This slide presentation was prepared by Jessica Shinkle under the supervision of Dr. Paul Amyotte, P.Eng. with the Chemical Engineering Department, Dalhousie University. Jessica was one of Dr. Amyotte’s students studying towards her Bachelor of Chemical Engineering. This teaching module was prepared in the year 2001 for use by chemical engineering educators. The purpose of the package is to provide undergraduates in chemical engineering programs an understanding and awareness of management of change and its role in chemical process industries.
The above outline illustrates the main points of the presentation. What is Management of Change - this section provides a definition of MOC as well as some information on its history and its place in Process Safety Management. Why do we need MOC - this is explained primarily through example Recognizing Change - this section explains the difference between changes that require MOC approval and those that do not. It also explains the different types of changes that can occur. The MOC Program Main Elements - this section explains the five main parts of a MOC program - identification system, change control mechanism, training, information management system, and auditing. Operation - this section shows a flowchart of how the MOC procedure operates. It also provides information of the MOC form and Risk Ranking methods. Keys to Success - this section lists some suggestions from industry as to how to ensure the success of a MOC program.
Change is a given in any industrial operation today. Some possible reasons for change would be: New laws and regulations Keeping up to date with current technology Producing more efficiently to remain competitive Whenever a change is made, large or small, permanent or temporary, managers and staff should assess the possible impact of the change. Management of Change is a systematic method used to do just that. It is defined as policies and procedures which ensure that changes do not result in operations outside of established safety parameters. This is an essential component of a plant’s process safety system as changes can occur daily in a chemical process plant. MOC is used to answer the following four questions: What could go wrong? How could it affect me or others? How likely is it to happen? What can I do about it? Since changes are a common cause of accidents, by managing change, we are managing potential incidents.
The focus of MOC is to prevent catastrophic accidents and to properly evaluate the concerns of safety and health and to accomplish this review in a timely manner. The “time” component of this statement is very important. If MOC cannot be completed in a timely manner than the system would be very ineffective. It is important that the program help the plant to continuously improve in a safe manner - not to impede this improvement from occurring.
Management of Change is relatively new to the chemical process industry (CPI). Formal MOC procedures were first introduced by the nuclear power industry in the early 1960s. These practices quickly spread to the defense industry. It wasn’t until 1976 that MOC made its appearance in the Chemical industry. Some farsighted chemical companies shared their progressive modifications procedures at the annual Loss Prevention Symposium. The procedures utilized by BP Chemicals International and Imperial Chemicals Industries Ltd. were presented and many of the practices they used are still valuable today. In 1985, the Canadian Chemical Producers Association (CCPA) acknowledged the importance of MOC in safety management systems. They released a pamphlet entitled Essential Components of Safety Assessment Systems. It included nine programs - one of which was a management program to formally examine and approve any significant changes in chemical components, process facilities, or process conditions whether temporary or permanent, prior to implementation. Around the same time in the states, focus on chemical process safety was increasing. In 1988, the Organization Resources Counselors, Inc (ORC) prepared a report entitled “Recommendations for Process Hazards Management of Substances with Catastrophic Potential”. This report emphasized the application of management control systems to facilities processing highly hazardous chemicals. Many future publications were based on this report, such as the API Recommended Practice 750, Management of Process Hazards , in 1990. This standard included the requirement that MOC must include a detailed safety review. IN 1992, the ORC report helped form a new law within the United States OSHA 1910.119, “Process Safety Management of Highly Hazardous Chemicals”. The law clearly outlines the ground rules for the chemical process industries to establish a method for managing change.
Process Safety Management (PSM) is the application of management principles and systems to the identification, understanding and control of process hazards to prevent process-related injuries and accidents. It was developed by the Center for Chemical Process Safety (CCPS) in the United States but has since been adopted in Canada. PSM consists of 12 elements designed to prevent accidents in the chemical process industries (see below). Management of Change is one of the 12 elements. It states that a system to manage change is critical to the operation of any facility and a written procedure should be required for all changes except replacement in kind. Management of Change is a continuous process as changes are forever occurring within a company. Many of the other PSM elements have a clear start and finish. However, compliance with MOC requires that it be performed throughout the life of the plant. Note - the 12 PSM elements are the following: accountability, process knowledge and documentation, capital project review and design procedures, process risk management, Management of Change , Process and Equipment Integrity, Human Factors, Training and Performance, Incident Investigation, Company Standards, Codes and Regulations, Audits and Corrective Actions, and Enhancement of Process Safety Knowledge.
So why is MOC considered a critical operation of any facility? It has been determined that 80% of all large scale accidents in the process industries trace their origins back to “Change”. Unfortunately, you can’t just get rid of the cause because “Change” is also critical to a company’s survival. Companies have to be able to change in order to continuously improve their process and to stay competitive in their industry. By successfully managing change you can reduce the number of incidents while still allowing, even encouraging, change to occur.
The following case study illustrates the catastrophic effects of implementing a change without the proper MOC procedure. Flixborough was actually one of the events that led to the development of management of change. ----------------------------------------------------------------------------------------------- On June 1 st 1974, the Nypro cyclohexane oxidation plant at Flixborough, England was destroyed by an explosion. The plant produced caprolactam, a raw material for the production of Nylon. The process consisted of oxidizing cyclohexane (which has similar properties to gasoline) with air in a series of reactors. There was a release of 30 tons of cyclohexane to the atmosphere which formed a vapor cloud. The cloud was ignited by an unknown source about 45 seconds after the release. The resulting explosion destroyed the entire plant. 28 people were killed and 89 others were injured (36 employees and 53 civilians). The number of fatalities would have been much greater had the accident occurred on a weekday when the administrative offices were filled with employees. The damage extended beyond the plant to 1821 nearby houses and 167 shops and factories. Total property damage reached $63million. The fire in the plant burnt for over 10 days. Flixborough is recorded in history as the largest single loss by fire or explosion in history.
The above photograph, illustrates the devastation caused by the Flixborough explosion.
The Flixborough explosion was the result of an unwise plant maintenance modification. The above diagram illustrates the 6 reactors used in the process. The reactors operated at 125 psig and 310 o F. Cyclohexane has a normal boiling point of 178 o F, so it would volatize immediately when depressurized to atmospheric conditions. Several months before the explosion, a leak was discovered in reactor #5 in the series. It was decided to remove the reactor for maintenance, but to install temporary piping joining reactors 4 to 6 and to keep the operation running. The feed pipes were 28 inches, however there was only 20 inch pipe stock available. The 20-inch piping was fabricated with two miters and installed between two 28-inch bellows (expansion joints). The bypass piping was supported by scaffolding. It is estimated that the bypass pipe section ruptured due to inadequate support and overflexing of the pipe section as a result of internal pressures.
The main reason that the bypass piping failed and that the explosion occurred was that no one recognized the large impact this change could have on the plant. As they did not respect the change, they did not recognize that it was a job for experts. There was no mechanical engineer on staff at the time of the modification. The men who were asked to design and install the piping did not have the proper training and considered the modification a simple plumbing job. The only drawing used to support the modification was drawn in chalk on the workshop floor. There was no safety review of the modification and the workers were not supervised and required no approval to implement the modification. Some other reasons taken from the “Minutes of Proceedings of the Court Inquiry into the disaster”: They did not realize that the piping assembly would be subject to a turning movement which would impose shear forces on the bellows (for which they are not designed) They did not realize that the hydraulic thrust on the bellows would tend to make the pipe buckle at the mitre joints. No calculations were done to ascertain if the assembly could withstand the forces No reference was made to any Standards
The Flixborough explosion illustrates the need for a system for the control of modifications. Had a MOC system been in effect at the plant, the explosion could have been prevented. The MOC system would have called for a proper safety review; adequate approval at all stages of the change process, and; a design created by trained professionals. The resulting inquiry came to the same conclusions and one of its main recommendations was that: “ Any modification should be designed, constructed, tested, and maintained to the same standards as the original plant.”
Suggested Activity Ask the class to try and recognize times in their life when they need to manage change. The next slide lists three “everyday” examples. Perhaps if they need a little help getting going you could show these then ask the class again.
Management of Change is important everywhere not just in the Chemical Process Industries. What many of us don’t realize is that we go through the steps of MOC in our day to day lives. Computer Software Computers are an excellent example of MOC as what is available on the market is continuously improving at a very rapid pace. If you want to improve your system there are many questions you need to ask before you do so. By asking these questions you are managing the change to ensure that it will be successful. Two more examples on next slide...
Adding a Course Deciding to take a new course also requires MOC. This illustrates both the short and long term aspects. In the short term you need to make sure that the course will fit in with your other courses so that you can actually go to class. In the long term you need to make sure that the course meets your graduation requirements so that you’re not wasting your time. Driving on an Icy Highway This illustrates hidden changes which are also important to MOC. You didn’t deliberately make the roads icy, but they changed nonetheless. An important part of MOC is recognizing that this change occurred. The current “safe” standard is 100 km/hr, but perhaps with this temporary change in place, a reduced speed would be more appropriate.
The most difficult part of management of change is recognizing that a change is taking place. It is essential that employees can distinguish between when the MOC procedure is required and when it is not. (For example, the replacement of a valve with an identical valve would not require approval through the MOC system, while the addition of a new chemical would.) It is also important to be able to recognize the difference between safety critical and non-safety critical changes. Continued on next slide
As shown in this diagram, for every 1000 work orders there would be about 50-100 changes that require the employees follow the MOC procedure. Of these 50-100 changes, about 5-10 of them would be considered potentially high risk changes. So, how do you determine which work orders fall into what category? The first place to start would be with a firm understanding of the definitions.
Replacement-in-kind (RIK) changes are not subject to MOC procedures (i.e. they don’t require formal authorization.) They are equipment and procedural alterations that do not vary from the documented design specifications. It’s the replacement of a component with an identical part or an equivalent part approved and specified by the applicable engineering standard. While they do not require MOC documentation, RIKs will require written documentation in accordance with the maintenance procedural guidelines (i.e. work orders). Some examples of replacements-in-kind are: Raising the reactor temperature within the “safe operating envelope” Repairing equipment or piping Replacing equipment or piping meeting the same specification as the original Area paving Painting
According to the OSHA standard, changes that require management are defined as “any change (except replacement-in-kind) to process chemicals, technology, equipment, and procedures; and, changes to facilities that affect a covered process.” A simple definition used in plant awareness training is - “If new equipment is not previously documented or procedures are not already written, then it is a management of change issue.” A third definition provided by Brian Kelly † is “change is an alteration or adjustment to any component, variable or property within an existing system (except those within clearly defined boundaries or responsibilities). Some examples of change are: facility changes made to significantly increase storage capacity of a hazardous chemical changes that alter the production rates New tools and equipment Changing the method or control scheme of an instrument loop Alterations to protective equipment systems - eg. changes involving safety relief or vent systems deteriorating equipment † Brian Kelly is a professional engineer with Syncrude. He is one of Canada’s strongest proponents for Management of Change and is considered an industry expert on the topic.
Suggested Activity: Ask the students in the class to identify if the above situations are examples of changes or replacements-in-kind. Answers Changing Metallurgy of a piping system - this is an example of a change. It would be considered Change of Facility and is determined by the piping specifications of the plant Recalibrating instruments - replacement-in-kind. As long as the instruments had remained within the safe operating envelope. Operating with a heat exchanger out of service - Change. This is an example of a temporary process change. Replacement of gate valves with ball valves (within the plant valve specifications) - in general a RIK as it meets the valve specification. But, this could be dependent on the level of maturity of your organization and your written procedure. Shows why its so important to clearly define what “change” means to your organization.
This case study illustrates the need to be aware of hidden changes as well as planned changes. A common cause of hidden changes is corrosion (i.e. deterioration of materials). This accident occurred in 1967 and at the time was considered the largest vapor cloud explosion reported to date. The location/company was not provided in the information source. A catastrophic explosion occurred due to the release of isobutane in a refinery operation. The explosion had the force of 10 to 12 tons of TNT and caused extensive damage. There was also a resulting fire that burned for two weeks. The total loss was tallied at 7 deaths, 13 injuries, and an insured loss exceeding $35 million in property damage and business interruption. Using an inflation index to 1995, this amounts to $80.8 million! Investigators determined the accident was caused by a valve failure. The valve failed due to a hidden change introduced by corrosion.
The equipment of interest in this case study was a 10” line connecting a storage tank to a process unit. The storage tank contained isobutane, a flashing, flammable fluid. It was determined that a leaky sulfuric acid line was in the vicinity of the 10” connecting line. The acid caused corrosion to occur at the valve bonnet bolts and thus weakened them. The valve no longer met the requirements of the high pressure operation, and catastrophically failed. The bonnet was blown off and an uncontrolled release of isobutane occurred.
Four broad categories of change are: Change of Process Technology - When the plant was initially designed, safeguards were built in to keep the process from exceeding safe operating limits. If parts of the process are subsequently altered, a new review should be conducted to ensure it does not compromise the process safety. Change of Facility - The introduction of new equipment could also introduce additional hazards or increase the risk. Organizational Changes - Occur through the transfer of employees to new assignments or through the addition/reduction of staff. It is very important that this be recognized as a change and the employees acquire the safety-related knowledge required to carry out their new responsibilities. Variance Procedures - Occurs when an operations supervisor or maintenance manager wishes to deviate from standard procedures. A review of the deviation should be conducted and appropriate approval received before the variance should take place.
When discussion MOC, the changes are generally assumed to be permanent. MOC ensures that permanent changes are conducted without compromising the safety of the plant. But MOC is also used to control temporary changes. Temporary changes have caused a number of serious accidents in the past. They are included in MOC to ensure that all of the safety considerations are addressed. They may not have same requirements as permanent change (eg. P&IDs won’t be changed), but when the change is being considered, the procedure used for a permanent change should be reviewed. Temporary changes must have a specified time limit - if it is later desired to extend this time, a new review should be conducted. MOC will keep track of the temporary changes and ensure that they are returned to their original conditions. Some examples of temporary changes are: substitution of parts pending delivery system testing operate unit above specified design conditions to meet production quota replacement workers
While it is best to always follow the MOC procedure, there will no doubt be situations that will not allow it. In these “emergency” situations, it could jeopardize the plant safety more by waiting for the correct documentation and approval. Thus there needs to be a contingency plan. The change should be reviewed to the best of the employees’ abilities. This means using any and all available resources and time to evaluate the risks involved with the change. The focus should be on the immediate risks only. Once normal conditions return, the change must be fully evaluated using the MOC procedure and a permanent change should be implemented.
The key elements for a successful Management of Change System are: An identification system - used to recognize when changes occur Change Control Mechanism - provides clear instructions on how to manage the change. Training - Employees must be trained in MOC procedure Information Management System - used to keep track of all changes. Auditing - to ensure the MOC system is effective (more detailed descriptions provided in the following slides) A company should have a MOC policy and procedure which will detail the specific requirements for each of these elements within the company. Note -A sample MOC policy and procedure is available to handout to the class.
As we’ve already seen, the most difficult part of a MOC system is identifying change. It is therefore extremely important to have an effective identification system. Most identification systems use a systematic approach. A detailed list of all hardware which is to be controlled is provided. The employee can use the list as a check-list to determine if the modification falls under any of the categories. There will also be a risk ranking system to determine the level of control the change requires. (eg. 5 approval signatures and a thorough hazard analysis vs. 1 approval signature and no formal risk assessment) Note - the risk ranking process is discussed in more detail in another section. As each company is unique, they may have different guidelines for determining changes. It is thus extremely important to have clear, written, definitions of system boundaries and what constitutes “change”. These are generally found in the beginning of the Management of Change Policy.
The Change Control Mechanism is the method used to control or manage a change. It is formalized in the MOC policy and procedure to ensure that the same methodology is used for every change. The change control mechanism includes a description of the work flow procedure. This shows all the steps that must be taken to control the change. Most companies have adopted a MOC form to help guide the employee through the procedure. The work flow procedure and MOC form will be discussed further in a later section. The Change control mechanism must also include a detailed list of who is responsible for what. This is imperative as many tasks could involve multiple staff, and all participants must understand their role for the change to be managed effectively. Finally the level of approval must be identified. In most companies this is directly linked to the risk ranking process in the identification system. As a change increases in risk, the level of required approval increases. Who’s approval/signature is required for each risk level must be clearly documented.
Training is imperative to the success of a MOC program as it will only function on the level that employees are trained to properly use it. Process safety could be jeopardized during a modification by the unintentional actions of one untrained individual. Employees should possess the proper respect for management of change and they can only acquire this through training. Anyone associated with a covered production process who could affect a change must be aware of and conform to the policies and procedures of change control. It is equally important for both management and regular staff to receive program awareness training as they all play an active role in the MOC process.
The information management system is used to account for the status of all changes currently under review. The system should ensure that: The most up to date information is available when considering a change, and; All changes are incorporated in the same database which is accessible to everyone. This prevents two inter-related changes from occurring concurrently without being aware of one another. The system must include a list of all documentation that must be reviewed and revised when a change occurs. For example, operating procedures, P&IDs, maintenance and testing procedures, and unit alarm listings. Most companies now use PC-based systems to keep track of their controlled documents. They may also have hard copies available in a central location.
Audits are used to ensure that the MOC system is working as effectively as possible. No matter how good a system is, there is always room for improvement, and audits are a way of continuously improving the management of change program. The audits determine whether all changes are assessed for their impact on safety and whether the documentation of the change is accurate and complete. Annual audits of the MOC system tend to be the norm in industry. However, if a MOC system is new then more frequent audits should be performed during the initial stages to ensure all the “bugs” are found.
MOC systems are different at every corporation and even slightly different at each location. They must be developed to fit the specific hazards, the available resources, the culture of the organization, and any required regulations. The result is broad differences in review and authorization philosophy. For example, some organizations would require only 1 signature for authorization of a specific change while others could require 5 for the same type of change. Despite the differences, the programs are all built on the same fundamental principles and with the same goal of preventing incidents.
The above diagram illustrates a possible flow chart for the operation of a MOC program - it is based on a flowchart used by Brian Kelly. (Note - the chart may be too small in landscape view and thus a slide is available in portrait view ) The program starts with the identification of a change. The change is then subjected to a risk ranking procedure (discussed later). High and medium risk changes continue down the path, while low risk changes can skip to the implementation step. The change must be reviewed by a team leader/manager at this point to provide approval for the process to continue. Further risk assessment is conducted at this point (as determined in the risk ranking procedure) and approval must once again be obtained to continue. The change has now been approved for implementation. Prior to implementation, the change must be communicated to all who could be affected. This should include training employees and updating documents when necessary. The change can now be implemented. Following implementation there must be some follow up to ensure that the change was successful.
Most MOC procedures utilize a MOC form to document the review and authorization of all changes. The form will be coupled with support documentation such as drawings and equipment specifications as needed for the safety review. The package will at all times remain intact and be routed to all reviewers and endorsers. The form ensures that no steps or signatures are skipped in the MOC process. MOC forms will generally include the following sections: Description, purpose, and technical basis for the change Assigned level of risk Safety, Environmental, and Health impacts Necessary time period for the change Authorization for the proposed change Interfaces with the PSSR program Note - a sample MOC form is available to handout to the class.
Most MOC procedures will include a method of ranking the changes based on the potential risk. It’s important to distinguish between low, medium, and high risk changes to avoid unnecessary work. If all changes were managed with the same rigor than the system would be too tedious and people would start to look for shortcuts. The level of risk involved with a change will have a direct impact on what sort of hazard analysis methods are used and what level of authority is required for the change to proceed. This allows low risk changes to be implemented quickly and ensures the proper assessment is made prior to making high risk changes. There are many different methods of ranking changes. The following slides illustrate one of these methods. It includes first determining the hazard level and the potential severity. This is followed by a risk ranking matrix to determine the risk level of the change.
The degree of potential hazard can be classified as either high or low. Checklists composed of yes/no questions (like the ones above) can be used to determine the hazard level.
The potential severity or significance of the change is also classified as either high or low. Checklists are generally used to determine the level of severity - the above questions are examples of typical checklist questions.
The above risk matrix was found in both the article “Make Plants Safer with a Proper Management of Change Program” and the book “Plant Guidelines for Technical Management of Chemical Process Safety”. The above matrix shows how the hazard level and the severity level can be used to determine the overall Risk Level. The risk level is then used to determine the type of safety review and authorization that is required for the change approval process.
There are many factors that can affect the success of a MOC program. The following slides show some of the most important things a company can do to ensure the program is effective.
Management support is critical to the success of a MOC system. One of the major obstacles to overcome in a MOC program is employees not using it properly. One of the reasons for this could be the employees don’t understand the importance of the MOC system. If management actively supports the system it will build credibility and instill a sense of priority. Another reason employees may not use the system is they don’t feel it will accomplish anything. To avoid this management must honor their commitment. If an employee goes through the MOC process and a change is approved reward them by implementing the change. Conversely, if people cheat on the system, cancel the change. Finally, there is the possibility of employees feeling bitter towards the system and that management doesn’t trust their judgement. Management must make them understand the benefits of the system and show how it can inhibit harmful changes.
Definition - “A stakeholder is a party who might be adversely affected by a change and/or who might be required to take compensating action to prevent against loss. Includes internal and external stakeholders.” A stakeholder is essentially anyone with a vested interest in the change. A common example of an external stakeholder would be the public. Internal stakeholders could be people in other departments. Stakeholder communication has taken a prominent role in safety and loss management programs. According to Brian Kelly, it is pivotal to the MOC process. The principles of stakeholder involvement come down to “Don’t keep secrets”. It is much better keep everyone informed right from the start so that they don’t put up “road blocks” for you down the road. Bypassing people in the beginning could upset them once they find out and they could make your life much more difficult. There are other advantages to stakeholder involvement aside from preventative measures. By informing people in other departments or offices, you can utilize the experience and perspective of others. Also providing the stakeholders with advance notice of the change enables them to take action to support that change. This will make the implementation of the change much smoother.
The above is a quote from Chemical Process Safety, which I felt was a good explanation of the importance of a simple MOC system. Basically it comes down to the fact that you don’t want the system to be so cumbersome that employees look for ways to get around it. It should be easy to use and the paperwork should not take too much time.
The following lessons have been learned in industry when setting up MOC programs. Don’t focus solely on equipment modifications - other changes are equally relevant to MOC procedures (eg. changes in operating procedures, staffing levels, and maintenance procedures). Don’t have unnecessarily tight equipment specifications - will cause MOC to be used much more often then would have been necessary had more thought gone into the original operating procedures and mechanical specifications. eg. using only catalog replacements instead of having functional descriptions of spare parts. Applies to all process units, not just those containing flammable or toxic substances - when dealing with hazardous materials, MOC should apply to indirect systems (eg. utility boilers) Make sure there is easy access to documentation - the correct information must be available to the team conducting the safety review.
Save all records - both approved and disapproved - some facilities saved only approved records. If the same change was requested again at a later date the initial safety review and reasons for disapproval are not available. Also disapproved records are useful during audits. Make sure EVERYONE is aware of MOC program - improper program awareness training will lead to incidents. MOC must address both types of risk - its important that the risk assessment looks at both types of associated risk. There’s short term risks which arise while the change is taking place. There’s also long term risks which can arise after the change has been implemented.
This is the end of the teaching module on Management of Change. The above slide lists some points which I felt were the most important for the students to take away from the presentation. The idea that changes are the leading cause of accidents and thus a system to manage them will prevent future accidents. Also that change is unavoidable in industry, thus all organizations should take preventative measures to protect themselves from the potential impact change can have.
management of change
Management of Change An Essential Process Safety Management Element.
Outline• What is Management of Change (MOC)• Why do we need MOC• Recognizing Change• The MOC Program – Main Elements – Operation – Keys to Success
Management of Change• “Policies and procedures which ensure that changes do not result in operations outside of established safety parameters”• Essential element in a plant’s process safety system• Managing change can mean managing potential incidents
Focus of MOC• To prevent catastrophic accidents and to properly evaluate the concerns of safety and health and to accomplish this review in a timely manner.
History of MOC• Early 60s - Formal procedures first introduced in the nuclear power and defense industries.• 1976 - First mention of use within chemical industry at Loss Prevention Symposium• 1985 - CCPA (Canadian Chemical Producers Association ) pamphlet, “Essential Components of Safety Assessment Systems• 1990 - API recommended practice “Management of Process Hazards”• 1992 - OSHA 1910.119, “Process Safety Management of Highly Hazardous Chemicals”
MOC and PSM• PSM is a method of identifying, understanding, and controlling process hazards and preventing process-related injuries and accidents• MOC is one of the 12 PSM elements• MOC is different from the other elements – MOC is never complete - must be performed on a continual basis throughout the life of the plant.
Why do we need MOC?• 80% of all large • Change is essential scale accidents in to a company’s the process VS. survival industries trace – they have to be able their origins back to continuously to “Change”. improve their process and keep up with industry standards.
Case Study: Flixborough• Vapor cloud explosion - fueled by release of 30 tons of cyclohexane• Largest single loss by fire or explosion in the United Kingdom – killed 28 people – injured 89 others – $63 million in property damage
Why did the Bypass Piping Fail• No safety review and inadequate supervision• Job was beyond professional capabilities of the workers• Only drawing was a full-size sketch in chalk on the workshop floor.• No one understood the forces that would be imposed on the pressurized piping
In Hindsight ...• A proper MOC procedure could have prevented this accident.• One of Main recommendations from inquiry – Any modification should be designed, constructed, tested, and maintained to the same standards as the original plant.
Everyday Life Examples• Computer software – when you upgrade/ add one component - will it be compatible with the rest of your system?
Everyday Life Examples• Adding a course to your schedule – does it conflict with your other courses? – does it meet your graduation requirements?• Driving on the highway when it is icy – does the speed limit still apply or should you reduce your speed?
What is Change?• Most difficult part of Management of Change is recognizing change. change• Need to be able to distinguish between a change that requires approval using the MOC procedure and one that does not.
Recognizing Change 5-10 potentially high risk 50-100 MOC 1000 Work Orders
Replacements-in-kind• Def. - a replacement that satisfies the design specifications.• Examples – raising reactor temp. within safe operating envelope – replacing equipment or piping meeting the same specifications as the original
Change• Change is an alteration or adjustment to any component, variable or property within an existing system (except those within clearly defined boundaries or responsibilities).• Examples – changes that alter production rates – changes involving safety relief or vent systems – deteriorating materials
Change or Replacement-in-kind?• Recalibrating instruments• Operating with a heat exchanger out of service• Replacement of gate valves with ball valves (within the plant valve specifications)
Case Study - Beware of Hidden Changes!• Vapor cloud explosion and major fire within a refinery – 7 deaths – 13 injuries – $35 million in losses (half in property damage, half in business interruption)• Cause: Hidden Change to a valve !!!
Case Study - Beware of Hidden Changes• Storage tank containing flashing, flammable fluid.• Tank connected to process unit via 10” line• Corrosion attacked valve bonnet bolts and weakened them.• Bonnet was blown off and an uncontrolled, catastrophic release occurred.
Main Types of Changes• Change of Process Technology• Change of Facility• Organization Change• Variance Procedures
Permanent vs. Temporary• MOC should be conducted on both permanent and temporary changes.
Emergency Changes• Sometimes you have no choice and you have to make a change without going through the proper approval process.• Need a contingency plan• Evaluate using limited skills and resources - focusing on immediate risk only.• When normal operations resume - implement a full MOC evaluation.
Key Elements of a Program•Identification System•Change Control Mechanism•Training•Information Management System•AuditingNote - The requirements for each element are detailed in a company’s MOC policy
Identification System• Screening process for identifying changes. – Includes risk ranking process based on effect item could have on safety of process• Requires clear, written, definition of system boundaries and what constitutes “change”
Change Control Mechanism• Explains how to manage the change.• Must clearly identify: – the work flow procedures (MOC form) – responsibility and authority – approval level
Training• Anyone who could affect a change must be properly trained in the Management of Change system• Commitment from all levels of management and staff
Information Management System• “Status Accounting”• Software/documentation that tracks all changes and their progress• Allows access to most current information – eg. If two changes are inter-related they will be aware of one another
Auditing• Ensures system is working as it should• MOC system should be constantly evolving and improving in efficiency and effectiveness• Verifies changes are assessed accurately• More often while the system is new to ensure all the “bugs” are found
Operating the MOC system• A MOC system is very dependent on the specific company – no two systems will be the same – eg. one company could require 1 signature for approval while another could require 5.• They are all based on the same fundamental principles
IDENTIFY CHANGE DETERMINE LOW SIMPLE RISK SIGNIFICANCE OF ASSESSMENT CHANGEFlowchart of a MEDIUM/ UNCERTAIN HIGH REVIEW WITH LOW RISK Management TEAM LEADER APPROPRIATE RISK ASSESSMENT of Change APPROVAL Program TRAINING AND COMMUNICATION IMPLEMENT CHANGE FOLLOW-UP
MOC Form• A MOC form is used by most companies to guide employees through the procedure• The MOC form should include: – Description, purpose, and tech. basis for the change – Assigned level of risk – Safety, Environmental, and Health impacts – Necessary time period for the change – Authorization for the proposed change – Interfaces with the PSSR (Pre-startup safety review) program
Ranking changes• Must explain changes – small – medium – large• Don’t manage all changes with same rigor (serious)• Hazard analysis method and level of approval dependent on type of change.
Determine Hazard Level• Examples of yes/no questions to determine the hazard level: – Does the change introduce a significant source of energy (chemical, mechanical, thermal, electrical)? – Does the change result in any increase of toxic, flammable, or reactive material? – Does the change significantly increase the potential for personnel exposure to a hazardous material?
Determine Potential Severity• Examples of yes/no questions used to determine potential severity level: – Could the change take the process outside the safe operating envelope? – Does the change significantly alter the heat and material balance?
Risk Matrix Severity of Change Low High Degree of Low Risk Level 1 Risk Level 2 Hazard High Risk Level 3 Risk Level 4Risk Level Type of Safety Review Authorization1 Simple Checklist Shift Supervisor2 What-if Checklist Unit Supervisor3 FMEA or HAZOP analysis Area Supervisor4 HAZOP with consequence analysis Plant manager
Management Support• Vital element in success of MOC system• Honor your commitment – if an employee follows the system and the change is approved - then implement change!!• Important to show full support so that employees understand the benefits and don’t feel like you don’t trust their judgment.
Stakeholder Involvement• Essential to keep stakeholders informed throughout the MOC process. – will prevent them from putting up “road blocks” later.• Stakeholder communication can provide a fresh perspective.
Simplicity• “A modest MOC system that is regularly used and works is much better than an elaborate, sophisticated system with an impeccable paper trail that is occasionally winked at, bypassed, or sometimes totally ignored.” – Roy E. Sanders
Lessons Learned• Don’t focus solely on modifications procedures (eg. changes in operating procedures, staffing levels, and maintenance procedures)..• Don’t have unnecessarily tight equipment specifications. (been necessary had more thought gone into the original operating procedures and mechanical specifications. eg. using only catalog replacements instead of having functional descriptions of spare parts. )• Applies to all process units, not just those containing flammable or toxic substances. ((eg. utility boilers)) (• Make sure there is easy access to documentation. (safety review) (
Lessons Learned (cont.)• Save all records - both approved and disapproved.• Make sure EVERYONE is aware of MOC program.• MOC must address both types of risk - short term and long term.
Conclusions• Improper plant modifications have been a major cause of chemical plant accidents.• A formal method to deal with change will prevent future accidents from occurring.• Change is unavoidable in industry – all organizations should have a MOC program.