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How Effective Is Your Management of Change System?

June 10th, 2015 · Comments

The Center for Chemical Process Safety (CCPS) defines Management of Change (MOC) as:

“A temporary or permanent substitution, alteration, replacement (not in kind), modification by addition or deletion of critical process equipment, applicable codes, process controls, catalysts or chemicals, feed stocks, mechanical procedures, electrical procedures, safety procedures, emergency response equipment from the present configuration of the critical process equipment, procedures, or operating limits.”

Or as stated by the U.S. Chemical Safety and Hazard Investigation Board (CSB):

“In industry, as elsewhere, change often brings progress.  But it can also increase risks that, if not properly managed, create conditions that may lead to injuries, property damage or even death.” 

On June 1, 1974, the Nypro cyclohexane oxidation plant in Flixborough, England was destroyed by an explosion. There was a release of 30 tons of cyclohexane to the atmosphere that formed a vapor cloud ignited by an unknown source about 45 seconds after the release. The resulting explosion destroyed the entire plant, resulting in the death of 28 people and 89 other serious injuries. The number of fatalities would have been much greater had the accident occurred on a weekday when the administrative offices would have been filled with employees. The damage extended beyond the plant to 1,821 nearby houses and 167 shops and factories; total property damage reached $63 million.

The Flixborough explosion was the result of an unwise plant maintenance modification. In short, there was no MOC process in place, and it was as a result of this incident that the regulators such as HSE introduced MOC as part of Plant Safety regulations (i.e. COMAH in the UK). If an MOC system has been in effect at the plant, the explosion might have been prevented. The MOC system would have called for a proper safety review, adequate approval at all stages of the change process, and a design created by trained professionals.

One of the main recommendations of the Flixborough inquiry was:

“Any modification should be designed, constructed, tested, and maintained to the same standards as the original plant.”

Many of our safety regulations, analysis methodologies, and technologies that we use today have evolved as a result of incidents such as Flixborough, Piper Alpha, Bhopal, and many more.

Thankfully, not all MOC related incidents are as severe as Flixborough, but these minor day-to-day infractions should be a big red flag, as they nevertheless have an impact on an organization.  If not resolved, they are likely to result in far more severe consequences.

MOC and related permit to work activities can be viewed as a burden on Operations and Maintenance personnel who are already working overtime on managing their daily activities of running the facility efficiently. However, MOCs must be implemented in a robust fashion and appropriate resources must be allocated.

The number of MOC a typical plant processes can be summarized in the following statements by Ian Sutton Ref (Process Risk and Reliability Management June 2009

  • 250 MOCs per year for a medium-sized site of say 140 employees
  • 1,000 MOCs per year for a large site of say 2000 employees
  • 1,400 MOCs for a world scale Refinery

How good is your MOC system, and can you safely and efficiently handle the MOCs in your facilities? Take into consideration the following questions:

  1. Can your MOC system provide the following Key Performance Indicators (KPIs)?
    • Percentage of MOCs past due date
    • Percentage of MOCs properly executed
    • Percentage of audited changes that used MOC prior to making the change
    • Number Temporary changes still to be MOC-ed
    • Number MOC performed per month, and monthly average
    • Percentage of work requests classified as a change
    • Percentage or variation in the number of changes processed on an emergency basis
    • Average backlog of MOCs/active MOCs
    • Average time taken between MOC origination & authorization
    • Percentage of work orders/requests that were misclassified as replacement-in-kind (RIK) but should have been MOCs
    • Ratio of identified undocumented changes to number of changes processes by MOC
    • Percentage of changes that were MOC-ed but reviewed incorrectly
    • Percentage of MOCs that were not documented properly
    • Percentage of MOCs for which drawings and procedures were not updated
    • Percentage of temporary MOCs where the temporary conditions were not corrected/restored to original state by the deadline
    • (#MOCs/#MOCs+#changes that by-passed MOC) *100% 
  1. Can you conduct a complete and thorough impact assessment to show all related data and information that needs to be reviewed and re-validated as a result of the proposed MOC (e.g. trip and alarm setting, procedures, LOTO, cause and effect diagrams, etc.)?

If you can confidently answer yes to these questions, you have a robust system in place and are in control. If not, we recommend reevaluating your MOC processes to help ensure your MOC system can effectively and safely process the large volume of MOCs that may flow through your facilities.

This has been a guest contribution by Clive Wilby.

Clive-Wilby-e1430850633639-150x146.jpgClive, Oil & Gas - Expert Practitioner Consultant at North Highland, has forty years of experience working for Owner Operators and Engineering Procurement Contractors in the Petrochemical sector fulfilling engineering, maintenance and project management roles. His passion is helping EPCs and Owner Operators with information and data management for new and existing assets involving operational excellence, integrity management, and process safety.

Tags: DefaultTag · Change Management · Blog Posts

294 - The Power of Shared Definitions

June 17th, 2013 · Comments

Greetings everyone, this podcast recorded while in Winnipeg, Manitoba. For the podcast this week I’d like to share an article written by Terry Mathis, published in February 2013 in EHS Today Magazine.  It was titled, The Power of Shared Definitions. The published article can be found under Insights at

I hope you enjoy the podcast this week. If you would like to download or play on demand our other podcasts, please visit the ProAct Safety’s podcast website at: If you would like access to archived podcasts (older than 90 days – dating back to January 2008) please visit For more detailed strategies to achieve and sustain excellence in performance and culture, pick up a copy of our book, STEPS to Safety Culture Excellence, available through WILEY (publisher), Amazon or Barnes and Noble.

Have a great week!

Shawn M. Galloway ProAct Safety, Inc

Tags: DefaultTag · Articles · Leading Safety · Safety Culture and Performance Excellence Strategy · Safety Excellence Strategy

291 - Safety As a Business

May 27th, 2013 · Comments

Most companies attempt to integrate safety thinking into their business, but forget to integrate sound business thinking into safety. Terry L. Mathis, CEO of ProAct Safety shares an important perspective often ignored in safety. ProAct Safety provides more strategies in the area of safety culture and safety excellence in the public domain than any other firm, organization or association. For access to increased, advanced value in the form of videos, podcasts, public workshops and seminars, please visit

This video can also be viewed at YouTube:

Tags: DefaultTag · Articles · Leading Safety · Safety Culture and Performance Excellence Strategy · Safety Excellence Strategy

Personal Development – The Books I Read April 2013

May 7th, 2013 · Comments

  1. Redirect: The Surprising New Science of Psychological Change by Timothy D. Wilson
  2. It Worked for Me: In Life and Leadership by Colin Powell

And of course please consider adding our book, STEPS to Safety Culture Excellence (WILEY, 2013) to your reading list. -

Happy reading! Shawn M. Galloway ProAct Safety, Inc.

Tags: DefaultTag · Books and Professional Development

Personal Development – The Books I Read May - June 2012

July 15th, 2012 · Comments

1. HBR’s 10 Must Reads on Strategy by Harvard Business Review

2. SEAL Team Six: Memoirs of an Elite Navy SEAL Sniper by Howard E. Wasdin and Stephen Templin

3. Onward: How Starbucks Fought for Its Life without Losing Its Soul by Howard Schultz with Joanne Gordon

4. Failing Forward: Turing Mistakes into Stepping Stones for Success by John C. Maxwell

5. Enchantment: The Art of Changing Hearts, Minds, and Actions by Guy Kawasaki

6. The Know-It-All: One Man’s Humble Quest to Become the Smartest Person in the World by A.J. Jacobs

Happy reading!

Shawn M. Galloway

ProAct Safety, Inc.

Tags: DefaultTag · Books and Professional Development

Personal Development – The Books I Read in July 2011

August 3rd, 2011 · Comments

1. Heaven is For Real: A Little Boy’s Astounding Story of His Trip to Heaven and Back by Todd Burpo with Lynn Vincent

2. Flow: The Psychology of Optimal Experience by Mihaly Csikszentmihalyi

3. The Fountainhead by Ayn Rand

4. 10 Stupid Things Couples Do to Mess Up Their Relationships by Dr. Laura Schilessinger

5. Reward Systems: Does Yours Measure Up by Steve Kerr with Glenn Rifkin

Happy reading!

Shawn M. Galloway

ProAct Safety, Inc.

Tags: DefaultTag · Books and Professional Development

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