Managing change effectively is an important aspect for maintaining operations and ensuring safety in the process industries. Directing change, in any team, organisation or industry, however, can be challenging.
But, luckily enough for those seeking to instigate change, there is a structured methodology designed to manage systematic modifications to processes, equipment, and personnel. Management of Change (MOC) systems identify potential safety risks and ensure that change, no matter how miniscule, does not adversely affect safety, health, and environmental compliance.
Despite the importance of MOC systems, many organisations struggle with the implementation and execution of change control.
At Sigma-HSE, we have witnessed a variety of common pitfalls that can, and have led to significant issues, including:
- operational disruptions
- safety incidents
- compliance failures
These major pitfalls often stem from the same root causes, a lack of thorough risk assessments, inadequate internal communication, insufficient training, and poor documentation practices.
In this short blog, we explore the fundamentals of MOC and examine a few of the common pitfalls that we have seen many organisations face. We hope that through this understanding, organisations can enhance and implement management of change practices to ensure safer, more efficient, and more compliant operations.
Why Do We Manage Change?
In the past, there have been multiple examples of when a Management of Change system was the catalyst for a catastrophic incident.
Organisations rely on getting things right the first time to sell their products and services successfully. To achieve this, industries often implement quality management systems that incorporate change management process. This approach ensures product and service quality, while also protecting organisations from reputational, economic and asset damage.
A robust management of change process allows a business to slow down and carefully consider the impacts of a proposed change.
Process Safety Management and the Management of Risk Pillar
Management of change is an aspect of process safety management and is contained within the management of risk pillar.
In the UK, Europe, and increasingly in the United States, process safety management follows a risk-based approach to safety in the workplace. This approach requires a thorough understanding of your processes, operations and manufacturing units in terms of what major accident hazards and risk they pose.
The primary objective of COMAH and the SEVESO directives (OSHA in the USA) is to mitigate major accidents, particularly those related to hazardous chemicals, and to minimise the environmental impact of chemical hazards in the event of such accidents. A driving factor behind this is the establishment of safety guidelines and standards that can and should be adhered to globally.
Managing process safety and process safety risk will inevitably rely on the correct execution of several risk assessment hurdles, DSEAR, HAZID, HAZOP, and LOPA etc. These risk assessment methodologies help us to understand potential hazards and implement precautionary measures, safeguards, barriers, and risk reduction measures to minimise the likelihood of undesirable incidents.
Management of change is vital throughout the risk management. After completing risk assessments and employing mitigation measures, companies, regulators, and stakeholders must be confident in the safety of a proposed design or existing manufacturing facility.
Cause and effect should always be the priority, and without a solid management of change system working in tangent with a PSM programme, how can you ensure that all precautionary measures have been, are and will be put in place will reduce the likelihood of hazards causing harm.
Top-Down Approach
A top-down approach is fundamental for successful change management. Support from upper management, including their buy-in, provision of training, and emphasis on the importance of using the system is key.
Segregating management of change from other safety systems can hinder the overall effectiveness of the system. As a result, it’s beneficial to integrate various safety systems, such as a pre-startup safety review (PSSR), to streamline processes and optimise resource utilisation across teams.
ALARP and Process Risk Progression
In the UK, you must ensure that new or existing process design meets the standard of having any risk as low as reasonably practicable (ALARP). This has been the case since Edwards v. National Coal Board in 1949.
Progression is a key to survival. Over time, and any good business should, new ideas to improve processes, increase productivity or enhance product quality should be implemented. Again, this is why management of change (MOC) is such a crucial element of process safety.
When a change is proposed, there must be strict assurances that it does not increase the level of risk. Even if you are satisfied with the current level of risk, any modification should not elevate that risk; you should aim to never move up the tolerability carrot.
Changes can introduce new hazards that were not accounted for in the original risk assessments. As a result, your MOC system should prompt you to reassess and manage any potentially new hazards via a risk assessment.
It must be remembered that any change to a material or process should start a DSEAR review.
Precautionary Measures
In today’s fast-paced industrial environment, we aim to be quick and agile to provide the best customer experience whilst avoiding prolonged delays.
In process safety, the MOC procedure should not be viewed as a quick fix or as a springboard for rapid change. It will require time, effort and thorough methodological consideration that must involve the consultation of technical experts within the organisation to evaluate whether a proposed change should proceed.
This evaluation may then require additional work, such as a LOPA or the revisiting of a HAZOP study, all of which will take more time before a decision can be made.
Based on the above risk assessments, your MOC can identify and document any necessary safety controls and precautionary measures. These can include engineering controls (e.g., safety interlocks, alarms), administrative controls (e.g., revised operating procedures), and personal protective equipment (PPE).
You should aim to install sufficient precautionary measures to maintain (at a minimum) the same level of risk. Again, the relevance of the MOC system is in the structured approach to the identification, assessment, and mitigation of associated risk.
Small Changes: Impact and Tracking
The impact of changes can extend beyond immediate alteration, potentially affecting drawings that need updating and triggering further hazard assessments based on outdated information.
Over time, numerous small changes can accumulate, making it challenging to maintain plant integrity and track alterations effectively. Therefore, it’s important to clearly define which changes should be logged and tracked.
Plan, Act, and Do
Management of change (MOC), as the name suggests, addresses change. Whether engineering or organisational, change can alter the level of risk. As a result, it is key to keep the change management as focused as possible to implement it effectively. There have been numerous instances where insufficiently considered or poorly implemented changes to processes, unit operations or organisations have led to significant issues.
To emphasise the importance of this, consider the following quote: “Planning without action is futile; action without planning is fatal.” This statement is particularly relevant to high-risk processing industries.
MOC is about planning, doing, checking, and acting on what you have discovered.
By following a structured approach, you can ensure that changes are managed safely and effectively.
Risk Decision Planning
Management of change involves planned and decisive decision-making. Not all risks will be the same, and although not all the risks involved in your processes can/will be understood, when considering change control (no matter how minute), you must decide whether it should proceed or if additional workplace safety measures or safety guidelines should be implemented.
Business Communication and Collaboration
Lastly, effective MOC processes ensure that all relevant personnel can collaborate towards change.
MOC also supports engagement across entire organisations. From stakeholders and business leaders to operators and designers, an MOC system guarantees that the right people are involved in and are working towards shared goals.
This ensures that everyone understands the new procedures, equipment, or processes, reducing the likelihood of accidents due to unfamiliarity or misunderstanding.
Business collaboration further fosters buy-in, manages process expectation, and creates detailed checklists to ensure that changes are well-planned, actionable, and checked to prevent any unexpected costs or delays.
The implementation of an effective MOC system will help your businesses to understand the resources required for positive change while building organisational confidence, working culture, and operational excellence.
Policy, Procedure, and People
Organisations don’t often struggle when creating policies and procedures for managing change. Instead, they find that the most challenging aspect is ensuring disciplined adherence to the process. Some systems may become overly complicated and attempting to fit all changes into a single framework can become tedious and inappropriate for certain changes based on their level of risk.
When systems become cumbersome or unpleasant to use, workers may circumvent them, resulting in unauthorised changes.
What’s needed is a transparent organisation where employees can request changes, receive feedback, and understand the reasons for approval or rejection.
Knowledge Loss – Case Studies
One of the biggest risks in process safety is the loss of knowledge.
Texas Gulf Coast
A notable example is the Texas Gulf Coast incident, where a reactor explosion investigation revealed that the engineers and operators had been employed for less than a year. Experienced personnel had retired, leaving the plant with inexperienced staff.
As key knowledge and practices were not shared, the company’s risk increased and led to repeated mistakes that were neither recorded nor analysed.
In the oil and gas industry, this issue is particularly pressing. With 25% of the workforce eligible to retire in the next five years, organisation change must be able reorganise effectively. Failure to manage this transition can result in knowledge loss, overlooked responsibilities, and inadequate training.
BP Texas City
Organisational changes, such as mergers and acquisitions, can also exacerbate knowledge loss. Staff turnover and expanded production won’t physically alter equipment but it will, if not properly managed, can have significant impact on operation. As an example, the BP Texas City incident highlighted the dangers of staff turnover. Cuts to training and staffing were not appropriately risk-managed, which ultimately led to disaster.
Key personnel leaving, absences due to illness, or role transitions where staff must handle safety-critical equipment all require careful management.
Managing these changes through an effective MOC strategy will ensure that knowledge is retained, set business/personnel responsibilities are clear, and training is adequate.
Create and Maintain a Meaningful Management of Change Policy
Managing change effectively is important for businesses in any industry. In the process industry, however, there is a difference, lives are at stake.
We have seen multiple Management of Change systems that have often focused on ticking compliance boxes – when really, it’s your people who are on this process safety journey.
At Sigma-HSE, we take the time to understand your business and processing needs. We are experts in the strategic integration of holistic management of change systems for enterprises of any size.
Implementing and recording effective Management of Change systems can be difficult to manage but, by partnering with us you can safely drive innovation, enhance product quality and grow your competitive edge.
