management of change

1. Management of Change
An Essential Process Safety
Management Element.

2. Outline
•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 a plant’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 MOCHistory 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”

6. 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.

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
•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

10. Cause: Temporary Modification
1
2
3
4
5
6
Bellows

11. 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

12. 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.

13. Do any of you ever
need to Manage
Change???

14. Everyday Life Examples
•Computer software
–when you upgrade/
add one component
- will it be
compatible with
the rest of your
system?

15. 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?

16. What is Change?
•Most difficult part of
Management of Change is
recognizing changerecognizing change.
•Need to be able to distinguish
between a change that requires
approval using the MOC
procedure and one that does
not.

17. Recognizing Change
1000 Work Orders
50-100 MOC
5-10
potentially
high risk

18. 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

19. 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

20. 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)

21. 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 !!!

22. 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.

23. Main Types of Changes
•Change of Process Technology
•Change of Facility
•Organization Change
•Variance Procedures

24. Permanent vs. Temporary
•MOC should be
conducted on
both permanent
and temporary
changes.

25. 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.

26. Key Elements of a Program
•Identification System
•Change Control Mechanism
•Training
•Information Management System
•Auditing
Note - The requirements for each element are
detailed in a company’s MOC policy

27. Identification SystemIdentification System
•Screening process for identifying Screening process for identifying
changes.changes.
–Includes risk ranking process based on Includes risk ranking process based on
effect item could have on safety of effect item could have on safety of
processprocess
•Requires clear, written, definition of Requires clear, written, definition of
system boundaries and what system boundaries and what
constitutes “change”constitutes “change”

28. Change Control Mechanism
•Explains how to manage the change.
•Must clearly identify:
–the work flow procedures (MOC form)
–responsibility and authority
–approval level

29. 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

30. 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

31. 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

32. 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

33. IDENTIFY CHANGE
DETERMINE
SIGNIFICANCE OF
CHANGE
SIMPLE RISK
ASSESSMENT
REVIEW WITH
TEAM LEADER
FOLLOW-UP
APPROPRIATE RISK
ASSESSMENT
APPROVAL
TRAINING AND
COMMUNICATION
IMPLEMENT
CHANGE
LOW
LOW
RISK
UNCERTAINMEDIUM/
HIGH
Flowchart of a
Management
of Change
Program

34. 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

35. 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.

36. Determine Hazard LevelDetermine 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?

37. 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?

38. Risk Matrix
Severity of Change
Low High
Degree of Low Risk Level 1Risk Level 2
Hazard High Risk Level 3Risk Level 4
Risk LevelType of Safety Review Authorization
1 Simple Checklist Shift Supervisor
2 What-if Checklist Unit Supervisor
3 FMEA or HAZOP analysis Area Supervisor
4 HAZOP with consequence analysisPlant manager

39. A successful MOC
program is
dependent on ...

40. 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.

41. 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.

42. 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

43. Lessons Learned
•Don’t focus solely on modifications procedures (eg. changes in Don’t focus solely on modifications procedures (eg. changes in
operating procedures, staffing levels, and maintenance operating procedures, staffing levels, and maintenance
procedures)..procedures)..
•Don’t have unnecessarily tight equipment specifications. (been Don’t have unnecessarily tight equipment specifications. (been
necessary had more thought gone into the original operating necessary had more thought gone into the original operating
procedures and mechanical specifications. eg. using only catalog procedures and mechanical specifications. eg. using only catalog
replacements instead of having functional descriptions of spare replacements instead of having functional descriptions of spare
parts. )parts. )
•Applies to all process units, not just those containing flammable Applies to all process units, not just those containing flammable
or toxic substances. (or toxic substances. ((eg. utility boilers)))
•Make sure there is easy access to documentation. (Make sure there is easy access to documentation. (safety review))

44. 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.

45. 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.