0 Egpc-Aud-001-Aprc Bowtie Voume 5

Egyptian General Petroleum Corporate
Process Safety & Asset Integrity Management

AMREYA PETROLEUM REFINING COMPANY
DEC. 2020
EGPC-AUD-APRC-05
Volume 5
Bow Tie Analysis Report
Copyright
This document is a property of EGPC. It is non-transferable and must be surrendered on demand or upon
termination of employment to EGPC. This document cannot be used except in the purposes it is issued
for. It cannot be reproducing this report in whole or in part unless by the approval of EGPC CEO Assist for
HSE and according to EGPC document control procedure (EGPC.GEN.GL.001).
Disclaimer
This assessment report has been prepared by the team formulated by the ministerial decree #1484 of
year2020 solely for EGPC and is confidential. Neither EGPC nor any of its respective officers or employees
accept any responsibility or liability whatsoever (including negligence) with respect to the contents of
this assessment report. No warranties, representations or conditions of any kind either express or implied
are given or made in respect of the contents of this report. Accordingly, if any reader chooses to rely on
any aspect of this report they do so entirely at their own risk.
All administrative queries should be directed to the EGPC HSE Department utilizing feedback form
according to document control procedure (EGPC.GEN.GL.001)
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Document No: EGPC-AUD-APRC-05
Table of Contents
Introduction ............................................................................................................................................... 5
Plant Overview ........................................................................................................................................... 6
Bow Tie Methodology ................................................................................................................................ 9
3.1 Bow Tie Concept .................................................................................................................................... 9
3.2 Study Recording ................................................................................................................................... 10
3.3 Barriers Effectiveness........................................................................................................................... 10
3.4 Priority Ratings Matrix ......................................................................................................................... 10
3.5 Team Composition ............................................................................................................................... 12
List of abbreviations ................................................................................................................................. 12
Bow Tie Recommendations ..................................................................................................................... 13
5.1 LPG in storage area .............................................................................................................................. 13
5.2 Gasoline in floating roof tank .............................................................................................................. 15
5.3 Floating roof in gasoline tanks ............................................................................................................. 17
5.4 Propane stored in bullets ..................................................................................................................... 19
5.5 HF in Alkylation unit ............................................................................................................................. 21
5.6 Hydrocarbon in VRU unit ..................................................................................................................... 24
: List of Attendees .......................................................................................................................... 28
: Bow Tie Diagrams ....................................................................................................................... 39
i. LPG in Storage Area ............................................................................................................................. 40
ii. Gasoline in Floating Roof Tanks ........................................................................................................... 51
iii. Roof in Gasoline Floating Roof Tanks .................................................................................................. 64
iv. Propane in bullets ................................................................................................................................ 75
v. HF in Alkylation unit ............................................................................................................................. 85
vi. Hydrocarbon release in VRU unit ........................................................................................................ 99
List of Figures
Figure 1: APRC Block Flow Diagram .................................................................................................................. 7
Figure 2: APRC Plot Plan.................................................................................................................................... 8
Figure 3: Bow tie analysis structure .................................................................................................................. 9
List of Tables
Table 1: Barriers effectiveness color code ....................................................................................................... 10
Table 2: Priority Ratings for Recommendations ............................................................................................. 11
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DOCUMENT INFORMATION SHEET

TITLE: Bow Tie analysis report
PURPOSE AND SCOPE: Bow Tie analysis is a part of the scope of PSM and Asset integrity assessment.
Bow ties are a useful tool to assist analysis of process and non-process industry risks. The general focus of
bow ties in the process industry is towards major Accident Events as APRC need to understand how these
may occur and the barriers and degradation controls deployed to prevent them.
Risk in bowtie methodology is elaborated by the relationship between hazards, top events, threats and
consequences. Barriers are used to display what measures an organization has in place to control the risk.
Document No: Issue No: Issue Date:
EGPC.AUD.APRC.01 Issue 01 December 30th 2020
HAZID TEAM APPROVALS:
Name Position Company Signature
OH&S Ass. GM
Sayed Eid Sayed Khalil Agiba
(BOWTIE Studies Team leader)
Operations Section Head
Ali Ahmed Elkhallal ANRPC
(Bow Tie Leader)
Operations Section Head
Ahmad Ismail BAPETCO
(Bow Tie Leader)
HSE Engineer
Passant El-Gheriany Petrojet
(Bow Tie Scribe)
Hany Tawfeek OH&S GM Ethydco
Hesham Seddik Inspection Ass.GM AMOC
Mohamed El Sayed Vacuum Distillation Unit AGM APRC
Mohamed Taha OH&S Ass. GM Petrojet
Mostafa Abdelhakim Operation Department Head AKPA
Mahmoud Attia OH&S Department Head MPC
Kareem Mahmoud Projects Department Head AMOC
Mohamed Bassiouni Instrumentation Department Head Ethydco
Youssef Talaat Senior Loss Prevention Engineer ENNPI
FINAL VERIFICATION & TECHNICAL SINGLE POINT OF ACCOUNTABILITY (SPA):
Signature:
Position: EGPC HSE GM
Name: ENG. Mohammed Abdelghaffar Hassan Date: December 30th 2020
APPROVAL FOR ISSUE:
Signature:
Position: EGPC CEO Assist for HSE
Name: Chem. Gamal Fathy Date: December 30th 2020
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Introduction
Egyptian petroleum general corporate (EGPC) has established a committee to review the process safety
management system in Amreya Petroleum Refining Co. (APRC). Part of the assessment process was to
conduct Bow-Tie analysis workshops for major hazards were conducted by participation of personnel from
different departments in addition to committee team in the period between 9 th December and 15th
December 2020.
The Bow Tie is a risk assessment method that can be used to analyze and communicate how high risk
scenarios develop. The essence of Bow Tie consists of credible risk scenarios around a certain hazard and
the barriers that prevent or reduce the severity of these scenarios.
The main objectives of performing the Bow Tie analysis:
1. Fulfill the requirement of the ministry of petroleum to develop Bow Tie for major hazards.
2. Analyze the major hazards in a systematic and structured way.
3. Identifying the process safety barriers in place and evaluate their effectiveness.
4. Engaging the workforce in developing Bow Ties and increase their risk awareness.
5. Provide a model for Bow Tie analysis so APRC team could develop their own for the hazards that
didn’t cover during the sessions.
6. Develop recommendations to strengthen the barriers and reduce the plant's overall risk.
The following hazards have been analyzed during Bow Tie workshops:
1. LPG in the storage area.

2. Gasoline in floating roof tank
3. Floating roof in gasoline tanks
4. Propane stored in bullets
5. HF in Alkylation unit
6. Hydrocarbon release in VRU unit
However, it should be noted that the Bow Tie analysis doesn’t replace the HAZOP study and other risk
assessment studies that must be conducted by APRC.
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Plant Overview
AMREYA petroleum refining company (APRC) is EGPC owned company. It had been established in 1971.
It is considered as one of the biggest EGPC refining companies. According to the annual report
throughput with about 13% of country refining capacity.
Currently the refinery's capacity is 11000 -12000 metric ton/day of crude oil (3.8 million ton per year).
APRC produces high octane gasoline, naphtha, kerosene elemental sulfur, diesel oil, gas oil, lube oil,
linear alkyl benzene, asphalt, blown bitumen, fuel oil, benzene, toluene, LPG, wax, jet fuels ,technical
white oil, medicinal oil, spray oil and turbine oils. APRC play an important role in exporting some products
through (EGPC) as fuel oil, slack wax, and (LAB), to Italy, Greece, Malta, Germany, and England.
Key processing units installed include:
⚫ 2 x Crude Distillation Units (CDU 3 and CDU 5)
⚫ 1 x Vacuum Distillation Unit (VDU with Blown Bitumen)
⚫ 1 x Vapor Recovery/LPG Recovery Unit (VRU)
⚫ Kerosene, Naphtha, LPG and Gas Oil Hydro-desulphurization Units
⚫ Lubrication Oil Plant which includes;
➢ Propane De-Asphalting Unit (Unit 13 decommissioned / Unit 13A available)
➢ Phenol Extraction Unit
➢ De-waxing Unit
➢ Clay Treatment Unit
➢ Hydro-finishing Unit
➢ Specialty Oil Unit
➢ Medical Oil Unit
⚫ Naphtha Platforming and Aromatic Extraction Unit including:
➢ Naphtha Hydro treater
➢ Fixed Bed Catalytic Reformer
➢ Benzene/Toluene Extraction Unit
➢ Naphtha Isomerization Unit
⚫ Linear alkyl benzene (capacity 40,000 tons)
⚫ Storage facilities
⚫ Utilities
The block flow diagram of APRC is shown in Figure 1, while the APRC plot plan is shown in Figure 2.
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Figure 1: APRC Block Flow Diagram

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Figure 2 : APRC Plot Plan

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Bow Tie Methodology

3.1 Bow Tie Concept
The bow tie diagram consists of the following elements (see Figure 3):
• Hazard: the bow tie starts with the hazard which is anything that has the potential to cause
harm.
• Top Event: the loss of control of the hazard.
• Threats are depicted on the left side (customarily the prevention side) of the bow tie diagram.
• Consequences of loss of control of the hazard are depicted on the right side (customarily the
mitigation side) of the bow tie diagram.
• Prevention Barriers on the left side of the diagram represent prevention barriers, which stop
threats from resulting in the top event.
• Recovery (Mitigation) Barriers shown to the right of the top event represent mitigation barriers,
which mitigate the top event (i.e., reduce the scale of and possibly stop undesired
consequences).
• Escalation (or Degradation) Factors can be applied to both prevention and mitigation barriers
and these can lead to impairment or failure of the barrier to which they are attached.
• Escalation (or Degradation) Controls act to mitigate the Degradation factors, helping maintain
the main pathway barrier at its intended function. Degradation controls can, but do not
necessarily satisfy, the effective, independent, and auditable criteria for barriers.
Figure 3: Bow tie analysis structure

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The followings steps were considered during the development of each bow tie diagram:
• Address the major accident hazard and top event;
• Define consequences and threats (initiating events);
• Define preventive and mitigation barriers;
• Define degradation factors and controls for barrier where specific concerns are highlighted by
the team
• Evaluate the effectiveness of barriers.
• Define the required actions to reduce the risk and to enhance barriers' effectiveness.
3.2 Study Recording

The Bow-Tie diagrams were developed using Bow Tie XP software © CGE Risk Management Solutions
B.V. 2004-2020.
3.3 Barriers Effectiveness

The effectiveness of barriers was discussed during the workshop to evaluate each barrier. However,
the EGPC gap analysis team was consulted in evaluation based on their findings during the PSM review
and physical barrier assessment. The color indicating the effectiveness of each barrier is shown in
Table 1.
Barrier Color Effectiveness
Effective
Partly Effective
Ineffective or Missing
Unknown
Table 1: Barriers' effectiveness color code
3.4 Priority Ratings Matrix

The priority of the action needed to address an individual finding is determined by an assessment of
the degree of risk arising, based on the business impact and of the likelihood of the risk being realized
as shown in Table- 2.
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Risk Definition Action Required

Rating
A finding, which in the opinion of the lead auditor • Actions required to permanently address the
identifies any one of the followings: absence of the Key Control are to be taken
• Failure to present compliance with HSMS element immediately
• Failure to present compliance regarding • If such permanent action is not reasonably
implementation of HSE Management system and possible within an immediate timeframe,
represent a significant risk to people, plant and then interim mitigation actions to address the
operation gap in Key Controls are to be implemented
• Failure to comply with Egyptian legislations immediately and to continue until permanent
Serious • P1 findings require urgent immediate attention from actions have been implemented.
(P1) company top management team • If such immediate actions or mitigations
cannot reasonably be applied, the relevant
administrative body is to consider a decision
to cease operations of the asset subject to the
serious finding.
• Actions requires immediate top management
intervention and provision of necessary
financial and technical resources to address
the gaps in the key controls
identifies anyone of the followings: gap identified in the high finding are to be
• Weaknesses or ineffective implementation of key taken in the short term.
control measures relevant to a single HSEMS element • “Short term” means within six (6) months of
and represent a high risk to people, plant or operation communication of the audit finding and
• Several weaknesses or ineffective implementation of recommendations.
High key control measures of the same element and/or
(P2) sub. element, and represent a high risk to people,
plant or operation either solely or cumulatively,
• Failure to comply with company established processes
and practices
• Failure to comply with internationally recognized
codes/standards/COP which accepted by the
company
identifies anyone of the followings: gap identified in the high finding are to be
Medium • Any failure of the key controls doesn’t represent risk taken in the short term.
(P3) to people, plant or operation • “Short term” means within twelve (12)
• Single or isolated deficiency of the key controls months of communication of the audit finding
and recommendations
• A finding, which in the opinion of the lead auditor
Low identified during site workplace inspection and an
(P4) immediate corrective action would enhance the
auditee’s existing risk controls
Table 2 Priority Ratings for Recommendations

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3.5 Team Composition

The Bow-Tie team was a knowledgeable person from different departments with the necessary
competency to identify the threat, consequences and barriers in place. The teams were usually
composed of:
• Bow-Tie Chairman
• Bow-Tie Scribe
• Process Engineers.
• HSE Engineer
• R&D Engineer
• Maintenance (Instrumentation Inspection Engineer, electrical, static and rotating)
• Civil Engineer.
List of abbreviations
Item Definition
ALARP As Low As Reasonably Practicable
BFD Block Flow Diagram
BMS Burner Management System
CCTV Closed Circuit Television
CDU Crude Distillation Unit
DECT Digital Enhanced Cordless Telecommunications
EGPC Egyptian General Petroleum Corporation
ERP Emergency Response Plan
HAZID Hazard Identification
HSE Health, Safety, and Environment
HSE CB HSE Capacity Building
HVAC Heat Ventilation and Air Conditioning
ITPM Inspection, Testing and Preventive Maintenance
MAH Major Accident Hazards
NORM Naturally Occurring Radioactive Material
PFD Process Flow Diagram
P&ID Piping and Instrumentation Diagram
PPE Personal Protective Equipment
PSM Process Safety Management
PSSR Pre Startup Safety Review
PTW Permit to Work
RCFA Root Cause Failure Analysis
R&D Research and Development
SOP Standard Operating Procedures
RBI Risk-Based Inspection
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Bow Tie Recommendations
4.1 LPG in storage area

No. Recommendation For LPG Bullets Priority
Take necessary actions to improve the effectiveness barriers that were classified during Bow-tie sessions as
1 ineffective or partly effective barriers and study developing the missing barriers. Moreover, for effective P1
barriers it shall be monitored and maintained.
Conduct Fitness of service assessment for all the bullets and the attached pipelines, and replace the defected
2 P2
ones if needed.
Conduct all the required inspection plans and activities for bullets and attached piping despite the production
3
constraints.
P2
4 Assure providing deferral form for any deviation from the inspection plan for any item. P3
5 Conduct/apply Risk-Based Inspection (RBI) for all facility static equipment and vessels. P3
6 Provide the advanced inspection techniques to be used for the proper inspection activities. P3
7 Assure providing required certified training for inspection engineers to perform their job. P3
8 Provide sufficient number of competent employees to perform the required inspection activities. P3
9 Study and review the existing bullets design and assess it against the new applied bullets design standard. P2
Assure creating warehouse stock philosophy considering the Min. and Max. stock philosophy for the required
10
spare parts.
P3
Assure adding “material testing” clause in the contract terms and condition for new material and ensure proper
11 P3
testing for the received material.
Assign specific inspection engineer to be responsible for all coating activities and provide them with the
12 P3
required tools and devices. Moreover, assure providing them with the required certified training
13 Assure providing the required certified training for the cathodic protection engineer. P3
14 Study and review adding cathodic protection system for the bullets as per the relevant code and standard. P2
Assure segregation between low pressure and high pressure flare system and provide required isolation manual
15 valves across safety relief valves to facilitate their dismantling during their regular maintenance and inspection P2
activities
Conduct the required studies for reviewing the depressurizing philosophy of the bullets taking into
16 consideration the severe hazard for releasing the propane and LPG to atmosphere and the probability of forming P1
vapor cloud.
17 Assure providing LO/TO at the open position for the manual valve up and down stream of PSV. P3
Assure providing the required certified training for the lifting planner, otherwise assign a certified 3rd party
18
lifting planner for any lifting activities.
P3
19 Study and review providing proper passive fireproofing as per the required standard API 2218. P2
20 Expedite the implementation of the new FF and detection system for propane & LPG bullets. P2
Assess and review the location of the firefighting manual valves and assure they are in safe location, locked
21
open with proper labeling.
P2
Conduct QRA & FERA study for the company facilities and review the effect of the existing LPG bullets on
22 the adjacent populated neighbors and the storage tanks. Moreover, use the outcomes for proper design of P2
firefighting and fire & gas system.
Ensure and improve using of Root Cause analysis techniques for studying any failure, and Provide proper
23
training for employees from different disciplines about Root cause analysis techniques.
P3
Study and review the existing condition of piping support to fix the regular vibration problem inside the rotating
24
equipment.
P3
Study replacing the single type mechanical seal with double type mechanical seal with proper plan as per API
25
682.
P2
26 Study and review installing automatic trip function for the transfer pumps. P3
27 Ensure that LPG discharge pumps are working inside their characteristic curve. P3
Ensure proper selection of the pumps strainer mesh size for any new pumps as per the manufacturer
28 P3
recommendation.
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29 Study providing CCTV and proper access control for the bullets area. P4
Conduct a survey to check the condition of the concrete structures inside the facility.
30
Prioritize them and make the required repairs for the defected items.
P3
31 Study installing double block valves for all samples and drains with plugs or caps. P3
Assure providing the required EX walkie talkie devices to be used inside the operation units and tank farm
32 P2
areas
33 Study and review lightening and earthing system and assess them against the relevant standard. P2
34 Assure develop Hazard Area Classification layout and schedules for all the facility areas. P2
Assure availability of certified ATEX engineers to check the conditions of the EX-rating devices and
35 P3
connections and assess compliance with the ATEX requirements.
37 Conduct HAZOP study for the LPG bullets to study the neediness for of installing ESD system. P2
38 Assure providing override management system for the existing detection system for the G06 LPG bullet. P3
Assure providing detailed specific LPG or propane release scenarios to the ERP with specific consideration
39
and procedures.
P3
Study and review the existing FF system and assess against the worst case scenario and the required flow
40
quantities and pressure needed.
P2
Build a rescue team and provide them with the required training, and ensure providing them with the proper
41
equipment/facilities, and check their physical fitness for work.
P3
42 Assure providing proper head counting system inside the facility. P3
43 Install proper number of fire alarm siren to ensure proper notification for the whole complex. P3
44 Conduct adequate and regular different level drills for all potential emergency scenarios. P2
45 Provide adequate number of first aid kits and conduct the required training for the medical team. P3
46 Assure providing adequate number of safety showers based on relevant standard. P3
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4.2 Gasoline in floating roof tank
No. Recommendation for gasoline release Priority

Take necessary actions to improve the effectiveness of barriers that were classified during Bow-tie sessions as
2 Perform the required inspection plan for the storage tanks despite the production constraints. P2
Conduct fitness for service assessment for the existing storage tanks and replace the corroded storage tanks
3 P3
with new ones if needed.
Assure providing the required process safety information for all vessels, equipment, and tanks prior to the
4 P2
selection process of any new item.
Assign specific inspection engineer to be responsible for all coating activities, provide him with the required
5 P3
certified training to perform his job, and supply him with the required tools and devices.
Conduct a certified training required for the inspection engineers and provide them with the required new
6 P3
version of codes and standards.
Study and review the existing cathodic protection system and assess the system against the relevant codes
8 P2
and standards.
9 Expedite the development of P&ID for the storage tank area. P2
10 Expedite installing the required transmitters over the storage tanks for measuring the tank parameters. P3
Conduct HAZOP study for the storage tanks area and check the possibility of installing ESD system for isolation
11 P2
of the storage tanks remotely without operator intervention from field.
Provide company with the required competent manpower for covering the technical, operation, and
12 P3
maintenance working activities.
13 Assure providing the proper labeling and color coding for all vessels, tanks, valves, and pipelines. P3
Check and assure the employees competencies and provide them with certified training for improving their
14 P3
skills.
Review and assess all civil foundations condition for all storage tanks and perform the required maintenance
15 P2
activities for the defected foundations.
16 Conduct frequent inspection/check for the housekeeping in the tank roof by the operation supervisors. P3
17 Provide the maintenance team with the required training and proper inspection tools. P3
Study the replacement of single type mechanical seal with the double type mechanical seal, considering the
18 P2
relevant standard.
Assure providing the required certified training for the lifting planner, otherwise assign a certified 3 rd party
19 P3
Expedite the new project for upgrading the Firefighting & cooling water system for all storage tanks despite
20 P2
the production constraints.
Study & review the condition of the secondary containment of the tanks area as per the relevant code and
21 P2
standard.
Conduct QRA & FERA study for the facility, and use the study outcomes for proper design/ or design verification
22 P2
of fire & gas system, active firefighting system, passive fire protection, shutdown system, facility siting etc.
Assure proper selection for the contractor and proper implementation of contractor management system
23 P3
inside the company.
25 P2
areas.
Conduct frequent gas testing during any hot working activities, and the testing frequency shall be
27 P2
proportionated to the associated risk.
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28 Assure creating Hazard Area Classification layout and schedules for all the facility areas. P2
Assure availability of certified ATEX engineers to check the conditions of the EX-rating devices and connections
29 P3
and assess compliance with the ATEX requirements.
30 P2
31 P2
Assure updating the existing ERP to include a detailed emergency scenarios, then train all employees on it, and
32 P2
perform regular drills with different levels.
33 P3
34 Assure providing proper head counting system for the employees. P3
Install proper number of fire alarm siren to ensure proper notification for the whole complex in any emergency
35 P3
situation.
37 Assure providing adequate number of safety showers based on relevant standards. P2
38 Improve and implement the existing waste management procedure. P3
39 Provide adequate housekeeping for storage tank area with adequate number of skilled contractor. P3
40 Study and review the existing drain system capacity and condition and upgrade the system accordingly P2
Study installing proper concrete base with proper slope towards proper destination waste management
41 P3
system
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4.3 Floating roof in gasoline tanks
No. Recommendation for tank roof failure Priority

Take necessary actions to improve the effectiveness of barriers that were classified during Bow-tie sessions
1 as ineffective or partly effective barriers and study developing the missing barriers. Moreover, for effective P1
2 Perform the required inspection plan for the storage tanks despite the production constraints. P2
Conduct fitness for service assessment for the existing storage tanks and replace the corroded storage tanks
3 P3
with new ones if needed.
Develop a proper process (with clear responsibilities) for tanks desludging to expedite the tanks internal
4 P4
cleaning prior to the inspection and maintenance activities.
Conduct the certified training required for the inspection engineers and provide them with the required new
5 P3
version of codes and standards.
6 Assure proper storage for the received materials P3
7 Conduct frequent inspection/check for the housekeeping in the tank roof by the operation supervisors. P3
8 P3
Study and review the existing cathodic protection system and assess the system against the relevant codes
9 P2
and standards.
10 Expedite changing single roof deck type to be double type deck roof. P2
11 Assure providing hose management system and consider it as part of asset integrity management system. P3
12 Assure compliance with the new codes and standard during the erection of the new tanks. P2
13 Expedite the replacement of the single type rim seal to double type ASAP. P2
14 Review the Rim Seal Specification According To the relevant Standards. P2
15 Expedite the development of P&ID for the storage tank area. P2
16 Expedite installing the required transmitters over the storage tanks for measuring the tank parameters. P3
17 P2
Provide company with the required competent manpower for covering the technical, operation, and
18 P3
maintenance working activities.
19 Assure providing the proper labeling and color coding for all vessels, tanks, valves, and pipelines P3
Check and assure the employees competencies and provide them with certified training for improving their
20 P3
skills.
21 P2
areas
23 P2
24 Assure creating Hazard Area Classification drawing for all the facility areas. P2
25 P3
26 P2
27 Conduct FERA Study to be used for the proper design required F&G detection system and firefighting system. P2
28 P2
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29 P2
Assure updating the existing ERP to include a detailed emergency scenarios, then train all employees on it,
30 P2
and perform regular drills with different levels.
31 P3
33 P3
situation.
36 Improve and implement the existing waste management procedure. P3
37 Provide adequate housekeeping for storage tank area with adequate number of skilled contractor. P3
38 Study and review the existing drain system capacity and condition and upgrade the system if needed P2
Study installing proper concrete base with proper slope towards proper destination waste management
39 P3
system
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4.4 Propane stored in bullets
No. Recommendation for Propane release Priority

Take necessary actions to improve the effectiveness of barriers that were classified during Bow-tie sessions as
Conduct Fitness for service assessment for all the bullets and the attached pipelines, and replace the defected
2 P2
ones if needed.
Conduct all the required inspection plans and activities for bullets and attached piping despite the production
3 P2
constraints.
4 Assure providing deferral form for any deviation from the inspection plan for any item. P3
5 Conduct/apply Risk-Based Inspection (RBI) for the facility static equipment and vessels. P3
6 Provide advanced inspection techniques to be used for the proper inspection activities. P3
7 Assure providing required certified training for inspection engineers to perform their job. P3
8 Provide sufficient number of competent employees to perform the required inspection activities. P3
9 Study and review the existing bullets design and assess it against the new bullets design standard. P2
Assure creating warehouse stock philosophy considering the Min. and Max. stock for the required spare parts
10 P3
items.
Assure adding “material testing” clause in the contract terms and condition for new material and ensure
11 P3
proper testing for the received material.
Assign specific inspection engineers to be responsible for all coating activities and provide them with the
12 P3
required tools and devices. Moreover, assure providing them with the required certified training
14 Study and review adding cathodic protection system for the bullets as per the relevant code and standard. P2
15 Conduct HAZOP study for the propane bullets to study the neediness for of installing ESD system. P2
16 Assure sending LT signal to the DCS of platformer instead of the existing signal on the lube oil DCS. P3
17 Study providing adequate number of EX walkie talkie devices to be used inside the bullets area. P2
18 Assure adding proper labeling and color coding for all vessels, valves and pipelines inside the facility. P3
19 Conduct Root cause analysis for failures of all the vessels, valves and equipment. P3
Assure providing updated register for internal valves leakage and communicate it on a regular basis to the
20 P3
related disciplines.
Conduct the required studies for reviewing the depressurizing philosophy of the bullets taking into
21 consideration the severe hazard for releasing the propane and LPG to atmosphere and the probability of P1
forming vapor cloud.
Assure segregation between low pressure and high pressure flare system and provide required isolation
22 manual valves across safety relief valves to facilitate their dismantling during their regular maintenance and P2
inspection activities.
24 P3
26 Provide clear KPIs for Safety Critical Elements "SCE” inspection (Testing/ year). P3
27 P2
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Conduct QRA & FERA study for the company facilities and review the effect of the existing propane bullets on
28 the adjacent MEK and toluene bullets, ammonia tank, Natural gas vessel and oil tanks. Moreover, use the P2
outcomes for proper design of firefighting and fire & gas system.
29 Study and review providing proper passive fireproofing as per the required standard API 2218. P2
Study providing/ renting thermal/IR camera to conduct survey leaks as a temporary solution till the
30 P3
implementation Fire & gas detection system.
Study and review the existing condition of piping support to fix the regular vibration problem inside the
31 P2
rotating equipment.
32 P2
682.
33 Study and review installing automatic trip function for the Propane discharge pump. P3
34 Ensure that discharge pumps are working inside their characteristic curve. P2
Ensure proper selection of the pumps strainer mesh size for any new pumps as per the manufacturer
35 P3
recommendation.
Assess and review the existing discharge pumps for propane and LPG bullets and replace the old design pumps
36 P3
with new pumps as per the new standard and code.
37 Study providing CCTV and proper access control for the bullets area. P4
Conduct a survey to check the condition of the concrete structures inside the facility. Prioritize them and make
38 P2
the required repairs for the defected items.
41 P2
43 P3
Assure providing detailed specific LPG or propane release scenarios to the ERP, then train all employees on it,
44 P2
and perform regular drills with different levels.
45 P2
46 P3
47 Assure providing proper head counting system P4
48 Install proper number of fire alarm siren to ensure proper notification for the whole complex. P3
49 Provide adequate number of first aid kits and conduct the required training for the medical team P3
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4.5 HF in Alkylation unit
No. Recommendation for HF release Priority

Study upgrading the carbon steel material used inside the HF facility to be alloy 400 relevant to the codes and
2 P2
licensor recommendations
3 Assure following up API 571 damage mechanism P2
4 Assure providing certified training for the inspection engineers P3
5 Assure providing inspection advanced techniques devices to be used for inspection of the facility assets. P3
6 Assure providing adequate number of competent technical staff for inspection department P3
7 Assure following up API recommendations for calculation after each equipment shutdown P2
Assure providing technical office design engineer to evaluate inspection report, recalculate the minimum
8 P3
required thickness for operation, and to approve repair or replacement.
Assure providing ASME/API training for different disciplines Engineers (Engineering, inspection, maintenance)
9 P3
annually to perform the one unit procedure.
10 Study the need for installing corrosion inhibitor injection points inside the HF unit P3
11 Revise with UOP the existing operating conditions P3
12 Study installing control valve for controlling the inlet and outlet feed temperature. P3
Assure calculating the fluid velocities inside the units to assess against the accepted velocity range for
13 P3
preventing erosion
14 Assure conducting regular iron content sampling analysis P4
Assure following up API advice for material type and operating temp. to determine the suspected under
15 P3
insulation sections
16 P3
17 Assure selection of the painting material to be compatible with HF application P3
18 Assure that any dissimilar material shall be isolated with approved procedure P3
Assure providing Pressure leak test with the required pressure prior to start up as per as the relevant codes
19 P3
and standards
Assure providing adequate quantity and pressure of Nitrogen for purging and pressure testing for operation
20 P3
units prior to start up
21 Assure conducting regular sampling analysis for the outlet of cooling water at HF unit P3
22 P3
Training for employees from different disciplines about Root cause analysis, and conduct meeting to identify
23 P3
the root causes for any failure
Expedite the project of installing ROIVs for suction and discharge of HTF pump as per the relevant code and
24 P1
standard.
Study installing spectacle blinds at suction and discharge of HF pumps to be used prior to any maintenance
25 P2
activities inside the HF pumps.
26 Assure providing the required certified training for Engineers and Technicians inside the rotating department P3
Study and review the existing condition of piping support to fix the vibration problems of the rotating
27 P2
equipment.
Study installing permanent vibrations sensors for all rotating equipment to start trip action at certain
28 P3
vibration value.
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29 P1
682
30 Study and review installing automatic trip signal for the suction pump. P2
31 Ensure that discharge pumps are working inside their characteristic curve P2
32 P3
spare parts.
33 Study providing stop signal for HF pumps from the DCS P3
34 Asses the location of local start/stop button as per relevant code and standard. P2
35 Operating envelope to be identified for operating parameters in local reading sheet P3
36 Assure providing adequate training for operation staff regarding dealing with HF P3
37 Assure providing maintenance plan for the defected local devices P3
38 Assure providing adequate number of manpower that can cover all surveillance activities. P3
Conduct HAZOP study for LAB unit to check the need for Basic control system, remote Shutdown system for
39 P2
isolation of the critical HF loop in case of any emergency.
40 Assure providing alarm management study and alarm management software P3
Confirm that all changes for alarm setting priority are subjected to MOC process and to be studied by
41 P3
engineering
Conduct root cause analysis for repeated failures of PSVs internals to investigate its suitability for sour gases
42 P3
medium
44 Ensure proper implementation of ITPM plan for the flare system downstream of the KOH system. P3
Assure that Inspection program shall include periodical radiographic survey for plugging due to fouling inside
45 P3
the relieving header.
Assure the compliance of the HF unit operators to the exposure time limits of the HF as per as the relevant
46 P2
code and HF MSDS.
47 Assure implementation of proper maintenance plan for all Level transmitters at HF storage tank P3
Study providing the ISO HF tank PSV with the proper connection to be connected to the flare system instead
48 P2
of the existing release to atmosphere during filling the lab unit with new HF catalyst.
49 Review the suitability for accessibility and escaping features on the HF ISO containers during filling process. P2
Assure implementation of hose management procedure and proper storage for flexible hoses with respect to
50 P3
their life time.
52 Expedite providing new HF suits compatible with the new applicable specifications P1
53 Assure Proper testing for HF PPE with proper inspection method P2
54 Assure providing PMI test for all received material P3
55 Assure including purging procedure in maintenance for HF instrumentation P3
56 Assure developing PSSR procedure with checklist and assure proper implementation. P3
Study the need for regular purging process for the instrumentation impulse lines to get rid of any precipitate
57 P3
scales as per the relevant standard.
Conduct a survey to check the condition of the concrete structures inside the facility. Prioritize them and make
58 P2
the required repairs for the defected items.
59 Assure including the inspection for steel structure and foundation inside the inspection plan of the HF unit. P3
60 Provide clear KPIs for Safety Critical Elements "SCE" inspection (Testing/ year) P3
61 Conduct QRA & FERA study for the facility. P2
62 Conduct periodic fire drill for the different release and fire scenarios inside the HF unit. P2
Expedite project for connection of new Firefighting system to the detection system to make it totally working
63 P2
on automatic mode.
64 Study and review providing proper passive fireproofing as per the required standard API 2218 P2
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65 Assess the existing gas detection system location and types according to gas mapping study. P2
66 Study replacing catalytic type detector with suitable reliable type for the HF unit. P2
67 Conduct regular HF gas leak survey using a permanent or rental camera/detector to detect any HF leaks. P3
68 Expedite implementation of the new drain system with the required capacity and proper slope P2
69 P2
70 Study the replacement of HF catalyst (unit 1500) with licensor fixed bed safer catalyst. P2
Increase the number of drills in HF area considering all expected scenarios, and the recommendations from
71 drills to be shared with all concerned parties. Moreover, ensure that all workers are well trained on the P2
emergency response plan.
72 Assure providing adequate training for paramedic to deal with HF injuries. P3
Develop escape route layout, provide signs inside the access points, and define the routes by colour and
73 P2
arrows.
74 Provide discriminating tone for the siren signals "one for alarming and one for evacuation". P3
Study providing breathing apparatus with higher capacity to give suitable time for intervention and
75 P2
evacuation
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4.6 Hydrocarbon in VRU unit
No. Recommendation for VRU Priority

Study and review the existing material of construction inside the VRU unit, and upgrade theses material with
2 P2
construction material compatible with the high sulfur content services.
3 Assure following up recommended practices of API 571 damage mechanism P2
Study all the modifications which have been performed before, conduct respectively MOC and conduct the
4 P2
required studies to analyze the effect of these modifications to the process, people, asset and environment
5 Assure providing the required Process Safety information including all drawings and equipment data sheets P2
Assure that Technical Office Design Engineer to be involved in risk assessment, follow up construction codes
6 P3
for all calculations for new and in-service equipment, and assess any repair procedure.
Assure providing technical office design engineer to evaluate inspection report, recalculate the min. required
7 P3
thickness for operation, and to approve repair or replacement
Assure providing ASME/API training for different discipline Engineers (Engineering, inspection, maintenance)
8 P3
annually to perform the one unit procedure.
9 Assure following up API recommendations for calculation related to assets after each equipment shutdown P2
Review the effectiveness of existing maintenance plan for all vessels and pipelines and assure proper
10 P3
implementation.
11 Conduct/apply Risk-Based Inspection (RBI) for all facility static equipment and vessels. P3
12 Assure providing proper turnaround period to cover all the inspection activities and all the backlogs P2
13 Expedite approval and implementation of agreed turnaround plan for all the facility units P3
14 Assure providing fitness for service assessment for all old vessels and equipment inside the facility P3
15 Assure providing adequate advanced inspection tools and techniques P3
Conduct HAZOP study to identify the need for basic process control system, and ESD system for proper
16 P2
isolation of critical loops in case of emergency.
17 Assure providing regular sampling for H2S and water content from suspected process streams. P4
Assure providing updated SOPs including the consequences of deviation scenarios and the recommended
18 P3
action
19 Conduct survey for all dead legs in operating units by operation team to be included in special inspection plan P2
20 Study possibility of removing dead legs to eliminate the existing hazard following existing MOC procedure P2
21 Assure providing adequate manpower to carry out all inspection activities P3
22 Conduct Service agreement with 3rd party to cover all the required activities during the turnaround period P3
23 Assure providing adequate certified training for inspection team P3
24 Study the need for installing corrosion inhibitor injection points P3
25 Review existing insulation and replace asbestos with a safe material P2
Assure following up API advice for material type and operating temp. to determine the suspected under
26 P2
insulation sections
Conduct a survey over all contact points between piping and supports, assess the corrosion in these points,
27 P4
and install non-metallic items between the pipelines and the metal supports.
Assign specific inspection engineer to be responsible for all coating activities, and provide him with the
28 P3
required certified training and tools.
29 Operating envelope to be identified for operating parameters in local reading sheet P3
30 Assure providing adequate training for operation staff P3
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31 Assure providing maintenance plan for local devices P3

32 Assure providing alarm management study and alarm management software P3
Confirm that all changes for alarm setting priority are subjected to MOC process and to be studied by
33 P3
engineering
Conduct root cause analysis for repeated failures e.g. failures of PSVs internals to investigate its suitability for
34 P2
sour gases medium. Moreover, train employees for possible techniques for Root cause analysis.
35 Assure studying replacement of obsolete relief valves P2
37 P3
Conduct QRA & FERA study for the facility, and use the study outcomes for proper design/ or design verification
38 P2
of fire & gas system, active firefighting system, passive fire protection, shutdown system, facility siting etc.
39 Provide clear KPIs for Safety Critical Elements "SCE" inspection (Testing/ year) P3
40 Expedite project for installation of new automatic Fire Fighting system and Fire & Gas system P2
Conduct survey for all dissimilar sizing/ material flanges and permanent replacement plan to be developed
41 P1
according to ASMI
Assure providing Pressure leak test with the required pressure prior to start up as per as the relevant codes
42 P3
and standards
Assure providing adequate quantity and pressure of N 2 for purging and pressure testing for operation units
43 P3
prior to start up.
44 Expedite the project of installing ROIVs for suction and discharge of VRU pump P2
45 Expedite project of control system revamp for existing compressors P3
46 Study installing spectacle blinds at suction and discharge of VRU pumps P2
47 Assure providing the required certified training for Engineers and Technicians for rotating department P3
48 Study and review the existing condition of piping support to fix the vibration problem P2
49 Study installing permanent vibrations sensors for all rotating equipment to take trip action. P3
50 P2
682
51 Study and review installing automatic trip signal for the suction pump. P3
52 Ensure that discharge pumps are working inside their characteristic curve P3
53 Study replacing the packing type pumps with proper type according to API 682 P3
54 P3
spare parts.
55 Study the possibility of providing closed drain system for all facilities. P3
57 Study providing means or method for detecting leakage of LPG or HC to the cooling water. P3
58 Study improving the material of heat exchangers bundles to prevent the internal leaks. P3
59 Provide necessary man power to perform the required tasks. P3
60 Assure providing the required EX walkie talkie devices to be used inside the operation units. P2
62 P2
Assure availability of certified ATEX engineers to check the conditions of the EX-rating devices and
64 P2
connections and assess compliance with the ATEX requirements.
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65 P3
67 P3
situation.
Assure providing adequate number of safety showers, first aid kits, escape breathing apparatus, based on
68 P3
relevant standards
Assure updating the existing ERP to include all the potential emergency scenarios especially H2S release,
69 conduct training for the employees on the emergency response plan, and perform regular drills considering all P2
potential scenarios and different emergency levels.
70 Assure providing adequate personnel H2S detectors for the VRU crew P3
71 Study installing permanent H2S detection system inside the VRU. P3
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Appendices
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: List of Attendees
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: Bow Tie Diagrams

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i. LPG in Storage Area

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Threats
Threat 1: Internal Corrosion
Threat 2: External Corrosion

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Threat 3 : Overpressure
Threat 4: Mechanical Impact/Unbalanced lifting

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Threat 5: Pumps mechanical seal failure
Threat 6: Flange, Valve& Joints failures

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Threat 7: External fires and explosions
Threat 8: Vent/ Drain / Sample valve left open/damage

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Threat 9: Structure failure
Threat 10: Horseplay
Threat 11: Vacuum Pressure

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Consequences
Consequence 1: Fatalities due to fire / Explosion

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Consequence 2: Equipment damage and loss of production due to fire & Explosion
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ii. Gasoline in Floating Roof Tanks

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Threats

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Threat 3: Overfilling
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Threat 4: Roof failure & Rim Seal Failure

• Described in Separate Module
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Threat 5: Tank Settlement & Foundation Collapse / Failure
Threat 6: Open Hatches

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Threat 7: Flange, valve & joints failures
Threat 8: Pumps mechanical seal failure

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Threat 9: Mechanical impact during lifting
Threat 10: External fires and explosions

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Threat 11: Leakage from valves
Threat 12: Drain valve left open

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Consequences
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Consequence 2: Equipment damage and loss of production due to fire

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Consequence 3: Environmental Impact

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iii. Roof in Gasoline Floating Roof Tanks

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Threats
Threat 1: Roof Corrosion
Threat 2: Rolling Ladders Hanging

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Threat 3: Liquids accumulation on roof
Threat 3: liquid accumulation inside pontoon

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Threat 4: Rim Seal Failure
Threat 5: Rapid tank filling operation

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Consequences

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Consequence 2: Fire / Explosion due to LOPC leads to Equipment damage and loss of production
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Consequence 3: Spill due to LOPC leads to Environmental Impacts

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iv. Propane in bullets

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Threats
Threat 1: Internal corrosion
Threat 2: External corrosion

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Threat 3: Overpressure
Threat 4: Mechanical Impact/unbalanced lifting

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Threat 5: External fires
Threat 6: Flange, valve & joints failures

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Threat7: Pumps Mechanical seal failure
Threat 8: Horseplay
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Threat 9: Vacuum pressure Threat 10: Structure Failure
Threat 11: Vent/ Drain / Sample valve left open/damage

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Consequences

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v. HF in Alkylation unit
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Threats
Threat 1: Internal Corrosion Vessel

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Threat 3: Leaks from flanges, pipelines, elbows, etc.
Threat 4: Leaks from vessels, towers, heat ex-changers etc.

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Threat 5: Mechanical impact/ unbalanced lifting
Threat 6: Leakage from the mechanical seal

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Threat 8: Loading and offloading

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Threat 9: Leakage from vents and drains
Threat 10: Leakage from instrument devices

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Threat 12: External fires

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Threat 13: Internal passing valves

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Consequences
Consequence 1: Fatalities or injuries due to corrosive nature

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Consequence 2: Environmental Impact

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vi. Hydrocarbon release in VRU unit

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Threats

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Threat 4: Mechanical impact

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Threat 5: External fire
Threat 6: Flange leakage

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Threat 7: Leakage from pumps and compressors mechanical seals

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Threat 8: Drain and vent valves left open

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Threat 9: leakage in water cooling heat ex-changer

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Consequences
Consequence 1: Fatalities due to Fire & Explosion
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Consequences 3: Environmental Impact
Consequences 4: Toxicity

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Egyptian General Petroleum Corporate

Process Safety & Asset Integrity Management

DOCUMENT INFORMATION SHEET

The main objectives of performing the Bow Tie analysis:

1. LPG in the storage area.

Figure 1: APRC Block Flow Diagram

Figure 2 : APRC Plot Plan

Bow Tie Methodology

Figure 3: Bow tie analysis structure

3.2 Study Recording

3.3 Barriers Effectiveness

Barrier Color Effectiveness

Table 1: Barriers' effectiveness color code

3.4 Priority Ratings Matrix

Risk Definition Action Required

Table 2 Priority Ratings for Recommendations

3.5 Team Composition

Bow Tie Recommendations

4.1 LPG in storage area

4.2 Gasoline in floating roof tank

No. Recommendation for gasoline release Priority

4.3 Floating roof in gasoline tanks

No. Recommendation for tank roof failure Priority

4.4 Propane stored in bullets

No. Recommendation for Propane release Priority

4.5 HF in Alkylation unit

No. Recommendation for HF release Priority

4.6 Hydrocarbon in VRU unit

No. Recommendation for VRU Priority

31 Assure providing maintenance plan for local devices P3

: Bow Tie Diagrams

i. LPG in Storage Area

Threat 2: External Corrosion

Threat 4: Mechanical Impact/Unbalanced lifting

Threat 5: Pumps mechanical seal failure

Threat 6: Flange, Valve& Joints failures

Threat 7: External fires and explosions

Threat 8: Vent/ Drain / Sample valve left open/damage

Threat 9: Structure failure

Threat 10: Horseplay

Threat 11: Vacuum Pressure

Consequence 1: Fatalities due to fire / Explosion

ii. Gasoline in Floating Roof Tanks

Threat 2: External Corrosion

Threat 4: Roof failure & Rim Seal Failure

Threat 5: Tank Settlement & Foundation Collapse / Failure

Threat 6: Open Hatches

Threat 7: Flange, valve & joints failures

Threat 8: Pumps mechanical seal failure

Threat 9: Mechanical impact during lifting

Threat 10: External fires and explosions

Threat 11: Leakage from valves

Threat 12: Drain valve left open

Consequence 2: Equipment damage and loss of production due to fire

Consequence 3: Environmental Impact

iii. Roof in Gasoline Floating Roof Tanks

Threat 2: Rolling Ladders Hanging

Threat 3: Liquids accumulation on roof

Threat 3: liquid accumulation inside pontoon

Threat 4: Rim Seal Failure

Threat 5: Rapid tank filling operation

Consequence 1: Fatalities due to fire / Explosion

Consequence 3: Spill due to LOPC leads to Environmental Impacts

iv. Propane in bullets