LONG PENDING FINDINGS

RELATED TO PROCESS SAFETY AND MECHANICAL INTEGRITY

Field Study Description Status Remarks

KDT / Dupont The use of a Cold Vent Stack instead of a Flare Stack for
SFGCS 2008, pressure relief headers at Kandhkot and Sui Field Gas SFGCS 40%
page 09 Compressor Station. However, industry practice since the completed (As
late 1960s has been to use a Flare Stack with pilot in this on 12 Mar’12)
service.
SFGCS Dupont There is no knock-out drum in the Foster Wheeler (F/W)
Not included
2008, design (that we saw), contrary to industry standard
in Action Plan
Page # 09 practice.
SFGCS Dupont The as-built at SFGCS was apparently “cost reduced” and
2008, now includes no flare; the vent is 45-feet high; there is no “
Page # 09 “sterile” zone and there is no flame arrestor.
SFGCS Dupont A similar problem is found in the PSV on the inlet (gas-
completed
2008, handling side) of SFGCS. There is no schedule for
(As on 12
Page # 12 inspection and recertification for ANY of the PSV in this part
Mar’12)
of the Compressor Station.
Sui DHP Dupont The new Condensate Loading Gantry designed about 2 Gantry
2008, years ago for installation at the Sui Dehydration Plant is In Progress Issue
Page # 12 well below multi-national standards.
Sui DHP Dupont There is no overfill protection on the loading arm. Gantry
2008, In Progress Issue
Page # 12
Sui DHP Dupont The lack of active fire detection systems. Gantry
Not included
2008, Issue
in Action Plan
Page # 12
Sui Well Dupont All of the gas production wells at Sui and most of the wells
2008, at other locations lack proper security. In many wells we Not included
Page # 14 saw, the fences are either missing or have significant gaps in Action Plan
or holes that would allow people to enter.
Sui Field Dupont None of the gas processing areas are declared “H2S Danger
2008, Area” with appropriate signs and breathing apparatus
Not included
Page#14 nearby. Today, the gas processing industry standard is to
in Action Plan
make this declaration anywhere the concentration is
10ppm or greater.
Sui Field Dupont “Comfo-Mask” air respirator with H2S canister every ~50
Not included
2008, feet for escape
in Action Plan
Page#15
Sui Field Dupont Full-face Supplied Air mask every ~100 feet for entry and
Not included
2008, work in the area if there is a leak OF ANY SIZE
in Action Plan
Page#15
Sui Field Dupont Facial Hair policy that requires EVERYONE who enters the
2008, area to be clean shaven AND to pass a respirator fit test as
Page 15 a prerequisite for working in the area. The point is that Not included
anyone with a beard cannot properly wear a respirator in Action Plan
mask and they will die if they try to do so in a significant
H2S leak.
Sui Field Dupont None of the small lifting gear has been lift tested, properly Not included
 2008, certified and tagged at ANY location.
in Action Plan
Page 17

General Dupont HAZOP are structured in a way that generally does not
2008, question the basic design assumptions and therefore is not
44, 17.3 the preferred hazard analysis method for new installations.
PHAs have not included consequence analyses and even Not attended
qualitative risk assessments are not typically used in a well-
structured way. Charters for PHA teams were not
prepared.
Dupont There is no documented Quality Assurance process for
2008, initial hardware and spare parts. It is clear that
45, 17.4 considerable attention is paid to QA aspects for facilities
Not attended
and hardware. It is not possible to audit the program, as
there is neither documentation nor an explicit
accountability.
Dupont There is no practice or procedure for a Pre-Startup Safety
2008, Review to provide a final verification that ALL aspects of
45, process safety have been properly addressed PRIOR to
17.5 commissioning. What we saw most frequently in field
observations were the absence of locking mechanisms on
block valves placed under PSVs, hand valves located where Completed
they were very difficult to operate, inadequate space or
facilities for maintenance activity (such as pulling tube
bundles from horizontal heat exchangers), inadequate
barricades to control truck traffic around loading /
unloading facilities.
110 All management and technical staff positions have a Job Manage
Description. This includes a statement of the Job ment of
Qualifications in terms of education, experience and skills / Personne
competencies. Despite the lack of a documented system, l Change
the turnover of personnel is being accomplished
successfully.
There is no way to ensure this will continue without a Not attended
documented system to follow.
So that practices will not deteriorate with the passage of
time and the turnover of key managing personnel, analyze
how personnel change is being managed for safety-critical
positions (staff and operating) and document the
requirements in a procedure.
111 Stores management (all sites) felt no particular PSI
responsibility to have an accurate MSDS on-hand for ALL of
the chemicals they stored. One of the Stores Managers
said, “That’s Purchasing’s responsibility” (which is decidedly Not attended
is NOT).
There should be a procedure by which Stores does not
accept ANY chemical without a proper MSDS on-hand.
113 International process safety standards require that the Not attended PSI
mechanical design basis be updated. A list of “safety
critical equipment” is also mandated and this definition
must be well-understood. The point is that all “safety
 critical equipment” be placed on an inspection and
maintenance program.
113 Develop and implement procedures satisfying the PSI
requirements of the PSI standard. The requirements for an
adequate PSI package are much too numerous to include in
this report, but there are many reference texts and internet
sites where this information resides. Each operating unit
will have to develop and implement process safety Completed
procedures to meet these requirements and designate an
individual to be responsible for developing and maintaining
their PSI package. Project procedures will also have to be
upgraded to ensure that all required information is put into
the proper PSI package when the project is executed.
113 Work should begin immediately to extend the definition of PSI
critical equipment to include everything that contains
hazardous materials or whose failure could conceivably
lead to release of a hazardous substance. This definition is
Not attended
crucial to adequate coverage and it is one of the
foundations of process safety compliance. Then, the
mechanical integrity system must be reviewed and
expanded to include all of this equipment.
113 Whenever a Process Risk Analysis is done, the PSI should be PSI
reviewed and completed sufficiently for the purpose of the Not attended
PRA.

117 Full responsibility for all aspects of PRAs in each operating PRA
unit must rest with the operating management. This
responsibility must include at least:
Providing formal charters to PRA teams,
Selecting team members meeting all the team composition
guidelines,
Arranging for the team members to have the necessary
time available for quality PRAs, rather than trying to
compress them into one or two days Not attended
Monitoring progress of PRAs in progress,
Carefully reviewing PRA reports,
Responding in writing to the recommendations,
Recognizing and rewarding good performance by teams,
and
Following-up on accepted recommendation until
completed and documented as an attachment to the file
copy of the PRA report.
117 The Process Safety Sub-committee should sponsor work on PRA
a critical PRA while the Sub-committee on Procedures and
Not attended
Standards comes up with a comprehensive set of
procedures for process safety implementation.
SFGCS 117 Concerning the Cold Vent on the Relief Header at SFGCS: Engineering PRA
 Verify “as built” situation, in particular the exit Study has
diameter of the vent pipe and the number / been
location of residences and the mosque relative to completed.
the vent. However, the
  Conduct a formal Consequence Analysis based on
total blowdown through existing vent
w/detonation and (separately) w/fire. Estimate the
ground-level H2S concentration and consider toxic
effects from H2S and (separately) the product of remaining job
H2S combustion, SO2 (which is also toxic). is in progress.
 Develop an appropriate location for a flare stack
(NOT a “cold vent) and place this on fast track 40 %
project schedule (As on 12
o Inside the fence and away from Mar’12)
encroachment
o Possibly use area south and west of SGFCS
 Tell Provincial and National authorities. (We can
assist with this, if asked.)
118 Develop a standard for block valves under pressure-relief PRA
devices that complies with the ASME Code. This code was
developed from long years of experience and should be
respected as a minimum standard. Existing standards and Not attended
practices should be upgraded to comply with it. A locking
device is definitely required for valves that the code
requires to be secured from inadvertent opening.
120 The Process Safety Sub-committee should sponsor work on Manage
a currently active project involving MOC-Technology while ment of
the Sub-committee on Procedures and Standards comes up Technolo
with a comprehensive set of procedures for process safety gy
implementation. Change
120 Add a review for adequacy of engineering and conformance “
to standards by peers or technical management for projects
above the basic level or complexity of major scope.
120 Consider adding a test authorization section to the “
management of change procedure to control conditions,
duration, etc. of tests and to ensure that results are
Completed
properly documented in the PSI package and that
recommendations emanating from tests are followed to
completion.
Sui Prod Appendix The two old Acid Tanks are a safety hazard. They should be
Completed
II, Page 02 flushed and removed.
Sui Appendix This note in the DHP Logbook describes a Change in
Dehydra II, Page 05 Technology for one of the control valves. There is no
tion formal Management of Change Procedure, so this change
Plant was verbally authorized. There was no HAZOP or other
hazard analysis and no consequence analysis. There was no In progress
Pre-start Up Safety Review. There was no Test
Authorization. And the drawings have not been updated.
All this is deficient versus commonly accepted process
safety standards.
SFGCS Appendix We could find no maintenance records for these Pressure
II, Page 16 Safety Relief Valves. There is nothing to indicate they have
Not included
ever been inspected, cleaned and re-calibrated since they
in Action Plan
were installed about 15 years ago. This is contrary to multi-
national standards and good process safety management.
Sui PP Appendix Lots of damaged insulation. This creates safety problems
II, Page 10 and wastes energy. The problem is mostly due to poor Not included
maintenance practices and a lack of Supervision. in Action Plan

Sui Appendix The underground fuel storage tanks at Sui Field (and Adhi)
Stores II, Page 16 are almost certainly leaking. In any case, they should be
inspected for internal corrosion and for external corrosion
(at the fittings, especially). It would be MUCH safer for
many reasons to replace these tanks with overhead tanks.
Not included
At Sui Field, there are some perfectly good fuel storage
in action plan
tanks that could be used (if only the Army gave permission).
At some point, PPL executive management will need to
decide who runs the Operation and who will get blamed if
there is a major safety incident because of these obsolete
tanks.
DUPONT STUDY 2016
Action plan Develop QHSE capabilities to carry out HAZID, LOPA, HIRA,
Sui Field
point 34 FMEA, hazardous consequence analysis and QRA
Conduct SIL for electrical and instrumented equipment
whose primary function is to contain harm (e.g. interlocks,
Action plan ESDs) –
Sui Field
point 60 Conduct RCM for equipment whose primary function is
production, however by improving the reliability of the
equipment the Plant will be inherently safer
Codify into written procedures and methodologies all
Action plan interlock testing during overhauls - it is not clear if WI exist,
Sui Field
point 62 example we could not tell what RAGAGEP was used (e.g.
IEC61511);
Record Test failures (of interlocks) when fixed and these
Action plan need to be recorded and tracked as leading indicators -
Sui Field
point 63 Launch specific RCA to find patterns of failure based on the
records
Codify Materials & Contracts Manual – it should clearly lay
Action plan
Sui Field out purchase, handling and storage of store PSM Critical
point 64
Equipment
Identify tools for facility siting (Consequence modelling
Action plan
Sui Field studies e.g. QRA) needs to be considered in different
point 123
emergency scenarios for personal and plant safety

EML STUDY 2014

SPP 14.01 Observations: Short bolting on flange bolts/studs (where
studs are not fully engaged in the nut) is prevalent at all
sites (except Sui Compression), which could result in bolts
being over-stressed and lead to gas releases at the flange.

Recommendation: It is recommended that the short

bolting is rectified. The cause of the short bolting should be
established, and preventive measures put in place to
ensure that it does not recur.
 Management of Temporary Pipe Supports:

Observations: A number of temporary piping supports

were observed at several sites, some of them had
reportedly been in place for a number of years (e.g.
Kandhkot Production and Sui Purification). Many of these
temporary supports did not appear to be fit-for-purpose
(e.g. not even in contact with the “supported” pipe in some
places). The controls in place for the installation of these
supports are questionable, and there does not appear to be
any means of tracking such temporary measures (i.e. the
sites were not able to present a summary of the temporary
supports in place).
SPP 14.02
Recommendation: Considering that poor design of
temporary pipe supports has been a contributory factor in
major historic losses, all temporary pipe supports should be
reviewed by a competent piping engineer for their
adequacy and replaced (made permanent) or improved
where necessary.
It is also recommended that the management of change
procedure is reviewed to ensure that all piping changes in
hydrocarbon service require review by a competent piping
engineer, that the validity period for all temporary
solutions (not just temporary pipe supports), and that there
is a means of tracking all temporary solutions.
Fire Water Pump Performance Test:

Observations: Most firewater pumps across the operation

are subjected to a regime of regular testing, however the
routines do not entail a full test to establish the current
performance curve as per NFPA recommendations. There
appears to be some confusion between function testing
and performance testing (which fulfil different objectives) –
this recommendation relates to performance testing, which
is not currently undertaken in accordance with industry
standards.
SPP 14.09
Recommendation: It is recommended that PPL reviews the
test regime for all firewater pumps to ensure that the
performance curve (head vs. flow) is established through
the annual test (for the entire range of each pump, not just
at its normal duty point). This periodic test is important in
order to identify potential / developing performance issues
such as pump impeller wear as manifested by a pressure
drop on the performance curve over time. NFPA 20
Chapter 11-3 gives guidelines for annual firewater pump
tests

SPP 14.11 Fire Pre-Plans:

 Observations: Emergency plans and procedures are
available at the sites, however the level of detail for dealing
with potential fire scenarios for the plant is very low.

Recommendation: Fire “pre-plans” should be established

by PPL.
A fire pre-plan is a scenario-based plan, specific to a
particular plant. Fire pre-plans should be referenced in the
site emergency response plan and should describe how the
fire protection and emergency response systems are to be
used in specific fire case scenarios.
The plans should take into account the nature and likely
effects of the fire scenario, the materials involved (process
materials and plant construction materials), the
surrounding environment, including plant layout, any
special hazards pertaining to that area, and the resources
required and available.
Install Fire & Gas Detection:

Observations: There is currently no fire and detection

provided at the Sui Purification plant, although it is
understood to have been planned for some time. Early
detection of releases can help to minimize the impact of a
leak by isolating inventories and isolating ignition sources,
SPP 14.43
and fire detection will enable prompt fire-fighting response.

Recommendation: The fire and gas detection

requirements should be reviewed against safety studies,
risk assessments, and corporate philosophy, and provided
as applicable.

Rectify Pipe Supports at ROVIs (SPP):

Observations: Remotely operated isolation valves (ROIVs)

have been retrofitted on the purification banks. Some of
the supports for these valves are considered inadequate,
the local pipework may be over-stressed.
SPP 14.44
Recommendation: The pipe supports around the
retrofitted ROIVs require review and rectification, so that
the valve body and actuator are directly supported.
Supports on purification bank number 6 can be referred to
as an example of better support.

SPP 14.45 Inspection of Pipe Resting Directly on Structures (SPP):

Observations: A number of pipes were noted during the

survey as resting directly on their structural support,
without any pipe supports such as shoes or pads being
 provided on the pipe, exhibiting signs or erosions and
corrosion. This mostly relates to small bore piping, located
in pipe-racks. Such arrangements are often prone to wear
(e.g. due to longitudinal movements caused by expansion),
leading to coatings being damaged exposing the surface of
the pipe, which can result in localized corrosion. Because
of the location these areas can be difficult to inspect.

Recommendation: It is recommended that all instances of

such pipe support arrangements are assessed for actual
and potential damage (considering process conditions and
piping flexibility), and that either pipe supports are
retrofitted in order to eliminate the threat, or an
appropriate inspection program is put in place for these
pipes in recognition of the risks.
Replace Spades at Piping Terminations (SPP):

Observations: During the survey, it was noted that in

several locations’ spades are being used as permanent
piping terminations (for tie-in points for potential plant
expansion) instead of blind flanges. Apart from being
SPP 14.46
inherently weaker than blind flanges, the spades present a
risk of corrosion at the spade / flange interface.

Recommendation: Spades should be replaced with blind

flanges as piping termination points.

Recording and Analysis of PSV “Pre-Pop”

Recommendation: The standard form for relief valve (PSV)

testing should be revised to include “as-removed” test
result. It is recommended that PPL reviews its procedure
SPP 14.05 for relief valve maintenance (specifically pre-pop tests) to
ensure that any failure is formally as an unsafe condition.
Consideration should be given to automatically recording
this as a near-miss and reported to HSE for follow-up
including review of root-causes.

SPP 03.06 Review and Implement Action plan to stop venting

Hydrogen Sulphide Gas to Atmospheric from Purification
Area

Observations: Waste of H2S gas from the purification area

is release directly to atmosphere using a 250 ft cold vent
within 1 km distance from the plant. H 2S is a highly toxic gas
with fatal effects in concentration above 1000 ppm. A leak
or catastrophic release at ground level could result in
multiple fatalities both in PPL permanent camp or the
surrounded populated area.

Recommendation: It is therefore recommended that PPL

 forms, as a priority, an action team to review this practice
and develop alternative strategies, A budgeted timeline
should be developed to implement the most cost-effective
solution.

PPL response: it is planned to install a H2S removal unit.

Installation of ESD system on all Purification Banks and
Dehydration Units shall take care to control such
eventuality. In the meantime, the ESD valves installed on
both inlet headers to the plant can be used after a little
modification in control to reduce the risk of such
eventuality.

Review of Fireproofing Requirements in the Purification

Area

Observation: Within the purification area, there is no

fireproofing of any structural or load bearing supports
within the plant area making them susceptible to the
effects of thermal radiation from a jet fire.
SPP 03.07
Recommendation: It is therefore recommended that the
fireproofing requirements are reviewed using API 2218,
“Fireproofing Practices in Petroleum and Petrochemical
Processing Plants” as a guideline.

PPL response: A consultant has been appointed for

revamping study.

SFGCS 14.03 Update of Hazardous Area Classification Drawings

Observation: The hazardous area classification drawings at

each site are mostly out of date, i.e. they have not been
kept up to date with plant modifications or changes to the
codes and standards (in some cases more than 20 years
since their last update and referenced out of date
standards). In more than one case a sample review of the
drawings highlighted clear errors in the application of the
standards.
It was not possible to establish a link between the drawings
and the purchasing or maintenance of electrical equipment
in potentially hazardous areas (i.e. they don’t appear to be
used at all).

Recommendation: It is recommended that there is clear

ownership of the hazardous area classification drawings,
that all drawings are reviewed and updated as necessary
against a current recognized standard, that the equipment
installed complies with the zones as per the updated
drawings, and that the revised drawings are communicated
with the relevant parts of the organization that use the
 information (e.g. purchasing, maintenance).
Control Room Documentation

Observation: During the survey it was found that paper

copies of P&IDs in local control rooms were out of date, in
some cases significantly. None of the documents were
marked as uncontrolled. Operations personnel were in
doubt as to whether paper or electronic versions were
considered to be the “master”. In one case the electronic
version was also out of date (compared with the DCS
graphic which captured more recent field changes). There
is a concern that out of date documentation can result in
SFGCS 14.08 incorrect decisions in operations or maintenance work
which could increase the possibility of a loss.

Recommendation: It is recommended that PPL adopts a

procedure as part of its change management process for
routinely updating all key control room documentation, in
particular that up to date P&IDs are available throughout.
Key documents such as P&IDs kept in control rooms as
paper copies should be clearly marked as uncontrolled or
kept up to date with documentation red lined to reflect
changes that have occurred between revisions.

Firewater pumps performance testing

Observation: Most firewater pumps across the operation

are subjected to a regime of regular testing, however the
routines do not entail a full test to establish the current
performance curve as per NFPA recommendations. There
appears to be some confusion between function testing
and performance testing (which fulfil different objectives) –
this recommendation relates to performance testing, which
is not currently undertaken in accordance with industry
standards.
SFGCS 14.09 Completed
Recommendation: It is recommended that PPL reviews the
test regime for all firewater pumps to ensure that the
performance curve (head vs. flow) is established through
the annual test (for the entire range of each pump, not just
at its normal duty point). This periodic test is important in
order to identify potential / developing performance issues
such as pump impeller wear as manifested by a pressure
drop on the performance curve over time. NFPA 20
Chapter 11-3 gives guidelines for annual firewater pump
tests.

SFGCS 14.47 Reduction in number of alarms in Control System (Sui

Compression):

Observation: A very high level of alarms at the control

 system panels was observed during the survey (500 alarms
per day was quoted by the site team, however at the time
of the survey more than 200 alarms had been raised in a
few hours, and about 30 in a few minutes were observed,
which was advised by operations personnel to be typical).
This is a nuisance to operations personnel and can have the
effect of concealing critical alarms.

Recommendation: It is recommended that PPL makes and

implements a plan to assess the volume of alarms at the
plant, including review of “bad actors”, the necessity of all
alarms, and devices set-points, with a view to reducing the
level to industry norms.
Lock PSV Isolation Valves Open

Observation: During the survey it was noted that the

isolation valves around the relief valves (PSVs) were open
but not locked in position – if the valves are inadvertently
SFGCS 14.49 closed the overpressure protection system would be
compromised. It is standard practice to lock all valves in
the relief system in the open position.

Recommendation: All isolation valves in the relief lines

should be locked or sealed in the open position.
Review Purging of Vent Header

Observation: It was noted during the survey that the

flare / vent piping network is not provided with a
continuous purge to prevent air ingress. Without this, an
explosive mixture may form in the system. Operations
personnel advise that there is normally a continuous flow
through one or more of the devices connected to the
SFGCS 14.50
system, however the pressure gauge (PG-540) showed
virtually zero pressure, and the pressure transmitter (PT-
525) reading in the control room actually indicted a
negative pressure.

Recommendation: It is recommended that a continuous

purge on vent header to atmosphere is considered in order
to prevent air ingress.
SFGCS 14.52 Review of Firewater Pump Control Procedure

Observation: During the survey it was noted that neither of

the firewater pumps were set to automatic mode
(presumably because of the firewater system integrity
issues, see previous recommendation). Manual
intervention would therefore be required to initiate
firewater, which is not standard practice and not as per the
design intent.

Recommendation: It is recommended that the procedure

and authorities for selecting the duty and standby pumps is
reviewed, to ensure that one pump is always in automatic
mode.