1. Welcome in the training section of
Management of Change
Vishnu K. Gupta
QA-System compliances manager
LCL Jodhpur ,
“Working Safe, Preventing Injuries, Increasing Profits”
2. Overview
• What is Management
of Change (MOC)?
• Why do we need
MOC?
• Recognizing Change?
• The MOC Program?
– Main Elements
– Operation
– Keys to Success
3. Management of Change
Policies and procedures which ensure that changes
do not result in operations outside of established
safety parameters Essential element in an
organization’s process safety system
Managing change can mean managing potential
incidents
4. 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.
5. 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 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”
6. MOC and Process Safety Management
•Process Safety Management is a method of identifying,
understanding, and controlling process hazards and preventing.
• Process-related injuries and accidents.
•MOC is one of the PSM elements.
•MOC is never complete - must be performed on a continual basis
throughout the life of the process.
7. Why do we need MOC?
• 80% of all large
scale accidents in
the process
industries trace
their origins back
to “Change”.
• Change is essential
to a company’s
survival
– they have to be able
to continuously
improve their process
and keep up with
industry standards.
VS.
8. Case Study: Flixborough, 1974
• 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
9.
10. The Flixborough explosion…
was the result of an unwise plant maintenance
modification.
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.
11. Does the our Industry ever need to
Manage Change?
13. BP Refinery in Texas City- Findings
• There were a number of misapplications of
the refinery MOC policy for changes
pertaining to the blowdown drum, the
splitter tower, and occupied trailers.
Chemical Safety Board - BP Texas City Final Investigation Report
3/20/2007 pg. 138
14. BP Refinery in Texas City- Findings
• Organizational changes that could adversely
impact process safety, such as changes in the
management structure, budget cuts, etc., generally
were not evaluated.
Chemical Safety Board - BP Texas City Final Investigation Report 3/20/2007 pg.
139
16. Lessons not learned….
“Despite some significant progress with process
safety indicator implementation in the downstream
oil industry…
in the offshore sector -BP, Transocean, industry
associations, and the regulator had not effectively
learned critical lessons of Texas City and other
serious process incidents at the time of the
Macondo blowout.”
Chemical Safety Board findings 7/24/12
17. Lessons not learned…
“Systems for managing the safety of process
changes were inadequate. The plan to complete and
“temporarily abandon” the Macondo drilling
operation was changed five times during the week
before the disaster, but there is no available
documentation that management of change
procedures or formal hazard assessments were
conducted.”
Chemical Safety Board findings 7/24/12
18. What is Change?
• Most difficult part of Management
of Change is recognizing change.
• Need to be able to distinguish
between a change that requires
approval using the MOC
procedure and one that does not.
20. Replacements-in-kind
• Defined - a replacement that satisfies the
design specifications.
• Examples
– raising reactor temperature within safe
operating envelope
– replacing equipment or piping meeting the
same specifications as the original
21. 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
22. Main Types of Changes
• Change of Process
Technology
• Change of Facility
• Organizational Change
• Variance Procedures
• Personal Change
24. Key Elements of a Program
• Identification System
• Change Control Mechanism
• Training
• Information Management System
• Auditing
25. 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”
26. Change Control Mechanism
• Explains how to manage
the change.
• Must clearly identify:
– the work flow procedures
(MOC form)
– responsibility and
authority
– approval level
27. 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
28. Information Management System
• “Status Accounting”
• Software/documentation
that tracks all changes and
their progress
• Allows access to most
current information
– ie. If two changes are inter-
related they will be aware of
one another
29. 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
31. Standard Operating Procedure (SOP)
SOP
No.
LCL/EHS/003/003
Subject: Management of Change
Original
Version No:
01 Date: 20-Dec-14 Revision
No:
00 Date: 20-Dec-14
Purpose: Management of Change Procedureis developed to ensure that changes are
properly reviewed and approved by persons with the required expertise prior
to implementation, to eliminate workplace hazards that could lead to injuries,
equipment damage, production losses,product quality,project reputational
impact or environmental impacts.
Responsibility: Head of the department, SHE Manager
32. Definitions, if any: 1. Major Impact Changes: A change expected to have an impact on EHS &product quality. Changes with
an uncertain impact level should be handled as major impact changes.
2. Minor Impact Changes: A change not expected to have an impact on the EHS &product quality.
3. Emergency Changes: An unplanned change of a piece of equipment as a result of an emergency,
which needs to be repaired immediately in order to maintain personal or equipment’s safety, or
preserve the quality of the product.
4. Chemical/Technology changes – include modification of operating conditions of predefined safe
operating limits, alarm or interlock set point revisions, software revisions, interlock logic revisions,
introduction of new chemicals, chemical substitution, and chemical re-introduction.
5. Equipment changes – include new piping/equipment, piping rearrangements, and equipment
revisions, new materials of construction, or design parameters, impairment of fire water systems,
impairment of alarm systems.
6. Procedural changes – include standard operating procedures, emergency procedures, safe work
procedures, temporary operating procedures, maintenance/inspection procedures, temporary operating
procedures, maintenance/inspection procedures or development of a new procedure for new equipment
installations.
7. Personnel/Organizational changes – include a change in the number of people, structure of an
organization, development of a new role in an organization, instrument/electrical or maintenance
support, or contractor for the site or unit, and absence from job for extended period.
8. Temporary change – planned for a limited duration; such as, a trial or evaluation or by-pass of a safety
system for maintenance. Planned operation of a process outside its normal operating range or transfer
of a product from its normal process train to another.
9. Facility change – includes buildings, utilities, containers, process/emergency equipment location and
other non-production related areas.
10. Replacement-in-kind – an item, equipment, chemical, procedure etc. that meets the design
specification of the production it is replacing.
33. Change Initiation:
•Once a potential change is identified, The HOD will initiate change management process.
•He will call a meeting with HODs of impacted departments.
•The impact with an estimate of accuracy and the forecasted effect on the schedule (days/weeks) should be added to the MOC Form. Any
extended comments and relevant backup documents should then be attached to and become part of the MOC Form.
•All HODs involved can question the change.
•All questions must be resolved before the MOC can be approved for implementation.
•Reviewers may reject the change if their concerns are not addressed through risk assessment or identified mitigation measures being
implemented.
Common Justifications for a Change:
Any change in the current management system, equipment’s, specifications of raw materials/ finished goods/intermediate/ packaging
materials & labels, process parameters, supplier, people need to be assessed with impact on the Quality, Health, Safety and environment.
The reason of change need to be justified appropriately.
There is accountability for proper change implementation. Change Management review procedures will address both permanent and
temporary changes. Temporary change reviews and approvals will specify the duration of the change and will require review if an extension is
required. Temporary changes are to be considered in the same manner as permanent changes.
NO. TYPE OF ISSUE DESCRIPTION
1 FSMS or HACCP Impact If there is change that affect the food safety of products and HACCP of process.
2 EHS The change will potentially affect the health and safety of persons, or protection of
the environment and Community, during fabrication, construction, commissioning,
operations, maintenance or decommissioning. The change could be outside of the
scope of approvals received and may require additional approvals/notifications.
3 Functional The facilities cannot function/be operated /be maintained
4 Constructability The facilities cannot be fabricated or constructed as designed or specified.
5 Statutory The change is necessary to comply with legislation or other mandatory
requirements.
6 Schedule The schedule may be at risk if the change cannot be accommodated.
7 Procurement Supplier cannot meet previous commitments and obligations. New Raw Material
introduction. Change in specifications etc.
8 Security Exposure to security risk is increased/decreased
9 People Assignment, job role change, resignation of employee.
The most common justifications for changes are listed as following:
34. esponsibility of the SHE Manager. The MOC Form, with any associated reference documents, is raised and signed by the affected department head
sted effect on the schedule (target dates) should be added in the actions of MOC.
MR
by SHE Manager.
Type of Changes
All types of changes as specified in definitions need to be considered during review.
Management of Change Review not required for:
•Equipment (vessels, agitators, heat exchangers, etc.) fabricated exactly to the original design and specification or existing approved design
and located in the same position as the original.
•Equipment and materials that are manufactured by an approved supplier toa standard specification, such as bolts, gaskets, flanges, steam
traps, piping, insulation, structural steel.
•Instrumentation (transmitters, pressure and temperature gages, etc.) of the same specification and range, and purchased from an approved
supplier. A change in instrument type e.g. RTD to thermo-couple does not constitute a replacement in kind. Electric motors, fuses and circuit
breakers of the same specification from an approved supplier.
•Replacement of piping with the same size, material, flange make-up and routing as the existing.
MOC
Checklist-Format.doc
Developed by: Vishnu Gupta Reviewed by: Milind Musale Approved by: Dr. Sanjay Modi
35. MOC Form
• A MOC form is used by company
to guide employees through the
procedure
• The MOC form should include:
– 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
37. Ranking changes
– Major Impact Changes:
– Minor Impact Changes :
– Emergency Changes
– Chemical/Technology changes
– Equipment changes –
– Procedural changes –
– Personnel/Organizational changes –
– Temporary change –
– Facility change
– Replacement-in-kind
– Don’t manage all changes with same rigor
• Hazard analysis method and level of approval dependent
on type of change.
38. 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?
39. 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?
– Does the change
introduce new
molecules?
40. ...
• Management Support
• Implementation not just
documentation
• Understanding and
utilization of developed
procedures
• Training
• Essential to keep
stakeholders informed
throughout the MOC
process.
41. Conclusions
• Unmanaged process and organizational
modifications have been a major cause of
accidents.
• A formal method to deal with change will
help prevent future accidents from occurring.
• Change is unavoidable in our industry
– all organizations should have a MOC program.
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 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.
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 industry. 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 United 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 14 elements designed to prevent accidents in the chemical process industries. Management of Change is one of the 14 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.
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 1st 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 to date.
The above photograph, illustrates the devastation caused by the Flixborough explosion.
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 “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.
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
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.”
The above photograph, illustrates the devastation caused by the Texas City explosion
A massive explosion kills 15 and injures 180 at the BP Texas City refinery. The explosion occurred in an isomerization unit at the site, resulting in the deaths and injuries. According to a report issued after the accident, actions taken or not taken led to overfilling the raffinate splitter with liquid, overheating of the liquid, and the subsequent overpressurization and pressure relief. Hydrocarbon flow to the blowdown drum and stack overwhelmed it, resulting in liquids carrying over out of the top of the stack, flowing down the stack, accumulating on the ground, and causing a vapor cloud, which was ignited by a contractor's pickup truck as the engine was left running. The report identified numerous failings in equipment, risk management, staff management, working culture at the site, maintenance and inspection, and general health and safety assessments.
On April 20, 2010, a sudden explosion and fire occurred on the oil rig. The accident resulted in the deaths of 11 workers and caused a massive oil spill into the Gulf of Mexico.
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…
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 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 - ie. changes involving safety relief or vent systems
deteriorating equipment
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. Do the change(s) effect?
– Standing operating procedures (SOPs)
– Mechanical integrity inspection intervals
– Mechanical integrity procedures
– Pre-startup safety review/checklists
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 (ie. 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
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
A company should have a MOC policy and procedure which will detail the specific requirements for each of these elements within the company.
.
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. (ie. 5 approval signatures and a thorough hazard analysis vs. 1 approval signature and no formal risk assessment)
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.
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.
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
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 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.
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.
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. Stakeholder communication has taken a prominent role in safety and loss management programs.
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.
Changes are the leading cause of accidents and thus a system to manage them will prevent future accidents.
Change is unavoidable in industry, thus all organizations should take preventative measures to protect themselves from the potential impact change can have.