Summary Bullets
Failure to identify the need for change
Failure to implement the management of change process
Vulnerabilities inherently increase
Background
A large facility with multiple units processed approximately 100 Management Of Changes (MOCs) each month. The Process Safety Management System(PSMS)Manager for the facility ran the MOC program in addition to being directly responsible for several PSMS elements and being deeply involved in the remaining elements
What Happened
An audit revealed several MOCs had been approved after the physical change had been made. During interviews with the PSMS Manager and others, there was not much concern about this and it apparently had been the norm for years. The prevailing belief was that MOC was satisfactory if the documentation was complete.
How can a facility cope with a large flow of MOCs and still treat each one with the appropriate sense of vulnerability?
How can a facility cope with a large flow of MOCs and still treat each one with the appropriate sense of vulnerability?
Safety Culture Focus
Everyone in the company has the responsibility for safety and following procedures.
A questioning environment is critical to overcoming practices that undermine safety.
Process reviews are necessary to identify weaknesses for continuous improvement.
Safety Culture Focus Note
**Only 37% of those surveyed indicated management of change was a strength in their organization.**
Source File
E.25.pptx
(321.27 KB)