Why
- Ensure that change is managed safely and responsibly. (1)
- Ensure that the MOC process is incorporated into the facility culture and applied when required.
- Identify where additional safeguards or additional risk reduction measures are necessary
- Modify/revise poor designs which may increase the risk by performing engineering /design reviews
- Confirm compliance with relevant recognized and generally accepted good engineering practices (RAGAGEP)
- Ensure that the impact of the prospective changes on safety and process safety is thoroughly reviewed. This is one of the important parts of the MOC review process.
- Incidents:
- CSB -US Ink Case Study January 2015
- An explosion and flash fires occurred at the US Ink manufacturing facility in East Rutherford, New Jersey, on Tuesday, October 9, 2012. Seven workers suffered burn injuries when they congregated at the entrance to the ink mixing room after hearing a loud thump from the newly installed dust collection system on the top of the facility and seeing signs of an initial flash fire from a bag dumping station. A second flash fire then occurred that led to the employee injuries. Before design of the new dust collection system, the engineering team filed a Capital Appropriations/Asset Request (CAR), which contained various levels of approvals from the local plant, engineering department, local operations manager, division controller and accounting department, corporate environmental health and safety department, and CAR approval committee. In the CAR environmental health and safety section, a checkbox indicating the need for a process hazard analysis (PHA) or management of change (MOC) was not checked, indicating that neither a PHA nor a MOC was necessary for the dust collection system. During interviews with company engineers and senior management, CSB investigators learned that the engineering team considered installation of the dust collection system as a replacement in kind for the old wet scrubber system. The CSB investigation revealed that corporate engineering managers who were responsible for executing the US Ink dust collection system project at Sun Chemical relied on the judgments and decisions of their reports and did not adequately oversee the dust collection system project. The new dust collection system is completely different from the old wet scrubber system, with different functions and design specifications. This exemplifies the potential severe consequences that can result when competent personnel are not involved in the review and approval of changes that clearly require an MOC review. (2)
- CSB -US Ink Case Study January 2015
How - General
- Define necessary competencies and competent personnel
- Knowledge and Expertise in both the MOC system and technical areas are required.
- For the safety review ensure that the team includes the necessary roles such as:
- EHS
- Mechanical design
- Process Technology
- Process safety
- Instrumentation
- Operations
- Maintenance and reliability
- Logistics
- Knowledgeable safety review leaders
- And others as defined by the type of change
- Have a process for training and approving competent personnel.
- Training should be conducted to provide a thorough understanding of the MOC process
- Personnel evaluating the safety aspects of the MOC must be trained and knowledgeable in all the potential equipment and process system hazards.
- At least one of the MOC reviewers should be trained and knowledgeable in performing safety reviews or PHA’s as appropriate.
- Competent personnel know and understand their limitations and when they need help (3)
- When MOCs are reviewed, the supervision and management must be fully aware of the design basis, i.e., the reasons why each and every piece of equipment is installed in a process and is designed the way it is.
- The supervision and management must be fully aware when there are limitations in the internal organization’s technical expertise and when external expertise/assistance is required during MOCs reviews.
How - Operators and Maintenance
- Seek out and participate in training opportunities.
- Learn and understand what requires an MOC.
- Learn and understand your role in the MOC process
- Examples include: Bring forward ideas for new MOCs to improve safety or productivity, participate in MOC safety reviews, when issuing work permits ensure that an MOC was performed when required, and write or review procedures impacted by the change.
- In order to support the MOC program learn and keep up to date on changes associated equipment operation, equipment maintenance schedules and process operations.
How - Management
- Ensure that the appropriate personnel receive training.
- MOC initial awareness and refresher training are provided to affected personnel.
- Ensure that appropriate personnel are assigned to review and approve MOCs.
- Ensure that all involved personnel have the expertise and knowledge for the evaluations they are responsible for. For example, how safety reviews, PHAs, design requirements and RAGAGEPs affect MOCs.
- Develop and implement periodic metrics which tracks the misclassification of changes and if MOCs are receiving the proper review and approval.
How - Engineers and Designers
- Seek out and participate in training opportunities.
- Training should focus on expertise required to have the appropriate expertise and tools. For example, how safety reviews, PHAs, design requirements and RAGAGEPs affect MOCs.
- Understand your role in identifying safety issues introduced by the change. Examples include: Bring forward ideas for new MOCs to improve safety or productivity, participate in or lead MOC safety reviews, coordinate the review and approval of individual MOCs, and work on action items resulting from the MOC, such as PSI updates, and procedure updates.
References and Supplemental Reading
- Supplemental Reading -CCPS Book-Guidelines for Risk based Process safety-Chapter 15- Management of Change
- Reference. CSB case study US Ink - Jan 2015 (Add link)
- Supplemental Reading -CCPS Book-Guidelines for Risk based Process safety-Chapter 3-Process safety Culture