Management of Change

MANAGEMENT OF CHANGE
NPC TRAINING PROGRAM
STUDENT HANDOUT
Presented by
Marcel Leal-Valias
Calgary Tel 1-403-221-8077 Fax 1-403-221-8072

E-mail: info@seal.ab.ca Website: www.seal.ab.ca
Table of Contents
COURSE OBJECTIVE.................................................................................................... 1
COURSE OBJECTIVE ......................................................................................................... 1
INTRODUCTION............................................................................................................. 2
DEFINITIONS .................................................................................................................. 4
CHANGE ........................................................................................................................... 4
Administrative Change................................................................................................ 4
Organizational Change............................................................................................... 4
Technical Change ....................................................................................................... 4
MOC POLICY ................................................................................................................... 5
SPIRAL TO DISASTER VIDEO .................................................................................... 6
“SPIRAL TO DISASTER” SYNOPSIS .................................................................................... 7
WORK PERMIT SYSTEM HAS DEGRADED. ........................................................... 7
RISK ANALYSIS HAS NOT BEEN PERFORMED..................................................... 8
SAFETY AS A PRIORITY............................................................................................ 9
COMMUNICATION BREAKDOWN .......................................................................... 9
DISCUSSION QUESTIONS ................................................................................................ 10
BENEFITS OF MOC ..................................................................................................... 11
SAFETY .......................................................................................................................... 11
Fewer hazardous releases......................................................................................... 11
Less hazardous repair and maintenance .................................................................. 11
Fewer operational incidents ..................................................................................... 11
Production................................................................................................................. 12
Assets......................................................................................................................... 12
Operations................................................................................................................. 12
Company reputation.................................................................................................. 12
THE CHANGE PROCESS ............................................................................................ 13
IDENTIFY PROBLEM OR OPPORTUNITY ............................................................................ 13
EVALUATE PROPOSED CHANGE ...................................................................................... 13
ANALYZE ROOT CAUSES................................................................................................. 13
OBTAIN APPROVAL ........................................................................................................ 13
UPDATE INFORMATION .................................................................................................. 14
NOTIFY ALL INVOLVED .................................................................................................. 14
IMPLEMENT CHANGE ...................................................................................................... 14
MONITOR CHANGE ......................................................................................................... 14
WHEN IS MANAGEMENT OF CHANGE REQUIRED? ........................................ 15
TYPES OF CHANGE ........................................................................................................ 15
In-Kind/Not In-Kind change ..................................................................................... 15
Critical change.......................................................................................................... 16
MANAGEMENT OF CHANGE I
S.E.A.L. International
Small/large change ................................................................................................... 16
Emergency change .................................................................................................... 17
Temporary change .................................................................................................... 17
Infrequently repeated change ................................................................................... 18
Instrumentation change ............................................................................................ 18
PHA recommendations for change ........................................................................... 18
OPERATING LIMITS................................................................................................... 20
DEFINING THE SAFE OPERATING RANGE ....................................................................... 20
DEFINING THE SAFE OPERATING RANGE ....................................................................... 21
MOC POLICY AND PROCEDURE ............................................................................ 22
MANAGEMENT OF MOC ................................................................................................ 22
TEAM APPROACH ........................................................................................................... 22
FORMAL STRUCTURE OF MOC....................................................................................... 22
MOC COORDINATOR’S RESPONSIBILITIES ..................................................................... 23
THE EIGHT STEPS OF THE MOC PROCESS ....................................................................... 24
1. Initial request .................................................................................................... 24
2. First review ....................................................................................................... 25
3. Detailed Evaluation .......................................................................................... 28
4. Formal Approval............................................................................................... 30
5. Information Updating ....................................................................................... 31
6. Notification ....................................................................................................... 32
7. Implementation ................................................................................................. 32
8. Follow-Up ......................................................................................................... 33
MANAGING A NEW PROJECT ................................................................................. 37
MOC AUDIT................................................................................................................... 38
APPENDIX...................................................................................................................... 39
CCPA Checklist for Management of Change ........................................................... 39
MOC Program Evaluation Checklist........................................................................ 39
CANADIAN CHEMICAL PRODUCERS ASSOCIATION (CCPA)........................................... 40
Checklist for Management of Change....................................................................... 40
MOC PROGRAM EVALUATION CHECKLIST .................................................................... 41
Management Systems ................................................................................................ 41
Change Process ........................................................................................................ 41
Personnel .................................................................................................................. 42
Process Engineering ................................................................................................. 42
Piping........................................................................................................................ 42
Instrument/Control Systems ...................................................................................... 43
Structural/Civil ......................................................................................................... 43
Mechanical................................................................................................................ 43
Electrical................................................................................................................... 43
Equipment ................................................................................................................. 43
GENERAL REFERENCES........................................................................................... 45
MANAGEMENT OF CHANGE II
COURSE OBJECTIVE
Course Objective
The objective for this course:
• To understand the keys to a successful Management of Change (MOC) program,

and learn ways to develop and implement an effective and complete MOC
procedure.
MANAGEMENT OF CHANGE 1
INTRODUCTION
Any facility or operation is subject to continual change. Changes often are made in
equipment, materials and processes to increase productivity or to correct hazards. In some
cases, temporary adaptations, connections, bypasses or other modifications are made to
the facility or process. System administrators may decide to move employees within a
specific process, which could eliminate or create positions within the facility or process.
All of these changes have the potential to create new workplace hazards, some of which
are not immediately recognizable. Although some changes are more critical than others,
each modification should be analyzed for inherent hazards that may result from the
change. Although change usually is proposed for a good reason, changes made to
improve one aspect of an operation actually may increase the potential for hazards in
other areas of the same operation. To assess the impact of change and to monitor its
implementation, it is essential to have a policy and procedure for Management of Change
(MOC).
MOC seems deceptively simple, but it can be one of the most difficult elements of HSE
management to implement effectively. MOC invariably impacts other elements of a
Health, Safety and Environment Management System once it is implemented. Therefore,
to be truly effective, MOC needs to be integrated into all aspects of the system, and the
involvement of everyone in a facility needs to be encouraged. Commitment from
company management creates a climate that empowers people to initiate needed change,
and provides a supportive structure for the implementation of change. Employee
participation is essential. Those on the line often are the first to notice problems, and
involvement in the design of the MOC program fosters commitment and ownership.
Commitment at all levels is crucial. No matter how well designed an MOC program is, it
will be ineffective if it is not used.
It is impossible to describe a single, uniform method for managing change. The unique
circumstances and needs of each facility require that a system be designed specifically to
meet those needs. This course is not offering to teach a generic MOC program; it is
designed to look at the elements of effective MOC and present ideas that can be used to
design a facility-specific program that works.
The course begins with a video that dramatizes the Piper Alpha disaster, which can be
directly attributed to poorly managed change and management’s lack of commitment to
safety. We will use the video as our reference point for discussion of the theoretical
aspects of MOC and its relationship to other elements of HSE management. Next, we will
build a model for an MOC program that addresses all the issues relevant to initiating,
evaluating and implementing change. This model will be one that easily can be adapted
in the development of your own MOC program.
ACKNOWLEDGEMENT
With thanks to Ian Sutton for the use of the information contained in his book,
Management of Change, in the development of this material. More information about his
publications is available at www.swbooks.com
DEFINITIONS
Change
Is the result of a conscious decision to exchange, substitute, convert, alter, add, modify or
vary a component of an existing process, its equipment and/or control and management
systems. Change can be administrative, organizational and/or technical.
Administrative Change
Administrative changes are modifications to work procedures. An example might be

decreasing the frequency of inspection or maintenance in one section of an operation.
The section involved may not view the change as significant; however, the consequences
of this change may seriously affect other parts of the operation.
Organizational Change
Modifying the structure of an organization, regardless of its size, is a major change, and
requires appropriate impact analysis. Typical organizational changes include:
• decreasing or increasing the number of supervisors

• decreasing or increasing the number of hours that employees work
• contracting instead of using company personnel
• changing operating philosophies
Technical Change
Technical changes affect the operating process. Adding or deleting equipment or

materials, or renovating or changing process techniques are examples of technical
change. Technical changes often are implemented to increase production and profits or to
decrease hazards. Yet they can increase the potential for hazards.
MOC Policy
A public statement of the company’s commitment to implement change in a safe manner.
The company needs to communicate its MOC Policy to all its workers. The MOC Policy
provides a values-based framework for addressing change in the company’s facilities and
operations. The MOC Policy must be applied to all activities that fall under the umbrella
of change.
MOC Program
A component of an HSE management system. A systematic program is necessary to
ensure that changes are managed in such a way that they do not compromise the safe
design and operation of a facility.
MOC Procedure
The approved sequence through which changes are initiated, evaluated, authorized,
implemented and followed up. The intention of an MOC procedure is to ensure that
changes are reviewed and approved by people with appropriate knowledge and
experience. These people will then be accountable for effective implementation of the
changes.
SPIRAL TO DISASTER VIDEO
From a Management of Change perspective, we will look at the events leading up to the
tragic and avoidable loss of the Piper Alpha offshore drilling rig and the lives of more
than two thirds of those on board.
What was the root cause of the accident?
How could an effective MOC program have changed or mitigated the outcome?
If you had been in charge of their HSE system, what might you have done
differently?
“Spiral to Disaster” Synopsis
• Piper Alpha was originally designed to be safe. The design of four fireproof
modules placed hazardous areas as far away from sensitive areas as possible.
However, some time later Piper Alpha is modified to extract both gas and oil. The
modification places gas compression equipment close to living quarters, the
helicopter landing pad and the control room.
• The addition includes two gas compression pumps, A and B.
• A work permit has been completed for a routine two-week overhaul for gas
extraction pump “A,” but it has not yet begun.
• On July 26th, the same gas extraction pump, “A,” is taken out of service because
a pressure relief valve needs maintenance. Pump “B” continues to pump.
• The pressure relief valve is removed, but the shift crew does not have time to
finish the work, so the open pipe is sealed with a blank flange.
• The shift engineer fills out the appropriate work permit, and brings it to the
control room. The supervisor is busy, so the shift engineer signs off on the permit
himself. He does not inform the supervisor of the status of pump “A” or file this
permit with the other work permit for the routine overhaul on pump “A”. No one
on the next shift knows about the potentially hazardous condition.
WORK PERMIT SYSTEM HAS DEGRADED.

The work permit system is treated as a formality only. Risks and possible
consequences are not being thought through before permits are filled in.
• Firewater pumps were designed to work automatically but, because divers

sometimes work near the pump intakes, the system is routinely switched to
manual operation. This means that, in the event of a fire, the fire suppression
system can be activated by hand only.
• Gas extraction pump “B” unexpectedly trips off-line and the crew unsuccessfully
attempts to restart it. Delay will cause the rig to lose power, endangering the drill
system – a very difficult and expensive situation.
• Because the only work permit on file for pump “A” is for the overhaul that has yet
to be started, the supervisor orders it to be started. No one knows about the
removed pressure relief valve, and its location is too high for the crew to see the
blank flange replacement.
• Pump “A” is started. Gas pressure blows out the blank flange replacement.
• The emergency shutdown closes all the valves, which ordinarily would isolate the
fire, but the blast blows out the walls in the oil separation area, which results in a
huge fire.
• The fire suppression system fails because the firewater pumps are switched to
manual, and are inaccessible because of the fire.
RISK ANALYSIS HAS NOT BEEN PERFORMED.

Risk analysis has not been performed on the risk of not installing expensive blast
walls between the gas compression area and the oil separation area.
• Emergency procedures have collapsed and the radio room is extensively

damaged, so fire-fighting coordination also falls apart. The rig has to be
abandoned.
• Rig supervisors have not informed Emergency Services on shore how they are
planning to evacuate the workers.
• Workers have not been informed about, or trained in, procedures for abandoning
the rig. Because of the fire, they cannot go to their lifeboat muster stations, so
they go to the fireproof accommodation block to await evacuation by helicopter.
However, unknown to them, the wind is blowing flames over the landing pad,
making evacuation impossible.
• The fire would burn itself out because the oil and gas valves into the facility have
been shut down; however, oil and gas from surrounding rigs continue to flow in
from pipes ruptured in the explosions.
• Personnel on the Claymore rig hear the first distress calls from the Piper Alpha
rig. However, because the manager on the Claymore rig does not have the
authority to shut the rigs down, he tries to reach higher level management on
shore for direction.
SAFETY AS A PRIORITY
Managers need to be given the clearly mandated authority to make difficult and
potentially costly decisions, if they believe the situation warrants. Corporate and
management commitment to safety as a priority must be communicated to
personnel.
• The oil fire causes adjacent gas lines to heat and burst in another massive
explosion. Management has known about this danger for two years, since a report
identified the potential for a catastrophic incident, but nothing has been done
about it.
• The blast knocks out communication between the other rigs and Emergency
Services, further isolating the Claymore manager. Too afraid to make the decision
to shut down, he tries to reach shore through a secondary satellite system.
Claymore continues to pump oil.
• In the meantime, a fire fighting ship that has been called in turns on its water
pumps too quickly, tripping the system. Before the pumps can be restarted or the
painfully slow evacuation equipment can be set in place, another explosion
generates so much heat that the fire fighting ship has to withdraw.
• If the other rigs had shut down the flow of oil as soon as they heard the first
distress call from Piper Alpha, the gas lines may have been saved and the oil fire
controlled.
COMMUNICATION BREAKDOWN
Clear lines of communication need to be established and communicated to all levels.
Everyone should know what to do and how to do it with confidence.
Discussion Questions
What was the root cause of the accident?
How could an effective MOC program have changed or mitigated the outcome?
If you had been in charge of their HSE Management system, what might you have done
differently?
BENEFITS OF MOC
Safety
Safety is the most important reason for implementing an MOC program. An effective
program will result in fewer incidents in the following areas:
Fewer hazardous releases
As we have seen from the Piper Alpha disaster, uncontrolled releases of hazardous
materials will have the most serious and sometimes catastrophic Health, Safety and
Environmental consequences.
Less hazardous repair and maintenance
Problems created by uncontrolled change often lead to equipment stress and damage, and
repair and maintenance of such equipment can be hazardous to personnel. Some
examples of these hazards are vessel entry, climbing on and moving heavy machinery,
and working on high voltage electrical systems.
Fewer operational incidents
Uncontrolled (unevaluated) change may move operating conditions into an unsafe range,
encouraging or often requiring operators to override built-in safety systems. In some
cases, uncontrolled change means that personal protective equipment must be discarded
or physical safety devices, such as pressure relief valves and fire water systems, must be
temporarily overridden.
Economic considerations
Economic considerations are another compelling reason for implementing an MOC

program.
Production
Production rates should increase because of fewer direct losses. Production quality and
capacity should increase and energy costs decrease because there will be less need to
recycle or reprocess off-spec materials.
Assets
Fewer incidents will lead to fewer losses.
Operations
Reduced down time for maintenance and repair and fewer injuries will result in increased
profit.
Company reputation
A company that has a reliable HSE record satisfies its
• customers
• shareholders
• employees
• local residents
• government agencies
• banks
The company then can attract investment capital, generate sales of its product, and
avoid legal expenses.
Conversely, dissatisfaction amongst customers may lead to lost sales. Anger amongst
members of the public and the workforce may result in costly lawsuits or disciplinary
actions by government regulatory bodies. If these problems tarnish the company’s
reputation, it may experience difficulty in attracting investment capital.
THE CHANGE PROCESS
Identify problem or opportunity

The change process begins when a problem or opportunity requiring change is
recognized. For continual improvement to take place, it is essential that all personnel
involved in an operation are actively encouraged to become part of the MOC process.
Management and senior technical people must be willing to listen to the ideas of workers
at all levels, including temporary and contract workers. Lack of education and experience
do not mean that a person cannot come up with useful insights and suggestions.
Evaluate proposed change

The next step is to decide if the change is practical, and if the desired outcome can be
achieved by using existing systems more efficiently. Examples are refresher training for
employees and improved document/communication management. If possible, corrective
actions should be taken while operations continue. If the desired outcome cannot be
achieved merely by increasing the efficiency of existing systems, a more thorough
analysis is required.
Analyze root causes

A detailed team evaluation is designed to identify the true, underlying causes of the
problem and the areas in which change can be most effective.
Note: Root Cause Analysis will be addressed in greater detail during a later module of
the HSE Management Training Program.
Obtain approval
Before a change can be implemented, plant management must formally approve it.
Update information
Prior to implementation of the change, safety information needs to be updated. This may
include the creation of new procedures, training workers in the new procedures, and
updating drawings.
Notify all involved

Before implementation, all affected parties need to be notified of the proposed change
and given an overview of what is being done, the reason it is being done, and what the
outcome is expected to be.
Implement change
The change is implemented as designed.
Monitor change
Assessments of the impact of change at any time during the design and operation of a
facility or process are critical. Unless the implementation of change is monitored closely,
opportunities to maximize the effectiveness of the MOC program can be lost. Monitoring
change involves ongoing hazard/risk assessment and follow-up to ensure requirements
are being met. Post-change assessment is a valuable method of identifying additional
need for improvement. It is only in monitoring and follow-up of implemented change that
the system can continue to be evaluated and improved.
WHEN IS MANAGEMENT OF CHANGE REQUIRED?
Many changes occur in the everyday operation of a facility. However, not all of these
changes require the scrutiny of an MOC procedure. Only initiated change (conscious
decision to change) can be analyzed and evaluated for its potential hazardous
consequences and, therefore, managed. Reactive, spontaneous or covert (hidden) change
cannot be managed because it cannot be anticipated. These kinds of changes must be
managed within other elements of the HSE Management System, for instance, Hazard
Identification and Mechanical Integrity.
Consideration of the following criteria should help to determine if the Management of

Change procedure needs to be followed in a particular case. However, as a general rule, if
the proposed change affects one or more of the other elements in the HSE management
system, the MOC procedure will probably need to be followed.
Types Of Change
In-Kind/Not In-Kind change
If it is proposed to replace a piece of equipment with another that is functionally identical
and of the same specifications, the change is In-Kind and does not require an MOC
process.
CAUTION: Always consider that a replacement In Kind may be Not In-Kind in

many respects, i.e., it may made by different people, made with different machinery,
made at a different time, stored for different lengths of time in differrent conditions,
or installed by different people.
Keeping the above points in mind, equipment replacement is considered In-Kind if it

meets the following criteria:
• Material specifications (dimensions, weight, etc.) are the same.
• The service for which the equipment is being used remains unchanged. All
process conditions must remain the same as for those of the original item.
Inspection and maintenance requirements should not change.
• The replacement is part of routine maintenance. The In-Kind item is being
replaced because it has a known life span. Replacing In-Kind equipment that is
failing without known cause requires investigation and Management of Change.
• The new item is equivalent to the original one, not an improved model or from a
new supplier. Upgrades or new vendors should be assessed using the Management
of Change process. Even a seemingly minor change in any of the specifications
may impact some aspect of the process in some way.
Critical change
A critical change is one that could create a serious incident if it is mismanaged. Critical
changes should receive more thorough scrutiny than those considered non-critical.
CAUTION: The criticality of a proposed change is not always obvious without a

detailed evaluation within the MOC process.
When a proposed change is deemed to be critical but also expensive, the proposal should
be subjected to a Quantitative Risk Analysis (QRA). The story of the Piper Alpha disaster
illustrates such a need. The decision not to install blast walls between the oil separation
unit and gas intake lines, because they would have been too expensive, proved to be a
fatal mistake. A QRA would have shown that the consequences/probability/risk equation
warranted the expense of the blast walls.
Note: QRA has been mentioned in the Process Hazards Analysis (PHA) portion of the
training, and will be discussed in more detail in a later session of the training.
Small/large change
Large changes usually involve many modifications to equipment, instrument systems and
administrative procedures, and therefore should receive a full MOC review. However,
small changes may not be reviewed with the same rigor because they can be implemented
quickly and do not appear to make a significant impact on the way a plant operates. MOC
reviews, at least through a checklist, should accompany even small changes.
CAUTION: Plant experience shows that it often is the small changes that ultimately
lead to serious incidents. Because they are small, they may not be subjected to the
scrutiny they really deserve.
Emergency change
Emergency change is one that has to be made very quickly when someone in authority
decides that the dangers of doing nothing are greater than those possibly associated with
the proposed change. An emergency change may be justified for reasons such as the
following:
• danger to personnel
• potential for major equipment damage
• potential for major operational loss
• serious environmental impact
• serious community complaint
• regulatory violation
Every effort must be made to minimize the number of emergency changes, because they
bypass the normal systems for hazard identification. After the fact, every emergency
change should be reviewed by the formal MOC procedure to ensure that no unforeseen
problems exist and to ensure the change is documented and monitored.
Temporary change
In many instances temporary changes also are emergency changes. They usually are
implemented to keep an operation running while a piece of equipment is repaired or
replaced. A temporary change should have an automatic termination date. A
temporary change of even a short duration should go through at least a Safety Review
Checklist (see Appendix) by at least two or three people. A new procedure should be
written and an emergency response prepared in case the modification does not work
properly.
CAUTION: Because of the short duration of some temporary changes, there can be
a temptation to by-pass the formal MOC procedure. Some of the most serious
incidents have occurred because of temporary changes. We saw in the introductory
session video how a temporary change that was not thought through or reviewed
was the cause of the catastrophic accident in Flixborough, England in 1974.
Infrequently repeated change
Infrequently repeat changes are those that have occurred at least once before and are
repeated at infrequent intervals. If a change has been carried out before, and if it was
properly managed, the MOC process generally will not need to be repeated. However, it
needs to be stated in the MOC records that this is the case.
Instrumentation change
Because computerization of instrument systems and the introduction of process

simulations has allowed plants to operate closer to their safe operating limits most of the
time, there is less latitude for reaction should a process upset occur. Usually, a proposal
to change instrumentation systems requires a formal MOC approval.
PHA recommendations for change

One of the most important roles of an MOC program is to manage the recommendations
arising from a Process Hazard Analysis such as a HAZOP study. These recommendations
could fall into any of the already described types of change and, like any proposed
change, each recommendation must be evaluated and managed. Even if a proposed
change has resulted from a PHA, an initial review may indicate the need for another PHA
or a Root Cause Analysis in order to identify hidden hazards caused by this specific
change. Without such an analysis, the quick solution may focus on the symptoms rather
than the real cause. Hence, the problem could recur.
MOC Decision Analysis Tree
Identify work, modification or improvement opportunity
IN-KIND
Ascertain if the desired result can be achieved by using

existing systems more efficiently?
NO YES
DECISION Make
necessary
ANALYSIS corrections
Will the proposed change involve and/or
YES modifications
piping or control systems normally
shown on flowsheets or shutdown
keys?
NO
Does the proposed change require
alternate or different material YES
specifications or process/production
chemical specifications?
FORMAL
NO MANAGEMENT OF
Is the proposed change the result of YES CHANGE

feedstock, product specs or PROCEDURE
operating conditions?
NO
Will existing equipment be modified YES
or non-specified parts be used.
NO
Will existing management controls YES
require revision, e.g., procedures,
practices, rules, training and
authority levels?
NO
ROUTINE OPERATION OR
MAINTENANCE ACTIVITY
OPERATING LIMITS
A successful MOC program first must establish the safe operating range for all key
variables in an operation, such as temperature, pressure and flow. It is necessary to know
the upper and lower limits in order to build in necessary safeguards to ensure that no
deviation outside these limits can take place. Clearly defined limits provide the necessary
reference points against which proposed changes can be measured. If change is to be
properly managed, these limits need to be communicated to all involved in evaluating
proposed changes.
Plant conditions usually do not instantly move from safe to unsafe. This movement more
often takes place along the continuum between the safe end of the operating range and
the risky end of the operating range. As conditions move further away from design
values, the operation becomes more risky.
CAUTION: A plant can move instantly from safe to unsafe in certain conditions,
e.g., if the wrong materials are used for construction or if unintended chemical
interactions occur.
Low-Low Low High High-High
Unsafe Risky Normal Risky Unsafe

Operation
Operation Operation Operation Operation
(Safe Range)
Defining the Safe Operating Range
Ideally, design engineers specify operating limits. When limit values are not provided,
those operating the facility need to find a means for determining safe limits and what
needs to be done if those limits are exceeded. The following are the most commonly used
resources for ascertaining design standards.
Design Standard Environmental and safety regulations are the

law and provide expectation guidelines rather
than technical information.
REGULATIONS
Very authoritative - compiled by industry

CODES AND experts, published and distributed by
STANDARDS professional organizations.
COMPANY Especially important if process involves

STANDARDS specialized chemicals or proprietary processing
conditions.
TECHNICAL
LITERATURE
Books, articles and conference papers are useful
information, but may not be detailed enough for
specific situations.
INDUSTRY
INFORMATION
Information from equipment vendors and

licensors of process technology provide
authoritative information about safe operating
limits.
MOC POLICY AND PROCEDURE
Management of MOC
Each company or facility develops its own policy and MOC procedure within the overall
HSE Management system. When designing such a policy and procedure it is important
that the system reflects the existing culture and the way in which people in a facility
actually work and interact with one another. In particular, the system should recognize
that informal discussions and conversations are a feature of virtually all aspects of change
management, and that these informal communications should be encouraged and, where
possible, recorded and attached to the MOC form. It is often in the informal
communications that valuable insights can be gained.
Team approach
A team of people should always carry out the Management of Change process. The
benefits of fresh ideas and increased commitment to the process make the extra time that
this may take worthwhile. More than one person should question the impact of even a
small, quick change (along the lines of the Decision Analysis Tree already discussed).
Because it is often the small, quick changes that have not been thought through that cause
incidents, if the change warrants a formal MOC review, it should be done. This being
said, it is important not to make the procedure so cumbersome that workers will be
tempted to bypass the process.
Formal structure of MOC

Once a suggested change has been discussed informally and the decision made to commit
it to the MOC form, the formal process has begun. It is important that the MOC
procedure and form be easy to use while also ensuring that a thorough review takes place
before the change is implemented. Designing the procedure and the MOC form is always
a challenge when first implementing a Management of Change Program. The following
sections provide a basic structure that addresses all the issues that should be covered
when recommending and evaluating change and around which your own policy,
procedure and MOC record form can be designed.
MOC Coordinator’s responsibilities

The HSE Manager usually is responsible for ensuring that the policy and procedures are
followed and that all appropriate documentation and authorizations are in place before the
proposed change is implemented. In larger facilities, a separate Management of Change
group often carries this responsibility.
The eight steps of the MOC process
Step 1 Step 2 Step 3 Step 4

Initial request First review Detailed Formal
evaluation approval
Step 5 Step 6 Step 7 Step 8

Information
Implementation Follow-up
update and Notification
monitoring
training
1. Initial request
The person who makes the initial request is called the Initiator. Usually the Initiator is
a manager, a supervisor or an engineer. However, all employees and contractors
should feel free to propose changes they feel will make the facility safer, cleaner or
more profitable. Participation of all employees is crucial if continual improvements
are to be made.
It should be recognized that, by suggesting the change, the Initiator is demonstrating

that he or she cares enough about the plant to want to make it better. So, for an MOC
program to encourage other workers to make their own suggestions, it is important
that the Initiator be kept involved in the discussions that take place once the proposal
for change has been submitted. If the Initiator has proposed a solution, it should be
considered along with suggestions solicited by the MOC Coordinator from others in
the operation.
2. First review
Before the formal MOC process is initiated, the proposed change needs a quick,
commonsense reality check from people the Initiator knows and trusts. If it turns out
that the idea is impractical, not much time will have been wasted and the Initiator will
not have been made to look foolish in front of his management or colleagues.
Regardless of how the Management of Change system is organized, it should be
recognized that the first review process will happen anyway, and so it should be
incorporated into the Management of Change process. The first review should
accomplish two things.
a) Make an initial assessment of the problem and the proposed solution and add
relevant information and suggestions based on knowledge and experience.
b) Determine if the change is In-Kind/Not-In-Kind. If the decision is made that the

change is In-Kind, the necessary action can be taken without further review or
analysis, and the formal Management of Change process is not pursued.
The “In-Kind/Not-In-Kind” decision is critically important and is the most

challenging aspect of managing change. If a supposed In-Kind change turns out to
be Not-In-Kind after all, a serious incident may occur.
Because of the criticality of this decision, supervisors and lead operators need to
be thoroughly trained in the criteria for deciding whether a change should be In-
Kind or Not-In-Kind, particularly since the choice of In-Kind change offers a
tempting way of by -passing the whole Management of Change process.
The MOC Form: Section A – Request for Change

When the request is formulated, it is entered in the first section of the MOC form.
This part of the MOC form is completed by the Initiator and the MOC Coordinator.
(In a smaller organization or facility, the Safety Manager usually acts as the MOC
Coordinator for the duration of the MOC process. In a larger facility or organization,
there usually is a dedicated, permanent MOC Coordinator.) The MOC Coordinator
assigns an MOC record number to the suggestion, and tracks the form’s progress as it
moves through the MOC process. The MOC Coordinator also is usually part of the
MOC Committee in the final approval process. The first section of the form should
contain the following information:
Administrative information
The first part of the form provides all the administrative information and the basis for
the proposed change and should include the following:
• name of the Initiator and the date
• change category (technical, organizational or administrative)
• process system and facility location
• equipment and process identification
• criticality (risk ranking) of the problem
• whether the change is deemed emergency, permanent or temporary and, if
temporary, its time frame
• related PHA information if the change is a recommendation arising from a
study
Technical basis for the change/description of the problem

The person(s) requesting the change should clearly define the problem to be solved or
outline the opportunity for improved performance. This will be the basis for other
evaluations of the situation. To the extent that the Initiator is familiar with the
historical background of the change scenario, it should be described at this point. In
particular, if previous solutions to similar problems were attempted, and failed, a
description of what happened should be provided. Here, also, the Initiator should
explain why he believes action must be taken. This could be for any combination of
the following reasons:
• safety
• environment
• operations
¾ increased production
¾ increased productivity/efficiency
¾ reduced energy consumption/losses
• maintenance
¾ reduced maintenance costs
¾ reduced spare parts inventory
• public relations
¾ public response
¾ other plants in the area
¾ other companies using similar technology
• regulatory requirements
• risk vulnerability (refers to those changes that are made to reduce risk, even if
an incident has not yet taken place)
See pages 34 and 35 for sample MOC form.
3. Detailed Evaluation
After the first review, if it is decided that the proposed change should be pursued, it
will proceed to the next stage of the process, the detailed evaluation. This evaluation
is performed by a team representing different disciplines and specialties according to
the nature of the change. The detailed evaluation Reviewers have three tasks.
a) Confirm the problem
i) Can the problem be solved by using existing controls more efficiently?

ii) Does the situation under consideration take the work process into an
unsafe range?
b) Analyze the problem
i) Thoroughly understand the problem.

ii) Use Checklist, Root Cause Analysis or PHA if necessary.
c) Identify possible solutions
i) Brainstorm.
iii) Think out of the box.
Note: Later in the HSE Management Training Program, the identification and
selection of solutions will be covered in more detail.
Evaluation Team
Each change is the responsibility of the MOC Coordinator. Following the same
steps as for PHA preparation, his next task is to seek out and select appropriate
experienced and technically knowledgeable Reviewers. Someone on the Team
also should have an understanding of the organizational issues, such as economics
and plant politics/rivalries, related to the proposed change. The Review Team
needs to be sensitive to these issues and adjust the proposal accordingly. The
following are the minimum selection criteria for the MOC Review Team:
• Experience: Members should have knowledge of the process under review
and knowledge of similar problems that occurred in the past and actions that
were taken to solve them.
• Knowledge: Collectively, the Team members should have multidisciplinary

technical knowledge in areas such as chemical, mechanical and
instrumentation engineering, materials of construction, equipment reliability
and Health, Safety and Environment. Someone with knowledge of regulations,
codes and engineering standards should review the final recommendations for
compliance.
• Creativity: Just as for a Process Hazards Analysis, at least some of the

Reviewers need to be able to think “out of the box” to generate new ideas.
Establishing time schedule and planning work flow

Having selected the Review Team, the next step for the MOC Coordinator is to
plan the work flow and establish a schedule that will make sure the evaluation
stays on track while also making sure that people have enough time to think about
what is being proposed. Scheduling may require coordination with other
departments or functions. For example, if the change requires that the plant be
shut down, and a full turnaround is scheduled for the near-term, the change
review needs to be completed before that turnaround so that the work required by
the change can be incorporated into the overall turnaround program.
Locked list
If it is important that people with expert knowledge in a specific area are part of
the Evaluation Team and that they review the information in a predefined
sequence, the Reviewer list can be locked. In this way the named Reviewers must
have input to the evaluation and analysis of the change in a certain order.
Technical information coordination

The Reviewers usually want access to technical documents in order to conduct
their evaluations. The MOC Coordinator, where possible, should make sure he
has ready access to documents that are likely to be requested by the Reviewers.
Providing a single source of information increases efficiency, and reduces the
time needed for the review. Such documents frequently include the following:
• process and instrumentation diagrams (P&IDs)
• equipment and material data sheets
• environmental and safety regulations
• plot plans
• other pertinent documents
Change Evaluation: Section B of MOC Form (p.34)

Once the Reviewers have completed their analyses, each should sign off as being
in agreement or disagreement with the proposed change and attach comments to
the MOC form. The Coordinator should collect all of the comments and ideas that
have been generated, and summarize and analyze them. Along with the Initiator,
he then decides on what action should be proposed. This is written up in a report,
which forms the basis for the recommendations that will be presented to
management.
4. Formal Approval
Before a change can be implemented, it must be formally approved and accepted by

the plant management. The MOC form and approval provide a paper trail in case
there is an incident in which the change is implicated as a possible cause.
MOC Committee
Most facilities use a permanent Management of Change Committee to evaluate
the proposed change on behalf of the company’s management, and, assuming that
it agrees with what has been proposed, and if more than one solution is presented,
selects the most appropriate of those presnted. The MOC Committee usually has
permanent representatives from Operations, Maintenance, Technical, Engineering
Construction and Environmental and Process Safety. Other specializations can be
added on an as-needed basis. Each of the Committee members should sign off on
the MOC form once they are satisfied that the change is safe and workable. The
change should be given an implementation timeframe, and the responsible person
from management should sign the formal authorization.
Process Hazards Analysis (PHA)

One of the most important decisions that the MOC Committee has to make is
whether or not to require that a Process Hazards Analysis be carried out.
With regard to most proposed changes, the following five guidelines can provide
assistance in determining whether or not a PHA is needed.
a) If the change will be large and extensive, a PHA helps to identify systems
problems. For example, if the change will modify or adapt the process and/or
layout of a facility, as it did in the Piper Alpha example, the effect on the rest
of the facility needs to be considered.
b) If the change involves input from many disciplines and departments, then a
PHA may help in the identification of accident scenarios that result from
potential interdepartmental misunderstandings.
c) If the consequences of the change could lead to a serious incident, a PHA

should be carried out.
d) If the proposed change involves adjusting critical operating parameters, such

as reactor temperatures, it should be evaluated with a PHA.
e) If new technology or a brand new process arrangement is proposed, a PHA

should be carried out in order to help identify currently unforeseen events.
(Think of Piper Alpha.)
5. Information Updating
Once the change has been approved, any new Safe Operating Limits must be defined,
and engineering and other documentation updated before start-up. Everyone affected
by the new values must be informed and trained in what to do if the new limits are
exceeded.
Process Safety Information (PSI), such as operating and maintenance procedures;

process and instrumentation diagrams (P&IDs); training and mechanical integrity
documentation, must be updated before the change is completed, otherwise there is a
good chance that these paperwork issues will be deferred indefinitely.
Information Updating – Section C of the MOC Form (p.35)

The MOC form should provide an information checklist that must be completed by
those responsible from each area before start-up.
6. Notification
Before the change is implemented, everyone who could be affected by the

consequences of the change should be notified. It is the MOC Coordinator’s
responsibility to make sure that relevant personnel are told of the proposed change
date, along with a brief overview of what will be done, why it will be done, and what
the impact on the process is likely to be.
7. Implementation
Before large changes/modifications are implemented, a Pre-Startup Safety Review

(PSSR) should be performed. Because there can sometimes be a considerable time
lag between the PHA/formal approval and the implementation of the change, there is
a danger that uncontrolled changes may occur during the intervening period.
On smaller projects, events usually move quickly, and the Management of Change
Committee’s formal review of the change usually is adequate. However, management
must be satisfied that the change cannot be modified between approval and
implementation.
8. Follow-Up
Once the change has been implemented, there should be a follow-up supervised by
the MOC Coordinator to make sure that all precautions and preparations were
handled properly and that the change has actually achieved the desired results of
improved safety or operability. A follow-up should include the following
considerations.
a) Was the change management procedure followed?
b) Were all the other elements of process safety properly evaluated to ensure that
there were no unexpected side effects?
c) Was the change itself implemented properly, and do the operators have an
understanding of the new operating limits and what to do if those limits are
exceeded?
SAMPLE MOC FORM
A Management of Change Authorization MOC number:
Technical MOC Process system/Area:

Organizational MOC Facility/Location:
Administrative MOC
Process: YES NO OTHER: Equip ID/Unit No
Emergency Permanent Temporary - From: To:
Change requested by: Date Initiated:
PHA Recommendation YES / NO Risk Rank: LOW MED HIGH PHA Report No.
Technical basis for change/description of problem: Recommendation No.
P&ID numbers: Additional sheets attached:
B Section B To Be Completed Before Authorization of Change
To Be Routed By Person Responsible for MOC

EVALUATION TEAM
Functional Area: Person Responsible Agree Disagree N/A By Initials & Date
Engineering:………………
Health & Safety:………….
Operations:………………..
Facility Management:…….
Mechanical Maintenance:...
Inst/Elect. Maintenance:….
Environmental:…………...
Other:……………………..
MOC COMMITTEE
Name _________________ Signature & Date: __________________________________

Authorization of Change: ACCEPTED REJECTED : By: ( Management)
Reason for Rejection Date:
C Section C To Be Completed Before Startup By Initials and Date
Major Modification……………………………….. YES NO If YES, complete a PSSR or PHA

Construction and Equipment in Accordance with
Design Documentation….……………………….. YES N/A Date
PSI Updated……………………………………… YES N/A Date
Operation & Maintenance Procedure Updated…… YES N/A Date
PHA Safety/Regulatory Items Resolved…………. YES N/A
Date
Training Completed………………………………. YES N/A
Date
Safe Work Practices in Place…………………… YES N/A
Date
Emergency Response Plan in Place………………. YES N/A
Impact on Health & Safety Documented…………. YES N/A
Date
Does RMP Need to be Updated…………………... YES N/A (Attach detailed statement)
Additional Forms or Backup Comments…………. YES N/A Date

Number of Forms
Startup of Change Authorized By: ________________________ ( Mgmt.) Date:
Date to be Implemented By: Date MOC Implemented:
REVIEW
If MOC Coordination was

your responsibility, what
would you be required to
do at each step? Review
and make notes beside the
diagram at each step
MANAGING A NEW PROJECT
It is important to have a way of safely managing change during a project. However, a

conventional Management of Change program, as described in this course, is not
appropriate for a new project environment. As suggested in the previous Process Hazards
Analysis session of this training program, project design and construction need to be
systematically reviewed using a PHA structure — with increasing levels of detail and
complexity as the project grows. A formal Pre-Startup Safety Review should be
undertaken after the PHA and before plant commissioning.
MOC AUDIT
Audits are an integral part of any management program, including Management of

Change. There is always a gap between what management believes is occurring and what
actually is taking place in the field. Hence, audits are needed to identify the gaps and to
provide guidance for improvements. With regard to Management of Change, audits can
help in the following areas:
• Ensures that a functioning and effective Management of Change system is in

place. (The audit must ensure that changes are being properly identified and
managed.)
• Identifies those situations in which the proper change analysis procedures were
not followed.
• Ensures that all those people who felt that they had a contribution to make were
given the opportunity to do so.
• Ensures that the formal change control procedures with respect to regulations and
standards were followed.
SEE INFORMAL MOC PROGRAM EVALUATION CHECKLIST IN APPENDIX
APPENDIX
CCPA Checklist for Management of Change
MOC Program Evaluation Checklist
Canadian Chemical Producers Association (CCPA)
Checklist for Management of Change
1. Does the change involve any different chemicals that could react with other
chemicals (including diluents, solvents and additives) already in the process?
2. Does the new proposal encourage the production of undesirable byproducts either
through primary reactions, side reactions or introduction of impurities with the new
chemical?
3. Does the rate of heat generation and/or the reaction pressure increase as a result of
the new scheme?
4. Does the proposed change encourage or require the operation of equipment outside
the approved operating or design limits of chemical processing equipment?
5. Does the proposal consider the compatibility of the new chemical component and
its impurities with the materials of construction?
6. Has the occupational health and environmental impact of the change been
considered?
7. Has the design for modifying the process facilities or conditions been reviewed by a
qualified individual using effective techniques for analyzing process hazards,
particularly when the modifications are being made in rush situations or emergency
conditions?
8. Has there been an on-site inspection by qualified personnel to ensure that the new
equipment is installed in accordance with specifications and drawings?
9. Have the operating instructions and engineering drawings been revised to take into
account the modifications?
10. Have proper communications been made for the training of chemical process
operators, maintenance craftsmen and supervisors who may be affected by the
modification?
11. Have proper revisions been made to the process control logic, instrumentation set
points and alarm points, especially
MOC Program Evaluation Checklist
The following MOC checklist provides an informal way of evaluating a Management of
Change program.
Management Systems
• Is there a procedure for ensuring that all regulations and standards that apply to
the facility are known about and are being complied with?
• Is there procedure for determining when a change is a “Replacement In-Kind”?
• Are changes coordinated with operations so procedures and training materials can
be updated?
• Are changes analyzed with a PHA?
• What criteria are used for determining when a PHA is needed?
• Which PHA methods are used?
• Is there a clear policy as to who signs off each Management Of Change request?
Change Process
• Are there adequate controls on design changes?
• Are field changes by operations or maintenance personnel handled in the same
way as engineering changes?
• What administrative control is necessary to ensure replacement of proper
materials during construction/modification/maintenance so as to avoid excessive
corrosion and to avoid producing hazardous compounds and reactants?
• Is there a system for ensuring that operating procedures are changed in a timely
manner, and that operators and maintenance personnel are trained in the new
procedures?
• Is there a system for ensuring that the Process Safety Information records are
updated in a timely manner?
• Is there evidence that operators and other workers keep private supplies of spare
parts so that they can get work done quickly but unofficially?
Personnel
• Is the person who initiated the change involved in all aspects of the review and
follow-up process?
• Is Management of Change effectiveness considered in performance reviews?
Process Engineering
Is there a procedure that ensures that the following items are considered in any proposed
change evaluation?
• location/siting
• layout
• pressure relief devices
• ignition sources
• flames
• electrical
• static electricity
• engines
• lightning
• chemical
Piping
• fireproofing
• emergency isolation
• fixed breathing air
• firewater/fixed suppression
• vent/flare systems
• drain systems
• sampling systems
• fall protection
• loading/unloading
• human factors (outside)
• heat stress
• safe access
Instrument/Control Systems
• human factors (inside)
• emergency shut down
• workstations
• alarm stations
Structural/Civil
• drainage
• support buildings
• process buildings
• secondary containment
• spill control
Mechanical
• noise
• storage tanks
Electrical
• Area Classification
• Alternate Power
• Lighting
Equipment
• In view of process changes since the last process safety review, how adequate is
the size of:
¾ Other process equipment?
¾ Relief and flare systems?
¾ Vents and drains?
• Are the flare, blowdown, and off-gas systems capable of handling overpressure
events (including loss of utilities) for the plant after the changes have been made?
• What safety margins have been narrowed by revisions of design, construction, or

operation in efforts to debottleneck operations, reduce cost, increase capacity, or
improve quality?
GENERAL REFERENCES
The following are general sources of information on Management of Change and Process
Safety Management used in the creation on this course.
AIChE-CCPS. 1992. Guidelines for Hazard Evaluation Procedures, New York: Center
for Chemical Process Safety.
AIChE-CCPS. 1994. Guidelines for Preventing Human Error in Process Safety, New
York: Center for Chemical Process Safety.
AIChE-CCPS. 1993. Guidelines for Auditing Process Safety Management, New York:
Center for Chemical Process Safety.
AIChE-CCPS. 1996. Guidelines for Writing Effective Operating Procedures, New York:
Center for Chemical Process Safety.
American Petroleum Institute.1990. API Recommended Best Practice 750,

Washington, DC
OSHA 29 CFR Part 1910. 1992. Process Safety Management of Highly Hazardous
Chemicals, Explosives and Blasting Agents, Final Rule
Sutton, Ian S. 1998. Management of Change, Houston, Texas: Southwestern Books

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MANAGEMENT OF CHANGE

NPC TRAINING PROGRAM

Calgary Tel 1-403-221-8077 Fax 1-403-221-8072

• To understand the keys to a successful Management of Change (MOC) program,

Administrative changes are modifications to work procedures. An example might be

• decreasing or increasing the number of supervisors

Technical changes affect the operating process. Adding or deleting equipment or

What was the root cause of the accident?

WORK PERMIT SYSTEM HAS DEGRADED.

• Firewater pumps were designed to work automatically but, because divers

RISK ANALYSIS HAS NOT BEEN PERFORMED.

• Emergency procedures have collapsed and the radio room is extensively

What was the root cause of the accident?

Fewer hazardous releases

Less hazardous repair and maintenance

Fewer operational incidents

Economic considerations are another compelling reason for implementing an MOC

Fewer incidents will lead to fewer losses.

A company that has a reliable HSE record satisfies its

Identify problem or opportunity

Evaluate proposed change

Analyze root causes

Notify all involved

Consideration of the following criteria should help to determine if the Management of

CAUTION: Always consider that a replacement In Kind may be Not In-Kind in

Keeping the above points in mind, equipment replacement is considered In-Kind if it

CAUTION: The criticality of a proposed change is not always obvious without a

Infrequently repeated change

Because computerization of instrument systems and the introduction of process

PHA recommendations for change

Identify work, modification or improvement opportunity

Ascertain if the desired result can be achieved by using

Is the proposed change the result of YES CHANGE

Low-Low Low High High-High

Unsafe Risky Normal Risky Unsafe

Design Standard Environmental and safety regulations are the

Very authoritative - compiled by industry

COMPANY Especially important if process involves

Information from equipment vendors and

Formal structure of MOC

MOC Coordinator’s responsibilities

Step 1 Step 2 Step 3 Step 4

Step 5 Step 6 Step 7 Step 8

It should be recognized that, by suggesting the change, the Initiator is demonstrating

b) Determine if the change is In-Kind/Not-In-Kind. If the decision is made that the

The “In-Kind/Not-In-Kind” decision is critically important and is the most

The MOC Form: Section A – Request for Change

Technical basis for the change/description of the problem

See pages 34 and 35 for sample MOC form.

a) Confirm the problem

i) Can the problem be solved by using existing controls more efficiently?

b) Analyze the problem

i) Thoroughly understand the problem.

c) Identify possible solutions

• Knowledge: Collectively, the Team members should have multidisciplinary

• Creativity: Just as for a Process Hazards Analysis, at least some of the

Establishing time schedule and planning work flow

Technical information coordination

Change Evaluation: Section B of MOC Form (p.34)

Before a change can be implemented, it must be formally approved and accepted by

Name _ Signature & Date: __________________