The Role of Management of Change in Incident Root Cause Analysis

Process units may be designed with safety components that are either prescribed or tied back to a risk-based analysis. Over the life of a unit, modifications to the process, equipment, and/or operational procedures can lead to a reduction or elimination of such safety components and additional safeguards might be required. The primary objective of the Management of Change (MOC) practice in the chemical process industry is to reduce the rate of incidents by evaluating the impact of such modifications on employee’s health, the environment, and equipment integrity based on an updated risk assessment. MOC practice can be considered a decision-making tool to either reject or approve any proposed changes, and to determine if additional layers of protection are required in order to prevent undesired outcomes. However, the lack or improper implementation of an MOC program may result in an undesired event, and also can critically affect the efficacy of the incident root cause investigation. Without the existence of complete MOC records, incident investigations are often forced to rely on more subjective sources, making it much more difficult to isolate the root cause and therefore limiting the ability to make specific recommendations to fix safety gaps. To this end, this paper presents case studies that contrast how well-implemented MOC records can successfully contribute to incident investigations, while in other cases the lack of change histories represents a limiting factor for incident root cause identification and therefore the loss of potential lessons learned. In order to assist companies, this paper will also provide a general overview of MOC systems and show statistics that support the need of such practices.