Process Safety Management
Management of Change
What if Our PHA’s Reveal the Need to
Change Something In our System to
Minimize the Potential for Release…
We Must Use Management of Change
(MOC)
Management of Change
1910.119(I)
The employer shall establish and implement
written procedures to manage changes
(except for "replacements in kind") to process
chemicals, technology, equipment, and
procedures; and, changes to facilities that
affect a covered process.
Management of Change - Why?
Many of the
catastrophic accidents
over the past few
decades can be
traced, in large part, to
a management of
change system that
was not in place or
was not functional
(e.g., Flixborough,
Bhopal).
Case Study: Flixborough
Vapor cloud explosion -
fueled by release of 30
tons of cyclohexane
Largest single loss by fire
or explosion in the United
Kingdom
killed 28 people
injured 89 others
$63 million in property
damage
MOC Cause: Temporary
Modification
Bellows
1
2
3
4
5
6
Why did the Bypass Piping
Fail
No safety review and inadequate
supervision
Job was beyond professional
capabilities of the workers
Only drawing was a full-size sketch in
chalk on the workshop floor.
No one understood the forces that
would be imposed on the pressurized
piping
What Was Learned?
A proper MOC procedure could have
prevented this accident.
One of Main recommendations from
inquiry
Any modification should be designed,
constructed, tested, and maintained to the
same standards as the original plant.
Focus of MOC
To prevent
catastrophic
accidents and to
properly evaluate the
concerns of safety
and health and to
accomplish this
review in a timely
manner.
Failures in MOC
Vapor cloud explosion
and major fire within a
refinery
7 deaths
13 injuries
$35 million in losses (half in
property damage, half in
business interruption)
Cause: Hidden Change
to a valve
Failures in MOC
Storage tank containing
flashing, flammable fluid.
Tank was connected to
process unit via 10” line
Corrosion attacked valve
bonnet bolts and
weakened them.
Bonnet was blown off and
an uncontrolled,
catastrophic release
occurred.
Performing Management of
Change
The Keys to Success
Management of Change
(MOC)…Our Program Must
Explain the purpose of MOC
Set the provisions to be considered for
temporary change
Define and give example of change in
equipment that requires MOC
Define and give examples of changes in
procedures when need
Define and give examples of change in process
technology
Management of Change
(MOC)…Our Program Must
Define and give example of a major change
Define and give example of a minor change
Define and give examples of "replacement in kind”
Describe and list the procedures required for
initiating and completing a MOC
Management of Change
Important March 31, 2009 Letter From
OSHA:
“Some organizational changes such as
changes resulting from mergers,
acquisitions, reorganizations, staffing
changes or budget revisions, may affect
PSM at the plant level and would therefore
trigger a PSM MOC procedure
MOC
Replacement in Kind
A replacement that
satisfies the design
specifications.
Examples
raising reactor temp. within
safe operating envelope
replacing equipment or
piping meeting the same
specifications as the
original
MOC-What is a Change?
Change is an alteration or adjustment to
any component, variable or property
within an existing system (except those
within clearly defined boundaries or
responsibilities).
Examples
changes that alter production rates
changes involving safety relief or vent
systems
deteriorating materials
Management of Change
Are These Change or Replacement in Kind?
Changing metallurgy of a
piping system.
Recalibrating instruments
Operating with a heat
exchanger out of service
Replacement of gate
valves with ball valves
(within the plant valve
specifications)
Coded
Metal
What Type of Stainless? What type of Nozzle?
MOC Application
Management of
Change should be
Completed on BOTH:
Temporary
Permanent Changes
MOC Emergency Procedures
Emergencies May
Required Changes
without Formal MOC
Contingency Plans
Should be in Place
When Normal
Operations Resume,
Complete MOC
Should be
Implemented
MOC Program Elements
Identification System
Change Control Mechanism
Training - Employees & Contractors
Information Management System to
Manage & Track All MOC Projects
Auditing of the MOC Program
Performance
Identification System
Screening process for identifying
changes.
Includes risk ranking process based on effect
item could have on safety of process
Requires clear, written, definition of
system boundaries and what constitutes
“change”
Change Control Mechanism
Explains how to manage the change.
Must clearly identify:
the work flow procedures (MOC Forms &
Process)
Responsibility and Authority Required to
Implement Change
Approval Levels Required to Start MOC
Process
MOC Training
Anyone who could affect
a change must be
properly trained in the
Management of Change
system
Commitment from all
levels of management
and staff
Contractors if Affected,
Must be Included
MOC - Information Management
System
Method to Track MOC
Documentation and
Actions
Software/documentation
that tracks all changes
and their progress if
Preferred
Allows access to most
current information
eg. If two changes are
inter-related they will
be aware of one
another
MOC - Auditing
Ensures That System is Working as
Designed
MOC system should be constantly
evolving and improving in efficiency
and effectiveness
Verifies changes are assessed
accurately & tracked
MOC - Flowchart
IDENTIFY CHANGE
Flowchart of a DETERMINE
SIGNIFICANCE OF
CHANGE
LOW SIMPLE RISK
ASSESSMENT
MEDIUM/ UNCERTAIN
MOC HIGH
REVIEW WITH LOW
TEAM LEADER RISK
Program APPROPRIATE RISK
ASSESSMENT
APPROVAL
TRAINING AND
COMMUNICATIO
N
IMPLEMENT
CHANGE
FOLLOW-UP
MOC Documentation Form
A MOC form is used by most companies to guide
employees through the procedure
The MOC form should include:
Description, purpose, and tech. basis for the change
Assigned level of risk
Safety, Environmental, and Health impacts
Necessary time period for the change
Authorization for the proposed change
Interfaces with the PSSR program
MOC-Determine Hazard Level
Examples of yes/no questions
to determine the hazard level:
Does the change introduce a
significant source of energy
(chemical, mechanical,
thermal, electrical)?
Does the change result in any
increase of toxic, flammable,
or reactive material?
Does the change significantly
increase the potential for
personnel exposure to a
hazardous material?
MOC-Potential Severity
Examples of yes/no questions used to
determine potential severity level:
Could the change take the process outside the
safe operating envelope?
Does the change significantly alter the heat and
material balance?
Does the change introduce new molecules?
Remember - Risk Analysis
Can PHA Recommendations
Affect MOC’s?
Any Changes in
Defense Designs, or
System Engineering will
Require Management of
Change
P&ID
Equipment Lists
Inspection/Testing/
Maintenance Procedures
PHA’s
Can MOC’s Affect Everything in
Our Program?
Might Affect: Might Affect:
Process Information
PHA’s
Process Toxicity
Operating Procedures
Technology of the
Process Safe Work Practices
Equipment in the Training for Both
Process Employees &
Mechanical Integrity Contractors
Inspection & Testing Compliance Audits
Quality Assurance
Basically….Everything!
Process & Goals of
Management of Change
Both Pre & Post
Management of Change (MOC)
MOC procedure should ensure that equipment and
procedures are returned to their original conditions at the
end of a temporary change
MOC forms/clearance sheets are acceptable control
methods of tracking changes
More complex changes require a more "formal hazard
evaluation" than simple changes (PHA not specifically
mentioned).
Management of Change (MOC) -
Pre-Modification Issues
Check codes, standards, internal engineering
specifications
Complete design review
Perform reactivity testing for new substances
Add materials to TSCA/SARA inventories
Complete safety and health impact review
Comply with safety and loss prevention requirements
Remember all the Codes We Have Already Discussed
Management of Change (MOC)
- Pre-Modification Issues
Complete maintenance review/revise spare parts list
Evaluate change against vent, relief, and flare capability
Complete industrial hygiene review
Review change against existing environmental permits
Obtain required approvals from
Management of Change (MOC)
Post-Modification Issues
Completed Process Safety Systems Review (PSSR)
Also References Pre-Start Up Safety Review
Completed training on change for affected employees
SOPs marked-up
P&IDs, PFDs, plot plans and other affected Process Safety
Information (PSI) marked-up
Training program modifications identified
Preventive maintenance program modifications identified
Management of Change
Summary
We must establish and implement written
procedures to manage changes except
"replacements in kind" for a covered process.
If a Change in Design or Components is
Required, Management of Change Must be
Employed, Tracked, and Analyzed.
All PHA’s, P&ID’s & Required Procedures Must
be Revised
Work-site employees and contract employers
must be informed and trained on the changes
prior to start-up.
PSM Documentation -
Technology Use
Consider the Use of
Technology to:
Perform
Document
Track
Adjust
Maintain
The PSM Program
NASA High Pressure Gas
Plant
Management of Change
Case Study
Team Exercise
Nitrogen & Helium Plant
Team Exercise
With the Information to Follow in The
NASA Case Study Video, Presentation &
Notebook,
With Your Team Members, Perform the
Following Exercises & Answer the
Following Questions:
Case Study Exploration
1. When is Management of Change Required?
2. What Authorizations must be Obtained Before Beginning MOC?
3. If A Repair of the Shell Plate of Hydrogen Tank V267-LH Was
Necessary, Would the repair be Governed Under MOC?
4. If the Software Program that Manages the High Pressure Gas
Plant Was Changed, Would the Project be Governed Under MOC?
5. If a Change in the Design of the Piping between the Pumps and
the Tank Was Required by the Recommendations in a PHA,
Would the Project be Governed Under MOC?
6. What Codes might Govern the Change of the Pipe Design?
7. What MOC Team Members Would You Suggest be Involved in the
Re-Design of the Piping Between the Pumps?
We will Discuss the Findings of Each Team in the Class
What’s Next
Are There Procedures Required to
Operate any Covered Process?
Operating Procedures
