Management of Change

25.1 INTRODUCTION

Human factors considerations enter into management of change in several ways, in-
cluding:

Process changes may affect the way people interact with the process. For ex-
ample, changes in chemicals, technology, equipment, procedures, or facilities
may impact process safety by increasing the likelihood of human failures
when using the chemicals, technology, equipment, procedures or facilities.
Such human factors issues should be addressed when assessing the impact of
proposed changes.
Changes related to people and organizations may have implications for
process safety. This includes changes in personnel assignments, roles and re-
sponsibilities, reporting relationships, abilities and competencies, organiza-
tional structure, management systems, goals and objectives, equipment opera-
tion or use, manning levels and workloads, levels of automation, engineering
and technical support, available resources, communications systems, etc.
Many plants experience reorganization in the form of downsizing, re-engi-
neering, centralization, mergers and acquisitions, etc. Regardless of the cause,
organizational changes can cause temporary or permanent impacts on person-
nel and processes and possible adverse impacts on safety.
Sometimes, the potential importance of such changes is not recognized.
OSHAs Process Safety Management (PSM) standard, 29 CFR 1910.1 19
(OSHA, 1992) requires that companies address changes in process chemicals,
technology, equipment, procedures, and facilities that affect a covered
process. However, organizational and some other types of changes are not
specifically addressed in the PSM standard.
The process of managing changes involves a variety of human factors issues,
including:
The willingness of personnel to use the Management of Change (MOC)
procedure, because:
0 It may be viewed as a bureaucratic and paperwork-intensive require-
ment that interferes with production.
0 The plant may be operated differently between shifts.

Himman Factor.$Methods for Improving Performance in the Process Industries 165

C 2007 American Institute of Chemical Engineers
166 MANAGEMENT OF CHANGE

o There may be time pressures to make a change.

o People may consider themselves to be competent to design and imple-
ment changes without the need for a formal review process.
o People may consider a change to be minor and not worth consideration.
o Consultation with the necessary people may be difficult.
Ability of personnel to properly use the MOC procedure:
0 Personnel may not be aware of the procedure.
o Personnel may lack understanding of change types and review require-
ments.
o Signoffs may be inadequate and documentation incomplete.
rn Adequacy of training in MOC:
0 Personnel may fail in their responsibilities owing to inadequate train-
ing.
rn Ability and willingness to properly review the change:
0 Reviewers may be biased or have preconceived ideas.
0 Time pressures may produce inadequate reviews.
w Acceptance of change by affected personnel:
0 People generally dislike change and may resist it.
0 If people are not involved, they will likely not be committed. Thus,
changes may not be accepted in practice by personnel.
The process of implementing changes can involve various human factors is-
sues. Problems that may arise include:
w Improper implementation of the change (e.g. not installing as designed).
rn Inadequate checking and verification that the change has been correctly
implemented.
rn Inadequate management of temporary changes (e.g. changes approved for
a specific time period are extended without further review).
w Inadequate training of personnel on how the change affects their work.

Considerable time may be required to take a change from conception to completion

and the MOC process often involves circulation of documentation for review and
approval by various people. There is the potential for shortcuts and sloppiness and
there are many human error pitfalls along the way. MOC training that provides ex-
amples and case histories of how things have gone wrong in making process
changes is of considerable value in convincing people of the need to properly ad-
dress MOC.
Approaches for handling these issues are not addressed in standard references on
managing process changes (CCPS, 1992; CMA, 1993; Sanders, 1993; Sutton,
1998) other than brief mentions of the need to address organizational changes.
Figure 25-1 shows the damage resulting from the Flixborough, UK accident in
1974. This accident was the result of inadequate management of change.
 25.2 TOOLS 167

Figure 25-1: The consequences of a vapor cloud explosion owing to inadequate change
management. [Reprinted from HSE (2003).]

An engineer who had been assigned responsibilities for various PSM activities
was laid off during company downsizing. However, his responsibilities were not
reassigned. Work on his PSM activities ceased but the problem was not discov-
ered until a PSM audit was conducted two years later.

25.2 TOOLS

The Chemical Manufacturers Association (now the American Chemistry Council)

has published guidance for managing safety and health during organizational
change (CMA, 1998). It provides sample worksheets and checklists. Human factors
are not specifically addressed in this guidance but the checklists include some ques-
tions relating to human factors. The UK Health and Safety Executive (HSE) has
also published guidance on managing organizational change (HSE, 2003). It deals
with common pitfalls and suggests a framework for managing organizational
change that includes consideration of human factors. The HSE and the UK Energy
Institute have published guidance on de-manning (HSE/EI, 2005).
There are no other tools currently available that have been specifically devel-
oped to address human factors in managing process changes. However, tools identi-
168 MANAGEMENT OF CHANGE

* Indicates Field must be filled in before saving document.

Area* DeDartment* EauiDmenk

Plant General
Initiator. if Not Author Duration of Process Chanae*

MICHELLE BROWN Permanent or Temporary? 1'6 Ip t * d w in I 1 ,II I

AFE / Work Order # Select if Off-shift:

TvDe of Chanae

Are there new or updated SOPS associated with this MOC?*

(If you click Yes, revisions to the Operating Procedures will be required. You must enter the name
responsible person in Section B before submitting this MOC t o the PS&H Manager.)

Attach new or red-lined electronic SOP here:

Enter a Detailed Description of the Proposed Change*:

Complete and specific description of WHAT is to be changed

Technical Basis of Proposed Change*:

Technical explanation of W H Y the change is needed and how i t will be implemented

Is there Paper (non-electronic) Documentation Associated with this MOC?

Mark the PSI to be Updated as a Result of this Change.

Specify the PSI that will Require Revisions by clicking Yes t o that PSI.

Figure 25-2: An on-line management of change system.

 25.2 TOOLS 169

Operations/ Process :

Maintenance :

Figure 25-2: Continued

 170 MANAGEMENT OF CHANGE

Responsible Care :

Action items may be entered, but SAR's cannot be created until an MOC number is assigned.
To expand the PSI Action I t e m table for item entry, Click button:
PSI Action Items

Figure 25-2: Continued

 25.2 TOOLS 171

Checklist to be filled in by Initiator and reviewed by Process Safety & Health Manager

Answer Questions. Note any Follow up Issues in the Comments Column.

(Each "Yes" answer requires a Comment.)

Process Safety & Health Manager :

Process Safety Code Specialist :

Figure 25-2: Continued

 172 MANAGEMENT OF CHANGE

When the PS&H Manager has reviewed Sections A, B & C, and completed Section D, Click button :
(Note The Classification & Hazard Identification Checklist must be reviewed by the PS&H Manager before this
MOC may be Submitted for Approval.)
I
Reviewed by: Date Reviewed:

Figure 25-2: Continued

fied in other sections of this book that address human factors for equipment, proce-
dures, process control, competence management, operator workload, etc. can be
adapted to address human factors issues in managing changes. CCPS is currently
preparing technical guidelines on management of change.
Figure 25-2 shows an on-line management of change form.

25.3 REFERENCES

CCPS (1 992). Plant Guidelines for Technical Management of Chemical Process Safety
(New York: AICHE Center for Chemical Process Safety).
CMA (1993), A Managers Guide to Implementing and Improving Management of Change
Systems (Washington, DC: Chemical Manufacturers Association, now the American
Chemical Council).
 25.3 REFERENCES 173

CMA ( 1998), Management of Safety and Health During Organizational Change (Washing-
ton. DC: Chemical Manufacturers Association, now American Chemical Council).
HSE (2003), Chemical Information Sheet No. CHIS7: Organisational Change and Major
Accident Hazards (London: U.K. Health and Safety Executive).
HSEEI (2005), http://www.energyinst,org.u!dhumanfactors.
OSHA (1992), OSHA 1910.1 19: Process Safety Management of Highly Hazardous Chemi-
cals (Washington, DC: U.S. Occupational Safety and Health Organization).
Sanders, R. E. (1993). Management of Change in Chemical Plants (London: Buttenvorth-
Heineman).
Sutton, I. S. (1998), Management of Change (Houston, TX: Southwestern Books).