Issue Date: June 11, 2021 Alert No.

: OG-HSE/SA/05-2021

SAFETY ALERT
AMINE LEAKAGE CASE
Background:
In Amine Gas Purification Process, sour gas containing the acid
gases interacts with Lean Amine in Absorber and exchanges its
impurities with Lean Amine. The gas leaves Absorber as Sweet Gas
while the Lean Amine turns into Rich Amine. After coming out of
the Absorber, Rich Amine contains absorbed acid gases including
toxic H2S. On leakage of a Rich Amine, the absorbed gases get
desorption from the liquid and disperse in the area. Therefore,
such leakages are significant and must be arrested to avoid any
undesired consequences.

Incident:
On June 06, 2021 at about 0620 hrs, Area Operator informed InCharge Shift about the Rich Amine leakage
at Dakhni Sour Gas Facility. The leakage was observed from a crack in the welding joint, located downstream
of the Liquid Control Valve 20-LCV-3B of Amine Absorber. InCharge Shift further informed InCharge Process,
PM Dakhni and InCharge HSE. The system was depressurized and wells were cut down. Later, the spool was
removed and the standby 20-LCV-3A was commissioned. The spool was handed over for maintenance and
analysis at Workshop.

Situation analysis:
The H2S level in the Mixed Feed was around 5% (50,000 ppm) at the time of incident. Since the outburst
consisted of dissolved H2S with Amine in relative liquid form, therefore due to the dissolved nature, it
dispersed further in the air at 100:1 ratio and hence concentration became 500 ppm at the time of incident
in the adjacent areas. However, at workable distant, its concentration was shown by various multi-gas

Disclaimer: A Safety Alert provides advisory information and is issued after occurrence of an incident or when there is a current or emerging HSE
issue that needs immediate corrective & preventive action. HSE Department notifies all workforce members and concerned stakeholders regarding
the description of associated dangers so that lessons be timely shared. It is encouraged that the Recipients of Safety Alert to share it further within
their coworkers. Responsibility Toward Safety: It is categorically stated that the Prime Responsibility remains with Location InCharges to ensure
that the existing and potential hazards & risks of the facility/ site/ location are identified and documented; whereas the concerned Sectional InCharges
and Supervisors are responsible to ensure proper communication of the same to their respective teams prior to start of each process, operation or
job.

HSEQ Department, OGDCL Pakistan

Issue Date: June 11, 2021 Alert No. : OG-HSE/SA/05-2021

SAFETY ALERT
detectors as 15 ppm up till about an hour after the incident. The crack diameter was not wide enough, only
a pinhole, otherwise catastrophic impacts would have observed. Nevertheless, the Area Operators were
confined to their respective zones by barricading the incident site, and as the direction of wind was towards
NGL Storage Area (the unmanned part of the plant), even any nuisance to be expected subsided.
Note: SDV/ ESD hadn’t to respond since the operating conditions remained normal.
Probable causes:
 No approved/ structured integrity management procedure prevails.
 NDT Ultrasonic Thickness Gauge (UTG) Tests were not performed during
2020 due to limited SOW for ATA-2020, hence violating facility own
approved Process Safety Monitoring Plan.
 No documented Leak Detection And Repair (LDAR) Survey Plan found for
the corrosive-intensive process areas.
 Systematic deficiencies, laxity and irrelevance established in the planning,
execution and documentation of the Hazard Identification & Risk
Assessment (HIRA) with respect to the operations & maintenance (O&M)
activities during normal and abnormal conditions.
 Dakhni's Hazards Hunt Program appears to be ineffective as the collective
interest levels found almost to zero.
 Complacency observed amongst Field’s Process and HSE Teams in exhibiting true comprehension and
alertness towards Hierarchy of Controls in Process Safety and Layers of Protection Analysis (LOPA).

Recommendations:
 Develop and implement Standard Operating Procedure (SOP) on Integrity Management especially
considering pipelines, vessels, storage tanks etc. The Integrity Management Protocol (Regime) to include
a consolidated Preventive, Predictive and Corrective Maintenance Scheme for the assets. In addition,
Preventive Maintenance Schedule (PMS) must be challenged amongst Dakhni's corrosive environment by
formulating Condition Monitoring Plans based on PMS lessons learned and breakdown repair trends.
 The prescribed frequencies of carrying out NDT Ultrasonic Thickness Gauge (UTG) Test of pipelines,
spools, valves, etc. as defined in the approved Dakhni's Process Safety Monitoring Plan be complied upon.
A comprehensive Leak Detection And Repair (LDAR) Survey Plan be developed for the process areas.
 Frequencies of Mock H2S Emergency Scenario Drills be increased as a key lesson learned from the incident
and an extraordinary HSE MRC meeting be called to discuss the necessary revision of
Emergency Response Plan (ERP). At the same time, Hazard Identification & Risk Assessment (HIRA) Plan
be re-chalked by constituting an expert-level Risk Assessment (RA) Team for carrying out proper HIRA of
O&M activities considering all normal and abnormal conditions as well as probable emergency
scenarios. In addition, Dakhni Hazards Hunt Program be rejuvenated by judiciously linking it with HSE
Reward & Recognition System.
 The skill, knowledge and attitude of Field Process and HSE Teams be augmented to acquire the minimum
set of requirements, true comprehension levels and alertness towards Hierarchy of Controls in Process
Safety and LOPA so that process incidents are timely reported, tracked, considered for proper Root Cause
Analysis (RCA) in Maximo and eventually reflected in Field’s Monthly HSEQ Reports and KPIs.
Disclaimer: A Safety Alert provides advisory information and is issued after occurrence of an incident or when there is a current or emerging HSE
issue that needs immediate corrective & preventive action. HSE Department notifies all workforce members and concerned stakeholders regarding
the description of associated dangers so that lessons be timely shared. It is encouraged that the Recipients of Safety Alert to share it further within
their coworkers. Responsibility Toward Safety: It is categorically stated that the Prime Responsibility remains with Location InCharges to ensure
that the existing and potential hazards & risks of the facility/ site/ location are identified and documented; whereas the concerned Sectional InCharges
and Supervisors are responsible to ensure proper communication of the same to their respective teams prior to start of each process, operation or
job.

HSEQ Department, OGDCL Pakistan