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lunes, 16 de septiembre de 2013






Recommendations Review Report

corresponding to 29-30 January 2008 survey

This report does not purport to set forth all hazards or to indicate that other hazards do not exist. Inspections and recommendations are purely

advisory and are for the purposes of assisting the insured or other entities in loss control and safety procedures. The Company assumes no

responsibility for management and operational loss control and safety procedures. Neither the Company nor its employees, or agents, make

any warranty, express or implied, concerning the contents of this report. Further, neither the Company nor any of its employees, or agents,

shall be liable in any manner to any third party for personal injury or property damage or loss of any kind, whatsoever, arising from or

connected with this survey.

AIG UK Limited is authorized and regulated by the Financial Services Authority. Registered in England: company number 1486260.

Registered address: The AIG Building, 58 Fenchurch Street, London EC3M 4AB. A member company of American International Group


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DATE OF VISIT 29-30 January 2008 (3 days)

PRIOR AIG SURVEY(S) 23-24 April 2007 (short recommendations follow-up visit)

22-23 February 2005 (3 days)


ENGINEER David Dalla Costa (AIG)

INSURED PDVSA Puerto La Cruz Refinery (RPLC)



PLANT(S) ADDRESS P.O. Box 4064, Puerto La Cruz, Edo. Anzoategui




Omar Gonzales Operation Superintendent

Lino Flores Finance

Andres Avila Plant & Equipment Supervisor

Angel E. Figueroa Hydroprocessing Superintendent

Marcos Vieira Safety Officer

Manuel Biso Operation

Jesus M. Brito Operation Superintendent



Technical Manager

Omar Flores Utilities Superintendent

Humberto Romero Operational Projects Analyst

Cesar Malave Industrial Safety Manager

Miguel Fontan Marine Terminal Operations Supervisor

Sandy Gonzalez McyP Coordinator

Armando Buriel Products Movements Superintendent

Freddy Conde Jetty Mechanical Coordinator

Jose Rangel Corrosion & Materials Supervisor

Jose Guevara Routine Inspection Leader

Isaac Correa Reliability Engineering Supervisor

Pedro Lobatón Static Equipment Inspection Supervisor

Ysrael Molero Plant Engineering Supervisor

José Ochoa Electrical Engineering Supervisor

Tomas Cabrera Instrumentation Engineering Supervisor


José Sosa Rotating Equipment Supervisor

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Flor Aimeida Maintenance Contractors Superintendent

Tomas Coa Maintenance Planning Superintendent

Miguel Veliz Maintenance Planning Supervisor

Alexander Osio Industrial Safety - Risk Analyst

Gustavo Martinez Industrial Safety Superintendent

Jose Tuarez Fire Fighting Team Supervisor

José Acedo Industrial Safety

Angel Esteban Industrial Safety Management

Rafael Torres AIT

Luis Perreira Operations

And Others

Norberto Nunez Risk Engineer - AIG Energy Division

Latin America & Caribbean Region

Carlos Tosta Vida y Patrimonio / CooperGay representative

Juan Quilote PDVSA Corporate Industrial Safety Manager


Maritza Vallejo PDVSA Risk & Insurance

The water deluges on spheres 201 & 202 were tested during the course of the survey.

This report was prepared following a 3-day site survey and discussion with management and plant personnel.

Thanks are due to the personnel at RPLC for their co-operation and the open nature of the discussions held.

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1 INTRODUCTION.......................................................................................................................................... 5

2 RECOMMENDATIONS............................................................................................................................... 5

2.1 New & Outstanding/Prior Recommendations .......................................................................................... 5

2.2 Prior Completed / Closed Recommendations......................................................................................... 36

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This Recommendations Review Report provides a review of the new and past recommendations applicable to the

PDVSA Puerto La Cruz refinery (RPLC), Anzoátegui state, Venezuela, following a 3-day survey carried out at

the facility on 29, 30 and 31 January 2008. Where applicable Spanish translation has been provided to assist

RPLC in the understanding of the key information contained in this report



8 new formal recommendations, as well as additional observations, were discussed at the site wrap-up meeting

on 31 January 2007 through a presentation made to a large RPLC audience consisting of personnel from all key

departments and including senior management. The meeting was also attended by managers of PDVSA

Corporate Safety. RPLC appeared to positively receive these recommendations and expressed its commitment to

address them. However, the response to previous risk reduction recommendations is considered unsatisfactory as

only a very few were completed.

The full write-up of the new recommendations is submitted here below in English and Spanish1 for further

consideration and in no particular priority order.

1 Where discrepancies may exist between the English and the Spanish version, the English wording prevails.

Las siguientes 8 nuevas recomendaciones fueron discutidas a la reunión de cierre el 31 de Enero 2008. Se hizo

una presentación a la cual asistió una importante audiencia representada por personal de los departamentos

claves de RPLC, incluyendo representantes de la gerencia superior. Las recomendaciones fueron recibidas de

manera positiva y la gerencia expresó su compromiso en implementar estas mejoras después de evaluarlas de

manera mas detallada. Sin embargo, la respuesta a las recomendaciones previas se considera insatisfactoria y

lenta ya que sólo algunas se realizaron. El texto completo de las recomendaciones está listado mas abajo en

Ingles y Español1 para su consideración y sin ningún orden particular de prioridad.

1 En casos de discrepancias entre la versión inglés y español, la versión Inglesa prevalecerá.
Title summary of new and outstanding recommendations

Resumen de los títulos de las recomendaciones nuevas y de las propuestas de mejoras previas consideradas

como todavía abiertas por parte de los ingenieros de re-aseguro.





2008 Status

Situación 2008

01.2008 Groundwater infiltrations in electrical buildings (example of MCC


Infiltraciones de agua subterráneas en las galerías de edificios

eléctricos (ejemplo: MCC DA-1)



02.2008 LPG Pressurized Storage Relief Valves Overdue Inspection

Inspección retrasada de las válvulas de seguridad de los

almacenamientos presurizados de GPL



03.2008 Improve communication between Operations, Maintenance and


Mejorar la comunicación entre Operaciones, Mantenimiento y

Seguridad de Procesos



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04.2007 Positive Isolation – Best practice for hydrocarbon pumps

Doble aislamiento - “Best Practice” / Practicas recomendadas para

bombas (para hidrocarburos)



05.2008 Storage tanks Independent Ultimate High Level Alarm

Alarma ultima independiente de alto nivel en tanque de




06.2008 Fixed Fire Protection on LPG Vessels and Pumps

Protección fija contra incendio sobre las capacidades de GPL y

bombas de GPL



07.2008 Atmospheric Storage Tank Housekeeping and Oil Spillage in Bunds

(example of crude tank 80x15)

Tanques de Almacenamiento Atmosféricos - Orden y Limpieza, más

Minimización de los Derrames en los Cubetos (ejemplo del tanque de

crudo 80x15)



08.2008 Fire Pre-Plans & Fire Fighting Exercises

Planes de Intervención de Lucha Contra Incendios y Simulacros



01.2006 Equipment Isolation Procedures

Procedimientos para aislamiento de equipos

In progress

En progreso

02.2006 Installation of Remotely Operated Isolation Valves

Instalación de válvulas remotas de bloqueo

In progress

En progreso

03.2006 Double Mechanical Seals

Sellos mecánicos dobles

In progress

En progreso

04.2006 Long Bolt Flanges *

Pernos largos en bridas y otros accesorios *

* Recommendation not understood / * RPLC no entendió la recomendación

No Progress

Sin progreso

05.2006 DA-3 Alarm Management

Alarmas en sala de control de la planta DA-3 de El Chaure



06.2006 Existing Pressurized Storage Areas (Sphere 60.001 and Associated


Área existente de almacenaje presurizado (esfera 60.001 y Balas)

No Progress

Sin progreso

07.2006 New Pressurized Storage Areas (Spheres)

Nuevas áreas de almacenaje (esferas GPL)

No Progress

Sin progreso

08.2006 Fire Detection / UVIR Detection / Flame Detection on Tanks

Detección de Fuego / UVIR / Deteccion de llama en Tanques



09.2006 Housekeeping

Mantenimiento, Orden y Limpieza

No Progress

Sin progreso

10.2006 Multidisciplinary Audits

Auditorias Multidisciplinarias

No Progress

Sin progreso

11.2006 As Built P&ID

Planos P&IDs

In progress

En progreso

12.2006 Protection Of Compressor Lube Oil Consoles in HDT

Protección al sistema de lubricación de compresor en HDT



13.2006 Bently Nevada System in the FCC Wet Gas Compressor

Sistema Bently Nevada – Compresor de Gas Húmedo de FCC

No progress

Sin Progreso

14.2006 Lube Oil Analysis

Análisis aceite lubricante

No Progress

Sin Progresso

15.2006 15.2006 El Chaure – Tank 15

Tanque15 (El Chaure)



16.2006 Tank Inspection

Inspección de tanques



01.1998 Safety Trip Bypass Procedure

Procedimiento para el desvió de sistema de parada de emergencia



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02.1998 Work Permit (part b only) / Permiso de trabajo (solo parte b) Open / Pendiente

03.1998 Management of Change Procedure (MoC)

Manejo de Cambio (MDC)

No Progress

Sin Progresso

04.1998 Technical Services – Inspection Department

(b) Inspectors´certifications

(c) Use of Pre-pop test in adjusting PSV inspection frequency

Departamento de Inspección – SSTT

(b) certificaciones de los inspectores/técnicos

(c) uso de los resultados de las pruebas de “Pre-pop” para ajustar la

frecuencia de inspección de las válvulas de seguridad

In Progress

No Progress

En progreso

Sin Progresso

05.1998 RPLC Refinery Central Control Room

(a) Out-of-order and/or inadequate pressurization

(b) Pressurization alarm

(h) Gas detection in ait inlet

Sala de control principal RPLC

(a) Presurización del edificio

(b) Alarma en caso de perdida de presurización o modo defectuoso

(h) Detección de gas en la entrada de la toma de aire


No Progress



Sin Progreso


07.1998 El Chaure Gas Detection Systems

Sistema de detección de Gas, El Chaure


(see 02.1995)


(véase 02.1995)

08.1998 PLC Refinery LPG Storage Facilities (ROVs)

Instalaciones de almacenamiento de GLP (válvulas de

aislamiento/bloqueo remoto)


(included in 06.2006)


(incluida en 06.2006)

09.1998 Firewater Supplies (pump issue)

Bombeo de agua contra incendio

Mostly Without


En mayor parte Sin


10.1998 Protection Equipment Impairment Procedure*

Procedimiento para controlar la puesta afuera de servicio de los

equipos asociados a los sistemas contra incendio (bombas, monitores


* Recommendation not understood / * RPLC no entendió la recomendación

No Progress

Sin Progresso

11.1998 Miscellaneous Process Safety Issues

(a) Plugging discipline on end-of-line points in hydrocarbon service

(b) Restore fire proofing intumescent paint on the ROV isolation

valves on the No. 7 Jetty loading arms

(c) Properly bolts all electrical equipment enclosure

Casos específicos insatisfactorios de orden y limpieza

(a) Tapones / obturación - terminación abierta de líneas procesando


(b) pintura intumescente en las válvulas de bloqueo remoto de los

brazos de carga del muelle 7

(c) Atornillar correctamente cualquier cuadro y caja de equipos


Superseded by


Open (no information)

Superseded by


Sustituida por


Pendiente (no


Sustituida por


01.1995 LPG Storage Spheres

Esferas de almacenamiento GLP

Superseded by


Sustituida por


02.1995 Gas detection system

Sistema de detección de gas

No Progress

Sin Progresso

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01.2008 Groundwater infiltrations in electrical buildings (example of MCC DA-1)

The MCC room of area DA-1 (atmospheric distillation 1) was visited during the site tour. This building has a

shallow basement where wiring runs in and out of the electrical cabinets. Several inches of water were found to

flood this basement and immerse most of the cabling. This situation appeared to have been lasting for a long

time and to be known by plant personnel without any corrective action being taken. It was explained that the

MCC room suffers from groundwater infiltration and that the same issue also affects other buildings on site, one

of them being the control room where a permanent pumping system has reportedly been installed.

Such amount of water in key electrical buildings as the visited MCC room is a highly unsafe situation which

could lead in case of shortcuts to a local fire and/or to the sudden shutdown of key equipment and units with

potential consequential damage. It is recommended to:

1) establish a remedial plan so as to maintain the basement of MCC DA-1 waterproof and dry

2) identify and monitor all similarly affected buildings and includes them in the corrective plan

2008 client comment:

01.2007 Infiltraciones de agua subterráneas en las galerías de edificios eléctricos (ejemplo: MCC DA-1)

Durante nuestra visita, se inspeccionó la sala eléctrica de MCC de la unidad DA-1. Este edificio tiene varias

galerías con un número importante de cables debajo de los armarios eléctricos. Se observó que varios

centímetros de agua inundaban las galerías y sumergían la mayor parte de los cables. Esta situación parecía

durar desde hace bastante tiempo y era conocida por parte del personal de planta sin que se hubiera tomado

ninguna acción correctiva. Fuimos informados de que infiltraciones de agua subterráneas habían causado esta

situación y que el mismo problema afectaba a otros edificios de la refinería, siendo uno de ellos la sala

principal de control, donde se había instalado un sistema de bombeo permanente como medida de mitigación.

Esta cantidad de agua en edificios eléctricos claves, como la sala de MCC DA-1, es una situación muy insegura

que podría resultar en caso de corto circuitos, en un fuego local y/o en la parada no programada de importantes

equipos y unidades de procesos con posible daños materiales.

Se recomienda:

1) Establecer un plan correctivo que permita mantener las galerías del edificio MCC DA-1 impermeable y


2) Identificar todos los edificios que presentan la misma anomalía y riesgo con respecto a la presencia de

equipos eléctricos, evaluar regularmente el estado del problema en cada uno de ellos e incluirlos en el

plan correctivo

2008 comentarios de PDVSA:

02.2008 LPG Pressurized Storage Relief Valves Overdue Inspection

The survey team visited the two distinct pressurized storage areas consisting of the sphere 60.001 and the two

bullets D-1001/D-1002 on one hand and the two spheres, E-201 & E-202, on the other hand. These areas

presented an obvious lack of maintenance and the same anomalies already recorded and addressed by previous

recommendations were still observed (see 06.2006, 08.1998, and 01.1995).

A review of the pressure relief valve (PRV) inspection records associated to the spheres also revealed long

overdue inspection. For example, RV-1064 on sphere E-201 was last inspected and recalibrated on 24/04/1999,

i.e. almost 8 years at the time of the visit. Note also that at that time, the recorded result of the pre-pop test was

30 psig when the lifting set pressure should have been 80 psig, indicating perhaps that careful and regular

recalibration is required. In addition, the last E-201 external inspection and UT measurement report (RTIC-222-

2007, dated April 2007), which we reviewed, already flagged the extended period since the last PRVs calibration

and recommended them to be inspected. When on top of one of the D-1001/D-1002 bullets, each fitted with

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three RVs, the inspection tags attached to these PRVs indicated years as old as 2000. The tag associated to RV-

1590, one of the two RVs fitted on sphere 60.001, was dated June 2001 and there was no tag on the other valve.

Overall, such intervals appear excessive and beyond RPLC´s internally set guideline. It is recommended that:

1) RPLC verifies the inspection status of its PRVs on all LPG pressurized storage so as to clearly identify

any overdue situation and diligently carries out the required inspections

2) RPLC ensures that the PRVs associated with its pressurized storage are inspected at a safe frequency

2008 client comment:

02.2008 Inspección retrasada de las válvulas de seguridad de los almacenamientos presurizados de GPL

Visitamos las dos áreas de almacenamiento de GPL, la primera consistente de la esfera 60.001 y de las dos

balas D-1001/D-1002, y la segunda de las dos esferas E-201 y E-202. Dichas áreas carecen de mantenimiento y

las mismas anomalías ya indicadas por anteriores recomendaciones, fueron igualmente observadas (véase

06.2006, 01.1995, y 08.1998).

La comprobación de los registros de la válvula de seguridad de las esferas reveló inspecciones retrasadas desde

hace mucho tiempo. Por ejemplo, RV-1064 de la esfera E-201 fue inspeccionada y recalibrada el 24 de abril de

1999, es decir hacía más de ocho años desde la fecha de la visita. Hay que destacar además que el resultado de

la prueba pre-pop realizada en 1999, indicó una gran desviación con respecto a la presión de apertura

esperada (30 psig en vez de 80 psig). Está desviación indica que se debería realizar la inspección y recalibración

regularmente. Adicionalmente, el último informe de la inspección externa y de medición UT de la

esfera E-201 (RTIC-222-2007, de abril de 2007), ya alertó de la calibración retrasada y recomendó su

inspección. Además las etiquetas de inspección de las válvulas de seguridad asociadas a las balas D-1001/D-

1002 indican también fechas de últimas inspecciones muy antiguas como del ano 2000. La etiqueta de

inspección de la RV-1590, una de las dos válvulas de seguridad de la esfera 60.001, indica la fecha de Junio

2001 y no hay etiqueta en la otra válvula.

En resumen, todas estas observaciones demuestran que los intervalos de inspección son muy excesivos y muy

por encima de los recomendados en las guías internas de RPLC.

Se recomienda que:

1. RPLC verifique el estado de inspección de sus válvulas de seguridad en todos los almacenamientos de

GPL para identificar claramente cualquier situación de retraso y realizar diligentemente las oportunas


2. Una vez puestas al día las anteriores inspecciones, RPLC se asegure de que en el futuro dichas

válvulas sean inspeccionadas con la frecuencia requerida.

2008 comentarios de PDVSA:

03.2008 Improve communication between Operations, Maintenance and Safety

During the visit of the FCC area, pumps J-18 and J-4A were observed to be severely leaking hydrocarbons from

the seals. Comments from the local field operator indicated that this situation was well over several days old and

that it had been reported, however no corresponding notes was apparently recorded in the shift daily logbook to

communicate the information from shift to shift. The safety department did not appear to be aware of these leaks

as no mitigating measures were in place around the leaking pumps while allowing them to keep running. From

our discussion with maintenance/inspection, the maintenance department was apparently only aware of the issue

affecting pump J-18 as evidenced by a technical recommendation (reference ER-2008-034) issued on 28/01/2008

by an inspector of the rotating equipment group. However, maintenance had not received any notification about

pump J-4A.

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Overall, it appeared to the survey team that communication and/or reporting between operation, safety and

maintenance was not fully effective on plant breakdown occurrences such as the one previously described. It is

recommended that:

1) all plant operational issues and especially equipment breakdowns resulting in hydrocarbon leaks be

scrupulously recorded in the relevant operators´ logbooks to ensure adequate continuity of

communication from shift to shift about any potential issue. To this end, Operations should retrain

accordingly the operators and regularly verify the quality and content of information recorded in the


2) Safety be systematically informed of any hydrocarbon leaks and that appropriate mitigation measures /

extra-safety precautions be jointly set up with Operations in the case the decision is taken to keep

operating any defective equipment, such as a leaking pump, following a risk assessment concluding that

it is safe to do so. The risk assessment, the authorization to keep operating the equipment and the

mitigating measures to adopt should be documented.

3) the information process flow with maintenance is reviewed and strengthened to ensure that all needed

repairs are diligently filled and notified to maintenance for quick remedial intervention. The situation of

any defective safety critical system (such as gas detector) is to be given the same high attention and

dealt with similarly high reporting standards.

2008 client comment:

03.2008 Mejorar la comunicación entre Operaciones, Mantenimiento y Seguridad de Procesos

Durante la visita del área FCC, se observó que las bombas J-18 y J-4A tenían serias fugas de hidrocarburos en

los sellos. Comentarios del operario de campo indicaron que esta situación ocurría desde hacía varios días y

que se había reportado, sin embargo, no había notas referentes a este problema en los libros de turno de los

operarios para comunicarlo de un turno a otro. El departamento de seguridad industrial no parecía estar

informado de estas fugas ya que no había ninguna medida mitigante establecida aunque las bombas siguieran

funcionando. De las entrevistas mantenidas con Mantenimiento/Inspección, se demostró que sólo el caso de la J-

18 era conocido (nota técnica ER-2008-034 del 28 de enero de 2008). Sin embargo Mantenimiento no fue

notificado del caso de la J-4A.

En resumen, nos pareció que la comunicación entre Operaciones, Seguridad y Mantenimiento no era

completamente efectiva sobre incidentes de roturas, como los arriba indicados.

Se recomienda que:

1. Todos los problemas operacionales y en concreto aquellos sobre roturas de equipos que resulten en

fugas de hidrocarburos sean escrupulosamente registrados en los libros de turnos del personal de

Operaciones para asegurar la continuidad de comunicación de un turno al otro. Con este fin,

Operaciones debe readiestrar a los operarios y regularmente verificar la calidad del contenido de la

información de los libros de turnos.

2. Seguridad debe estar sistemáticamente informada de cualquier fuga de hidrocarburos y establecer las

apropiadas medidas de mitigación / precaución extra de seguridad conjuntamente con Operaciones en

el caso de que se decida seguir operando con equipos defectuosos, tales como bombas con fugas,

siempre y cuando un análisis de riesgos concluya que es seguro. El análisis de riesgo, la autorización

para continuar operando el equipo y las medidas de mitigación a adoptar tienen que ser


3. El flujo de información con Mantenimiento sea revisado y reforzado para asegurar que todas las

reparaciones necesarias sean notificadas a tiempo para una rápida intervención. En el caso que se

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encuentra cualquier equipo defectuoso que sirve a la seguridad de las instalaciones (por ejemplo un

detector de gas), el mismo alto nivel de atención, aviso a Mantenimiento y respuesta tiene que ocurrir.

2008 comentarios de PDVSA:

04.2008 Positive Isolation – Best practice for hydrocarbon pumps

(Recommendation also issued at Cardon/Amuay during the Nov.-2008 visit)

- During the site tour, we noted maintenance drain lines on pump in hydrocarbon service without positive

isolation (i.e. most lines have only a single isolation valve). These lines often terminate and discharge

below the grating cover of the process drainage trenches and if the valve is passing, the leak could hence go

undetected. Positive isolation is recommended: for example, by having two valves on the drain line.

- In many instances, the connection between the drain line and the pump body was observed to be of the

screwed type, in some cases using PTFE thread tape in the joint. As this arrangement could easily become

loose, for example because of vibration, it is recommended to opt for welded or flanged connections.

It is recommended that the site carries out a review of its pumps to identify those with the above deficiencies and

improves the situation. A review of the corresponding PDVSA standard, if existing, should also be considered. If

no company standard covers these issues, then create one taken into account the suggested best practice.

2008 client comment:

04.2007 Doble aislamiento - “Best Practice” / Practicas recomendadas para bombas (para hidrocarburos)

- Durante la inspección se observaron líneas de drenaje de bombas para hidrocarburos sin aislamiento

positivo (es decir que la mayoría de estas líneas solo tienen una válvula y están sin tapón u otra forma de

cierre al final de la línea). A menudo, estas líneas terminan y descargan por debajo del nivel del suelo,

dentro de los canales de drenaje que existen en las unidades de proceso. En caso de una fuga de/en la

válvula de aislamiento en esta línea de drenaje, dicha fuga podría no ser detectada. Un aislamiento positivo

es entonces recomendable, por ejemplo mediante la instalación de dos válvulas en la línea de drenaje.

- En muchos casos se observo que la línea de drenaje se conecta al cuerpo de la bomba por medio de una

conexión roscada. Tomando en consideración que estas conexiones se podrían aflojar, por ejemplo a causa

de vibraciones, es recomendable que se consideren conexiones soldadas y/o mediante juntas / “flanges” /


Recomendamos que se revise la situación de las bombas en las plantas para identificar cuales presentan las

deficiencias anteriormente descritas y que se mejore como indicado la situación. Se debería también revisar el

estándar / la norma corporativa de ingeniera de PDVSA correspondiente, si existe la misma. En caso contrario,

se debe crear una norma corporativa cubriendo las mejores prácticas sugeridas.

05.2008 Storage tanks Independent Ultimate High Level Alarm

Most storage tanks have only a single level instrumentation system where high level alarms are fitted.

On some tanks, as it is the case at El Chaure, it was even reported that manual gauging is the only available

option and that it was one of the contributing factor of the July 2007 asphalt tank 80x34 overtopping (4000 bbl

were spilled).

It is recommended that the site develops an upgrading plan to fit storage tanks with an High High level alarm

independently ‘hard wired’ of the normal tank gauging system to ensure that any failure to the gauging system

does not also cause the ultimate safety alarm to malfunction. Where the tank gauging is still manual, then it is

recommended to fit all identified tanks with an automatic gauging system and an independent HHL alarm. (Note

that providing automatic gauging system is a recommendation that PDVSA own accident investigation team

made about tank 80x34; we consider that all significant tanks should have automatic gauging system).

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The recommendation is also applicable to pressurized storage such as spheres and bullets; however this is

already addressed by previous recommendations.

Consideration should also be given to a higher level of protection by configuring the high high level alarm so

that it triggers an emergency shut down (e.g. stop the filling pump, close valves or divert the flow, if

no action is taken following the high-level alarm) in order to prevent liquid overflow and remove the need for

human intervention.

2008 client comment:

05.2008 Alarma ultima independiente de alto nivel en tanque de almacenamiento

La mayoría de los tanques tienen un sistema de instrumentación único para la medición de nivel desde el cual se

genera las alarmas de alto nivel. En algunos tanques, como en el caso del El Chaure, se había reportado

además que la medición manual de nivel es la única opción disponible y que era uno de los factores causantes

del desbordamiento del tanque 80x34 de asfalto en Julio de 2007 (4000 barriles se vertieron).

Se recomienda que RPLC establezca un plan de modernización para equipar a los tanques de almacenamientos

con alarmas altas últimas que sean independientes del sistema habitual de medición de nivel, de manera que se

asegure de que cualquier fallo de este sistema no cause también el fallo de la alarma última. En aquellos casos

en los que la medición de nivel sea aún manual, se recomienda equipar a los tanques con un sistema automático

de medición de nivel y una alarma HHL independiente. (Nótese que el sistema de medición de nivel automático

es una recomendación que la propia investigación de PDVSA del incidente del tanque 80x34 ya indicó. Los

aseguradores consideran que todos los tanques importantes deberían tener el sistema automático).

Esta recomendación es también aplicable a los almacenamientos presurizados, tipo esferas o balas. Sin

embargo, este punto ya ha sido tratado en otras recomendaciones.

Se debe también considerar un nivel más alto de protección configurando las alarmas alta-alta de manera que

activen un sistema de parada de emergencia (por ejemplo, parada de la bomba, cierre de válvulas o desviación

del flujo si no se han tomado acciones desde la activación de la alarma de alto nivel) para prevenir el

desbordamiento y la necesidad de intervención humana.

2008 comentarios de PDVSA:

06.2008 Fixed Fire Fighting Protection on LPG Vessels and Pumps

The provision of fixed fire protection such as water deluge on in-process vessels containing large hold-ups of

light hydrocarbons should be improved. Such fire suppression systems were observed on some vessels in

specific units, Alkylation being one of them, yet many critical vessels across the refinery process units lack such

protection. The vessels being referred to include (but are not limited to) process columns, LPG accumulators or

drums, for example in the gas plants. Note that the absence of deluge systems on critical vessels is not only an

shortfall specific to the old units but concerns also the newer Valcor plants where it was for example observed

that the LPG feed surge drum D-2051 would deserve a deluge protection.

In case of a fire in the vicinity of vessel containing LPG type of material, the cooling of the vessel is crucial to

avoid catastrophic scenarios such as BLEVE, and water deluge systems, either automatic or manually activated

from a safe location, are the preferred option.

Similarly, the use of fixed water spray protection on LPG and hot pumps should be generalised, and where

already installed the operability and integrity of such system should be maintained. In this respect, note that

pumps B-P5 A/B in the Alkylation are missing their sprinkler protection since a March 2007 fire in this unit

destroyed the equipment. The repair of this piece of fire fighting system appears to be excessively long and its

reinstatement should be expedited.

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It is recommended that fixed water spray be installed in accordance with API 2030 over LPG and hot pumps as

well as on LPG drums within process units. To this end, identify and prioritize the pumps and vessels to be fitted

with such protection and set up accordingly an upgrading plan.

2008 client comment:

06.2008 Protección fija contra incendio sobre las capacidades de GPL y bombas de GPL

Se debería aumentar el número de protección fija contra incendio de tipo diluvio de agua sobre las capacidades

ubicadas dentro de los procesos y conteniendo grandes inventarios de hidrocarburos lleves. De momento, se

observó este sistema de supresión de fuego en solo algunas capacidades y en unas unidades específicas como la

de Alquilación, pero en general varias otras capacidades críticas a través de la refinería padecen de esta


Las capacidades a las cuales hacemos referencia incluyen (pero no se limitan) a acumuladores, tambores,

columnas etc… de LPG, por ejemplo dentro de las plantas de gas. Es importante tomar en cuenta que la

ausencia de sistema de diluvio en capacidades criticas no es una insuficiencia que caracteriza solo las antiguas

unidades pero existe también en las nuevas plantas del proyecto Valcor donde se observó a titulo de ejemplo que

el tambor de GPL D-2051 (que tiene un volumen de unos 38.5m3) no tiene dicha protección.

En caso de un fuego cerca de estos inventarios, el enfriamiento de la capacidad es crucial para evitar

situaciones catastróficas como la de un BLEVE, y un sistema de diluvio automático o activado manualmente

desde un lugar seguro es la opción preferida.

De la misma manera, el uso de sistema de diluvios, rociadores, etc... debería generalizarse sobre las bombas de

GPL y bombas procesando cualquier producto a temperatura y presión tal que una fuga en dicha bomba podría

causar un incendio ( por ejemplo, material de tipo aceite / crudo por encima de 250ºC). Donde esta protección

esta ya instalada, la integridad y operabilidad de dicho sistema tiene que ser continuamente mantenido. En tal

sentido, se observó que el sistema de diluvio que protege las bombas B-P5 A/B en la unidad de Alquilacion no

se ha reinstalado por completo desde el fuego de Marzo 2007 que ocurrió en esta área, lo que representa un

tiempo demasiado largo. Su reparación debería concretizarse mas rapidemente.

Recomendamos la instalación de sistemas de tipo diluvio / pulverización de agua, como indicado por la norma

API 2030, sobre las bombas de GPL (y también cualquiera bombas procesando material de tipo aceite / crudo

por encima de 250ºC), y sobre los inventarios de GPL dentro de las unidades de proceso. Para este fin,

Identificar y priorizar las bombas y los tambores donde esta protección seria beneficiaria de acuerdo con la

norma API 2030 y establecer un plan de implementación de estas mejoras.

2008 comentarios de PDVSA:

07.2008 Atmospheric Storage Tank Housekeeping and Oil Spillage in Bunds (example of crude tank


The following anomalies were observed during our inspection of crude tank 80x15:

- a large amount of rubbish consisting of oily cloths, gloves, bottles apparently used for sampling etc…

were found on the tank floating roof and represented poor housekeeping standards

- tank bottom water drain valves without blinded flange

- the bund corner where the bund drainage pit is located was heavily impregnated with oil on most of its

area (oil pools/puddles were still present). See picture 1. The situation was evidence in our opinion of a

substantial amount of oil that may have stagnated in this area for some time. It was explained that this

situation is regularly caused by the manual drainage of the water settling at the bottom of the crude

tank. Crude tank 80x15 as well as two other nearby similar tanks feed directly the atmospheric

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distillation unit DA-1 (one tank is in feed mode, one is in receiving mode, and the remaining one is in

water settling mode). From the distance, it was indeed observed that similar oil spills had affected the

bunds of these other tanks. Further explanations indicated that the discharge of any water/oil mixture

from the bund area to the refinery oily water drainage system was constrained because of availability

limitations at the downstream API separator. The bund drain of tank 80x15 which connects to the oily

water drainage system also appeared to show signs of blockage in our opinion. In any case, the

situation is that substantial oil quantities appears to be held for some time and on a regular basis in part

of the tank bund because of specific operational constraints and practice. This regular oil retention,

although in a bunded area, poses a significant flash fire risk and should be avoided.

Picture 1: Oil spill in bund of tank 80x15

It is recommended to:

1) to specifically address the anomalies highlighted on tank 80x15 (rubbish on roof and absence of

positive isolation on tank bottom valves) and, by extension, establish a housekeeping programme

ensuring that these issues do no occur on other storage tanks

2) to eliminate the practice of temporary and regularly holding up significant oil amount in bunds

following crude tank water drainage operation as it is the case for the three crude tanks feeding DA-1

(or any other tank with the same issue). In this respect, any constraints of the oily water drainage

system should be corrected to ensure that any liquid accumulation in the bund(s) can be rapidly


2008 client comment:

07.2008 Tanques de Almacenamiento Atmosféricos - Orden y Limpieza, más Minimización de los Derrames

en los Cubetos (ejemplo del tanque de crudo 80x15)

Se observaron las siguientes anomalías durante la inspección del tanque de crudo 80x15:

- Gran cantidad de basura consistente en trapos usados, guantes, botellas de plástico para muestras, etc.

encontrada en el techo flotante del tanque. Esto indica una condición pobre de orden y limpieza.

- Válvulas de fondo de drenaje sin bridas ciegas

- La esquina del dique donde está ubicado su sistema de drenaje estaba altamente contaminada con

crudo (charcos importantes). Véase foto1. La situación es prueba, en nuestra opinión, de una cantidad

importante de crudo que ha estado estancada en esta zona durante cierto tiempo. Se nos informó de

que esta situación se causa regularmente por el drenaje manual del agua residual del tanque. El tanque

de crudo 80x15, así como otros dos tanques vecinos, alimentan directamente la unidad DA-1 (un

tanque está en modo “alimentación”, otro en “recepción” y el tercero en “decante”). Desde lejos se

observó efectivamente que charcos similares habían afectado a los diques de estos otros tanques.

Explicaciones adicionales indicaron que la descarga de la mezcla de agua y crudo desde el dique hacia

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sistema de tratamiento de agua residual de la refinería, tiene cierta limitación debido al mal

funcionamiento y disponibilidad del separador API. El drenaje del dique del tanque 80x15, que conecta

con el sistema de drenaje de agua residual parecía también bloqueado en nuestra opinión.

En todo caso, parece que cantidades importantes de crudo están retenidas durante cierto tiempo y de

manera regular en parte del dique del tanque debido a limitaciones y prácticas operacionales. Esta

retención regular de crudo, aún en un dique, implica un riesgo de incendio (“flash fire”), y debe ser


Se recomienda:

1. Corregir las anomalías observadas en el tanque 80x15 (basuras en el techo, ausencia de aislamiento

positivo de las válvulas de drenaje de fondo) y, por extensión, establecer un programa de orden y

limpieza que asegure que estos problemas no aparecen en los tanques.

2. Eliminar la práctica regular de retención temporal de cantidades importantes de crudo en los diques

tras la operación de drenaje de agua residual, como se observó en los tres tanques alimentando DA-1

(o en cualquier otro tanque). Con este fin, cualquier limitación del sistema de drenaje de agua residual

debería ser corregida para permitir una evacuación rápida de cualquier retención de líquido en los


2008 comentarios de PDVSA:

08.2008 Fire Pre-Plans & Fire Fighting Exercises

The site fire emergency preparedness should be improved by making available more detailed fire pre-plans

which consider major scenarios on a higher number of key critical in-process vessels and equipment as well as

LPG storage. Considering the scale and the wide number of process units at RPLC, the actual fire pre-plans were

found not to be comprehensive enough, in their format, content and numbers. For example, there is no scenario

involving the LPG spheres and/or bullets. In addition, the current level of fire-fighting exercises based on

existing emergency intervention plans appeared to be low. For example, in 2007, only two main drills were

carried out (one involving the truck loading facility at the refinery and the other one simulating a fire on the

crude unit DA-3 at San Roque).

It is recommended that:

1) The concept of fire pre-plans be extended to major scenarios on all key process units. Vessels, columns,

drums etc… containing large inventory of light hydrocarbons (e.g. LPG), but also key rotating

equipment such as the Wet Gas Compressor, should be especially targeted and form part of the

available fire pre-plans. RPLC should identify such scenarios, rank the associated fire potential and

develop relevant intervention plans accordingly.

2) Any developed pre-plan clearly indicates the fire extinction / attack strategy including (but not limited

to): number of firemen to respond to the emergency, type and number of vehicles needed, first fire

attack requirements, itinerary to be taken to reach the fire scene, evacuation routes, communication

means, precautions to be taken during the intervention, foam concentrate amount and fire water

flowrate to be applied should be assessed and detailed in the plan as this would assist the site in

verifying that its fire fighting capabilities are adequate to tackle major scenarios, location of plant

equipment / critical vessels containing large flammable inventories which may need to be cooled to

prevent escalation, location of available fixed and mobile fire fighting equipment at the fire scene,

indication of radiation levels expected from a significant fire, actions required by operations, up-to-date

plant schematic/map/drawing summarizing key information etc…

3) All fire pre-plans are regularly exercised and the training is recorded. Particular attention should be

given to the exercise’s debriefing session to ensure that any lessons learned from the exercise are

translated into effective emergency pre-plan revisions and/or improvements changes or projects.

Detailed pre-plans can significantly improve the training and awareness of all participants in an

emergency scenario.

2008 client comment:

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08.2008 Planes de Intervención de Lucha contra Incendios y Simulacros

RPLC necesita mejorar sus planes contra incendios, poniendo a disposición una documentación más detallada

que considere escenarios catastróficos en un mayor número de capacidades y equipos críticos instalados en las

unidades así como los almacenamientos de GPL. Considerando la escala y el gran número de unidades de

proceso en RPLC, sus actuales planes no se consideran completos, en su formato, contenido y número. Por

ejemplo, no existe un escenario incluyendo las esferas o balas de GPL. Además el nivel actual de simulacros

utilizando los planes de emergencia actuales es bajo. Por ejemplo, en 2007 sólo dos simulacros se llevaron a

cabo (uno incluyendo la instalación de carga de los camiones cisterna y otro simulando un incendio en la

unidad de crudo DA-3 en San Roque).

Se recomienda:

1. Extender el uso de planes contra incendios que incluyan escenarios mayores para todas las unidades

de proceso relevantes. Capacidades, columnas, tambores, etc. que contengan grandes inventarios de

hidrocarburos leves (p.e. GPL), pero también equipos rotativos principales, como el Compresor de Gas

Húmedo, deberían ser los objetivos principales de dichos planes y formar parte de su documentación.

RPLC debe identificar los escenarios adecuados, priorizarlos en función de los riesgos de incendio

asociados y desarrollar los planes detallados de intervención correspondientes.

2. Que los planes elaborados indiquen claramente la estrategia de lucha contra incendios, incluyendo (

pero no limitado a):

- Número de bomberos interventores

- Tipo y número de vehículos

- Requisitos iniciales de lucha contra incendios

- Itinerario para acceder al lugar del incendio

- Rutas de evacuación

- Medios de comunicación

- Precauciones a tomar durante la intervención

- Cantidad y flujo de espuma/agua

- Localización de los equipos con grandes inventarios inflamables que necesiten enfriamiento

- Ubicación de todos los equipos de lucha contra incendios (fijos y móviles)

- Nivel de radiación esperado

- Acciones requeridas por Operación

- Planos/diagramas actualizados resumiendo las informaciones claves

- Etc…

3. Practicar regularmente y con alta frecuencia simulacros de incendios de acuerdo con los planes

desarrollados y registrar estos simulacros. Se debe dar atención especial al ejercicio del análisis

posterior para asegurar que las lecciones aprendidas son incorporadas en planes eficientes de

emergencia y conllevan mejoras o nuevos proyectos. Es importante saber que unos planes contra

incendios detallados aumentan la aptitud y mejoran el adiestramiento de todos los partícipes en un

caso de emergencia.

2008 comentarios de PDVSA:

Pending open recommendation

01.2006 Equipment Isolation Procedures

01.2006 Procedimientos para aislamiento de equipos

During the survey it was noted that a number of large pumps handling flammable material had been removed

without completing a proper mechanical and electrical isolation procedure. These pumps were located in the

Naphtha Splitter (G-0322), FCC (J-8A), Alkylation Unit, etc.

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Mechanical Isolation: The site's procedure for mechanical isolation, calls for positive isolation using double

block arrangements and /or insertion of spades. Additionally, corporate procedure for isolation calls for locking

and tagging of any valves that are closed as part of the isolation exercise. Deviations noticed were: no LO/TO,

no blind, 1-4 bolting procedures, etc.

Electrical Isolation: It is recommended to include for some form of "lock-out" on the switchgear in the

Substation/Motor Control Centre to provide a more positive form of electrical isolation. This could take the form

of the attachment of plastic seals provided that the design of the switchgear actually allows seals to be attached,

which appeared to be the case in the substation that was visited during the survey. Deviations noticed were no

removed fuses, no locked circuit breakers etc..

It is therefore recommended that RPLC review the site isolation philosophy and procedure, to ensure all

equipment in hazardous service is identified and that an appropriate level of isolation is developed.

2006 Client comment: None on records

2007 Client comment: A procedure exists within PDVSA and its content was spread through safety talks and

trainings, however without being recorded.

Apr.-2007 AIG recommendation follow-up visit: No Progress / Sin progreso

Pump J53 in the FCC Unit was not mechanically and electrically adequately isolated.

Jan.-2008 status: In Progress / En progreso
An electrical and mechanical isolation procedure exists indeed (SI-S-RF-02-PE, issue date: 30/05/2007, rev.1

dated 10/09/2007) and was provided to the survey team. This procedure is specific to RPLC and was found to be

comprehensive enough in terms of isolation requirements (e.g. it includes the use of a wide range of lockout

devices, such as tags, coloured locks by discipline, hasps, chains, group lock box and other hardware). The

procedure has been made available in a pocket-sized booklet format. 1000 booklets were reportedly printed, of

which several hundreds were already distributed to RPLC staff in the relevant disciplines (Operation,

Maintenance, Safety etc…) and evidenced by signed distribution records. The plant has established a

programme which extends into 2008 to implement the procedure (workshops are planned; locks / tags and other

LOTO devices are being purchased; lockout stations are being installed in field operators shelters from where

permits are controlled…). During our visit of the installations, the LOTO standard observed in the field was still

variable e.g. a pump being worked on in the FCC unit had its isolation valves adequately tagged but not chained

and no blinds were used; in the LPG area of sphere 60.001, pump P102A had been taken out reportedly for one

month, but there was no information tags in the area; in unit DA-6, an exchanger had been isolated with spades

but not all isolations were properly bolted and the work executor did not have his work permit copy with him.

This recommendation is considered in progress.

02.2006 Installation of Remotely Operated Isolation Valves

02.2006 Instalación de válvulas remotas de bloqueo

There is minimal provision of ROIVs in the process units to provide isolation of large inventories of

hydrocarbons in emergency situations. An Emergency Isolation Valve (EIV) fitted in the suction line of a pump

may well allow that pump to be quickly and safely isolated should the pump seal fail and a fire occur. However,

this has been recognized by the refinery and there is a project in place to install ROIVs in the DA-2 pump

suctions of the large fractionator. Additional vessels noted during the survey that should be considered for

ROIVs include the crude columns of DA-1, the OVHD Drum FA-1, debutanizer E5, etc.

However, it is recommended that a review is undertaken of the valves to be installed against the PDVSA criteria.

It is also recommended that the ROIV specification includes appropriate fireproofing if the valves are located in

a fire hazard zone. It is generally recommended that EIVs are fitted in the suction lines of all pumps taking

suction from vessels/tower:

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- with an inventory greater than 10m3 of light hydrocarbons e.g. LPG, or flash point below 23oC, or

operating above auto-ignition temperature

- with an inventory greater than 20 te of other flammable material.

- Pumping liquids above their auto-ignition temperature and taking suction from a vessel with an

operating inventory of 10m3 or more.

The valve bodies and seats should be designed for direct exposure to fire and the actuators and cabling designed

to withstand 20 minutes of fire exposure.

2006 Client Comment: None on records

2007 Client comment: Included in the projects portfolio. 80% progress on basic engineering. Column DA-3 is

fitted with ROIV. Column DA-2 bottom fitted with ROIV in the last planned shutdown. DA-1 column to be done

at the next planned unit turnaround in August 2007.

Apr.-2007 AIG recommendation follow-up visit: In Progress / En progreso

Jan.-2008 status: No further information was provided. RPLC stated that the E-5 and FA-1 cases will be
evaluated by its technical service. In Progress / En progreso

03.2006 Double Mechanical Seals

03.2006 Sellos mecánicos dobles

During the survey it was noted that there is limited application of pumps with high integrity seals (such as

tandem, double mechanical, etc, seals) at the refinery (e.g. bottom pumps of DA-1 and DA-2, feed Pump of DA-

2, LPG pumps in the FCC, pumps in the pressurised storage areas, etc.).

It is recommended that the refinery installing high integrity seals for all pumps either operating above the auto

ignition temperature or in LPG service. We recommend that a gap analysis is carried out across the refinery

process areas to identify all vulnerable pumps and that an investment program is developed and completed to fit

suitable high integrity seals. Typically high integrity seals should include inter-seal pressure detection and fitted

with alarm indication in the control room to alert panel operators of first seal failure. Seals are selected as per

API 682, based on the following suggested criteria:

􀂃 Product operating temperature greater than 260 oC (500 oF)

􀂃 Product operating pressure greater than 34 kg/cm2 (500 psig)

􀂃 Product operating above the flash point

􀂃 Product operating above the autoignition temperature

􀂃 Pumps in LPG service

􀂃 Pumps handling toxic products (e.g. HF, benzene)

2006 Client Comment: None on records

2007 Client comment: as examples, status and plans for the following pumps can be mentioned: pumps GA-

10/10S in DA-1 (replacement being evaluated as part of the DA-1 revamp project) / Pumps P-3/3A in DA-2: seal

upgrade being evaluated / FCC: requirement will be part of the evaluation of obsolete equipment in this unit,

which is currently ongoing / A listing of equipment identified as qualifying for the seal upgrade is available. Seal

improvements will be carried out progressively.

Apr.-2007 AIG recommendation follow-up visit: RPLC reports that the project is divided in 3 phase with design

to be finalized in 2008 and completion in 2012. In Progress / En progreso

Jan.-2008 status: In Progress / En progreso
RPLC reports that, to date, the upgrade was done on pumps P3A and P15 on residual crude service in unit DA-

2, P-28 and P-29 in the Alkylation and on P-5 at El Chaure. RPLC provided a first list of pumps it intends to

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upgrade and the required work steps up to 2011. In addition to the pumps already modified, the upgrades will


Plant Pump Installation Plant Pump Installation

year year

FCC 4/4A – slurry recycle 2010 Unit 051 G2803 – Naphta 2009

DA-1 GA-8/8S – gasoil 2008 Reformer G2805A/B 2009

DA-1 GA-10/10S–residual crude 2009/2010 Unit 300 G-2802 – Mixed diesel 2009

DA-3 P-6/6A – light naphta 2010 LPG unit B-6/7/8 – LPG 2008

DA-3 9/9A – residual crude 2010 FCC *Compressor J-12-wet gas 2011

Alkylation P-21A/B/S – LPG 2008 * New compressor will be purchased
04.2006 Long Bolt Flanges

04.2006 Pernos largos en bridas y otros accesorios

During the survey of the process and storage areas it was noticed that the refinery make use of waffle flanges /

long bolt flanges (DA-3, HDT, LPG service, etc.). The long bolts will be receive direct flame contact if there is a

fire in the area; the direct flame contact causes the bolts to expand rapidly and lengthen, allowing both gaskets to

leak product. The leaking material then adds fuel to the fire and if under pressure it causes a large spraying fire

that results in much more damage. It is recommended the following:

- Identify Long Bolt Flanges across the refinery

- Assess Fire hazard from the contained material and location hazards.

- To limit the problem of fast failing Long Bolt Flange valves they should be replace with normal flange

valves, but the hazard can be reduced by wrapping the long bolts with a fire resistant material and then

enclosing the entire assembly with a stainless steel covering. In addition PLC should gradually remove

Long Bolt Flange when in flammable liquids or LPG service.

Update PDVSA engineering standard in order to ensure that every new process unit will not have Long Bolt

Flange Joint installed any more. Infact it was surprising seeing many long bolt flange in the new HDT unit.

Please note that the same recommendation was issued at CRP (05.02).

2006 Client Comment: None

Apr.-2007 AIG recommendation follow-up visit: No progress / Sin progreso
Jan.-2008 status: RPLC has issued a technical note which aims to standardize the bolts, screws and stud bolts in

use across the site and in particular specifies the length which a stud needs to protrude from the bolt's nut.

However, this is not addressing the recommendation which RPLC has not understood. No Progress / Sin


05.2006 DA-3 Alarm Management – El Chaure

05.2006 Alarmas en sala de control de la planta DA-3 de El Chaure

Alarm handling is considered vital for managing control of the plant and direct operator's attention to the most

important problem that they needs to act upon. Currently the only alarm classification existing at PLC is between

Pre-Alarm and Alarm.

DA-3, located at El Chaure, is controlled by a DCS. At the time of the survey it was not possible to visualize the

Alarm Pages because that element of the DCS was out of service; therefore, no historical of alarms / pre-alarms

was available to review. It was also noticed that the temperature of the heater’s stack was in alarm and despite

the panel operator was handling the issue, he was not able to provide “verbal information” on the historical of

this specific alarm.

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It is recommended to the Refinery Management to repair the DCS as soon as possible in order to provide

handling of alarms. In the meantime is strongly recommended to constantly monitor the operation of the unit and

operating the plant with an extra safety margin (i.e. reduce capacity). Specifically to this issue, Refinery

Management should pay attention also on the current shift hand over procedure.

2006 Client Comment: None on records

2007 Client comment: RPLC states that the alarm history page in the DCS was always available. A training

specifically targeting the handling of alarms showing up in the DCS was nevertheless provided to the operators

post survey.

Apr.-2007 AIG recommendation follow-up visit: Completed / Completado. The issue at DA-3, which was the

unit targeted by the recommendation, was resolved, i.e. the alarm page in the DCS is operational, and refresher

training on alarm handling was indeed provided. However, during the visit of the main control room at RPLC, it

was noticed that the board operator operates the plants with a lot of “accepted alarms”, but still “active” on the

control panel.

06.2006 Existing Pressurized Storage Areas (Sphere 60.001 and Associated Bullets)

06.2006 Área existente de almacenaje presurizado (esfera 60.001 y balas)

During the survey, the LPG sphere area was visited and it was noticed a lack of maintenance activity in this area.

As a result of the visit, the following recommendations are made:

- Fireproofing of the sphere legs should be repaired

- Gas detector beneath the sphere should be repaired.

- Uncontrolled ground vegetation within the earthen bund should be corrected.

- The top section of the sphere’s water spray, during the testing, did not operate therefore it is

recommended to repair it. Similarly the water spray protecting the bullets should be repaired.

- The ground in the area should be properly graded and sloped to take all spills away from the spheres to

a safely located impounding basin.

- Motor operated valves (MOVs) should be installed in the line from the base of the spheres and bullets

- Sphere and bullet drainage line should terminate at a point away from the shadow of the sphere

- Sphere and bullet should be provided with a high, high level alarm working from an independent


It is recommended to address the points above in a sensible time period.

2006 Client Comment: None on records

Apr.-2007 AIG recommendation follow-up visit: No progress / Sin progreso
The visit of the sphere 60.001, still in service, revealed a “poor” maintenance status. It was not sure if the

sphere was still in compliance with the PDVSA or Venezuelan regulations

The Insured confirmed the intention for decommissioning the sphere in order to use the new ones within the next

5 years (see item 07.2006).

Jan.-2008 status: In Progress / Sin progreso
Same situation as in April-2007. The sphere 60.001 and the two bullets are still in service. The area was visited

and all previously reported anomalies still exist. Note that we also visited in addition the spheres E-201/202

area which also revealed a certain degree of lack of maintenance. Where applicable, this recommendation

should also be taken into consideration for E-201/202.

Se visitaron igualmente las esferas E-201/202 donde se observó también una cierta ausencia de mantenimiento.

Esta recomendación, donde aplicable, tendría que considerarse también para estas esferas.

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07.2006 New Pressurized Storage Areas (Spheres)

07.2006 Nuevas áreas de almacenaje (esferas GPL)

RPLC as part of the “Valcor” project has erected three spheres; however, final construction and commissioning

of the spheres was not completed because the project was put on hold. However during the survey of the

facilities, it was noticed that some positive features typical of a modern facility were not in place. API2510A

constitutes the main reference for these facilities; however, only provides the minimum requirements. It was

noticed that:

􀂃 The distance between spheres appeared below average

􀂃 It is not clear yet if gas detection system will be provided beneath and around each spheres

􀂃 A single all welded common fill/suction/recirculation line on the bottom of the vessel (sphere or bullet)

appears not being in place. It is not clear if small-bore connections or level gauge glasses are part of the


􀂃 A remote operated isolation valve (weld-end, tight shut-off type) appear not provided on the common liquid

phase with fireproofing of the valve, actuator and the control cabling.

􀂃 Is not clear if the sphere’s design will include remote indicating level transmitter with separate independent

level alarm device (high and low as required)

􀂃 It was not considered a concrete paving sloped away from the vessel to a remote pit to accommodate spills

and in the even of a fire in the pit located at such a distance to provide acceptable radiation levels.

􀂃 LPG pumps are not located well away from the spheres. It is not clear if pumps will be protected with high

integrity seals and gas detectors

It is therefore recommended to address the above issues if the project will go ahead.

2006 Client Comment: None on records

2007 Client Comment: The spheres are not in service yet. RPLC´s Project Department (´Dpto. de Proyectos

Operacionales´) confirms the following design features (either already in place or intended):

- Sphere separation complies with API2510, paragraph, which specifies a minimum distance of

5 feet or half the diameter of the largest vessel, whichever is the higher.

- The gas detection system is to include gas sensors located around and below each spheres in

accordance with API2510A

- A single line in/out at the bottom of the vessel (sphere or bullet) in compliance with API2510,

paragraph 4.5.1. No glass level gauge will be installed

- While the project considers the installation of an ROV in the line to the sphere(s), the fireproofing of the

valve and associated control cabling is no in the current scope. These requirements will be included in

a separate complementary project which is under preparation

- 2 independent level instrumentation on each sphere, one for normal gauging, the other for ultimate low

and high alarms

- Indeed the sloping of the ground around and below the spheres to direct any spill towards a

impounding basin, located sufficiently away from the storage vessels, has not been considered. This will

be included in the complementary project, which is under preparation.

- The distance between each pump and the suction line attachment point on the corresponding sphere is

greater than 10 feet which is the minimum distance stated in API2510, paragraph The pumps

will be fitted with double mechanical seals and gas detectors (to be installed in a sub-project after the

installation of the main equipment)

Apr.-2007 AIG recommendation follow-up visit: No progress / Sin progreso
The visit of the new spheres revealed that the spheres have been erected on an ungraded soil ground without

disengagement and catch-basin. The spheres are still not connected and there is no due date to complete the

project. The plan is to commission the spheres together with the upcoming Deep Conversion Project due to

completion in 2012.

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Jan.-2008 status: No progress / Sin progreso

This LPG storage was not visited during this survey as this facility is still not in service and its commissioning is

not foreseen before a number of years: this situation made the facility a low priority area to inspect in

comparison to other existing units in operation. RPLC´s 2007 answer clarified however that the intent of the

design scope is mostly in compliance with the relevant API standard. However, it could not be verified on the

field how much of the intended “best practice” design features has already materialized and/or is being

complied with. RPLC did not provide the latest status on what is currently installed. The sloping and

stabilization of the bunded area and the provision of a catch-basin are in any case items which we know are still

pending. The recommendation is considered with “No Progress”.

08.2006 Fire Detection / UVIR Detection / Flame Detection on Tanks

08.2006 Detección de Fuego / UVIR / Detección de llama en Tanques

Tanks are in generally protected against lighting in order to prevent any seal fire during storm; however, no heat

detection is installed on tanks. Therefore, PLC, during normal operation relies on the operators patrolling the site

looking for smoke / seal fire.

It is recommended to install fire detection on the tanks in order to guarantee a quick response and activation of a

pre-action suppression system that is a semi-fix foam system. Refining industry currently adopt various type of

detection such as linear heat detection (fuse) or UV detection. It is industry practices that the fire detection

system enunciates in the fire station and tank farm control room.

2006 Client Comment: None on records

2007 Client Comment: Being evaluated by Industrial Safety

Apr.-2007 AIG recommendation follow-up visit: No progress / Sin progreso

Jan.-2008 status: Rejected / Rechazada
RPLC instructed its Industrial Safety team to evaluate the recommendations 08.2006 and 12.2006. To this end,

Industrial Safety issued a technical note (# NT-ST-SI-2007-21, Rev.0, dated 06/11/2007) which concluded in the

rejection of both items. In the case of recommendation 08.2006, RPLC`s interpretation of the relevant PDVSA

standard IR-I-01 “Fire Detection and Alarm system” (revision 2, dated January 1996) is that the proposed fire

detection is not required on atmospheric storage tanks as these facilities are, in RPLC’s opinion, permanently

attended (at least through operators´ surveillance rounds) and do not represent high risk installations.

Furthermore RPLC is confident that any incipient tank fire will be promptly detected and responded to by its

current Emergency Response Team.

Our own review of the PDVSA standard indicates that, although not specifically addressing the fire detection

needs on storage tanks, this standard can be interpreted as done by RPLC when the use of flame detectors is

being considered. The standard states however, in our view, that the roof seal of atmospheric tanks storing

flammable liquid is considered a high fire risk area for which linear heat detection (or fuse type) is indicated.

Irrespective of the PDVSA standard, we still maintain that RPLC should, as a first step, risk assess its most

critical tanks and fit them with linear heat detection as a good early detection option.

09.2006 Housekeeping

09.2006 Mantenimiento, Orden y Limpieza

During the survey, several instances of unsatisfactory situations and/or work practices were noted. Examples


􀂃 Plugs and caps missing on small bore drains.

􀂃 Missing tags and lock on valve isolation

􀂃 Short bolting and missing bolts

􀂃 Vegetation all around tanks’ bottom

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􀂃 Fireproofing enclosure of conduit (Alky, CCR, etc.)

􀂃 Paper / documentation in substations

􀂃 Sections insulation missing, leading to the potential for external corrosion.

􀂃 Door closure of main control room

􀂃 On one storage tank at El Chaure (150x8) few electrical cables was not properly terminated.

It is recommended that efforts are made to improve the level of housekeeping at the site.

2006 Client Comment: None on records

2007 Client Comment: The plant safety audits (SOL and GIRASOL) are concentrating in raising housekeeping


Apr.-2007 AIG recommendation follow-up visit: No Progress / Sin progreso
The tour of the FCC facilities revealed insufficient progress in the implementation of this recommendation.

Jan.-2008 status: No Progress / Sin progreso
Good housekeeping standards were observed in the more recent Valcor units, but efforts are still needed in our

opinion in the remainder of the refinery. Discipline on positive isolation using plugs/caps on drain/vent and

small bore lines on hydrocarbon service should be particularly improved, as well as ignition control. Numerous

examples of missing plugs were found in the old units (e.g. DA-1, FCC, Alkylation and in the LPG storage

areas). Several electric instrument boxes either loosely bolted or missing bolts were observed, especially in the

Alkylation unit and the LPG storage areas. Very large electric bare-ended and exposed cables were found in the

in the MCC DA-1 building. Significant oil spills were observed in the bunds of various atmospheric tanks (see

item 07.2008) and rubbish found on tank roofs. Vegetation growth control could be improved, especially in the

sphere 60.001 area and at the transformers seen next to MCC DA-1.

10.2006 Multidisciplinary Audits

10.2006 Auditorias Multidisciplinarias

Sol and Girasol are the audits carried out at RPLC by a multidisciplinary group on monthly basis using a check

list approach. It was apparent from the various deficiencies discovered, that:

- these audits are not identifying all the hazards and deficiencies present in the plants

- the number of the audits carried out should be increased

- audits are not performed because of unavailability of personnel

By not clearly identifying deficiencies in the audits there is a concern that insufficient priority is being given to

correct the defect noted.

It is therefore recommend that the existing audit check list be revised to ensure plant protection systems are

included and includes all points highlighted in Recommendation 06.10 to ensure all risk aspects are being

observed and deficiencies monitored and tracked until corrected. An intensive training program should be

implemented to raise the standard of audits.

2006 Client Comment: None on records

2007 Client Comment: there is an established schedule of audits (Sol and Girasol audits). Completion rates:

50% for Sol and 32.25% for Girasol

Apr.-2007 AIG recommendation follow-up visit: In Progress / En progreso
The audit programme focuses on “personnel safety” and the visit of the FCC plant and equipment showed no

progress on plant safety audit.

Jan.-2008 status: No Progress / Sin progreso

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It was clarified by RPLC that the Girasol audit focuses on topics such as occupational and personnel safety,

staff’s motivation and general concerns, quality of the working environment, health and hygiene occupational

issues, relationship between management and staff etc… and not process or operational safety except for a few

low hazard level items. RPLC, including the San Roque operation, divides itself in 26 auditable areas (for

example DA-2, FCC, Alkylation, etc…). Each one of these areas sees on average two Girasol audits per year

according to a schedule. Girasol audit teams consist usually of 4 members coming essentially from senior

management. Therefore the Girasol audit, in its current format, is not the appropriate audit vehicle to tackle

process and operation-related safety.

The Sol audit and planning are similar to the Girasol inspection but focuses much more on low to medium

process safety. The Sol audit is normally carried out by a multidisciplinary team (maintenance, operation,

instrumentation, etc...) composed of personnel, technician or engineers working on the unit/area being audited.

Auditors use a check-list approach. The 2007 schedule indicated that, at best, key areas like the FCC, the

atmospheric distillation areas, etc… see a maximum of only three Sol audits per year while others like Offisites,

jetties etc...only undergo one Sol audit per year. Furthermore, information provided suggests that a good 30% of

the planned 2007 Sol audits were not completed mainly because of staff unavailibility. On the other hand, when

carried out, the Sol audit do pick up anomalies such as process leaks, absence of plugs/caps on drain/ vents, fire

fighting equipment that went missing, deteriorated insulation and steel / concrete structures, broken

instruments, general housekeeping items etc…Resulting actions are kept in a simple (Excel) database which

records a description of the deviation, the associated audit date, plant, % completion status and department (not

the individual) assigned for closing the recommendation. It was unclear if the figures presented to the survey

team were 2007 year end result, but the overall action completion rate seen was only in the 50% region. The

SOL audits appear to be an adequate vehicle for the routine monitoring of process safety, but the current

number and intensity of such audits is still insufficient, as already flagged in the recommendation. Recurrent

housekeeping issues, as described in 09.2006, were also still present across the plants.

11.2006 As Built P&ID

11.2006 Planos P&IDs

During the survey it was noticed that copies of the P&IDs are not kept in the control room.

It is recommended that a controlled copy of “as built” P&IDs to be held in the control room.

2006 Client Comment: None on records

Apr.-2007 AIG recommendation follow-up visit: In Progress / En progreso
During the visit of the control room, 3 sets of P&IDs were presented, none of them being updated/reviewed and

controlled documents. During the tour of the FCC, the position of the vessel F2 was found wrongly reported on

the Plot Plan.

Jan.-2008 status: In Progress / En progreso
Various internal memorandums were provided demonstrating that some PIDs updating activity is taking place.

However, the majority of the PIDs is still in needs of review: this is reportedly ongoing for FCC, Alkylation, DA-

3/4 and MCyP. RPLC states that its most updated PIDs are on computers and managed by the drawing office. A

spot check of the information held in this system showed some PIDs of the Alkylation last reviewed in 2005,

others corresponding to DA-1 were dated 2001. Uncontrolled copies are in circulation, for example one

engineer was working with an older version of PID 6565-225-KD-102 (alkylation area) than the one on in the IT

system. In the central control room, the copies seen of available PIDs for the old units were from the 90s and the

ones for the new Valcor units were still “For Construction” drawings, and not “As Built” documents.

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12.2006 Protection Of Compressor Lube Oil Consoles in HDT

12.2006 Protección al sistema de lubricación de compresor en HDT

Despite being a new unit it was noticed that the lube oil system for the compressor in the HDT is located directly

beneath the compressor without any protection or any form of early detection in place.

It is recommended installing fire detection and fixing protection (i.e. fixed foam protection or fixed water spray

system) on compressor lube oil consoles. Since process compressors are critical items of machinery it is

recommended that fixed fire detection is provided in each compressor house. The detectors should alarm to the

control room

2006 Client Comment: None on records

2007 Client Comment: No progress

Jan.-2008 status: Rejected / Rechazada
RPLC checked its own site standard (IR-M-05) and concluded that there is no need for a fire detection and

suppression system on this equipment. RPLC argues that the normal operating temperature of the lube oil of

compressors G 4503A/B is 140ºC and well below its flash point of 350ºC and that there is no open flame

equipment or process stream in the vicinity which in case of a leak could expose the lube oil system to such


13.2006 Bently Nevada System in the FCC Wet Gas Compressor

13.2006 Sistema Bently Nevada – Compresor de Gas Húmedo de FCC

A Bently Nevada system was installed in 1999 on the Wet Gas Compressor, in the FCC Unit; however, this

system was never connected and never being used. The refinery is currently taking vibration with portable


It also appears that PLC could not connect the Bentley Nevada during the Oct.-Dec. 2005 FCC T&I because

unavailability of spare parts.

It is recommended to have on site all required spare parts in order to carry out the connection at the earliest

opportunity without waiting for next FCC T&I that is currently scheduled for 2008.

2006 Client Comment: None on records

2007 Client Comment: The replacement of the J-12 compressor and its driver is included in the 2007 investment

plan. The new equipment will come with online vibration monitoring.

Apr.-2007 AIG recommendation follow-up visit: In Progress / En progreso
The compressor should be fully replaced by a new one, with Bently Nevada system, by 2008.

Jan.-2008 status: No progress / Sin Progresso
The next FCC planned shutdown is now scheduled in Q2 2009 for ~45 days in conjunction with the

environmental ´RECA´ project dealing with FCC emission reduction. Furthermore, delays in the Deep

Conversion project means that the final compressor specifications have yet to be finalized hence holding-up

further the final installation which may well only occur during the 2011 Turnaround. RPLC stated that “in any

interim period, a provisional vibration and temperature monitoring system will be installed”, but no details were

provided and this is understood to be essentially a closer monitoring using portable equipment. It has to be

noted that, on review of recent plant & equipment unplanned outages, the WGC tripped at the end of December

2007 on high lube oil temperature. As a result the plant was out of service for nearly a month to allow for the

compressor spare rotor to be installed. This type of outage and the long period until the WGC replacement

materializes reinforce the insurers´ desire to see all relevant instrumented protections to be restored on this

equipment without delay, and RPLC to deal with this recommendation as a priority.

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14.2006 Lube Oil Analysis

14.2006 Análisis aceite lubricante

Compressor Lube oil analysis is not part of the compressor’s PdM program and its only conducted when

requested by operation.

It is recommended to introduce lube oil analysis as part of their compressor’s PdM program in order to increase

the equipment’s reliability (i.e. every 6 months).

2006 Client Comment: None on records

2007 Client Comment: A preventive maintenance program including monitoring/analysis of the refinery

rotating equipment lube oil is being developed.

Apr.-2007 AIG recommendation follow-up visit: No Progress / Sin Progresso

Jan.-2008 status: No Progress / Sin Progresso

RPLC states that lube oil analysis for critical equipment is in the process of being contracted.

15.2006 El Chaure – Tank 15

15.2005 Tanque15 (El Chaure)

Tank 15 (150’x48’), a cone roof tank storing diesel located at El Chaure, at the time of the survey was showing a

severe deformation on the top two courses like if corrosion is occurring. The inspection department appeared not

aware of the problem.

It is recommended to investigate the reason of such deformation and verify the integrity of the tank; however it is

recommended to take Tank 15 out of service.

2007 Client Comment: No technical note was issued about this tank. The next scheduled maintenance of this

tank is in 2009.

Apr.-2007 AIG recommendation follow-up visit: In Progress

Jan.-2008 status: Completed / Completado
Tank checked by inspection/maintenance against API653 guidelines and its integrity was found not to be

compromised. The corresponding RPLC technical note (#RTIP-016-08, dated 28/01/08), including inspection

results and conclusions, was provided to the survey team as evidence.

16.2006 Tank Inspection

16.2006 Inspección de tanques

Despite the refinery has a well detailed tank internal/external inspection schedule, it was noticed that the

frequency of inspection for crude oil tanks was extended from once every 10 years to once every 18 years;

similarly, the internal inspection of gasoline tanks was changed from once every 8 years to once every 12 years.

These changes resulted from a “cost analysis Vs risk” assessment.

Considering that the refinery recognize that its having some issues with tanks integrity such as corrosion,

replacement of tank’s bottom, replacement of cathodic protection, leaks, etc. it is recommended to re-introduce

the original internal inspection frequency and developing an appropriate inspection schedule.

2007 Client Comment: The inspection schedule will be reviewed in line with insurers´ recommendation
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Apr.-2007 AIG recommendation follow-up visit: No Progress

Jan.-2008 status: Completed / Completada

RPLC carried out an excellent and detailed study to establish its atmospheric tank inspection backlog. This

technical note, referenced RTIC-486-2007 and dated 09/10/2007, was provided to the survey team. For this

evaluation, RPLC has reverted to taking the tank inspection intervals set forth in the PDVSA standard TC-S-ST-

006-P as the rule to comply with. This standard, which is understood to have been in use before deciding to

extend the inspection intervals, is based on API653 and overall specifies maximum internal inspection intervals

which do not exceed 12 years (this is the case for tanks on slop, diesel and ballast water service; interval for

crude tanks is set at 10 years by this PDVSA standard). API653 maximal internal inspection interval is 20 years

irrespective of the product. RPLC study concluded that out of 152 relevant tanks, 54% were overdue (42 by 1-4

years, 21 by 5-9 years, 14 by 10-14 years and 5 by more than 15 years). To correct this backlog, a specific

inspection schedule has been established (included in the RPLC study) for these overdue tanks. This extra

inspection programme runs from 2008 to 2016, considers approx. 9 tanks per year, is understood to be in

addition to RPLC´s normal tank inspection schedule, and gives priority to the tanks with the largest overdue

time. The tank inspection frequency as set forth in PDVSA TC-S-ST-006-P is understood to have been reverted

to. The recommendation is considered as completed.

01.1998 Safety Trip Bypass Procedure

01.1998 Procedimiento para el desvió de sistema de parada de emergencia

A procedure to control the application and duration of by-passes applied to safety trip and emergency shut down

systems has been developed and is planned to be introduced 4Q 1998. We reviewed the procedure and have the

following comments:

(a) The first draft of the procedure was issued in 1997 and has yet to be introduced. We fully endorse the

procedure and encourage that it is adopted into working practice as soon as reasonably possible.

(b) We noted that the permit is initially authorised by the Shift Supervisor and Area Manager. Once completed

the permit is then signed off by the representatives of the operations, electrical and instrumentation

departments but not the original authorising senior personnel. To close the loop of information regarding

the by-pass we recommend that the original authorising senior personnel i.e. Area Manager and Shift

Supervisor, also sign off the permit. In this way everybody concerned with the by-pass is aware when the

permit is applied and removed.

(c) A common feature of by-pass permits is a regular review of all outstanding permits to identify any by-passes

that extend beyond the initial estimate of duration. If a by-pass extends significantly beyond the original

estimated duration further justification for the by-pass and/or additional safety precautions may be required.

We therefore recommend a regular review of by-pass permits is included in the adopted procedure.

2006 Status:

a) Completed / Completada. The Safety Trip By-Pass Procedure was reviewed in December 2005 and approved

in February 2006. The procedure is currently in use.

b) Open / Pendiente. Review of old “by-pass records” showed good compliance with the authorization

procedure. However, it must be noted that while it was noticed that the Area Manager always approved and

signed off the by-pass of an emergency shutdown system, the PDVSA procedure does not state that an approval

of the Area Manager is required; it only specify that the Area Manager need to sign off the permit.

c) Open / Pendiente. A log book reporting all the by-pass in place is kept in the control room and daily

reviewed. However is not clear yet what is the procedure for by-pass that extend beyond the initial estimate of


Apr.-2007 AIG recommendation follow-up visit: No Progress / No progreso

Jan.-2008 status:

a) Completed in 2006 / Ya Completada en 2006
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b) Completed / Completada. A copy of the latest ESD trip bypass procedure was provided (# OP-S-001-P,

revision 3, dated 27/09/2007). The next revision due date, which is Sept.-2010, is also indicated on the

procedure, showing by the way that a review process is in place. This procedure specifies on page 12/13 that the

permit controlling the ESD bypass needs, in its authorization phase, the signatures of the Bypass requestor, the

Shift Supervisor and the Area Manager. Closed ESD bypass permit, reviewed in the control room, were found to

be appropriately signed by this trio of persons. The procedure states also (e.g. on page 10) that the signatures of

the Shift Supervisor, the Area Manager and the Instrumentation Supervisor are requested in the closure step and

this was observed to be complied with. The current procedure (and its implementation as observed in the control

room) appears to ensure an adequate level of awareness among the relevant personnel concerned with the ESD

bypass permit. This part of the recommendation is considered completed.

c) Completed / Completada. Reviewed records of closed bypass permits kept in the control room were all for

bypasses that had been closed the same day they had been authorized and that did not exceed the initial bypass

duration estimate. The procedure requests that a daily review of outstanding bypasses is carried out and states

on its page 10 that the existing bypass permit has to be closed and a new one emitted in case the bypass extends

beyond the initial duration estimate. There is however no specific definition of the maximum bypass duration,

that can be entered on the permit. The procedure implies nevertheless that “several days” represent a prolonged

period after which special scrutiny and re-authorization would be required. As previously mentioned, in

practice, no bypass exceeding a day was found on records. Overall, the current approach is considered

satisfactory and meeting the intent of the original recommendation which focused on including a regular review

of bypass permits in the procedure (this is the case).

02.1998 Work Permit / Permisos de trabajo
We found the completion standards of work permits and their associated ARO and ARETE forms to be to an

excellent standard throughout the PLC complex. We have two recommendations to enhance the existing system:

(a) Each work permit is issued together with an ARO and ARETE risk analysis form. Currently there is no

formal method of cross-referencing the three forms which may allow confusion over which risk analysis

applies to which work permit. We understand there are plans to cross reference the forms by equipment

number. We recommend that a system of cross referencing is introduced.

(b) The work permits are filed for one month following their completion. However, we recommended permits

are filed for a suitable length of period to ensure all permits can be audited during the regular ‘Management

Safety Inspections’. Typically we suggest six months as a minimum filing period, otherwise, a period

should be determined in line with the inspection frequency for each area.

2006 Status: a) Completed / Completada. There is a cross reference number in order to associate an ARO and


b) Open / Pendiente. Permits are audited; however has not been decided yet the time that a PTW need to be


Apr.-2007 AIG recommendation follow-up visit: No Progress / No progreso

Jan.-2008 status:

b) Item not verified on the plant and therefore left Open, despite RPLC stating that permits are now filed for a 6-

month minimum period / No se puso comprobar los archivos en la planta. Entendemos que RPLC afirma que

los permisos de trabajo se archivan ahora para al menos de 6 meses. Dejamos como Pendiente el estatus de

esta recomendación.

03.1998 Management of Change Procedure (MoC)

03.1998 Manejo de Cambio (MDC)

A management of change procedure has been successfully used since 1997. On review the procedure appears

very extensive but we have the following suggested recommendations to enhance the existing system.

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(a) There is no method of tracking the many Hazop actions which may be generated by the Hazop review. A

tracking system should be introduced which ensures all actions are satisfactorily addressed before the

modification is put into service.

(b) There is nowhere in the procedure where a final statement is made to say that the Hazop has been fully

completed and all actions have been addressed. Such a final sign-off section should be included onto the

modification tracking form.

A formal close out section should be added to the modification tracking form to confirm when all documentation

has been updated. This will aid in ensuring that all P&ID’s, PFD’s operating procedures and engineering data is

updated before the modification is closed.

2006 Status: a) Open. A rigorous tracking system is not yet in place.

b) Open. The MOC procedure dated 1997 do not includes a final check list that states that all action requested

have been addressed (training, update of documentation, etc). However, MOC examples showed a section where

are requested list of action to be taken. RPLC to modify the MOC procedure and make sure that all actions are

completed before close-out of the MOC.

2007 Client Comment: No report

Apr.-2007 AIG recommendation follow-up visit: No Progress / Sin progreso
Jan.-2008 status: RPLC states that this is in progress as its corporative MoC procedure (#IR-S-06) has been

accordingly reviewed by a multidisciplinary team and is awaiting local approval for roll-out. A copy of this

procedure was provided to the survey team and it has to be noted that the procedure builds on an original 1991

version, itself revised in July 1997 and that the last revision is in draft status since October-2007.

a) No Progress. No tracking system in place / Sin progreso. No existe un sistema de seguimiento (por ejemplo

un base de datos) para registrar y confirmar el cumplimiento de las acciones o recomendaciones generadas

durante los análisis de riesgos que acompañan cualquier manejo de cambio y que deben ser realizados antes de

la puesta en servicio del cambio.

b) No Progress. The section E of the MoC form, titled “Physical execution of the change”, contains indeed a list

of only six activity titles (Physical execution (understood to be the commissioning action), operators´ training,

hazards notification, procedures, drawings/PIDs, and Pre Start-up Safety Review). Against each of these

headers, the person responsible for the corresponding work only needs to fill in his name, the estimated

completion date and the actual completion date, and to sign. This list is not considered to be detailed enough

and does not allow a proper follow-up. Furthermore, the current MoC procedure is such that the authorization

for the implementation of the change precedes section E, which could lead to relevant actions being completed

only some time after commissioning. Unless encompassed in the Pre Start-up Safety Review header, there is no

clear statement or checklist in the MoC form detailing what items has to be completed before the change can be

commissioned. Finally, the analyst in charge of the MoC has the ultimate responsibility for reviewing that the

above activities have been completed and the corresponding information or documentation updated. If this is the

case, he then requests the Area Superintendent of Manager to fully close the MoC (by signing it) / Sin

progreso. El listado de requerimientos a cumplir (en la sección E del MDC) nos es suficientemente detallado.

También se debería asegurar que ciertas de estas actividades sean cumplidas antes de dar la autorización para

ejecutar el cambio.
04.1998 Technical Services – Inspection Department

04.1998 Departamento de Inspección - SSTT

A number of issues are recommended for the improvement of services from the Technical Services department.

(a) From our review of thickness measurements for the F-2 vessel in the FCC unit there appears to be no formal

method of trend analysing the data. We understand the latest version of SIEM data management system will

include this feature and we fully endorse its introduction as soon as reasonable practical.

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(b) Currently there are no inspectors/technicians qualified to international standards such as ASNT, although,

we understand technicians are planned to be sent on ASNT training courses for radiography and ultrasonic

techniques. We fully endorse this training and recommend additional qualifications are achieved by senior

members of the department and the majority of the inspectors.

(c) Safety relief valves are currently pre-pop tested before overhaul and servicing. The pre-pop test results are

noted but are not used to determine the future frequency of testing for the valves. The pre-pop tests provide

a rich source of information indicating the state of readiness of relief valves and highlighting problems with

dirty services that may be clogging up and interfering with the operation of the valves.

We recommend the pre-pop tests are reviewed after each test and used to determine the future testing

frequency for all safety relief valves.

(d) The testing of flexible hoses is reported to be the responsibility of the marine terminal department. The

proper and adequate testing of the hoses is essential in preventing leakage’s and possible failures in the

marine area. Although we did not review the testing procedures and standards at the marine terminal we

recommend that the responsibility for the testing/inspection of the hoses comes under the Technical Services

department. This will ensure that the inspection work is overseen by the most experienced

inspectors/technicians within the organisation and that test results and analysis comes within the common

SIEM data management system.

2006 Status: a) Completed. b) Open. c) Open. d) Completed.

Apr.-2007 AIG recommendation follow-up visit: No Progress on the previously open items / Sin progreso para

los puntos que eran pendiente.

Jan.-2008 status:

b) In Progress / In progreso. The status of the qualifications currently held by the inspection team members was

presented. The records made available indicated that, out of 13 inspectors/technicians, only 5 hold currently

international standard type of certifications (three in only ASNT X-ray, one in only NACE Cathodic Protection

level-1, and one in both ASNT Dye Penetrant (DP) and Magnetic Particle (MP) Inspection). However, a

majority of members has completed the training and already gone through the relevant exams for DP, UT, MP

and, thermography. Two are in the similar position regarding the American Welding Society – section 6.1

certification and two for ASNT X-ray. We recognise that the number of staff holding certifications should hence

imminently increase. However as this has not happened yet, the recommendation is kept as “In Progress”. The

team strength is overall lesser in respect to API653/579/510/570, ASME and NACE CP certifications.

El numero de inspectores / técnicos que tienen varias certificaciones es de momento todavía bajo, pero

valoramos que una mayoría del equipo de Inspección Rutinaria esta muy cerca de obtener dichas

certificaciones. Hasta que se materialice la obtención de estas certificaciones, dejamos el estatuto de esta

recomendación como “En progreso”.

c) No progress / Sin Progreso. No evidence provided that the pre-pop tests currently carried out influence the

PSVs testing frequency. No se ha demostrado que se utilizan los resultados de la pruebas de “Pre-Pop” para

adaptar las frecuencias de inspección de las válvulas de seguridad cuando las válvulas fallan dicha prueba.

05.1998 RPLC Refinery Central Control Room

05.1998 Sala de control principal RPLC

- Items c to g of the original recommendations were closed in previous surveys –

A number of protection deficiencies were noted in the central control room which we recommend are addressed

as follows:

(a) The pressurization system for the building was found to be out of action and requiring repair. We

recommend the system is repaired as soon as reasonable possible. In the mean time we understand the

pressurization for the building will be inspected daily until the system is repaired.

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(b) The pressurization should be equipped with an audible alarm to highlight when either pressurization is lost

or the system goes into ‘fault mode’.

(h) The inlet air vent for the control room’s pressurization system is equipped with a HF acid detector only.

Due to the location of the unit between the DA-1 and FCC units, where mainly flammable materials are

handled, we recommend a flammable gas detector is also installed in the inlet.

2006 Status: a) Completed / Completado. The control room was pressurized and indication was adequate.

b) Open / Pendiente. Installation of an alarm to highlight when pressurization is lost is ongoing.

h) Completed. Flammable gas detectors are in the process of being installed in the central control room air


Apr.-2007 AIG recommendation follow-up visit: No Progress / Sin Progreso
During the visit of the control room, the pressurization system was faulty again and there was no alarm.

Jan.-2008 status:

a) Re-opened / Re-abierta. As already observed in Apr-2007, control room pressurization was found to be again

inoperative. Three sets of wall mounted pressure gauges were seen in the main control building: one serves the

pressurization of the DCS computer room and the two other correspond to the two pressurization and

purification units (PPU) existing for the remainder of the building. But all were either showing zero or

insufficient pressure.

Actually, RPLC provided the survey team with a copy of a technical tender request for fitting all manned

buildings in hazardous areas with new air conditioning units, pressurization, gas detection in air inlet,

automatic air inlet shutdown in case of hazardous gas detection, restoration of air tightness in the buildings

etc… The document clearly states that all these protection systems are in need of repairs and upgrading in

RPLC´s central control room, satellite control locals, MCCs, substation, field operators´ buildings, changing

rooms etc...The document basically says that most of these features, wherever originally existing, have been out

of order and inadequate for a number of years. The tender had been responded to by Emerson Venezuela as

early as August 2006, but the project did not progress further. During the January 2008 visit, RPLC presented a

new schedule indicating that the project is revived (engineering to be completed by Q1 2008, procurement in Q1,

Q2 and beginning of Q3 2008, then implementation until end of 2009). The scope of the project is wide and

considers some 24 buildings across the site including the central control rooms at RPLC, El Caure and San

Roque (DA-3).

La presurización del bunker central de PLC se encontró afuera de servicio. Los manómetros, en su mayoría, no

estaban indicando ningún valor de presión en sala. Las PPUs no parecen ser operativos. Además, se nos

facilitó una copia del proyecto “Sistemas de Seguridad, Presurización y Calidad de Aire en Casetas de

Operadores, Salas de Control y CCM Refinería PLC” con la oferta hecha en Agosto de 2006 por Emerson

Venezuela: entendemos que este proyecto, hasta ahora, no se ha implementado y que hay un nuevo cronograma

para el, con el final de 2009 como fecha de culminación (según los documentos presentados por parte de

RPLC). El análisis de la situación de 2006, que sigue sendo la misma en el momento de nuestra visita, es que la

mayoría de los edificios con presencia humana en zona de riesgo no cuenta con la adecuada infraestructura de

los sistemas de presurización, calidad del aire y seguridad.

b) No Progress / Sin Progreso. Operators and other staff in the control room were not aware of the existence of

any such alarm. Will be part of the project described in the update provided for point a.

Incluido en el proyecto de mejora, descrito en la actualización del estatus del punto a).

h) Re-opened / Re-abierta. Provision of “double detection”, i.e. external and internal combustible and H2S gas

detectors with pre-alarm serving the protection of RPLC central bunker, and similar installation on other

manned buildings are part of the upgrading project detailed in the update provided for point a). However, it was

observed that RPLC central bunker has already both these types of sensors (understood to be for the detection

inside the building); these appeared to be operational, but it was unclear whether any associated alarm is

working and what was the situation with the inlet air external detectors.

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Se entiende que la detección de gas combustible y de H2S esta incluida en el proyecto de mejora, descrito en la

actualización del estatus del punto a). Sin embargo, se observaron estos dos tipos de detectores en el bunker

central de PLC que sirven solo la función de detección interna de la sala de control. Estaban aparentemente

operacionales, pero no es seguro que haya cualquiera alarma asociada y en estado operativo. Con respecto a la

detección externa (por ejemplo en la toma de aire), este punto esta contemplada en el proyecto.

07.1998 El Chaure Gas Detection Systems

07.1998 Sistema de detección de Gas, El Chaure

Two gas detectors were found to be in alarm mode during the survey. It was stated that the detectors were

expected to be repaired at the end of the shift but supporting documentation did not appear to support this. We

recommend the gas detectors are repaired as soon as possible. In addition, the reporting standards for work

orders involving safety critical systems such as gas detectors should be reviewed and stressed that they are filed

immediately for the attention of the maintenance department.

2006 Status: Open. There is an ongoing project to replace and repair all gas detectors across the refinery

including El Chaure. The deadline for the entire project is 3Q2007.

Apr.-2007 AIG recommendation follow-up visit: No Progress / No progreso
Jan.-2008 Status: Withdrawn / Retirada (ya era parte de 02.1995, pero un requisito hace ahora parte del

punto 3 de 03.2008)

The issue about out-of-order gas detectors across the units is considered to be already covered by

recommendation 02.1995 and the request for a higher degree of attention and response to be given by

Operations and Maintenance for the correction of defective safety critical systems is superseded by part 3) of

recommendation 03.2008. The refinery gas detection upgrading and replacement project has been delayed, see

recommendation 02.1995 status.

08.1998 PLC Refinery LPG Storage Facilities

08.1998 Instalaciones de almacenamiento de GLP

Further to the observations and suggestions completed in Recommendation 95.1, we have the following

additional recommendations for the LPG storage area (60,000 bbl sphere and two 10,000 bbl bullet vessels):

(a) The remotely operated valves in the outlet lines of the sphere were found to be not operational and leaking.

This is an extremely unsafe condition and should be repaired immediately.

(b) The remotely operated valves on the sphere can only be operated from push button stations positioned inside

the diked area surrounding the sphere. We recommend that the valves are arranged so that they can also be

activated from a safe area e.g. refinery control room.

(c) There are no remotely operated valves installed in the outlet lines from the bullet vessels. The vessels have

an inventory greater than 8 m3 and should therefore be installed with ROV valves in line with PDVSA


2006 Status: a) Removed. There is no ROV in the outlet line of the sphere.

b) Removed. There is no ROV in the outlet line of the sphere.

c) Open. No ROV valves have been installed.

2007 Client Comment: No Report.

Apr.-2007 AIG recommendation follow-up visit: Replaced by 06.2006 / Reemplazada por 06.2006
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09.1998 Firewater Supplies

09.1998 Bombeo de agua contra incendio

A number of fire pumps were tested during the survey and the following deficiencies were noted:

(a) Both firewater pumps at tank T115 were found to be either isolated (electric pump) or in the ‘off’ mode

(diesel pump). We understand at least one fire pump in this installation should be maintained in automatic

mode at all times and by the end of the survey this was rectified. Please ensure checks are made on the

pumps to ensure one pump is always in automatic mode.

(b) The firewater pumps installed at Jetty No. 7 are being maintained in manual mode. We understand the

problem is with the UV flame detectors at the jetty which are arranged to operate the water curtain

automatically to protect the jetty. The flame detectors are faulty therefore the protection system is left in

manual mode and hence the pumps are also currently maintained in manual mode. We recommend that the

flame detectors are repaired or replaced as necessary as soon as possible to enable the system to operate as it

was intended.

(c) The B-3 diesel firewater pump at the new El Chaure refinery pump house was not in service because the

engine’s batteries were removed for servicing. The batteries should be replaced as soon as possible.

(d) All diesel pumps were arranged to start at low engine speeds which then have to be manually increased to

the rated speed of the engine. In line with the requirements of NFPA 20, the diesel engine speed governors

should be set at the speed to achieve the rated performance of the pumps and secured at that setting at all

times. It should be noted that fire pump diesel engines are designed for this type of harsh service.

(e) The flow test results for the firewater pumps were reviewed and it was found that the last tests were

conducted in 1995. In accordance with the guidance given in NFPA 25, Standard for the Testing, Inspection

and Maintenance of Water-Based Fire Protection Systems, each fire pump should be flow tested annually.

We recommend the regular flow testing of the pumps is re-introduced.

2006 Status:

a) Open.

b) Open. The pumps are still in manual mode and a project is ongoing to have all pumps maintained in

automatic start –up mode.

c) Open.

d) Open.

e) Open. The flow performance test was conducted for the fire water pumps at RLPC but not at el Chaure, Cerro

and Terminal. RPLC stated that starting from 2006 a flow performance test will be carried out on all pumps.

2007 Client Comment: No Report.

Apr.-2007 AIG recommendation follow-up visit: No Progress

Jan.-2008 Status:

a) Completed / Completado. The pump house associated with the fire water tank 115 was visited and the

automatic pump start was demonstrated (on falling main pressure). Note however that one diesel pump had been

removed, reportedly for a one-day preventive maintenance work on the pump starter.

b) No Progress / Sin Progreso. Note that the other jetties experience apparently the same problem. The

connection and/or installation of various instrumentation panels at the jetties is still pending and required to

restore the pumps automatic mode. The work has been given to the Tecno Fuego company, with the bulk of the

work supposed to start in January 2008, however after already several delays.

In the specific case of jetty #7, UV flame detectors were reportedly installed but quotes for replacing the

required instrument panels was still ongoing.

c) No Progress / Sin Progreso. It is reported that new battery sets were purchased and that 10 diesel pump

controllers/ starters / chargers are in procurement. Various other diesel fire water pumps are concerned

(B1/2/3/4, pumps at tanks 97x1 & 97x2pumps, pumps at the jetties)

d) No specific information provided. Considered as Open / Considerada como Pendiente. RPLC states that

pumps are start tested and operated for 30 min weekly

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e) No Progress / Sin Progreso. Reportedly, pressure vs. flowrate tests were recently done for the available FW

pumps at the jetties (but documentation was not provided). However, it does not appear that pump curves are

reproduced for systematically for all fire water pumps systematically and annually.

10.1998 Protection Equipment Impairment Procedure

10.1998 Procedimiento para controlar la puesta afuera de servicio de los equipos asociados a los sistemas

contra incendio (bombas, monitores etc…)

With so many fire pumps and protection systems at the refinery we recommend that a centralized ‘impairment’

permit system is introduced to control the isolation of any protection system. The system should be administered

and authorised by a senior member of the fire team or emergency response organisation. In this way a central

record of any protection systems that have been isolated can be monitored by the fire team to ensure the system

is isolated for only the minimum amount of time and all isolated systems are always returned to service.

Furthermore, the record of impairments will ensure the fire team is always aware of what systems are

unavailable. This is particularly important during the first response to an incident when the fire team must be

aware of what systems are available for their use.

2006 Status: Open /Pendiente

2007 Client Comment: No Report / No reportó

Apr.-2007 AIG recommendation follow-up visit: No Progress / Sin Progreso

Jan.2008 Status: No Progress / Sin Progreso
RPLC has developed a procedure in Nov.-Dec. 2007 for authorizing the use of fire water for operational

purposes (i.e. by non fire team members and outside of fire drilll or fire emergency situations). This procedure

does not address the issue raise by the recommendation.

No se encendió la recomendación. El procedimiento nuevamente elaborado para la solicitud de permiso de

utilización de recursos hídricos del sistema de agua contra incendios no responde a la recomendación.

11.1998 Miscellaneous Process Safety Issues

11.1998 Casos específicos insatisfactorios de orden y limpieza

During the site survey a number of miscellaneous process safety issues were noted which we recommend are


(a) In a number of areas we witnessed sample points, drain lines, level indicator drain lines and vent

connections which had not been properly ‘double isolated’ with end-of-line plugs. One of the more obvious

examples included the 3 inch drain line on the FA-1 vessel in DA-1 unit. We recommend all open, end-ofline

points in hydrocarbon service are properly plugged. This problem should be included as a specific point

in the regular safety audits performed in the process areas.

(b) The fire proofing intumescent paint on the ROV isolation valves on the No. 7 Jetty loading arms was flaking

away from the body of the valves and thereby compromising the fire proofing integrity. We recommend the

coating is repaired or replaced as necessary.

(c) An electrical panel at the loading jetty was found with loose enclosure sealing bolts. We recommend all

electrical equipment is properly sealed with adequately tightened bolts.

2006 Status: No progress on all items / Sin Progreso en cada uno de los puntos

2007 Client Status Report: No Report / No Reportó

Apr.-2007 AIG recommendation follow-up visit: No progress / Sin Progreso
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Jan.-2008 Status:

a) & c) No Progress. Plugs/caps discipline is still unsatisfactory and various occurrences of loose and/or

missing sealing bolts on electrical or instrument boxes were observed. Items a & c are considered to fall under

the scope of recommendation 09.2006 which addresses these issues in a more general manner, item a & c are

hence considered to be superseded by 09.2006 / Sin haber sido resueltos, los puntos a & c son reemplazados por

la recomendación 09.2006 que trata de estas anomalías de manera mas general.

b) Open / Pendiente. The jetties were not visited during the 2008 visit and RPLC did not provide any update on

this specific item / No se visitaron los muelles durante la inspección de 2008. Por lo tanto, RPLC no facilitó una

actualización de su estado.

01.1995 LPG Storage Spheres

01.1995 Esferas de almacenamiento GLP

The refinery has two 60,000 bbl pressurized storage spheres for LPG, although only one of these is in use at this

time. The LPG facilities are situated to the north of the refinery in fairly open ground. The following items were

noted during the survey.

The surface fireproofing on both spheres was showing signs of spalding, particularly on the temporarily out of

service sphere, 60002. In the event of a spill fire, the cracking would lead to material detaching and reduce fire

resistance. The in-service sphere 60001 should be examined and repaired as required. Before sphere 60002 is

returned to service, its fireproofing should be re-instated.

2006 Status: No progress / Sin Progreso

In 1998 it was already stated that there was a plan to decommission the spheres.

2007 Client Status Report: No Report / No reportó

Apr.-2007 AIG recommendation follow-up visit: Withdrawn. The recommendation is replaced by 06-06.

/ Sustituida por 06.2006

02.1995 Gas Detection Systems

02.1995 Sistema de detección de gas

There are some 280 toxic and combustible gas detectors on the site, many of which were installed as part of a reinstrumentation

project in 1992/1993. It was found that more than 25% of the detectors monitored by the MSA

Gas Monitor in the basement of the Central Control Room were out of service. So although the physical cover of

the site is to a very high standard, the actual cover is severely limited.

We suggest that a high priority be given to the following:

to determine the case of failure of the detector heads/system;

to set a target for returning the site cover of gas detection to full working condition as soon as possible;

to maintain a log of gas detection problems that is analysed on a weekly basis.

1998 Status: Open / Abierta

Unreliability of gas detection system remains (20%). Faults and maintenance records are kept (100%

complete). Plant now considering alternative technology. Installation of an alternative technology in the

Alkylation unit during the Sept. 98 plant's stoppage is considered.

2006 Status: Open / Abierta
However, there is a project that will replace by 4Q2006 all gas detectors in the area of FCC, ALKY and DA-3.

The remaining process units will be addressed by 3Q2007.

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2007 Client Comment: No Report / No reportó

Apr.-2007 AIG recommendation follow-up visit: No Progress / Sin Progreso
The alarm panel still shows many faulty gas detectors / El panel de alarma todavía muestra muchos detectores

de gas en falla

Jan.-2008 Status: No progress. The situation, as observed in the RPLC central bunker, was unchanged at the

time of the visit. However, RPLC maintains that its in-process gas detection (and also fire detection) upgrading

project will still go ahead. For example, procurement of gas & fire detectors is reported to be complete. Field

installation is supposed to start in Q2 2008, firs with the jetties. Project conclusion which includes DA-3,

Alkylation, FCC and DA-1/2, is planned for 2008 year end.

Sin Progreso porque la situación en las instalaciones sigue la misma desde 1995. Pero valoramos el hecho que

hay un proyecto de adecuación de los sistemas de detección de fuego y gas en los muelles y las unidades DA-3,

Alkylacion, FCC y DA-1/2, aún hay que subrayar que se habla de este proyecto desde ya varios anos. La

finalización del proyecto es anunciada por final de 2008.


06.1998 FCC vessel FA-2 Temporary Repair Patch

FA-2 is the FCC fractionator accumulator FA-2 temporary patch repairs were certified by DNV to be API510-

compliant (in a 1999 report sent to Willis). Report stated that if vessel was not replaced in 2002, then wall

thickness measurements were recommended to check accuracy of previous measurements and calculated

corrosion rate. However due to manufacturer delay the replacement, initially scheduled for the 2005 FCC

turnaround, did not occurred, and PDVSA carried out instead the required inspection which demonstrated that

the FA-2 integrity was OK so as to allow replacement to take place in the next FCC T/A (scheduled in 2008).

This was sufficient evidence for the 2006 survey team to consider the recommendation as closed.

2006 Status: see above explanation ITEM CLOSED

Additional 2008 comment: The next FCC planned shutdown is now scheduled for Q2 2009. The FA-2

replacement vessel is on site and is planned for installation at that time.

05.1998 RPLC Refinery Central Control Room

c) Out of action automatic smoke detection

d) Halon system (missing nozzle; low cylinders pressure)

e) Cable installation standards below the computer room under floor and damp conditions

f) P&ID’s in the control room not the latest version

g) No CCTV camera monitoring the units

2006 Status: Completed ((f) removed) ITEM CLOSED