(131b) Becoming "Wiser" in Management of Change

An Arabian Proverb identifies four types of people based on their level of knowledge and self-awareness: the fool who is to be shunned; the simple who is to be taught; the sleeping who is to be awoken; and the wise who is to be followed. This proverb speaks to the various levels of experience and potential areas for developmental growth of the process safety workforce. Developing workforce competency is especially important when evaluating a physical, chemical, or parameter change to an existing safe process. In a Management of Change (MOC) program, it is important to establish the known (and unknown) impact of a proposed modification. When changes are evaluated by individuals with sufficient expertise, and self-awareness of the limitations of their expertise, MOC programs can be used to effectively manage new and existing process hazards. Unfortunately, the existence of an MOC program alone does not guarantee that process incidents related to facility modifications will not occur. When post incident investigations find root causes related to process changes, a question commonly raised is: “Why wasn’t this incident’s consequence identified and evaluated through the MOC process?” This paper presents several case studies where process incidents occurred as a result of a modification at a facility despite the application of an MOC process. Cases will highlight critical points within an MOC program where a mistake or lack of knowledge during execution of an MOC can lead to unintentional increased hazards and risks. Corrective actions and lessons learned will be discussed in an effort to improve the overall design, development, implementation, operation, and monitoring of a facility’s MOC program. Through the use of case studies and lessons learned, the authors’ intent is to teach, awaken, and cultivate wisdom in those responsible for process safety management