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 plants 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 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 scale accidents in the process industries trace their origins back to Change. Change is essential to a companys VS. survival
they have to be able to continuously 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

Cause: Temporary Modification

Bellows 1 2 3 4 5

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.

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

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. 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?
Changing metallurgy of a piping system. 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 Auditing Note - The requirements for each element are detailed in a companys 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 SIGNIFICANCE OF CHANGE

LOW

SIMPLE RISK ASSESSMENT

Flowchart of a Management of Change Program

MEDIUM/ HIGH
REVIEW WITH TEAM LEADER

UNCERTAIN

LOW RISK

APPROPRIATE RISK ASSESSMENT

APPROVAL

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 program

Ranking changes
Must delineate changes
small medium large

Dont manage all changes with same rigor 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? Does the change introduce new molecules?

Risk Matrix
Severity of Change

Low
Degree of Hazard Risk Level 1 2 3 4 Low High Type of Safety Review Simple Checklist What-if Checklist FMEA or HAZOP analysis HAZOP with consequence analysis Risk Level 1 Risk Level 3

High
Risk Level 2 Risk Level 4 Authorization Shift Supervisor Unit Supervisor Area Supervisor Plant manager

A successful MOC program is dependent on ...

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 dont feel like you dont trust their judgement.

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
Dont focus solely on modifications. Dont have unnecessarily tight equipment specifications. Applies to all process units, not just those containing flammable or toxic substances. Make sure there is easy access to documentation.

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.