Level 1 Course 4 Unit 3 Slides - Management of Change

Copyright ©American Institute of Chemical Engineers 2016. All rights reserved.

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SAChE® Certificate Program

Level 1, Course 4: An Introduction to Managing Process Safety Hazards

Unit 3 – Management of Change

Narration:

[No narration]


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Objectives

Narration (male voice):

This is the third unit in the “An Introduction to Managing Process Safety Hazards” course. By the

end of this unit, titled “Management of Change,” you will be able to:

• Explain the purpose of Management of Change (or MOC);

• Identify who is involved with MOC; and

• Given a case study, explain how MOC could be implemented to prevent an accident.


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Management of Change – Introduction


At a chemical plant in Flixborough, England, cyclohexane was converted in a series of reactors.

One of these developed a six-foot crack. Management decided to remove the reactor and

replace it with a temporary pipe designed in the maintenance shop without drawings or

engineering review. The pipe was held in place by scaffolding.

The temporary piping worked for about two months. However, unknown to the operators, it

was causing enormous stress to the reactor bellows. Finally, the bellows failed, releasing hot

cyclohexane which ignited.

The plant and surrounding homes were extensively damaged. Scores of people were injured and

28 people were killed.

As a footnote, the original crack in the reactor may have been caused by a temporary water

spray used to cool the system during a process upset - another abrupt departure from the

original design.


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Any change, however minor it seems to be, can introduce new complexity into an already

complex process and increase the risk of an incident. So, although change is a fact of life at most

facilities, it must be managed carefully.

Part 2


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Part 3


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Part 4


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Part 5


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SECTION 1: The Management of Change Element

Narration:

[No narration]

Section 1


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The Management of Change Element


Management of Change is one of the elements of the “Manage Risk” foundational block in the

Process Safety Management System.


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Why Do We Have Management of Change?


Why do we have MOC?

• It helps insure that changes to a process do not inadvertently introduce new hazards or

unknowingly increase the risk of existing hazards;

• It can assess the risk associated with a change; and

• It can mitigate that risk to acceptable levels.

• Overall, MOC is employed by establishing and implementing written procedures to

manage changes (except for “replacements in kind”, or RIK) to process chemicals,

technology and equipment, and changes to facilities.


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Key Elements of MOC Programs


All effective MOC programs have some common key elements:

• Documentation;

• Change recognition;

• Competent personnel and system ownership;

• Change communication;

• Consideration of impact on training;

• Consideration of impact on operating procedure;

• Consideration of impact on process safety information;

• Consideration of the effect of organizational changes; and

• Consideration of return to status quo after temporary changes.


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MOC Interfaces with Other PSM Elements


The MOC element interfaces significantly with a number of other PSM elements, most

frequently:

• Process Knowledge Management;

• Hazard Analysis;

• Operating Procedures;

• Asset Integrity; and

• Training.

Narration (female voice):

Click the arrow above each element to see how it’s related to MOC.

[When the arrow pointing to Process Knowledge Management is clicked...]


If a change covered by these procedures results in a change in the required process safety

information, such information also must be updated accordingly.


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[When the arrow pointing to Hazard Identification and Risk Analysis is clicked...]


As the change is being reviewed by the appropriate organizational resources, it may be

determined that the impact on safety is significant enough that a hazard analysis needs to be

part of the change review.

[When the arrow pointing to Operating Procedures is clicked...]


If a change covered by these procedures changes the required operating procedures or practices,

they also must be updated.

[When the arrow pointing to Asset Integrity and Reliability is clicked...]


The change may introduce new items into the Asset Integrity system.

[When the arrow pointing to Training and Performance Assurance is clicked...]


Employees who operate a process, and maintenance and contract employees whose job tasks

will be affected by a change in the process, must be informed of, and trained in, the change

prior to startup of the process or startup of the affected part of the process.


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MOC Scenario


Consider this scenario…

A plant has a hazardous chemistry reactor with maximum allowable working pressure (MAWP),

or design pressure, of 250 psig, and rupture disc protection set at 200 psig.

During the annual maintenance testing, it’s determined that some areas of the vessel wall have

thinned and the plant decides to lower the MAWP to 150 psig. The team conducts a

Management of Change review which results in a number of actions.

Think about how the elements in the Process Safety Management System apply to this scenario

and then click ‘Next.’


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MOC Scenario (continued)


In order to manage the change, first the team needs to go into the equipment files and update

the pressure rating on record for this vessel. This is important because down the road it might

affect the choice of processes which can be run in this vessel.

That rupture disc is still sitting there with a set point of 200 psig. That set point is higher than

the newly claimed design pressure for the vessel. In this case, not only does the disc need to be

changed, the records pertaining to it need to be updated as well.

The changes involving the rupture disc are sometimes missed.


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Who is Involved in MOC?


Who is involved in MOC? The change system must include employees who have the background

and expertise to review proposed changes and assure that they won’t result in operations

outside established safe operating limits. Following on this, the MOC system must have

established levels of required review and approval.

Functional areas commonly involved in MOC include the:

• Process Safety department;

• Maintenance department;

• Operations department;

• Departments of various Engineering disciplines;

• Training department; and

• Environmental department.


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Temporary Changes


This tank collapsed when material was pumped out after somebody had covered the tank’s

atmospheric vent with a sheet of plastic during a temporary cleaning activity. This activity could

have been considered a temporary change and the MOC review might not have been

comprehensive enough in stipulating the return to normal conditions, particularly the removal

of the plastic.

• As we’ve learned, temporary changes can lead to catastrophic events. As a result, attention

must be given to certain considerations:

All the process safety considerations given to a permanent change should be applied.

• Temporary changes should have a prescribed time limit and be properly documented.

• Renewal of temporary change time limits must be reviewed to assure that adequate

safeguards are being maintained.

• At the conclusion of a temporary change, a means must exist to verify that original conditions

are restored.


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SECTION 2: The Process Change Form

Narration:

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Section 2


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Change Form Contents


CCPS has provided guidance for the types of things that should be included in a Process Change

form:

• Description and purpose of the change

o Specifically, what change(s) is/are being proposed?

o What are the test details? What technology and facilities are being changed?

o Why is the change being proposed? Is it necessary?

• Duration of the change

• Technical basis for the change:

o What is the technical basis for the change? (If the approvers and authorizer do not

understand the technical basis for the change, how can they assess the hazards of

scale-up?)

• Safety, Health and Environmental considerations

o What are they?

o Is a formal process hazards review required?


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o Does the change significantly affect any previously conducted risk analysis?

• Process Documentation:

o Are changes required to:

� Operating procedures?

� Mechanical procedures?

� Piping and instrument diagrams?

� Others?

• Personnel Training:

o What training and communication regarding the change will be required?

• Pre-startup inspection required?

o Level of approval and authorization


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Sample Change Review Form


Take a few minutes to scroll through and read this sample change review form prepared by

CCPS. You can print it for further review if you like.


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SECTION 3: Auditing Process Safety Performance

Narration:

[No narration]

Section 3


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Metrics for Assessing Effectiveness of PSM Element Application


• There are leading metrics that an organization can use to assess how effectively they are

applying any of the PSM elements. A few interesting ones for MOC include:

Number of incidents with MOC as a root cause;

• Percentage of work orders and/or requests that were misclassified as replacement-in-kind (or

were not classified) but should instead have been classified as changes;

• Percentage of temporary MOCs for which the temporary conditions were not corrected or

restored to the original state at the deadline;

• Number of MOCs performed each month;

• Percentage of MOCs reviewed that didn’t have adequate hazard and risk analyses completed;

and

• Percentage of MOCs for which the workers were not informed or trained.


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Metrics Example


During a process safety audit, the review team compiles the following data tracking the facility’s

system for change management. What could be a possible conclusion?

This data recording could be a useful leading metric to assess the effectiveness of the facility’s

change management system. On the negative side, the annual number of MOC exercises has

been declining. This could indicate:

• There’s less competence in recognizing change;

• Complacency has set in; or

• The facility is taking more shortcuts.

On the positive side, it could mean the facility is showing more stability and less change is

needed. This must, however, be assessed against the facility’s business situation. It might be

that numerous operations have been discontinued over this time period and less process

activity is taking place.


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Conducting an Audit of Process Safety Performance


During your chemical engineering career, you may be part of an audit team assessing process

safety performance at one of your company’s plants. CCPS has published useful guidance on

how to conduct such an activity.

Interview the person(s) at the facility who has or have the responsibility for managing the MOC

program. Interview persons responsible for:

• Initiating the change;

• Evaluating the safety impact of the proposed change;

• Authorizing changes;

• Updating safety information;

• Updating operating procedures;

• Training operators and other personnel;

• Reviewing MOC procedures; and

• Interviewing affected personnel to confirm updated training.


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Conducting an Audit of Process Safety Performance (continued)


During the audit you should also:

• Check that the written procedure exists and is comprehensive;

• Check that the procedure clearly defines what constitutes change;

• Check that the procedure clearly provides for assessment of the impact of the change

on safety and health; and

• Check that the procedure assures that the authorization requirements for the change

are addressed.


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Organizational Changes


Poorly managed changes in an organization can have as serious adverse effects as other

categories of change. Keep in mind that organizational changes can cover:

• Changes in working conditions;

• Personnel changes;

• Task allocation changes;

• Organizational structure changes; and

• Policy changes.


The CCPS “Guidelines for Managing Process Safety During Organizational Change” book provides

more detail on this subject. You can learn more about this resource by clicking the book icon.


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SECTION 4: Examples of MOC Failures

Narration:

[No narration]

Section 4


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MOC Failure – Example 1: Fire Box Explosion


Let’s look at an example of MOC failure.

This heater was severely damaged during start-up as a result of a fire box explosion. The

operator had some difficulty with the instrumentation and decided to complete the start-up by

bypassing the interlocks on a one time only basis. This allowed the fuel line to be commissioned

with the pilots out. The main gas valve was opened and gas filled the heater. Then...KABOOM!...

the heater exploded, destroying the casing and damaging several tubes. Fortunately, no one was

injured.

As you can see, this was a case where the operator unilaterally decided to deviate from an

established start-up procedure. Never disable an interlock or protective device unless a

thorough Management of Change review has been conducted.


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MOC Failure – Example 2: Tubing Rupture


Let’s look at another example.

A filter on the suction of a pump frequently plugged. Because of this, the pressure needed to be

monitored, both in the field and at the control panel. To minimize installation time for a

pressure transmitter, it was decided to install a tap on the existing connection for the local

pressure gauge and connect a pressure transmitter to this tap. Because of the rush and the

temporary nature of the change, it was decided to use tubing for the change.

The installation, though accepted as a temporary installation, did not follow appropriate design

codes or engineering standards, and no MOC review was done. Approximately three years later,

the tubing ruptured and combustible material at a temperature of 360 degrees Celsius leaked to

the atmosphere. The leaking material ignited and started a major fire, which destroyed the plant.


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MOC Failure – Example 3: Texas City Explosions/Fires


The BP Texas City incident was an example of a failure of many PSM elements. One of the most

important lapses occurred in Management of Change.

On March 23, 2005, a series of explosions and fires occurred at the BP Texas City oil refinery

during the start-up of one of its columns. As a result, 15 workers were killed and about 170

others were injured - some as far as 480 feet from the source of the release. There was

extensive facility damage.

OSHA imposed major fines as a result. CSB issued three first-ever “urgent” recommendations -

the first time the agency had done so in its then eight year history. These recommendations led

to the Baker Panel report and a revamp of API 752 (covering facility siting).

This event brought the concept of safety culture firmly into the regulatory and industry

discussion.


Click the book icons if you would like to read these documents.


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Part 2


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Part 3


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MOC Failure – Example 3: Texas City Explosions/Fires (cont.)


One area that was subjected to a Management of Change process at the refinery was the

location of temporary buildings - trailers - brought to the site to service plant turnarounds. At

Texas City, the MOC program required that each new siting be subject to an MOC review.

At the time of the incident, trailers had been located 150 feet from the vent of a blowdown

drum stack. The local rule for wood frame trailers was that they should be no closer than 350

feet from process equipment without an MOC review. This review hadn’t been done.


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MOC Failure – Example 3: Texas City Explosions/Fires (cont.)


Click the images related to the Texas City incident to explore the event in more detail.

[When Refinery Layout thumbnail is clicked…]

This illustration shows the refinery layout of the areas surrounding the ISOM unit.

[When Destroyed Trailers thumbnail is clicked…]

As shown in this photograph, the trailers west of the blowdown drum were destroyed.

[When Blast Overpressure Map thumbnail is clicked…]

This blast overpressure map depicts the areas of highest blast pressure (10 plus, five plus, and

2.5 plus psi).


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Refinery Layout (Slide Layer)

[When Refinery Layout thumbnail is clicked…]


This illustration shows the refinery layout of the areas surrounding the ISOM unit.


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Destroyed Trailers (Slide Layer)

[When Destroyed Trailers thumbnail is clicked…]


As shown in this photograph, the trailers west of the blowdown drum were destroyed.


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Blast Overpressure Map (Slide Layer)

[When Blast Overpressure Map thumbnail is clicked…]


This blast overpressure map depicts the areas of highest blast pressure (10 plus, five plus, and

2.5 plus psi).


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Unit 3 Summary


We’ve reached the end of the third unit in the “An Introduction to Managing Process Safety

Hazards” course. Having completed this unit on “Management of Change,” you should now be

able to:

• Explain the purpose of Management of Change;

• Identify who is involved with MOC; and

• Given a case study, explain how MOC could be implemented to prevent an accident.

In the next unit, we’ll examine some commonly used safeguards in process safety management.

Level 1 Course 4 Unit 3 Slides - Management of Change

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