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SAP Incident Reference No: REF/23/62125 Incident Type: Near Miss

Contractor Name: Doha Petroleum Construction Project Title / Number: EPIC For New MP Boiler, DM
Company Limited (DOPET) MP Boiler Water Plant, and associated Facilities at QatarEnergy
Refinery Mesaieed / GC-19100700

Executive Summary

Incident Date / Time: 03-09-2023 / 10:10 hrs. Location: RUTL - BOILERS AND WATER TREATMENT
AREA:

Extent of Injury / Damage: No injury and No damage

Background:

On 3rd Sep 2023, during the commissioning of the DM Plant, HCL bulk tank 5126UF1 implosion occurred on west
side of the tank.
The regeneration of the Demin train 5126UC1/3 was ongoing when the incident occurred. HCl dosing pump
5125UJ1B was in service at that moment, sending about 1.5 m3/hr. of HCl to cationic bed 5126UC1. The pump
was immediately stopped, and the plant has been put in safety conditions (a rinse to prevent the chemical from
being in contact with the resins has immediately started).
The negative pressure in the tank has been reinstated crack opening the valves in the HCl loading line (3/4”-ZC-
51-1007-017112X). The shell of the tank went back into its original position and no leak of acid has been
observed HCL bulk tank 5126UF1.

Incident Description:

An incident occurred during pre-commissioning activities at the New DM Water Plant. While regenerating a
cation/anion bed in tanks 5126UC1/UC3, the HCL bulk tank 5126UF1 underwent a vacuum implosion. The acid
injection was stopped, and the tank was restored to its normal shape by opening the filling/drain valve. Further
checks were ongoing for the fume scrubber (5126UE3).

Root-cause:

The incident occurred because no vacuum breaker or NVR is installed in the vent line of the HCl bulk tank
5126UF1 (4”-ZC-51-1028-1-17112X). This line is routed inside the Fumes Absorbers tank 5126UE3 to avoid the
dispersion of the toxic fumes generated by HCl in the atmosphere. The vent ends inside the fume absorbers in a
deep pipe whose termination is under the level of the liquid that fills the absorber. The implosion has been
determined by the impossibility of air entering the tank to maintain the atmospheric pressure inside the tank
itself, pressure led to negative by the action of the pump.

Recommendations:

Mini HAZOP was carried out as per the recommendation, 2” check valve (2 no’s) will be installed in HCl bulk tank
as a vacuum breaker.
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Investigation, Root-cause Analysis and Corrective Action

Sequence of Events:

**03 Sep 2023**

10:00 Hours – 3 Sep 2023, the regeneration of the Demin train 5126UC1/3 was ongoing and HCl dosing pump
5125UJ1B was in service at that moment, sending about 1.5 m3/hr. of HCl to cationic bed 5126UC1.
10:10 Hours – While regenerating a cation/anion bed in tanks 5126UC1/UC3, the HCL bulk tank 5126UF1
underwent a vacuum implosion.

**05 Sep 2023**

11:53 Hours – PNM Construction notified DOPET.

13:49 Hours – A notice of the incident was submitted, and an investigation has been initiated.

Immediate Corrective action:

1. The pump has been immediately stopped and the plant has been put in safety conditions (a rinse to
prevent the chemical from being in contact with the resins has immediately started).

2. The negative pressure in the tank has been reinstated crack opening the valves in the HCl loading line
(3/4”-ZC-51-1007-017112X). The shell of the tank went back into its original position and no leak of acid
has been observed HCL bulk tank 5126UF1.

Preventive Action:

Mini HAZOP was carried out as preventive action, 2” check valve (2 no’s) will be installed in HCl bulk tank as a
vacuum breaker.

Facts Established During Investigation:

1. The incident occurred because the vent line of the HCl bulk tank 5126UF1 (4”-ZC-51-1028-1-17112X) is
routed inside the Fumes Absorbers tank 5126UE3 to avoid the dispersion of the toxic fumes generated
by HCl in the atmosphere.
2. The vent ends inside the fume’s absorbers in a deep pipe whose termination is under the level of the
liquid that fills the absorber. The implosion has been determined by the impossibility of air entering the
tank to maintain the atmospheric pressure inside the tank itself, pressure led to negative by the action of
the pump.
3. This happened due to design issue.
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Root-Cause Analysis Process:
HCl bulk tank 5126UF1 imploded.

Why?

Due to the negative pressure in the tank

Why?

HCl dosing pump 5125UJ1B in service when the Demin train 5126UC1/3 was undergoing regeneration.

Why?

Regeneration process not properly coordinated.

Why?

Lack of communication and coordination.

Recommendation Closeout

Recommendation Action Taken Date Closed

1. Review of all engineering drawings
related to drawing revisions (to be
applied to all projects).
Document revisions were reviewed. It
was found that all the revision submitted
by vendor to EPIC Contractor was not
submitted for QatarEnergy review. Check
valve was provided by vendor to avoid
vacuum in the HCL tank was removed in
the intermediate revisions by Contractor,
without informing to QatarEnergy.
Henceforth, all the revision submitted by
vendors shall be submitted by Contractor
to QatarEnergy. 19/12/2023
The same shall be communicated as a
lesson learnt for all ongoing and future
projects.

Drawings and tag number updated.

QatarEnergy approval obtained.

Evidence: Please refer Attachment No:

04.
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2. HAZOP recommendations / action
items to be reviewed and endorsed
by QatarEnergy prior to site
execution (construction phase).
3. Separate HAZOP shall be conducted
for all supplied packaged equipment
with all vendor data (drawings, P&ID,
data sheets).
4. Study and revalidate venting /
vacuum arrangement for DM & MP
Boiler project / and any other design
changes through PHA
All the action items pertaining to HAZOP
for D.M. Plant was closed ( Ref: Doc. No.:
4139-51-19-53-0033, rev.02). However,
fume absorbers design was freeze later,
including check valve for preventing
vacuum in HCL tank.
However, check valve was omitted by
Contractor/ Vendor, without QatarEnergy
approval.
Any addition and deletion of components
19/12/2023
to ensure safety shall be properly
communicated by Contractor to
QatarEnergy for approval.
Two check valves have been installed in
the vent line.
Evidence: Please refer Attachment No:
05.
A separate Vendor HAZOPs were
conducted for D.M. PLANT, M.P. Boiler
and B.F.W. Pump. Chemical injection
packages involving respective package
Vendors, DOPET, BCCES and QatarEnergy
. HAZOP action items were closed out.
Ref. no. 4139-51-19-53-0032- HAZOP 2
CLOSE-OUT REPORT: (CHEMICAL
INJECTION SKID, ASCO)
Ref. No. 4139-00-19-53-0003 - HAZOP 3
CLOSE-OUT REPORT: (BFW PUMPS,
SUNDYNE).
Ref. No. 4139-51-19-53-0033 - HAZOP 2
24/12/2023
CLOSE-OUT REPORT: (DM PACKAGE,
ARTES)
Ref. No. 4139-51-19-53-0034- HAZOP 2
CLOSE-OUT REPORT: (MP BOILER
PACKAGE, MACCHI).
HAZOP has been conducted. Mini
HAZOP Study Report for HCL Tank
5126UF1.
Evidence: Please refer Attachment No:
06.
A separate Mini HAZOP was conducted
on this issue, involving ARTES, DOPET,
BCCES (Eng. Consultant) and QatarEnergy 19/12/2023
on 18/09/2023. HAZOP action item under
close out- along with Temporary and
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permanent solutions proposed by
vendor- M/s. ARTES- ITALY. All the action
items such as NRV valves, pressure drop
calculation for HCL tank, Temporary hose
arrangements etc., were communicated
to Refinery, OV and PNM, PTE for review
and approval. Multiple meetings with
D.M. Plant Vendor for technical close out
of Mini HAZOP actions were also
organized.

Two check valves have been installed in

the vent line.

Evidence: Please refer Attachment No:

05.
Please ref. action item No. 1. All the
relevant changes communication from
Contractor were reviewed and approved
by QatarEnergy. However, any missed
out item( if any) shall be reviewed and
5. All engineering changes shall be
communicated by Contractor to
communicated through formal
QatarEnergy. 19/12/2023
communication and documentation
protocol
Drawings and tag number updated.
QatarEnergy approval obtained.

Evidence: Please refer Attachment No:

04.
OTP have already been proven for the
pumps. When we take the water filling
again in HCL tank, we will fill the water in
fume absorber also and system will be
6. During OTP, system to be tested at
tested at normal operating parameters
normal operating parameters &
and conditions. 27/12/2023
conditions to identify operating
limitations of the system.
OTP completed verifying the operation
of newly installed check valve and same
was witnessed by QatarEnergy.

HCL tank – Hydrostatic test was carried

out to check and ensure the integrity of
HCL tank and related piping. The same
was inspected by QatarEnergy (OV team,
Operation team, PNM Team) on
7. HCL tank and associated Equipment /
25/09/2023 and ensured the integrity of 25/09/2023
Piping integrity to be verified
HCL Tank and connected piping.

Evidence: Please refer Attachment No:

07.
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Investigation Team

Name Designation
Antony T D Head of Engineering & Commissioning
Shahzada Hammad Gull Site HSE Manager

Sitharthan. K Sr. Commissioning Engineer

Raja Suthan. M Sr. Commissioning Engineer

Reported by: Noted by:

Raja Suthan. M / Sr. Commissioning Engineer Y. Santaiah / Manager-Projects

Signature: Signature:
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Attachments:
1. Notice of Incident.
2. MOM (Minutes of Meeting).
3. Joint site inspection by QatarEnergy and DOPET.
4. Updated drawings and tag numbers. QatarEnergy approval obtained.
5. Updated drawings of the two check valves installed in the vent line.
6. Mini HAZOP Study Report for HCL Tank 5126UF1.
7. RFI (Request for Inspection).
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ATTACHMENT NO - 01

NOTICE OF INCIDENT
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ATTACHMENT NO - 02

MOM
(MINUTES OF MEETING)
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ATTACHMENT NO - 03

JOINT SITE INSPECTION BY

QATARENERGY AND DOPET.
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ATTACHMENT NO - 04

UPDATED DRAWINGS AND TAG NUMBERS.

QATARENERGY APPROVAL OBTAINED.
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ATTACHMENT NO - 05

UPDATED DRAWINGS OF THE TWO CHECK

VALVES INSTALLED IN THE VENT LINE.
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ATTACHMENT NO - 06

MINI HAZOP STUDY REPORT FOR

HCL TANK 5126UF1
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ATTACHMENT NO - 07

RFI
(REQUEST FOR INSPECTION)
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