Environmental

CHAPTER 19

MANAGEMENT OF CHANGE: SECTION 5.1.3 OF 210

Section 5.1.3 in ANSI/AIHA Zl0-2012 is entitled "Design Review iµid Management of Change." As was said in Chapter 15, "Safety Design Reviews," the processes for design reviews and for management of change are major elements in a safety and health management system. Although they have some common characteristic,:s, they are implemented through d jstinctively separate management processes. . ,

One of the reasons that the management ,of cliange process in addressed s_ep~ately is to promote .an understanding and application of the change analysis .concept on which it is based. In this chapter we: . .

• Make the case that having an effective Management of Change System (MOC) in place as a distinct element in a safety and health management system will ~educe the potential for serious injuries and fatalities, one of the focus poi,its In this book. (Effective MOC system~ ._ also reduce the potential for injuries, environmental damage, and other forms of damage at all levels of severity.)

• Intr~~ce the change analysis concept and relate it to the management of change prov1s10ns in ZlO. ,

• Cite statistics in support of having effective MOC systems in place. ' Defi h ne t e purpose and methodology of a management of change system. • ~~ta~lish the significance of management of change as a m~thod to prevent serious

InJunes and fatal 't1' · 1 es.

Second &r afety Management: Focusing on ZJO and Serious Jnji1ry Prevention , © 2014 Jo:::ion. Fred A. Manuele.

Wiley & Sons, Inc . Published 2014 by John Wiley & Sons, Inc.

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360 MANAGEMENT OF CHANGE: SECTION 5.1.3 OF 210

• Outline management of change procedures, keeping in .mind the staffing limitations at moderate-sized locations and their need to avoid burdensome paperwork. 4 ' • •

• Provide guidelines on how to initiate and utilize a MOC system. • Emphasize the significance of communication and training. • Include examples of four management of change systems in place and provide

access to six other real-world MOC systems.

ON CHANGE ANALYSIS

Change analysis is a commonly used process. Inquiry through an Internet search engine will show that the. liter.ature on change. analysis is abundarit. A few examples related to safety follow. OSHA say~ this abou•t change analysis in · Saf;ty, & Health . r , Management System eTool-Worksite Analysis: ' , :

Anytime something new is brought into the workplace, whether it be a piece of equipment, different materials, a new process, or an entirely new building, new hazards may unintentionally be introduced. Before considering a change for a worksite, it should be analyzed thoroughly beforehand. Change analysis helps in heading off a problem before it develops.

In the Aviation Ground Operations Safety Handbook, 6th edition, change analysis is listed within "The .. Risk Management Process" as a ·inethod "to detect the hazard implications of both planned and unplainied change." '(p·. 10) :, In MORT Safety'Assurance·Systems, ,William Johnson makes references to change analysis throughout the book as he discusses applying the "Management Oversight and Risk Tree (MORT)''. In System Safety for the 21st Century, Richard Stephans has a ch'apter entitled "Change Analysis."

Provisions for design reviews and management of change are also contained in other standards and guidelines, perhaps by other names. For example, in Quality management systems-Requirements, ANSIIASQ Q9001-2000,-Section 7.3.7 is titled "Control of design and development changes." It reads as follows:

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Design and development changes shall be identified and records maintained. The changes shall , be -reviewed, . verified and validated1 as appropriate, ,and approved before. iipplemeptation1.The i:eview, of design and <Jevelopment changes

,shall) nclude e,vf11uatip.n of ~e effe~f of the changes on constituent p~ and product already delivered. Records of the results of the review of changes, and any necessary actions shall be maintained.

Change analyses are made to assess the consequences of a change on a broad scale and to provide a' base for planning the change to assure that succes~ is achieve_d and that negative consequence.& are as few as,reasonably practicable. Ch,ange analysis

STUDIES THAT SUPPORT HAVING A MOC S,YSTEM IN _PLACE 361

. th fundamental process on which the MOC provisions .in ZlO are built. Literature :n c~ange analysis is abundant. Throughout the liter11ture, emphasis is given to: ' .

, Pl~ning for the change process, as,in ZlO's Section 4.0 , Attempting to foresee the obstacles that could arise , Repeated communication , Involving all personnel who are affected by the change , Being aware of the normal resistance to change that many ,of the persons involved

may demonstrate and its probable intensity , Going gradually, step by step, if that is .practicable , The additional training that may be required • Appreciating the extent of the culture change that will be necessary if the process

change is to be successful

STUDIES THAT SUPPORT HAVING A MOC SYSTEM IN PLACE

Three significant studies establish that having a management of change system as an element within an operational risk management system would serve well to reduce serious injury potential.

Reviews made by this author of over 1800 incident investigation reports, mostly for serious injuries, support the need for and the benefit of having MOC systems. They showed that a significantly large share of ,incidents resulting in serious · injury occurs:

' ' unusual and nonroutine work is being performed

• In nonproducti.on activities • In at-plant modification or construction operations (replacing a motor weighing

800 pounds to be installed on a platform 1? feet above ~e floor) • During shutdowns for repair and maintenance, and during startups • Where sources of high energy are present ( electrical, steam, pneumatic, chemical) • Where upsets occur: situations going from nbrmal to abnormal

. / . l

Having an effective MOC system in placeciwould have served to reduce the P~obability of serious injuries and fatalities occurring in the operational categories 8 own above.

res~t~dy led by Thomas Krause, chairrn~~ of th~ b.?!11:d at BST in 2011 produ~ed co . s 10. support of having MOC systems in place. (Data were provided in pe~sonal co lllinu~ication with Krau·se. BST is' tb' publish a paper including these data.) Seven fo~Pantes Participated in the study. Shortcomings in pre-job planning, another name fat:{t;nagem~nt of change, were found in 29% of incidents that had serious injury or app y ~otential. Focusing on reducing that 29%, a noteworthy number, would be an

ropnate goal.

362 MANAGEMENT OF CHANGE: SECTION 5.1.3 OF 210

Correspondence with John Rupp at ~uto 'York_ers in Detroit confirmed the continuing history with respect to fata~ttes occumng 1~ UAW~re~resented Work. places. A previously issued UAW bulletin (no long~r available) md1cated that from 1973 through 2007, 42% of fatalities occurred to skilled-trades workers, who repre- sented about 20% of the membership. ·

Additional data provided by Rupp for the years 2008 through 2011 indicated that 47% of fatalities occurred to skilled-trades ~ork~rs. The point is that skilled-trades workers are not in routine production jobs. 'ijiey are often involved in unusual and nonroutine work, at-plant modification or construction operations, shutdowns for repair and maintenance, startups, and where sources of high energy are present. That is the sort of activity for which' a MOC system would be beneficial.

PURPOSE OF A MANAGEMENT OF CHANGE SYSTEM

Although the tenn management of change is not defined in 210, its purpose is clearly established. Appendix H-Management of Change--provides guidance on what the writers of Zl O intended. With respect to operational risks, the MOC process is to assure that

• Hazards are identified and analyzed and risks are assessed. • Appropriate avoidance, elimination, or control decisi9ns are made so acceptable

risk levels are ci9hieved and ~tained throughout the change process. • New hazards are not knowingly brought into the workplace by the change. • The change does not have a negative impact on previously resolved hazards. • The change does not make the potential for harm of an existing hazard more severe. • The occupational safety arid health man~gement system is not affected negatively.

APPLICATION CONSIDERATIONS · . '

In the following list of categories to which the management of change process could apply, subjects oth~r tl}an for the safety of employees are included to demopSttate the breadth of benefits that could be obtained from an effective MOC syStem. Consjderation would be giver\, as ~pplicable, to:

• The safety of employees making the changes • The safety of employees· in adjacent areas I, • The safety of elllployees who will be engaged in operations after changes are made • Environmental aspects • Safety of the public • Product safety and product quality . 1 • Fire protection so as to avoid property damage and business interruption

EXPERIENCE OF OTHERS IMPLIES OPPORTUNITY 363

stated in ES.1.3 in Z 10,. the management of change provisions may apply when As · h l . t ·1·. es are made m tee no ogy, eqmpmen , 1aci ities, work practices and procedures,

chang · t ·al · · al . specificauons, raw ma en s, orgaruzation or staffing changes affecting skill design d .

b·liu·es and standar s or regulations. capa t ' OSHA 's Rule [or Pro~ess Safety M~nagement of Highly Hazardous Chemicals, 29 cFR 1910.119, issued m 1992, requrr~s that an ~pe.ration affected by the standard have a management of change process m place. Similar requirements do not appear in other OSHA standards. . .

However, as shown previously, change analysis (management of change) was an element in OSHA's Safety & Health Management System eTool-Worksite Analysis. Also, having a MOC system in place is a requirement to achieve OSHA's VPP desig- nation (OSHA's Voluntary Protection Program).

ASSESSING THE NEED FOR A FORMALIZED MOC SYSTEM

Useful data can be developed on the need for a formalized MOC system through a risk assessment initiative and a study of an organization's incident experience and that of the industry of wlµch the organization is a part. Workers' compensation claims experience can be a valuable resource for such a· study.

To develop meaningful and m~nageable data, ,it is proposed Jha~ a computer run be made of an organization's claims experience covering at least three years, to select out all claims valued at $25,.000 or more-paid and res~rved. If experieµce in other organizations is a guide, the computer fUn will probably encompass .. b~tw.een 6 and 8% of the total number of claims and from 65 to 80% of the total costs.

An analysis of the data acquired should be ~ade to identify job titles and incidents that have occurred when changes were taking pl~ce, and to determine whether th~ resulting data support proposing a formalized MOC system. If available, industry experience, such as through a trade association, should also be part of the study.

If it is found that very few incidents resulting ' in' serious , injury occurred when changes were being made, that should not deter proposing that the substance of a Moc system be applied for particular changes that present serious injury potential.

EXPERIENCE OF .OTHERS IMPLIES OPPORTUNITY

J0 test Whether personnel in operations other than chemicals had recognized the need ~:~d devel?ped management of change systems, assi~tance ~f ~e st~ at the Ar ncan Society of Safety Engineers responsible for practice ~pecialti~s was soug~t.

f equest was sent to members of the management specialty group asking that copies

0 Moc · procedures for operations other than chemicals be forwarded. The response was overwh 1 · · · d th' e mmgly favorable The number of documents receive was more an cou\ct b ·

Ex e practicably used. . , . . reco a~ples received demonstrate that managements m a variety of operations

gnized the need to have MOC systems in place. Four real-world MOC systems

364 MANAGEMENT OF CHANGE: SECTION 5.1.3 OF 210

are addenda to this chapter. Because of space co~i;ider~ti_ons, all of the examples are not included here. But, as will be shown later, six additional MOC systems can be accessed by going on the Internet. These 10 MOC systems were selected specifically to show:

• The broad range of harm and damage categories covered • Similarities with respect to subjects covered • The enormity of the variations in how those subjects are addressed

These examples are real-world applications that display the substance of MOC systems in place.

HISTORY DEFINES MOC SYSTEM NEEDS AND DIFFICULTIES IN THEIR APPLICATION

At least 25 years ago, personnel in the chemical and process industries recognized the importance of having . a management of change process in place as an element within an operational risk management · system. That awareness developed because of the number of major accidents that occurred when changes were taking place.

In 1989, the Center for Chemical Process Safety issued Guidelines for Technical Management of Process Safety, which included a maqagement of change element. In 1993, the Chemical Manufacturers Association published A Manager's Guide to Implementing arid Improving Management .of Change_ Systems.

In 2008, the <;enter for Chemical Proce~s Safety issued' Guidelines for Management of Change for Pro~ess Safety. It builds. on and considerably extends the previous publications. These comments ap~ear i~ the Preface: ·

I I ! • I ' The concept and need to properly manage chang~ are not new; many com- panies have imple~ented m~nagei:nent of chapge (MOC) systems. Yet inci- dents and near misses attributable io inadequate MOC systems, or to subtle, previously unrecogniz~d sotirces of change (e.g., organizational changes), continue to occur. To improve the performance of MOC systems throughout industry, managers need advic;e on how to better institutionalize MOC systems within their companies and faciliti es andl t~ ~dapt

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' such systems to managing non-traditional sources of change. (p. xiii)

Note th~t incidents and near misses (~ear hits) that are attributable !o, in.adequate MOC systems continue to occur. Also, recognition is given to organizational chan~es as a pre~iou~ly unreco~nized so~rce from which maqagement of change difficulties could anse. Authors of the Guidelines recognized that:

Management of Chang~ ,is one of the most important elements of a process safety management system. (p. 1) ·

THE MANAGEMENT OF CHANGE PROCESS 365

ntE MANAGEMENT OF CHANGE PROCESS

. the case with all management systems, an administrative procedure must be As_ is to communicate what the management of change system is to encompass and wntt~tn·s 10 operate. Care should be taken to assure that the MOC system is designed hOWl 1 • to be compatible with:

, The organization's and industry's inherent risks , Other relevant management systems in place , Toe organizational structure , Toe dominant culture , Toe expected participation of the workforce

Although brevity is the goal, consideration should be given to the following as subjects are selected for inclusion in a MOC procedure:

I. Defining the need for and the purpose of the MOC system 2. Establishing accountability levels 3. Specifying the criteria that are to trigger the initiation of formal change requests 4. Making clear how personnel'are to submit change requests, and specifying the

change request form to b~ used 5. Outlining the criteria f9r request reviews and the responsibilities for reviews

' . 6. Indicating that the f'4OC system is to encompass:

a. The risks to the workers who are to do the work and other employees who are affected

b. Possible damage to the property, and business interruption c. Possible environmental damage d. Product safety and quality e. The procedures to ·accomplish the change

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f. How the results are to be evaluated 7. Establishing that minute-by-minute . control · is to be maintained to achieve

acceptable risk levels, ,and that risk assessments will be made as often as necessary as the work progresses ,.

8· Giving instruction on the action to be taken if, as the work proceeds, unanticipated risks of concern are encountered

9 · ~ssigning responsibility for acceptance or declination of the change request,

Including MOC approval form IO, Outlining a method to determine the actions necessary because of the effect of the

changes (e.g. , additional training of operators and maintenance workers; revision

11 of standard operating procedures and drawings; updating emergency plans)

· 1ndicating that a final review of the work will take place before startup of operations, and identifying the titles of the persons who are to make the review

366 MANAGEMENT OF CHANGE: SECTION 5.1.3 OF 210

RESPONSIBILITY LEVELS

In drafting an MOC system, responsibility levels must be defined ~d be in accord With an entity's organizational structure. This is a highly important step m ~eveloping a MOC system. In an entity where even minor chapges in a process are considered critical with respect to employee injury and illness potential, possible environmental contamination and the quality and safety of the product, the levels of responsibility can be many. '

Responsibility levels are set forth clearly in some examples of MOC systems, but not in others. Examples of levels of responsibility, as outlined in an organization where the inherent hazards require close control, are shown here as reference points in drafting MOC systems.

Initiator: The initiator owns the change and is r~ponsible for initiating the change request form. If the complexity of the proposed change requires, the initiator's responsibilities may be reassigned at any time d~ng the change process. The initiator will fully describe and justify changes, ensure that all appropriate depart- ments have assessed the changes, manage the execution of the change request, and ensure that the changes are implemented properly.

Department Supervisor: The department supervisor has ·the responsibility to assign q~ed personnel to initiate change requests. The change control process is criti- cal to the safety of our employees, an av9idance of ~nvironmental contamination, and the quality of our products. The departmental supervisor is responsible to ensure that the change request is feasible, and presented adequately for review.

Document Reviewers: Document reviewers will review and approve change request forms. The review/approval activities include a review of the document for accuracy and adequacy with respect to the changes proposed.

Approvers: Department managers will select pre-approvers with expertise-related to the nature of the proposed change. Each reviewer will be responsible to evaluate and assess the impact of the proposed change on existing processes in his or her area of expertise. The reviewers must also review and approve the change request form and the implementation plan to evaluate the change and assure that the steps for implementation are appropriate. This is the final 'review before the proposed change is implemented.

Pos!-lmplementation Approvers: Department managers will select post-implemen~ti~n ~~ers who are to assure that the change has been implemented appropnate Y as m<licated when approval for the requested change was given This process is also

assure that only the changes shown on the change requ~t form have been lillplemented.

ACTIVITIES FOR WHICH THE MOC PROCESS SHOULD BE CONSIDERED .

Hazard· and ·risk c 1 · · ak place . . . omp exities of an organization in which change is to t e Jy and the desirability of establishing a MOC system that is adequate but not o~e\r complex should be kept in mind when selecting the activities that are to trtgg

MANAGEMENT OF CHANGE REQUEST FORM 367

. . g the MOC system (see Appendix Hin ZlO). A list follows from which acuvaun 1 d . . categories can be se ecte . ac11v1ty

, Non-routine and unusual work is to be performed , The work exposes employees to sources of high energy , rypes of maintenance operations for which pre-job planning and safety reviews

would be beneficial because of inherent hazards , Substantial equipment replacement work , Introduction of new or modified technology , Modifications are made in equipment, facilities, or processes , New or revised work practices or procedures are introduced , Design specifications or standards are changed , Different raw materials are to be used , Modifications are mad~ i_~ he~ih ~nd safety devices ~d equipment • Significant changes occu~ in the site's organizational structure • Staffing changes in numbers or skill levels are made that may affect operational risks • A change is made in the use of contractors

MANAGEMENT OF CHANGE REQUEST FORM

Developing a management of change request form is a necessity, and the content of the form should be in concert with an organization's structure and other management systems in place (e.g., capital expenditure request, work orders, purchasing proce- dures). Saving the form as a computer file allows flexibility when descriptive data and comments are to be added. A list follows of subjects to be considered in drafting the request form.

' Name of person initiating the request. ' Date of request. ' Department, section or ~ea. ' The equipment, facility, or processes affected ' Brief description of the proposed change and what is to be accomplished by it. : Potential performance, safety, health, and environmental considerations.

litles and space for entering the names of personnel who are to review the change. ' The effect the change may have on standard operating procedures, maintenance,

and training, etc. I s , Pace for reviewers to enter special conditions or requirements. , Approvals and authorizations.

Routin . d' . t g in tcators or provisions for copies to be sent to personnel responsible or trainin d • · g an updaung operating procedures, drawmgs, etc.

368 MANAGEMENT OF CHANGE: SECTION 5.1.3 OF 210

Management or Change Request Form

General Information Date Originator

Department

Sent to: Equipment, facility or process effected Urgency of change: _Emergency _Priority

_Routine

Basis for the Change (Check those applicable) _ Improved safety-risk reduction _ Improved performance-efficiency _ Pollution prevention-waste minimization

_ Essential to operation ' Other -

Description of Proposed Change and Potential Hazards ' } Summarize the technical basis for the proposed change and any potential safety, health, or environmental impacts from the proposed change. Describe how the change will affect SOPs, maintenance, training, etc. State the change start _and end dates.

Approved or disapproved by

Name and date Organization/Position

Comments L

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- -

FIGURE 19.1

Figure 19.1 is an example of a management of change request form . Others maY be found in some of the examples in the addenda to this chapter. As would be expe~ted, each form was developed to reflect the views and needs of a particular organizauon.

IMPLEMENTING THE MANAGEMENT OF CHANGE PROCESS · ·tude of

Senior management and safety professionals must appreciate the magni t the task they face when initiating activity to implement a MOC system, E,xpe: pushback: egos get in the way; territorial prerogatives may be maintained ; t e . tance to power structure may present obstacles; and the expected and normal rests 'th change can be huge since the people affected may have had little experience wt the administrative systems being proposed.

IMPLEMENTING THE MANAGEMENT OF CHANGE PROCESS 369

Although MOC sy~tems have _been ~uired in the 'chemical industries for many the literature indicates that difficulties have been encountered in their application. co(llJllents occur in Guidelines for Management of C~nge for Process Safety:

Even though the concept and b~n~fi~s of managing change are not new, the aturation of MOC programs w1thm industries has been slow, and many com-

;anies still struggle with implementing effective MOC systems. This is partly due to the significant levels of resources and management commitment that are required to implement and improve such systems. MOC may represent the biggest challenge to culture change that a company faces . (p. 10)

Developing an effective MOC system may require evolution in a company's culture; it also demands significant commitment from line management, depart- mental support organizations, and employees. (p. 11)

Management commitment, evidenced by providing adequate resources and the leadership required to achiyv,e the necessary culture change, must be emphasized. Stated or written management commitment that is not followed by providing the necessary resources is not managemynt commitment. Be.cause of the magnitude of the procedural revisions, necessary when a. MOC system is initiated, it must be recognized that methods to achieve a culture change are to be applied. A list follows of subjects to be considered in an attempt to successfully implement a MOC/Pre-Job Planning system.

• Management commitment and leadership rhust be obtained and demonstrated. That means providing personal direction and involvement in initiating the pro- cedures, providing adequate resources, and making the appropriate decisions to achieve acceptable risk levels when there is .disagreement in the change review process.

' Keep procedures as simple as practicable. A less complicated system that is actually utilized achieves better results that an unused complex system.

' A goal is to obtain widespread acceptance and commitment ' Communicate extensively. Infonn all affected employees in advance of a decision

to ini~ate an MOC system, solicit their input, and respect their perspectives and concerns.

' Recognize the need for and provi'de the necesJary training. ' If practicable, go sl~~-step by step. ' Field-test a system prior t~ implementation. Debugging pays off in the long run. ' After the system is refined through a field test, select a job or an activity for which

a Moc system would be beneficial for both productivity/efficiency and safety. ' Tbe purposes of testing the MOC system in a selected activity are to:

' Demonstrate the value of the system • Achieve credibility for it , . ' Create a demand for additional application of the system

370 MANAGEMENT OF CHANGE: SECTION 5.1.3 OF 210

• Emphasizing the potential efficiency ben~fit of a_ MOC system i~ encouraged, Doing so should result in more favorable interest m the system bemg proposed.

• Monitor the progress and performance of the system through periodic audits and through informal inquiry of employees on their perspectives.

MANAGING ORGANIZATl(?NAL CHANGE

In some of the examples given in this chapter, procedures require that risk assessments be made of the significance of organizational changes. Those procedures exist because it has been recognized that organizational and personnel changes can have a negative impact on the effectiveness of an operational risk mahagement system.

Although there is considerable literature on the subject, I have chosen Managing the Health and Safety Impacts of Organizational Change as a reference because it fits closely with the intent of some of the examples of MOC system included in this chapter. The publication was issued by the Canadian Society for Chemical Engineering in 2004. It can be accessed, and downloaded at no cost, at http://psm.chemeng.ca/ Products/OCM_Guidelines.pdf.

Types of organizational and personnel changes that can have a negative effect on operational risk management, as lis(ed in this publication, follow:

• Reorganizing or reengineering • Downsizing the workforce • Attrition and aging of the workforce • Outsourcing of critical services • Changes that affect the competence or performance of other organizations

providing critical services under contract (e.g., equipment design, process control software, hazard and risk assessment)

• Loss of skills, knowledge, or attitudes as a result of the above

Such changes, the authors say, are not as well addressed in applicable guidelines as a,re changes ii) equipmynt, tools, work methods, and processes. The purpose of the publication is to promote what is considered to be the appropriate d~msideration ..

I now give more emphasis to· the impact of organizational changes on operation~ nsk management because incident ryports on some serious injuries and fatalities indicate that a significant contributing factor was a reduction in staffi~g, as to both number

0 ~

employees and talent level. As a result, unacceptable risk situations developed for such as.

• Inadequate maintenance • Inadequate competency • W~rkers being stressed beyond their mental and physical capabilities (tw0 persons

domg the work for which three had previously been assigned) . • A person working alone in a high-hazard situationfor which the standard operaung

procedure calls for a work buddy

THE SIGNIFICANCE OF TRAINING 371

RISK ASSESSMENTS

Of the MOC examples require that risk assessments be made at several stages of some Th . . hi the change activity. e mteThnt is ~okac eve and maintain acceptable risk levels thfOughout the work proc~s. us, ns assessments are to be made as often as needed

changes occur and particularly when unexpected situations arise. In this regard, ~ety professionals who beco~e ~killed in making risk assessments can provide a consultancy that demonstrates s1gruficant value added.

Appendix F, Risk Assessment, in Z 10 is a valuable resource. In addition, a recently developed American National Standard is recommended as a reference on risk assessment. ANSI/ASSE Z590.3 is titled Prevention through Design: Guidelines for Addressing Occupational Hazards and Risks in Design and Redesign Processes. This standard was approved by ANSI on September 1, 2011. Risk assessment is its core. Its content is applicable to management of change whether the contemplated change involves new desigris or redesign of existing operations. Of particular interest should be the sections on:

• Relationships with Suppliers • Safety Design Reviews • The Hazard Analysis and Risk Assessment Process • Hai.ard Analysis and Risk Assessment Techniques • Hierarchy of Controls

RISK ASSESSMENT MATRICES

In Z590.3, the use of a risk assessment matrix in the risk assessment process is strongly recommended. It is also emphasized that all involved ~n risk assessments arrive at a common understanding of the meanings of the terms used in the matrix. Severat examples of matrices are given in a 2590.3 addendum. . An example of a matrix is available in Chapters 2 and 11. It was selected because 11

was preferred by operating employees who were brought intp the risk assessment Process. They said that establishing a mental relationship between numbers such as 6 and 12, first made it easier to understand the relation between terms such as Mocte · ' · rate Risk and Serious Risk.

THE SIGNIFICANCE OF TRAINING

1'o emphasize the significance of training in achieving a successful MOC system, ref-erence. S .~ 18 made again to the Guidelines for Management of Change for Process aJety.

1'rainin c • • t d g 10r all personnel is critical Many systems fatled or encoun ere severe ProbJe bee · 1 h . ms ause personnel did not understand why the system was necessary, ow It Worked, and what their role was in the implementation. (p. 58) ,

372 MANAGEMENT OF CHANGE: SECTION 5.1.3 OF 210

The culture change necessary to put a successful MOC system in place cannot b achieved without a training program that helps supervisors and workers understa : the conc~pts to be appl~ed. ~ere the MOC system ~lates to many risk categori:s ( occupational, the pubhc, envrronmental, fire protection and business interruption product quality and safety), the training provided must be more extensive. '

I would like to avoid the impression that training is not of great importance because of th~ brevi~ of the comment_g made h~re on the subj~t. ~t i_s a near ~~solute certainty that mstallatmn of MOC/pre-Job planrung systems will frul 1f the trrurung given is not appropriate to the significance of the changes to be made.

DOCUMENTATION

The importance of maintaining a history of operational changes needs emphasis. It is vital that all ,modifications be recorded in drawings, prints, and appropriate files. They become the historical records that would be reviewed when changes are to be made at a later date. Comments on changes made that were not recorded in drawings, prints, and records are found too often in reports on incidents resulting in serious consequences. Examples found in incident investigation reports of unrecorded changes include the following:

• The system was rewired. • A blank was put in the line. • Control instruments were disconnected. • Relief valves for higher pressures had been installed. • Sewer line sensors to detect hazardous waste were removed.

ON THE MOC EXAMPLES

To display the substance and variety ·of the MOC systems that organizations have in place, very little change was made in the examples that I received. They Va:'J greatly in content and purpose. Some are contained in one page. Others require several pages to cover the complexity of exposures and procedures. Some M~C procedures have introductory statements on policy and ' procedure. Some don t. Nevertheless, it is apparent that a MOC system need not necessarily have to meet a theoretical ideal to provide value. th

Examples are to serve as references. It is highly re\:ommended that none 0 ~i; examples be adopted as presented. A MOC system should be drafted in accord an organization's particular needs and its culture. , fthe

As each of the MOC examples was reviewed, it became apparent that some O rms terms used in them were not readily understandable . But more than likely, the t~ded are understood in the orga~zation µiat develope~ the MOC ~ystem. It w~s ~:Cly is to leave those terms in the examples to emphasize ,that: whatever terrruno gage included in a MOC procedure, the tei:m.'s 'must be i,n concer,t with the la:tu all commonly used within an organization; and the terms 'must be understoo Y who become involved in a MOC initiative.

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ON THE MOC EXAMPLES 373

Four examples are included in this chapter as addenda. They are designated MOC Examples 1, 3, 4, and 10, the designations given to them in the total of 10 MOC systems available.

Access to six other MOC systems, some of which cover several pages, can be btained at www.asse.org/psextra. This is an American Society of Safety Engineers site

;or which open access is provided. An earlier and briefer version of this chapter was published in the July 2012 issue of Professional Safety . Click on "Professional Safety ExtraS," scroll down to Archives, and go to July 2012. You can click on supplemental material for my article and bring up 43 pages of MOC system examples.

Example 1: For An Operation Producing Mechanical Components Toe Pre-Job Planning and Safety Analysis system shown in Example 1, a one-page outline, was developed because of adverse occupational injury experience in work that was often unusual or one-of-a-kind or required extensive and complicated main- tenance activity. (Example 1 is an addendum to this chapter.) .

Its relative simplicity in relation to other examples will be obvious. But it was applied successfully for its purposes. It would be well to note that safety professionals:

• Prepared the data necessary to convince management and shop floor personnel to try the pre-job planning system they prl?posed

• Said that the training sessions held were highly significant in achieving success • Emphasized that work situations discussed in the training sessions were real to

that organization • Addressed the benefits for both productivity/efficiency and risk control in their

proposal and in the training sessions ,

For whoever initiates a MOC system, the procedure described in the following will be of interest.

At a location where the serious injury experience was considered excessive for non-routine work, safety professionals decided that something had to be done about i~. As they _prepared a course of action and talked it up at all personnel levels, from top management down to the worker level, they encountered the usual nega- tives and push-back: e.g., it would be time consuming, µte workers would never buy into the program, and the supervisors would resist the change. The safety pro- fessionals considered the negatives as normal expressions of resistance to change.

Their program consisted, iri effect, of indoctrinating management and the workforce in the benefits to be obtained by doing pre-reviews of jobs so that lbe work could be done effectively and efficiently while, at the same time, controlling the risks.

~ventually, management and the line workers agreed that classroom training sessions could be held. Later the safety professionals said that the classroom tr ' ' ' aining sessions and follow-up training were vital to their success. . At the beginning of each of those sessions, a management representative introduced the subject of Pre-Job Planning and Safety Analysis and discussed

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MANAGEMENT OF CHANGE: SECTION 5.1.3 OF 210 374

reasons why the new procedure was being adopted. Statistics. on accident perience prepared by safety professionals were a part of that mtroduction.

~en, safety professionals led a discussion of the _outline_ shown in MOC Example J. It set forth the fundamentals of the pre-Job review sy~t~m being proposed. After discussion of those pr~edures, a~endees were d1v1d~ into groups to plan real-world scheduled maintenance Jobs that were descnbed in scenarios that had previously been prepared.

At this location, supervisors took to the pre-job planning and safety analysis system when they recognized that the system made their jobs easier, improved productivity/efficiency, and reduced the risks. And they took ownership of the system. As one of the safety Pr<?fessionals said: "Our supervisors and workers have become real believers in the system." A culture change had been achieved.

· Note the requirements under the caption 'Vpon Job Completion" in the Pre-Job Planning and Safety Analysis Form. The detail of the requirements reflec~ particular incidents with adverse results thai occurred over several years. It is recommended that every MOC system include similar procedures to be followed before the work can be considered completed.

Example 2: Specialty Construction Contractor This Field Work Review and Haz.ard Analysis system is encompassed within twci pages. It was provided by a safety professional ·employed by a specialty construction contractor that has several crews active in various places at the same time. Note that the names of employees on a job are to be recorded as having been briefed on the work to be done. The checklist included in the form pertains to occupational, public, and environmental risks.

When asked what gave impetus to the development of the change procedure, the safety professional responded "We learned from costly experience." It was said that the procedures required by the change system are now embedded in the company's operations and that it is believed that the procedure results in greater efficiency. It is known that fewer costly incidents have occurred.

This example has a direct relation to the purposes of ANSI/ ASSE 10.1, a standard for construction and demolition operations entitled Pre-Project & Pre-Task Safety and Health Planning. This standard is an excellent resource for contractors and for 0:g~niz~tions that establish requirements contractors on their premises. Note tbe d1stmc11,ons: Pre-Project Planning and Pre-Task Planning.

Example 3: Form for An Operation That Has Had Serious Injury Experience , Thi ' th s Pre-T~kAn~ysis form makes much of obtaining required permits and of assuring ::;u:_ervisors bnef emp!oyees on the order of activities and of the risks to be encoun-

h te · mploye<:s are requrred to place their signatures on the form indicating tha

t tbeY

ave been so bnefed Thi · th ' Jedge b th . . · s is e only example requiring employees to ackn°W ' Y e;r signatures, !hat they have been informed about hazards and risks prior to tbe

start o work. (Example 3 is an addendum to this chapter.)

ON TH E MOC EXAMPLES 375

example 4: Paper Setting Forth a Management p0IICY and Procedure This is a basic guidanc_e paper on MOC concepts and procedures, conde nsed to three ages It is a composite of several MOC policies and procedures · 1 • d p . . . . . 10 p ace iss ue

by organizauons 10 which o~,eratlons_ were not highl y complex. Reference is made in this example to a M<;><? . Champmn ." The point made is that someone has to be assigned the resp~ns1b1hty fo_r the change to be accomplished and manage it thfough to an appropnate conclus10n. (Example 4 is an addendum to this chapter.)

example 5: MOC System With a Specifically Defined pre-Screening Questionnaire

This MOC system, in three pages, begins with an interesting pre-screening ques- tionnaire. If the answer is "No" to all the questions asked, the formal management of change checklist and approval form need not be completed for the work being proposed. The question often arises in discussions of management of change systems: To what work does the system apply? 1bis organization developed a way to answer that question for its own operations.

Example 6: High-Risk Multiproduct Manufacturing Operation This Management of Change Policy and Procedure reflects the high hazard levels in the organization. Captions in this four-page system are safety; ergonomics; occupational health; radiation control; security/property loss prevention; clean air regulations; spill prevertion and community planning; clean water regulations ; solid and hazard waste regulations; environmental, safety, and health management systems; and an action item tracking instrument. The following appears in the procedure paper announcing the system:

If a significant change occurs with respect to key safety and health or environ- mental personnel, the matter will be reviewed by the S&H Manager and the Environmental Manager and a joint report including a risk assessment and their recommendations will be submitted to location manag~ment.

Example 7: Food Company This four-page Management of Change policy includes produc~ safet_y and_ pr~uct quality among the subjects to be considered . Detail on the su~Jects hsted !s highly techni~al and extensive. The safety director at this loc~tio_n _10formed t~s author that discipline in the application of this MOC system 1s ng1d a_nd that It reflects management's determination to avoid damaging incidents affect.mg personnel and the environment and variations in product quality and taste. Provisions for pre-StartuP and post-modification are extensive. A risk assessment is to be made after changes are made and prior to startup.

376 MANAGEMENT OF CHANGE: SECTION 5.1.3 OF Z10

Example 8: A Conglomerate

Iota Corporation bas a five-page management of change procedure outlined in four sections. It is worthy of review.

Section I requires completion of a Change Request and Tracking System Requirements form in which the change is described, a tracking number is assigned, and approval levels are estab~sbed. Approval levels are numerable, including headquarters in some instances.

Section II outlines a Change Review and Approval Procedure that is extensive with respect to occupational safety and health and environmental concerns.

Section ill is a Pre-Implementation Action Summary Form which lists subjects for which actions are necessary before work on the change can be begun, and the persons responsible for those actions.

Section IV lists 11 points in a Post Completion Form.

Example 9: An Extensive MOC System for a Partlcular Operation Reading this Management of Change standard is recommended for educational purposes because of its structure and its content. It is somewhat different in relation to the other examples. In its seven pages:

• Requirements for technical changes and organizational changes are dealt with separately and extensively.

• Much is made about organizational changes for which risk assessments are required. • Technical changes to which the standard applies are outlined in detail. • Risk assessment is a separately listed item pertaining to all operations. • After a lengthy discussion of general considerations, requirements for a six-point

management of change standard are outlined. They are: Management Process; Capability; Change Identification; Risk Management; The Change Plan; and Documentation. Each of these subjects is discussed thoroughly.

This is a concept and procedural paper. It does not include the forms used to imple- ment the procedures.

Example 10: An International Multloperatlonal Entity

Application of this MOC system, a Management of Change Policy for Safet_y and Environmental Risks, extends the activities of safety and environmental professionals beyond that of any other example. It is an informative read. The example shown here covers 10 pages. (Example 10 is an addendum to this chapter.) The bulletin, issued by the Safety and Industrial Hygiene entity within the organization, is much longer th.~ is shown here. All exhi~its could not be made available for proprietary reasons. Bne comments follow on the unique aspects of this MOC system.

D D ·1 · · · J · • nmental • ue 1 1gence 1s me uded m a list of Definitions. Safety and env1ro · professionals are to assess acquisitions et al.

REFERENCES 377

, Global franchise Management B?ard M~mbers are listed under "Responsi- bilities." They are to ensure comphance with the standard.

, A Preliminary Environmental, Safety & Health Assessment Questionnaire shall be initiated during the project planning stage.

, Under a Section titled Evaluating Change (Risk Assessment Guidelines) these subjects are included, which may not be included in other examples, at least not as extensively: , New Process Product and Development , Capital Non-Capital Project , External Manufacturing , Business acquisitions , Significant Downsizing/Hiring

, Conducting Risk Analyses is a major section.

This is a noteworthy MOC system because of its breadth. It is interesting that the system was issued by the Safety & Industrial Hygiene unit. That implies management support for personnel in that unit and superior operational risk management.

CONCLUSION

It is the intent of this chapter to provide a primer that can serve as a base from which a MOC system suitable for a particular entity can be crafted. I recommend that safety professionals consider whether the organizations to which they give counsel could benefit from having MOC systems within their overall Operational Risk Management Systems. Having such a system in place for changes that should be pre-studied because of their inherent hazards and risks and which may affect the safety, productivity, and environmental controls is good risk management.

REFERENCES

A Mana?ers Guide to Implementing and Improving Management of Change Systems. ~ashi?gton, DC: Chemical Manufacturers Association (now known as the American

hemistry Council), 1983. ANSI/AIHA 210 . . . M -2012. Amencan National Standard, Occupational Health and Safety

. anagement Systems. Fairfax, VA: American Industrial Hygiene Association, 2012. ASSE is now the se · · • ANS cretanat. Available at https://www.asse.org/cartpage.php?link=z 10_2005. /A~Q Q900l-2000. Quality Management Systems-Requirements Milwaukee, WI:

mencan Society for Quality 2000 A.Nsu • ·

H ASSEZS90.3-20l 1. Prevention Through Design: Guidelines for Addressing Occupational s; ~rt/Es an_d Risks in Design and Redesign Processes. Des Plaines, IL: American Society of . e Y ng10eers, 20 I I.

Aviation G . . round Ope ra11ons Safety Handbook, 6th ed. Itasca, IL, Nauonal Safety Council. 2007.

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378 MANAGEMENT OF CHANGE: SECTION 5.1.3 OF 210

Guidelines for Management of Change for Process Safety. Hoboken, NJ: A joint public . of the Center for Chemical Process Safety of the American Institute of Chemical Engin ation (New York) and John Wiley & Sons (Hoboken, NJ), 2008. eers

Guidelines fo r Technical Management of Process Safety. New York: Center for Chemical Process Safety, I 989.

Johnson, William. MORT Safety Assurance Systems. Itasca, IL: National Safety Council 1980. (Also published by Marcel Dekker, New York.) '

Managing the Health and Safety Impacts of Organi;:ational Changes. Ottawa, Canada· Canadian Society of Chemical Engineering, 2004. Accessible at http://psm.chemeng.c~ Products/OCM_Guidelines.pdf.

OSHA 's Rule/or Process Safety Management of Highly Ha;:ardous Chemicals. 29 CFR 1910.119. Washington, DC: U.S. Department of Labor, 1992.

OSHA's Voluntary Protection Program (VPP). Section C. in CSP 03-01-002-TED 8.4, Voluntary Protection Programs (VPP): Policies and Procedures, 2003 . At http://www.oshagov/pls/ oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=2976.

ANSUASSE AI0. 1-201 I. Construction and Demolition Operations: Pre-Project & Pre-Task Safety and Health Planning. Des Plaines, IL: American Society of Safety Engineers, 201 I.

Safety & Health Management System eTool-Worksite Analysis. U .S. Department of Labor, OSHA, at http://www.osha.gov/SLTC/etools/safetyhealth/comp2.htrn1.

Stephens, Richard A . System Safety Jorthe 21st Century. Hoboken, NJ: Wiley, 2004. (This is an updated version of System Safety 2000, by Joe Stephenson.)