7) Always Communicate Changes to Affected Personnel | AIChE

Our websites use cookies to offer you a better browsing experience and analyze site traffic. By using our websites, you consent to our use of cookies.

Other Sites & Tools

Technical Groups

You are here

7) Always Communicate Changes to Affected Personnel

Last updated September 18, 2024

Table of Contents

7) Always communicate changes to affected personnel

Why

  1. Personnel need to be aware of changes to the process and equipment they work with.
  2. Personnel need to be aware of the impact of changes on their roles.
  3. Incidents:
    1. On October 9, 2012, a flash fire caused burn injuries to seven workers, including three who sustained third-degree burns, at the US Ink/Sun Chemical Corporation ink manufacturing facility in East Rutherford, New Jersey. Workers were drawn to a black ink mixing room by the initial flash of a fire from a bag dumping station and by a loud thumping noise from the rooftop. As the workers congregated at the doorway, they observed a small fire in the ductwork of a newly installed dust collection system above a process mixing tank. Suddenly, a large flash fire emerged from the room and engulfed the seven employees in flames. A new dust collection system had been commissioned 4 days before the incident. The workers received 15 minutes of training and attended a walk-through of the new dust collection system. As designed, the dust collection system started automatically when any of the mixing tank motors was energized and automatically shut off (after a specified delay) when all mixers were inactive. However, the dust collection system actually continued to run overnight, even when all the ink mixers were shut off. The CSB concluded that the explosion and flash fires occurred because of continuous manually controlled heating of the mixing tanks and operation of the dust collection system for several hours after commissioning, with the system continuing to draw condensable vapors into the duct. Continuous operation of the dust collection system led to self-heating and spontaneous self-ignition of the accumulated sludge-like material and the powdery dust mixture of carbon black and clay in the ductwork. Although aware of the change, the communications did go into enough detail on operations of the ink mix tank heating systems when connected to the new dust collection system. (1)

How - General

  1. Define a documented process for appropriately communicating changes to all affected personnel. (2) (3)
    1. Identify personnel affected by the change. Examples include operations, maintenance, laboratory, or anybody else who will interact with the impacted systems
    2. Simple changes may only require documented communications. Informing affected personnel about minor changes is adequate.
    3. Training may range from required reading and sign off to classroom or hands on training.

How - Operators and Maintenance

  1. Understand and appreciate the change and its impact on your role. (4)
  2. Do not operate or maintain a changed system without adequate training or information.
  3. Seek out assistance from supervision if further clarification is required. (4)

How - Management

  1. Ensure that the communications are made to all impacted personnel prior to operating or maintaining the change. (2) (3)
  2. Verify that the communications that are made to all impacted personnel are understood through interviews, walk-throughs, simulations or other appropriate techniques. (3)
  3. Management review should include assessing the effectiveness of change communications to include reviewing communications/training records and interviews with affected personnel. (5)

How - Engineers and Designers

  1. Understand and appreciate the change and its impact on your role. Often, this role is the MOC coordinator. (4)
  2. Seek out assistance if further clarification is required. These may be internal or external subject matter experts as needed (4)
  3. Issue change communications as defined by policy. (2)
  4. Ensure that communications and training are clear and understandable to the audience. (2) (3).

References and Supplemental Reading

  1. CSB - US Ink/Sun Chemical Corporation Ink Dust Explosion and Flash Fires Final Report – 10/9/2012 (add link)
  2. Supplemental Reading, - Guidelines for Risk Based Process Safety, Chapter 15, Management of Change
  3. Supplemental Reading, - Guidelines for Risk Based Process Safety, Chapter 14, Training
  4. Supplemental Reading, - Guidelines for Risk Based Process Safety, Chapter 3, Process Safety Culture
  5. Supplemental Reading, - Guidelines for Risk Based Process Safety, Chapter 22, Management Review

Go to Process Safety Glossary

Download the app: iTunes | Google