HSE&Q FFC MM AMMONIA DRY RUN 2021

AMMONIA DRY RUN - 2021

REPORT

ABSTRACT
Heavy Ammonia Leakage Dry Run exercise was conducted on September
24th 2021 to evaluate:
1) Emergency preparedness for handling “Heavy Ammonia Release”
emergency at plant
2) Compliance to “Plant Emergency Plan” WP-011-XX-174

``

ISSUED BY

HSE&Q DEPT.

12th OCT. 2021

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HSE&Q FFC MM AMMONIA DRY RUN 2021

Contents

Executive Summary ...................................................................................................................................... 2

Exercise Timeline .................................................................................................................................. 3

Area Wise Findings .................................................................................................................. 4

Recommendations…………………………………………………………………………………………..7

Pictorial Representation…………………………………………………………8

Ammonia Dispersion Modeling……………………..10

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HSE&Q FFC MM AMMONIA DRY RUN 2021

Executive Summary

Mock drill scenario was planned as follows:

Date September 23rd 2021

Start time 1004 hrs

Warden/ Deputy Warden on duty Mr. Saleem Akhtar / Mr. Jamshaid

Wind Direction North East to South West @ 8 km/h

Location of Front Control Center (FCC) Central Control Room (CCR)

Location of Rear Control Center (RCC) Admin Conference Room

Exercise end 1052 hrs

Heavy ammonia leakage from E-105A process side
Emergency Scenario drain valve upstream flange with flow rate of 20
Ton / Hour.

One contract worker engulfed in ammonia cloud

Rescue Scenario # 1
and fainted.

One fire squad member fell and suffered back

Rescue Scenario # 2
injury.

Evacuation Scenario Evacuation required at EM Amm/Urea Workshops.

Leakage from transmitter 01-PR-10 HP leg.

Maintenance team action
Rectification by Instrument team required.

EVALUATION
- Overall response of Plant and Township personnel (permanent & casual) was satisfactory.
GM-M&O appreciated the coordinated efforts of all concerned teams. He emphasized to exercise
more efforts to improve shortcomings in certain areas noted during the activity.

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HSE&Q FFC MM AMMONIA DRY RUN 2021

Exercise Timeline

Overall time log of the exercise is as follows:

10:04 Emergency Scenario ticket handed over to operator
10:07 Message received via Radio in Control Room
10:08 Fire Alarm sounded in CCR and Safety Control Room
-do- 1st rescue ticket handed over operator.
10:10 Arrival of Fire truck
10:11 Coord. Engr. and Shift Engr. arrival in area
10:12 Ammonia Disaster siren sounded
-do- First action – water shields of 01 area actuated
10:15 Fire Squad assembled
10:23 Maintenance action ticket handed over to Coord Engr.
10:26 Ambulance Arrival
10:27 Duty officer joined FCC
10:33 1st rescue completed
-do- 2nd rescue ticket handed over to Coord Engr.
10:45 2nd Ambulance arrival
10:47 2nd rescue completed
10:51 Leakage rectified by Instrument team
10:52 Dry Run exercise declared Over

1st Rescue timeline 2nd Rescue timeline

10:08 1st rescue ticket handover to 10:33 2nd rescue ticket handover to Coord. Engr.
operator.
10:20 Call for Ambulance by Coord. Engr. 10:37 2nd rescue from area completed
10:26 Ambulance Arrival 10:38 Call for 2nd ambulance by Coord. Engr.
10:32 1st rescue from area completed 10:45 Ambulance arrival
10:34 Ambulance departed with 1st rescue 10:47 Ambulance departed with 2nd rescue

Maintenance action timeline

10:23 Maintenance action ticket handed over to Coord. Engr.
10:34 Request for Instrument team by FCC
10:42 Instt. team arrival in CCR
10:46 Instt. team arrival in Field
10:51 Maintenance action completed

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HSE&Q FFC MM AMMONIA DRY RUN 2021

Area Wise Findings

Area Observations Remarks

 Dry Run information slip was handed over to HP  Initial actions of area operator, Shift
operator @ 10:04 Hrs. He proceeded as follows: and Coord. Engrs. were swift and
- Verified wind direction, precise
- Put on SCBA and actuated fire alarm zone point  Delay observed in 01 area west side
# 32. water shields setup as fire monitor #
- Informed CCR through Motorola 13 remained offline for 20 min.

 Shift & Coord. Engr arrived in area equipped  Downwind roads not cordoned off.
with all PPEs including SCBA @ 10:11 Hrs.
 Disaster siren sounded @ 1012 hrs. after  Improper hose laying for water
confirmation from area. shields observed.
 Water shields were immediately established at
E-105 east side. (commendable action)  One squad member wore chemical
- Affected Area suit over his SCBA. Consequently, he
- 01 area  Fire truck arrived and parked at northeast
could not close his suit from front.
corner of Urea plant battery limit.
- Road A / B  Fire squad assembled @ 10:15 Hrs.
Demand for additional gas tight suits
- Bulk store was not raised.
- EM-AMM/
 Operator received 1st rescue information slip @  Delays observed between rescue slip
Urea 10:08 Hrs. Ambulance request to FCC was made handover and call for ambulance.
Workshops at 10:20 Hrs. Ambulance arrived @ 10:26 Hrs.
Rescue completed from area at 10:32 Hrs.  Evacuation Hiace and bus tried to
take route to EM workshop from
 Coord Engr. received 2nd rescue slip @ 1033 hrs. Road 3 to Road B which is downwind.
Completed rescue from area at 10:37 Hrs. and
called for ambulance @ 1038 hrs. Ambulance
departed with 2nd rescued person at @ 1047 hrs

 Upon receiving Information Slip for 01-PR-10

leakage rectification @ 1023 hrs, Coord. Engr.
Requested FCC for maintenance team
assistance. Instt and EQP teams arrived @
10:46 Hrs. and took prompt actions.

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HSE&Q FFC MM AMMONIA DRY RUN 2021

 Precise message received in Control Room  The location of hot-line phone set
from area operator @ 1007 hrs needs to be reviewed, as they were
 Shift Engr. and unit incharge were already behind the chair of Coord. Engr.
present in the CCR.
 Coord. Engr communicated to shift engr.  Number of evacuees was not
ammonia to sound the disaster siren. communicated. As a result, 10
persons evacuation was requested
 FCC Leader entered CCR upon hearing the against headcount of 60.
siren. He declared CCR as FCC, established  Duty officer faced difficulty in
contact with RCC leader and promptly ensured communication with evacuation
following actions: vehicle drivers. Hence, vehicles
- I-23 actuation & ammonia plant load reduction moved unsupervised to location.
Front Control - Conveyed information to Duty Officer,
Center (FCC) Telephone Operator, WTCR and B&S through
ammonia plant shift engr.
- Diverted waste water from canal to evap. pond.
 CCR doors were sealed with wet cloth and head
count was verified.
 Area Operators of unaffected areas assembled
near CCR and head count was ensured.
 DM-MNT (EQP) requested evacuation from EM
workshops near B&S store @1021 hrs. Message
was received by SE-PRD and relayed to RCC via
HSE designate.
 Bus was dispatched against revised headcount
of evacuation. Bus & hiace reached at 1042 hrs
and evacuation was completed @1053 hrs.
 GM-M&O (RCC leader) received disaster  Calls / messages from Duty Officer
message from FCC leader. He established and Tel. operator were delayed due
Admin conference room as RCC @1013 hrs to network issue.
 Last member joined RCC @1020 hrs
 Dispersion modeling against 20 Ton/hrs was  Cordless phone is not available at
established by HO-HSE&Q @ 1025 hrs. landline number of RCC
 He apprised the forum that red zone spanned
300m south west, covering the bulk store, EQP  Admin building emergency exit doors
ammonia & urea workshops and UCT. RCC to be kept unlocked in emergency
Rear Control
leader declared the scenario as Tier-1 disaster. scenario.
Center (RCC)  The communication between FCC and RCC was
done on landline number instead of hotline.  Admin AHU was stopped from
 M-ADMIN ensured sealing of all shelter rooms emergency button located outside
 M-MNT and M-E&I maintained liaison with their building. AHU to be stopped from
on ground teams inside the building.
 SM-PRD kept RCC leader updated about
leakage scenario. He confirmed rescue
/evacuation completion from FCC @ 1051 hrs.
 RCC leader declared exercise over @ 1052 hrs.

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HSE&Q FFC MM AMMONIA DRY RUN 2021

 EM Amm workshop shelter was

overcrowded despite less occupation
Un-affected  Overall response from regular and casual
than declared capacity.
Plant areas. employees was satisfactory
 GCF machinery employees head
count was not maintained.
Main Workshop,  Lack of awareness of emergency
Plant canteen, procedures by casual workers was
 Overall response and movement of workers
observed in all areas.
Fab shop/ Veh. was satisfactory
 Ammonia shelter doors were not
Shop, Engg sealed at Engineering Office and
offices. Warehouse.
 Occupancy limit was not mentioned
Bagging, Truck  The overall response of contractor and
in Distribution office shelter room.
Canteen, UCT, company employees was satisfactory and in
 Truck drivers were guided to
line with the laid down procedures.
Petrol / Service Assembly point No.3 (Truck Canteen)
 No unauthorized vehicle movement was
Station, DIST. observed during the activity
by security supervisor which was
office, Security downwind.
 Mandatory requirements of shelter room were
 Some drivers kept sitting in their
Gate # 4. adequately fulfilled
trucks during the dry run activity.
 TTC kitchen exhaust fan was in
Shopping Moll, service and not sealed.
 Following areas lacked awareness of
CWO, Banks, T/S  Overall response was slow by the people after emergency protocols and Ammonia
Gate, Plant Gate, sounding of siren Shelter arrangements:
TPT office, HSE, - Bank personnel. ( Askari Bank is
Finance, TTC. without Ammonia shelter )
- Ladies/Maids Gate
 All window type ACs were
Staff side operational in shopping mall area
Township Area,  Overall response was slow by the people after  Sealing cloth/full face mask was not
Shopping available at Watch tower # 13
sounding of siren
 Exhaust fans and desert cooler were
Center, not turned off
Horticulture,  Complete ammonia shelter arrangements in
 Staff club ammonia shelter had 192
Staff Club, Vocational Center and Staff Hostel # 1
occupants against max. 100.
Hostel # 1, 2 & 3.  Staff hostel # 2 ammonia shelter had
no phone line.
Mngt side, Club,  Overall response of residents was satisfactory.  30~35 employees observed in C-type
Mosque which is not a declared
Café, MESS,
 No unauthorized vehicle movement was ammonia shelter. Wet Cloth was not
BOQs, Medical observed during the activity used to seal doors in Medical
Center, Schools. Center’s ammonia shelter rooms

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HSE&Q FFC MM AMMONIA DRY RUN 2021

Recommendations
Sr# Recommendation Action By
Fire Squad skills improvement training to be planned as follows:
a. Annual squad training to be carried out.
1 HO-HSEQ
b. Fire drills effectiveness to be evaluated as per SOP.
c. Annual Fire squad competition to be held.
In the light of delays in evacuation / rescue, Plant emergency procedure(WP-011-XX-174) to be
reviewed to address following observations:
2 a. Protocol for guiding ambulance from medical center to rescue site HO-HSE&Q
b. Protocol to guide evacuation vehicles from plant gate to respective areas.
c. Evacuation Plan (Annex-IX) to be further elaborated.

Following hardware improvement in FCC/RCC is required:

a. Location of Hot-line and Coord. Engineer’s phones to be reviewed as these are placed
behind the desk and not conveniently accessible. M-PRD /
3
b. Cordless handsets to be provided at hotline numbers of RCC and FCC. M-ADMIN
c. Site plan of Plant and duty officer schedule to be displayed in CCR
d. Hot line to be provided at WTCR being mandatory requirement of FCC.

Safety guidelines for Ammonia disaster to be included in Safety Talk Plan for :
M-Admin
4 a. Company employees on contract / Ex-servicemen
DM-CWO
b. Contract labor working at plant / township
M-P&S

Safety talk with shopkeepers, HBL and Askari Bank personnel to be conducted on half-yearly Market
basis with communication to HSE&Q committee
5
M-ADMIN
WP-005-XX-174 to be revised to incorporate Point #4 & 5 HO-HES&Q
All ammonia shelters to be reviewed as per guidelines of HSE&Q for the following:
- Maximum occupancy to be declared according to 6 sq. feet per person. (e.g dry run
6 observation EM workshops) -all concerned-
- Additional ammonia shelters to be declared in line with guidelines of HSE&Q (e.g. dry run
observations of Admin ammonia shelter as existing shelter of IT has limited access)

Additional Ammonia shelters to be established at the following locations:

Masjid
7 a. Jamia Mosque /C-type Mosque
committee
b. Truck canteen
M-Admin

Reliable means of communication, allowing instant contact amongst Duty officer, FCC leader
8 M-E&I / DM-IT
and RCC members to be reviewed in consultation with IT dept.

9 Disruption in radio communications during exercise to be investigated and rectified. M-E&I

10 All maids and milkmen to be briefed about disaster emergency guidelines by their employers -all concerned-

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HSE&Q FFC MM AMMONIA DRY RUN 2021

Pictorial Representation

Leakage Point Arrival of Shift / Coord. Engineer

Fire tender parked according to wind Arrival of first rescue team

direction

2nd rescue
1st rescue

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HSE&Q FFC MM AMMONIA DRY RUN 2021

Areas requiring improvements

Insufficient water shielding at 01 opt.

Hydrant/Monitor # 13
cabin/ Road B

Water shield missing at east of E-105 Ambulance mobilized with rear door open.

Casual response of drivers at canteen Improper hose laying

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HSE&Q FFC MM AMMONIA DRY RUN 2021

Ammonia Dispersion Modeling

Geographical Dispersion Scale

Plant Dispersion Model ALOHA Dispersion Graph

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