Summary Bullets
Failure to question business as usual
Inadequate review process results in potential risks
Background
A specialty chemical facility had several reactors that make various products. When the research group needs to trial a new product or when a new product is launched, a Management Of Change (MOC) was written addressing the introduction of the new products
What Happened
The MOC considered the new feed materials and the processing conditions would be examined. However, it did not normally require the rupture disks be verified to ensure they would adequately relieve the pressure excursions that could occur with the new chemistry. This would only happen when a Process Hazards Analysis was performed and a high-pressure deviation was identified.
What holes exist in this approach?
What holes exist in this approach?
Safety Culture Focus
A questioning environment is essential when managing change to identify potential risks.
Integration of review/analysis processes are necessary to effectively mitigate risk.
Safety Culture Focus Note
**Only 54% of those surveyed indicated risk planning was a strength in their organization.**
Source File
E.24.pptx
(319.89 KB)