INTRODUCTION
Major
incidents such as fires, explosions and the release of toxic chemicals that
cause fatalities, damages to the environment as well as to the facilities are
real threats to the process industries. Unfortunately, such major incidents are
becoming incrementally harder to control with the increasing scale and
complexity of the modern chemical process industries (CPI). Large scale
incidents like those in Flixborough (1974), Saveso (1976) and Bhopal (1984)
caused much grief and are major tragedies that have forever altered the process
industry landscape and have led to widespread changes in regulations and
development of standards and management systems. As a result, In 1992, OSHA had
published the PSM regulations to provide standards that covered processes to
obtain and evaluate data regarding contractors' health and safety programs as
well as the contractors' performance evaluation.
DEFINITION OF
PSM:
The
purpose of process safety management is to prevent or minimize the consequences
of releasing hazardous chemicals in a facility or the environment surrounding a
facility. Hazardous chemicals are those that may be toxic, reactive, flammable,
explosive, or a combination of these properties. Industries handling hazardous
chemicals are required to develop an effective PSM program that protects
employees, contractors, and visitors of the facility. These industries
include: petrochemical, pharmaceutical, paints, adhesives and sealants,
food processing, industrial organics and inorganic, and paper mills.
ELEMENTS OF PSM:
The
process safety management program is divided into 20 elements as follows:
- Management
Review and Continuous Improvement
- Auditing
- Measurement and
Metrics
- Incident
Investigation
- Emergency
Management
- Conduct
Operations
- Operational
Readiness
- Management of
Change
- Training and
Performance Assurance
- Contractor
Management
- Asset Integrity
and Reliability
- Safe Work
Practices
- Operating
Procedures
- Hazard
Identification and Risk Analysis
- Process
Knowledge Management
- Stakeholder
Outreach
- Workforce Involvement
- Process Safety
Competency
- Compliance with
Standards
- Process Safety Culture
MOC:
Management
of Change (MOC) is a best practice used to ensure
that safety, health, and environmental risks and hazards are
properly controlled when an organization makes changes to their facilities,
operations, or personnel. Having a properly implemented MOC policy in
place when implementing changes can help ensure that new hazards aren’t
introduced and the risk levels of existing hazards aren't being increased. Inadequate
MOC on the other hand has the potential to increase risks to the health and
safety of employees and the environment.
When is MOC used…?
- Generally, a
business need or opportunity becomes a project or business solution and
requires changes in the workplace that can affect processes, systems,
people, or organizational structure. Think about whether implementing this
change improves your safety program and makes good business sense.
- One
obvious benefit Management of Change gives is avoiding the consequences of
unforeseen safety and health hazards through planning and coordinating the
implementation of change in your facility. This is why Management of
Change is required in the PSM rules when highly hazardous chemicals are
used.
- While
MOC is generally used to examine the effects of a proposed permanent
change to a facility, temporary changes should not be overlooked. A number
of catastrophic events have occurred over the years due
to temporary changes in operating conditions, staffing, etc. For this reason,
an effective MOC program should address all changes that could affect the
safety of a facility or personnel, regardless of whether or not it
is permanent.
What are the benefits of MOC…?
•
It minimizes unplanned adverse impacts on system integrity, security,
stability, and reliability for the business process being altered or added.
•
It maximizes the productivity and efficiency of staff planning,
coordinating, and implementing the changes.
•
It provides a stable production environment.
•
It ensures the proper level of technical completeness, accuracy of
modifications, and testing of systems before implementation.
•
It provides an appropriate
level of management approval and involvement.
What is a Change…?
The MOC
procedure must clearly define when it is and is not applicable. The site MOC
procedure could be applicable to any change involving:
- Plant: adding
or removing plant hardware.
- Processes: changing the plant control.
- People:
changes to the organization supporting the plant.
§
Procedures: changes to operating procedures.
TYPES OF CHANGE THAT MAY BE EXCLUDED
FROM THE MOC PROCESS:
REPLACEMENTS
IN KIND (RIK):
Where an
item is replaced with an identical item, usually in the course of routine
maintenance, it is a direct like-for-like replacement.
v THOSE COVERED BY ALTERNATIVE PROCESSES:
Where
other specific and documented processes exist on site to manage specific
changes, the MOC process will not be applicable. Common examples of these
are:
1)
Larger projects or modifications, usually where designed and
executed by a projects function.
2)
Certain (defined) changes in feed stock to the site or defined
changes to operating modes.
3)
Instrument or control system changes within defined parameters.
4)
Changes or updates to operating procedures.
5)
Organizational changes.
·
The MOC process should apply equally to both permanent and
temporary changes. In the case of temporary changes, the process must ensure
that a clear time limit for the validity of the change is defined. After this
time, the change should be properly reviewed and either granted an extension,
be managed as a permanent change, or reverted to original condition.
·
The MOC process must apply to the removal of plant items or safeguards
as well as their addition.
·
For plants that operate on a continuous basis, the process must
define how emergency changes are managed – often known as emergency management
of change (emergency MOC) – and how it is followed up by the days-based
organization.
Although
this list is not exhaustive, some typical changes that should be covered by the
site MOC process unless covered by another process are:
•
Any alteration to the plant that makes a change to the piping and
instrumentation diagrams (P&IDs).
•
Physical changes in the piping configuration, whether or not a
P&ID change occurs.
•
Changes in materials of construction.
•
Changes to relief valve type or manufacturer, whether or not a set
point/size change occurs.
•
Changes to pump type, manufacturer, or impeller size or speed.
•
Additions or removals to insulation or change of insulation type.
•
Changes to plant structures, such as platform types,
materials of construction, or fireproofing.
materials of construction, or fireproofing.
•
Electrical hardware changes in zoned areas.
•
Alterations in control system hardware, such as changes to valve
manufacturer, type, or trim.
•
Changes to process control software, ESD logic, and alarm and trip
settings.
•
Changes (new supplier, type, increase, or decrease in rate) to
process control chemicals or changes to process gases.
•
Feedstock source, supplier, and quality changes.
•
Product quality changes, including changes to product additives.
•
Changes to operating modes, operating conditions, or operating
envelopes.
•
Changes to key spares suppliers (maintenance spares, lubricants,
and so on).
•
Suppliers of spares, lubricants, chemicals, and consumables.
The Contribution of MOC to Process
Safety incident in the CPI:
CPI is
often challenged with their operational excellent practices priority in safe
operating process. Due to the amounts of dangerous substances handled in CPI
and plants complexity, they are characterized with a major incident potential.
Many major process incidents take place directly or indirectly related to
process safety management elements and a lot of these incidents are in some way
related to inadequate and / or inappropriate MOC which is one of the Process
PSM elements. Due to the existence of ineffectiveness in managing changes, many
organizations in CPI suffered tremendous losses. The mismanaged changes could
have caused significant impacts on safety, environment, finance, community, and
integrity and delivery schedule. It is a matter of fact that for business
survival and continuity, changes are unavoidable in the workplace which can
affect facilities, organizational structure, processes or systems.
The
research on case histories incident investigation report revealed that 9.1 % of
all incidents and precursor events in the CPI are MOC related. The significance
of MOC or lack of it was never more apparent than in the Flixborough
incident. The temporary modification to piping between cyclohexane
oxidation reactors failed causing catastrophic incident in June 1974 resulting
28 employees killed and 89 employees injured which the incident was largely due
to a mismanaged of change. Concerning the MOC, US-CSB (2001) has discussed two
incidents that occurred in the United States in 1998.
The first
incident in November 1998 involved a fire at an Equilon Enterprises oil
refinery in Anacortes, Washington. The fire in the delayed coking unit
caused six fatalities. The second incident in October 1998 involved a reactor
vessel explosion and followed by fire at the CONDEA Vista Company detergent
alkylate plant in Baltimore, Maryland that injured four people and caused
extensive damage. There is a need for CPI to have MOC policies that include
abnormal situations, changes to procedures, and deviations from standard
operating conditions.
a.
Result and Discussion:
A total of 630 chemical process industry
related incidents cases were reviewed for this research. Based on the statistic
on PSM elements incident occurrence frequency, a frequency of 149 out of 1,633
incidents are contributed by MOC due to multiples causation.
MOC Incident Ranking:
Preliminary
result shows that the contribution of MOC failure to CPI incidents is found to
be 9.1 %. It ranked top number 6 behind the other 5 PSM elements of process
hazards analysis (17.7 %), operating procedure (17.6 %), employee participation
(11.5 %), training (11.3 %) and mechanical integrity (10.1 %) as demonstrated
in Figure 1. It is worthwhile to study due to MOC related incident cases are
not decreasing over the period of study and its potential in contributing to
major incidents.
MOC Typology:
From the
results of study, requesting system change demonstrated the highest percentage
contribution of 45.6 % in MOC typology failure frequency. Breakdown/ failure
system change ranked number 2 contributing to 30.9 % followed by temporary
system change of 10.1 %, administrative system change of 8.1 % and organization
system change of 5.4 % as shown in Figure 2.
MOC incident main factors:
An
important aspect of MOC related incident cases study is to identify main
failure factors for preventing similar event from recurring. Other main failure
factors are personnel competency, resources limitation, human factor,
inadequate tools and equipment, lack of supervision, cost control, pressure and
stress from management which can directly or indirectly contribute to MOC
failure.
The three
major common main failure factors namely the lacking in management
involvement, inadequate in procedure and risk assessment.
a.
Requesting System Change
b.
Breakdown / Failure System Change
c.
Temporary System Change
d.
Administrative System Change
e.
Organization System Change
a.
Requesting System Change:
r Objective:
•
Modification to achieve higher production rate.
•
Modification to achieve better product quality.
•
Change of production type with existing
operating facilities and system.
•
Replacing different type of equipment /
instruments to achieve higher production rate or better equipment integrity.
•
Operating control system change.
•
Process
line change.
•
Start up and shutdown system change.
•
Complete
system change involving equipment, instruments, procedures, organization, and
process.
•
Setting higher production output without
equipment / instruments upgrade (changing operating parameter, higher
temperature, pressure, flow, human limitation).
r Main Failure Factor:
•
Lack of Management involvement.
•
In-adequate of Procedure.
•
In-adequate of risk assessment
•
Lack of
Competency personnel
•
Resources limitation
•
Human factor
•
In-adequate Tools and Equipment
•
Lack of Supervision
•
Lack of Communication
•
Cost control
b. Breakdown / Failure
System Change:
r Objective:
•
Equipment breakdown / failure change
•
Piping / vessel or high corrosion effect change
•
Sudden / urgent shutdown operating change
•
Change to prevent safety issue
r Main Failure Factor:
•
Lack of Management involvement
•
In-adequate of risk assessment
•
In-adequate of procedure
•
Cost control
•
Tools & Equipment
•
Pressure and stress (time constrain)
c. Temporary System
Change:
r Objective:
•
Temporary by pass normal operating system to
keep operation process running with part of the system / equipment taken out
for service or replacement
•
Temporary interlock by pass
•
Temporary safety protective devises by pass
•
Chemical substitution
•
Temporary changing different material and or
chemical
r Main Failure Factor:
•
Lack of Management involvement
•
In-adequate of risk assessment
•
In-adequate of Procedure
•
Tools and Equipment
d. Administrative
System Change:
r Objective:
•
Changing SOP / work flow for operational and
safety issue
•
Changes in establish training method to
software method
•
Change in operation parameter, limit, control
•
Change procedure from hard to soft copy
r Main Failure Factor:
•
Lack of Management involvement
•
In-adequate of Procedure
•
In-adequate of risk assessment
•
In-adequate of Training
e. Organization system
change:
r Objective:
•
Manpower (work force / reduction / work
distribution)
•
Contractors / vendors change
•
Work pattern change
•
Human behavior change (emotional / feeling)
•
Cost saving implementation
•
Restructuring (competency)
•
Policy change
•
Stake holder change
•
Business unit change
•
Realign audit function
r Main Failure Factor:
•
Lack of Management involvement
•
In-adequate of Procedure
•
Human factor
•
Lack of Competency
•
Cost control
•
Pressure and stress
KEY ROLES
REQUIRED TO OPERATE THE MOC PROCESS:
Each site will have its own organizational structure and may have
different titles for the key job roles within the organization. However the
following key roles in the MOC process must be fulfilled in some way on each
site.
v MOC Owner:
The process requires a person who takes
overall ownership for driving the change through the MOC process. This person
will also typically:
• Produce a written proposal for initial approval.
• Ensure that the key people are involved at the right times.
• Ensure that the process has been followed properly.
The owner may not be a fixed role within the organization – it often varies depending on the nature of the change. Although the most common owners will probably be members of the operations staff, it may be from a discipline appropriate to the type of change being proposed. For example, a piping change would typically be owned by mechanical engineers, a process or relief change by process engineers, and so on.
• Produce a written proposal for initial approval.
• Ensure that the key people are involved at the right times.
• Ensure that the process has been followed properly.
The owner may not be a fixed role within the organization – it often varies depending on the nature of the change. Although the most common owners will probably be members of the operations staff, it may be from a discipline appropriate to the type of change being proposed. For example, a piping change would typically be owned by mechanical engineers, a process or relief change by process engineers, and so on.
v Risk Assessment
Authority:
MOC
process requires risk assessment processes appropriate to the size and nature
of the change to be selected and executed. Sites require a person or person(s)
who are capable of taking this view and supporting the execution of these
processes to be appointed. It is considered good practice that the risk
assessment authority is independent of the change being made.
v Discipline
Engineers:
Depending
on the nature of the change, a number of different disciplines may input into
the MOC process. As highlighted earlier, one of the discipline engineers may
also be the owner of that change.
Discipline
engineers may need their input to the MOC process to be checked or verified by
the corresponding technical authorities on site, depending on their level of
seniority or experience.
v MOC Approval:
There are
a number of approval steps in the MOC process. The precise number of sign off
steps will be site specific and
may involve budget-related approvals in addition to safety and hazard evaluation type steps.
may involve budget-related approvals in addition to safety and hazard evaluation type steps.
The MOC approval on site must be an appropriate, competent (often senior) person relevant to part of the site which the change affects. MOC approvals are often senior members of the operations staff.
KEY STEPS IN THE MOC PROCEDURE:
1) MOC Initiation,
Initial Approval and Registration:
When an applicable change is required on
a site, a written summary of the proposed change should be produced for review
and initial approval and authorization by one of the MOC approves on site. Once
approved, this initiation step then requires:
·
Assignment of an owner/coordinator for the MOC
(the MOC owner).
·
Registration of the change within the site MOC
system.
2) Production Of A Design:
The
purpose of this step is to ensure that a suitable design is made by a competent
person. This initial design then forms the basis of the risk assessment
processes that are performed. The MOC owner should ensure that a suitable
design has been made, bearing in mind the following practices:
·
Checking that the design satisfies the fundamental
requirements of the MOC.
·
Consulting with all appropriate disciplines
·
Documentation of all calculations, referring to
appropriate standards
·
Following the site internal technical processes
for approval of the design.
3) Choice And Execution
Of Risk Assessment Processes
The risk assessment element is central to the
whole MOC process. It ensures that all of the consequences of the change are
fully understood, with all risks appropriately managed.
The first step is to determine which risk assessment processes will be used for the specific change under consideration. It is normal that different levels or types of risk assessment processes can be used within the MOC procedure, appropriate to the size and / or significance of the change being made.
Good practice is that the selection of risk assessment processes must be done by the identified risk assessment authority. Sometimes a structured approach, such as a complexity test, is used to assist the selection of the appropriate risk assessment process.
ΓΌ Sites should have at least two levels of
process available:
I.
Short Form/Checklist Methods:
These can either be paper or software based. In
order to use this methodology, sites should have a suite of checklists
available to be used for different types of
change. Note that:
change. Note that:
·
The risk assessment authority should approve which checklists are
applicable to the change in question.
·
Actions from the checklists must be recorded in the MOC
documentation system.
·
Each checklist must be formally signed/authorized when it is
completed
II.
Full Hazard Analysis:
It is expected that for larger and more
complex changes a more in depth, rigorous method of hazard analysis will be
performed. In many cases, the HAZOP process will be the most appropriate one to
use. Some key points are:
·
That the HAZOP is based on a fixed/frozen design (it is not a
design process).
·
That the HAZOP team leader is trained and competent to lead a HAZOP
study.
·
That the HAZOP team leader is independent of the change owner or
site.
·
That the appropriate disciplines are included in the HAZOP team and
that they have appropriate knowledge of the plant and the change.
·
That the team has all of the appropriate documentation and enough
time to perform the HAZOP study.
III.
Engineering Design, Construction, And Installation:
Progression to the design, construction,
and installation of the change should only occur after the appropriate
completion of the risk assessment processes. This is often a stage where the
site may also have formal steps in the process relating to budgetary approval
for the change. The site should have access to the appropriate capability to
design the modification to the relevant codes and standards, either through its
own organization or the use of third parties.
IV.
Pre-Commissioning:
Prior to the commissioning of the change,
a number of check steps must be performed. Together these are often called a
PSSR or pre startup safety review. The PSSR could consist of a number of
different elements depending on the nature and complexity of the change. As a
minimum, it is expected that the PSSR will cover:
• Verification that the change has been
properly installed according to the design. This usually involves the act of
punch listing the change in the field.
• Completion of the writing of, or changes
to, any operating procedures required by the change.
• Training of relevant personnel
appropriate to the change and any changes to the operating procedures.
• Notification of any other personnel as
required.
V.
Final Authorization And Commissioning:
Typically the designated MOC approval performs a review of all of the MOC steps and checks that the process has been
followed and the correct individuals involved. This person then approves or
rejects the change as suitable for commissioning.
rejects the change as suitable for commissioning.
VI.
CLOSE-OUT:
The close-out part of the process
involves ensuring that all of the follow-up actions after commissioning of the
change are completed. This should include (but not be limited to):
•
Update of the drawings, data sheets, and other key documents to “as
built” status.
•
Identification of new required spares and the addition of these to
stock.
•
Any performance testing being completed and documented.
•
Registration of new plant items in the maintenance management and
inspection systems.
•
Any changes to operating procedures required after commissioning
made and appropriately communicated.
•
Completion of any incomplete actions associated with the change
(from the risk assessment processes, from pre-commissioning punch listing, and
so on).
The close-out processes required are
often themselves identified on a checklist of potential actions and steps. They
will be different depending on the nature of the change.
For temporary changes (handled under a
temporary MOC), one of the key and final actions is the return of the plant to
the original design. The MOC Owner should retain formal ownership of the
change, and the MOC documentation should remain at “open” status within the
tracking system until all of the close-out processes are completed.
KEY PERFORMANCE INDICATORS:
Each site
should routinely produce KPIs to monitor the performance and health of its MOC
system. The KPIs should be produced monthly and be reviewed at an appropriate
site forum, such as the site process safety management committee. Routine KPIs
would typically include:
•
Total number of open MOCs, with some details showing when they were
originally raised.
•
The number of MOCs raised in the review period.
•
The number of emergency MOCs raised in the review period.
•
The number of temporary MOCs, and identification of any which are overdue.
•
The number of completed MOCs with open and with overdue close-out
actions.
•
The number of incidents and near miss reports attributable to
failures in the MOC process. It is expected that the discovery of any change
that was not handled using the MOC system would be raised as a near miss
report.
In the case of overdue temporary changes and
overdue actions, it is often useful to identify which MOC owners the overdue
items are associated with.
APPENDIX 1
ABBREVIATIONS
i.
CPI: Chemical Process Industries
ii.
PSM: Process Safety Management
iii.
MOC: Management of Change
iv.
SOP: Standard Operating Procedure
v.
KPI: Key Performance Indicators
vi.
OSHA: Occupational
Safety and Health Administration
vii.
RIK: Replacement In Kind
No comments:
Post a Comment