CSB Bulletin Says 'Managing Change' Is Essential to Safety

Sept. 7, 2001
A new safety bulletin from the U.S. Chemical Safety and Hazard Investigation Board advises companies to review their management of change policy.

In industry, as elsewhere, change often brings progress. But it can also increase risks that, if not properly managed, create conditions that may lead to injuries, property damage or even death.

A new safety bulletin from the U.S. Chemical Safety and Hazard Investigation Board (CSB) released concerning "Management of Change" discusses two incidents (one in Maryland and the other in Washington State) that occurred in the United States in 1998.

The first incident involved a Nov. 25 fire at an Equilon Enterprises oil refinery in Anacortes, Wash. The fire in the delayed coking unit caused six fatalities.

The second incident on Oct. 13 involved a reactor vessel explosion and fire at the CONDEA Vista Co. detergent alkylate plant in Baltimore, Md., that injured four people and caused extensive damage.

According to CSB, each case history offers valuable insights into the importance of having a systematic method for management of change (i.e., managing changes in chemical processes using a formal Management of Change [MOC] program).

An MOC methodology should be applied to operational deviations and variances, as well as to preplanned changes --- such as those involving technology, processes, and equipment.

The CSB MOC safety bulletin explains that lack of time for safety decision-making was not a factor in causing the incidents.

According to the bulletin: "Neither the Equilon Enterprises oil refinery nor the CONDEA Vista Co. explosion and fire involved emergencies that required rapid decision making. In each instance, time was available to look into the circumstances more thoroughly. Each situation could have been avoided with a more analytical and structured approach to problem solving."

CSB found that there were numerous contributing factors that caused these incidents.

However, CSB believes that properly conceived and executed MOC programs could have helped to prevent or mitigate the effects of both events.

Both OSHA''s Process Safety Management standard and EPA''s Risk

Management Plan require facilities to manage changes in covered processes handling highly hazardous materials using a formal MOC program.

However, the CSB bulletin states, "it is good practice to do so, irrespective of the specific regulatory requirements".

CSB is urging organizations to review their MOC policy to be sure it covers operational variances in addition to physical changes. If your organization doesn''t have a systematic method for handling changes, develop and implement one.

To maximize the effectiveness of your MOC system, the bulletin suggests that the following activities be included:

  • Define safe limits for process conditions, variables and activities --- and train personnel to recognize significant changes. Combined with knowledge of established operating procedures, this additional training will enable personnel to activate the MOC system when appropriate.
  • Apply multidisciplinary and specialized expertise when analyzing deviations.
  • Use appropriate hazard analysis techniques.
  • Authorize changes at a level commensurate with risks and hazards.
  • Communicate the essential elements of new operating procedures in writing.
  • Communicate potential hazards and safe operating limits in writing.
  • Provide training in new procedures commensurate with their complexity.
  • Conduct periodic audits to determine if the program is effective.

The complete CSB safety bulletin on management of change may be viewed or downloaded from CSB''s Web site at www.chemsafety.gov/bulletins/2001/moc082801.pdf.

by Virginia Foran

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