4) Sparingly Use Emergency/Verbal MOCs | AIChE

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4) Sparingly Use Emergency/Verbal MOCs

Last updated August 6, 2020

Table of Contents

4) Always use emergency/verbal MOCs sparingly

Why

  1. Frequent use of emergency MOCs will bypass the critical and deliberate thinking that is needed in an MOC process, and also tend to bypass careful safety reviews of each change. (3)​​​​​​
    1. Emergency MOCs are necessary to abate an immediate safety or process safety hazard that represents a clear and present danger.
    2. This is a simpler and quicker way of getting an MOC approved than the normal process.
    3. It should not be abused or overused because of its convenience.
  2. Incidents:
    1. An automatic drum loading system developed problems on a Friday evening.  A temporary “quick fix” was put in place by the shift foreman without using MOC so that the drum loading system could be used in a manual mode until it could be permanently repaired on Monday when the maintenance staff would be available.  In the manual mode, a valve had to be opened with an adjustable wrench and the drum had to carefully positioned under the filling head because it could not be lowered into the drum.  A week later, this manual mode was still being used because the maintenance personnel failed to repair it.  A drum was not positioned accurately and the liquid splashed into the operator’s face causing an injury.  It is sometimes necessary to make changes on short notice in order to keep a system running.  In such cases, the normal management of change process should be carried out as soon possible and not later than the next working day. (2)

How - General

  1. Define a process for review and approval of emergency MOCs. This may be outside of or made part of a standard MOC process. (1) (3)
    1. Permanent versus temporary emergency changes
    2. How verbal and temporary emergency changes can be made into permanent changes
    3. Ensure documentation is completed
    4. Define the triggers for use of emergency and verbal MOC process.  The use of emergency MOCs should be limited to situations where the change must be made imminently, and it cannot wait for the next time period when all or most of the normal reviewers/approvers are onsite and available.  (1) (3)
      1. The situations where emergency MOCs should be invoked should be limited to changes needed to preserve the normal environmental, health, safety, or process safety status of the facility, e.g., to prevent an imminent release of hazardous materials. 
      2. Emergency MOCs should not be used for programmatic changes in policies or procedures where an imminent EHS threat or vulnerability does not exist.
      3. Emergency MOCs should not be used for changes that will preserve or enhance the ability to meet production goals.
    5. Emergency MOCs should exist for time periods that are no longer than is needed for a normal temporary or permanent MOC to be created, reviewed, and approved.  This should normally be the next regular working period plus a nominal amount of time to replace them with a normal MOC that is expedited as much as possible. (2)
    6. Typically, a fairly senior level person will be required to approve an emergency change. 
      1. The rules for who has to approve an emergency MOC should be such that they cause the person who is initiating an emergency MOC to pause briefly and think about whether it is important enough to wake up someone fairly senior in the middle of the night with the request for verbal approval.
      2. Emergency MOCs should involve several people to help ensure nothing important is missed during the abbreviated review and approval. (3)
    7. Communication methods that are allowed for verbal approvals of emergency MOCs (if applicable), and how these communications are to be documented should be defined.
      1. Various communications means should be allowed, including cell phone, texting, e-mail, video or audio teleconferencing, or face-to-face approvals.
    8. Some abbreviated form of documentation for emergency MOCs should be created that can be easily and quickly completed by those seeking the approval of them. 
      1. This can be brief hand-written forms, computerized versions of such forms, pre-formatted e-mail or text submittals and approvals, or other forms of recording what is being proposed and what has been approved for each emergency MOC.
      2. An emergency MOC should still include the core parts of an MOC, i.e; the technical justification; known EHS impacts of the change; the approvals; informing affected personnel before operating the change; identification of whether the change temporary or permanent.
      3. Other topics that are typically addressed during the normal MOC process, such as permanent modifications to SOPs and PSI can wait until the emergency MOC is replaced with a normal MOC.  Temporary procedures needed to implement the emergency MOC should be included with the emergency MOC.
      4. The date and time of the approval of the emergency MOC and its execution should be recorded.
  2. Perform a more thorough review of each emergency MOC at the first available opportunity, normally on the next working or operational day when staff that typically review a temporary or permanent MOC are physically available. (1) (3)
    1. The replacement of the emergency MOC with a normal temporary or permanent MOC should be expedited to the extent possible without sacrificing technical correctness, or the ability to adequately think through the possible ramifications of the change, particularly the possible safety and process safety impacts. 
    2. The replacement of the emergency MOC should be accomplished expeditiously because the change has actually been physically made to equipment or procedures and if the normal MOC reveals a critical flaw in the emergency MOC it needs to be reversed as quickly as possible.
  3. Train or inform all facility personnel on the emergency MOC processes.  This should be accomplished using the same methods as normal MOCs.
  4. Ensure that there is an effective communication process for emergency MOCs.
    1. Shift to shift and within the department of the facility.
    2. Management of the facility.
    3. Emergency MOCs should receive the same level of communication and importance as bypassed or removed safety devices.
    4. Emergency MOCs should be agenda items during daily operational meetings held among senior staff at the facility.
    5. The time that it takes to replace emergency MOCs with normal MOCs should be tracked and reviewed as often as necessary to ensure that they do not exist any longer than is necessary.

How - Operators and Maintenance

  1. Be aware and understand the impact of emergency and verbal MOCs in your unit. 
    1. Operating and maintenance personnel should receive written notice as they begin their shift of the existence of an emergency MOC in their unit or area or responsibility.  This should be prominently posted in a manner similar to bypassed or removed safety devices. 
    2. Emergency MOCs should also be part of pre-shift briefings and also be part of formal shift turnover between personnel in the area(s) affected by the emergency change.
  2. Understand your role in monitoring a given emergency and verbal MOCs.
    1. Operators in particular, but also other personnel should be vigilant in monitoring the equipment or operations modified by emergency MOCs while they are in effect.
    2. Personnel must be aware that emergency MOC were made quickly without the benefit of the more careful and deliberate MOC process that is normal. 
    3. There may be technical issues related to safety or process safety that were not identified during the rapid and verbal-only emergency MOC approval.  This issue should be re-emphasized during pre-shift briefings and shift turnover for each occurrence of an emergency MOC.
    4. The equipment that was modified in an emergency MOC can be added to operator rounds and logs for added monitoring while it is in existence.

How - Management

  1. Ensure that the expectations for managing emergency and verbal MOCs are being met.
    1. Make the status of emergency MOCs a daily operational meeting agenda item and closely monitor the status of replacing any emergency MOCs.
    2. Apply an appropriate level of importance to emergency MOCs.  This is important so that emergency MOCs are not treated routinely, and they are not allowed to exist any longer than is necessary.
    3. Develop and implement a periodic metric which tracks the number and rate of emergency MOC use , or the ratio of emergency MOCs to total MOCs (1) (3)
  2. Ensure that proper rigor is applied to design, review and approval of emergency and verbal MOCs.
    1. Since emergency MOCs are usually made rapidly, and often reviewed and approved verbally or remotely, it is important that the careful deliberation associated with normal MOCs be applied when replacing the emergency MOC. This should be done as soon as the normal reviewers and approvers are available. (1 (3)
  3. Discourage the use of emergency and verbal MOCs whenever practical.  (3)
    1. Management and supervisory personnel should monitor the number and rate of emergency MOC usage to determine if they are being used as intended or if they are being used for convenience. 
    2. A metric should be established to monitor emergency MOC usage and that metric should be reviewed periodically by management.

How - Engineers and Designers

  1. Apply proper rigor to design, review and approval of emergency and verbal MOCs.
    1. There should be written guidance on how engineering and other technical services personnel are made part of the emergency MOC review and approval process. 
    2. The emergency MOC initiator or approver(s) can add reviewers during the process depending on the specifics of each proposed emergency change. Technical screening criteria can be developed and inserted into the emergency MOC procedure to help initiators and approver(s) to quickly make this decision.  The review and approval of emergency MOCs should include several people to help ensure that nothing important is missed. (3)
      1. Another example would be adjusting the temperature or pressure alarms on a reactor.  Someone who understands the implications on reactor safety should be consulted when approving an emergency MOC to alter alarm setpoints. 
      2. For example, if the proposed emergency change would have a direct effect on pressure relief capability, it is advisable that someone with the requisite knowledge regarding the facility pressure relief system and equipment be verbally consulted when the emergency MOC is being approved. 
  2. When the emergency MOC is being replaced with a normal MOC at the next opportunity, the full technical capabilities and knowledge of the facility, the company, or other subject matter experts should be involved in the review and approval of the normal MOC. (3)

References and Supplemental Reading

  1. Supplemental Reading - Center for Chemical Process Safety, Guidelines for Risk Based Process Safety, Chapter 15, 2007.
  2. Reference - Kletz, What Went Wrong, 5th Ed., section 25.2.6, Elsevier, 2009.
  3. Supplemental Reading - Center for Chemical Process Safety, Management of Change, Chapters 3, 4, 2008.

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