Root Causes of MOC System Failures and Industry Best Practice Solutions

Management of Change (MOC) failure is a frequent root cause of accidents.  But it is not enough just to identify MOC as a root cause; it is important to implement sustainable corrective actions to reduce the chance of future MOC failures.  To do that, it is necessary to examine the deeper root causes and cultural causal factors of MOC failures.  This paper will present an approach for evaluating MOC failure modes, including design, rollout, implementation, and monitoring failures.  Results from evaluating 100+ MOC systems will be summarized.  This paper will also present the result of industry benchmarking of MOC effective practices and design and implementation efforts.   Suggestions for MOC leading indicators and management review focal points will be given.