hose 4% Connection 12% Corrosion 2% Fracture 7%

Scuppers 3%

Pump Seal 17%

Gasket 9%

Hydraulic 5% Pump Engine 9% Piping 3% MLA 12%

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Source: STUSCO North America Incident Spreadsheet

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FINDINGS

There is no evidence of a weather or seasonal trend.

20 18 16 14 12 10 8 6 4 2 0

6 3 1 9 5 6 10 11 9 8 8 5 6 8 3 11 8 8 6 8 8 10 7 5

2010 2009

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Source: STUSCO North America Incident Spreadsheet

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FINDINGS

Most incidents occurred during transfer operations.

50 45 40 35 30 25 20 15 10 5 0 Unloading

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Spill LOPC

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Voyage

Berth Ops

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Source: STUSCO North America Incident Spreadsheet

OTHER FINDINGS

Time of day was not a factor. Type of product was not a factor. Weather-related incidents often involved high ambient temperatures causing pressure leaks at weak points in the system. Pump seal leaks, hydraulic oil leaks and fuel leaks from spin on fuel filters were the most common equipment failures. Many of the pump seal leaks were caused by improper operation and/or priming of the pump. Spill rails have reduced spills to water but more attention to scupper plugs is needed. Fewer LOPCs would occur if tankermen would "place a hand on every valve" before a transfer or before assuming watch.

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OTHER FINDINGS

Distractions and interruptions of routine procedures can cause people to forget to perform important steps. Pre-transfer conferences require time but are often cursory and lack substance. Weak pre-transfer conferences are exposed when the Persons-in-Charge (PICs) cannot agree on what was discussed after an incident. More attention to proper completion of the ship-shore safety checklist is needed. Too often the form is found deficient after an incident. PICs are sometimes reluctant to intervene with their counterpart, even when one or the other does not act as agreed in the pre-transfer conference. PICs view their duties and responsibilities as independent of one another, instead of working as a team.

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CONCLUSION

The environmental incidents reviewed for this Lessons Learned were preventable. Viewed individually, the learnings from these relatively minor incidents may be hard to discern, but studied collectively patterns emerge that point to needed corrective actions. It is imperative that we take the learnings seriously so we can correct the underlying causes. If we pay attention to the small things we can prevent the big things from happening. One method of accomplishing this is strict adherence to Shell's Golden Rules: Comply with the law, standards and procedures Intervene in unsafe or non-compliant situations Respect our neighbors

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Q&A

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