Objective of lecture 1. Give an understanding of the elements included in the title; Designing management of change procedure to act as barriers to major offshore accidents 2. Shortly describe experiences from major accidents 3. Give an understanding of the different steps in designing a management of change (MOC) procedure

1. Designing management of change
procedure to act as barriers to major
offshore accidents
Trial lecture – PhD
06.12.2011
Jon Espen Skogdalen
1

2. Objective of lecture
1. Give an understanding of the elements included
in the title; Designing management of change
procedure to act as barriers to major offshore
accidents
2. Shortly describe experiences from major
accidents
3. Give an understanding of the different steps in
designing a management of change (MOC)
procedure
2

3. Elements in the title
• Designing management of change procedure
to act as barriers to major offshore accidents
• Designing
• Management of change
• Procedure
• Barrier
• Major offshore accidents
3

4. Major offshore accidents
• Limitation – major offshore accident within the oil
and gas (O&G) industry
-Designing
-MoC • A major accident in the O&G industry is often
-Procedure
-Barrier
understood as an accident out of control with the
-Major
offshore
potential to cause five fatalities or more, caused
accidents
by the failure of one or more of the system‘s
safety barriers.
4

5. Major accidents, offshore O&G
-Designing
-MoC
-Procedure
-Barrier
-Major
offshore
accidents
Norsok, (2010). Standards Norway. Norsok Standard: Risk and emergency preparedness analysis, Z-013 3ed. Oslo.
5

6. Major accidents, offshore O&G
• Blowouts, including shallow gas and reservoir zones, unignited
and ignited
• Process leaks, unignited and ignited
• Utility areas and systems fires and explosions
-Designing • Riser and pipeline accidents
-MoC • Fire in accommodation areas
-Procedure
-Barrier • Accidents from subsea production systems
-Major • Escape, evacuation and rescue accidents, i.e. until a so-called
offshore
accidents
‘safe place’ has been reached
• Structural collapse, including collapse of bridges between fixed
and/or floating installations
• Foundation failure
• Loss of stability/position
Norsok, (2010). Standards Norway. Norsok Standard: Risk and emergency preparedness analysis, Z-013 3ed. Oslo.
5

7. Designing
• Designing management of change procedure
to act as barriers to major offshore accidents
-Designing
-MoC • Something more than just “make”
-Procedure
-Barrier • System perspective;
-Major
offshore – Who are the stakeholders?
accidents
– What is the goal?
– What are the surroundings and limitations?
6

8. Management of change (MoC)
-Designing
-MoC
-Procedure
-Barrier
-Major
offshore
accidents
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
7

9. Management of change (MoC)
• Designing management of change procedure
to act as barriers to major offshore accidents
-Designing
-MoC
-Procedure
-Barrier
-Major
offshore
accidents
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
7

10. Management of change (MoC)
• Designing management of change procedure
to act as barriers to major offshore accidents
-Designing
-MoC
-Procedure
-Barrier
-Major
offshore
accidents
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
7

11. Management of change (MoC)
• Designing management of change procedure
to act as barriers to major offshore accidents
-Designing
-MoC • ”MoC is a process for evaluating and controlling
-Procedure
-Barrier modifications to facility, design, operation,
-Major
offshore organization or activities – prior to implementation
accidents
– to make certain that no new hazards are
introduced and that the risk of existing hazards to
employees, the public, or the environment is not
unknowingly increased.”
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
7

12. Management of change (MoC)
• Designing management of change procedure
to act as barriers to major offshore accidents
-Designing
-MoC • A socio-technical system:
-Procedure
-Barrier 1. The work and technological system
-Major
offshore
accidents
2. The staff level
3. The management level
4. The company level
5. The regulators and associations level
6. The government level
Rasmussen,
J.,
(1997).
Risk
management
in
a
dynamic
society:
a
modelling
problem.
Safety
Science,
27:
183-­‐213.
8

13. Management of change (MoC)
• Designing management of change procedure
to act as barriers to major offshore accidents
-Designing
-MoC
-Procedure
-Barrier
-Major
“We cannot change the human condition, but we
offshore
accidents
can change the conditions under which
humans work”
James Reason
Reason, J., (2000). Human error: models and management. Bmj, 320: 768-770.
9

14. Procedure
• Designing management of change procedure
to act as barriers to major offshore accidents
-Designing
-MoC • “A procedure is a sequence of actions or
-Procedure
-Barrier operations which have to be executed in the same
-Major
offshore
manner in order to always obtain the same result
accidents
under the same circumstances.”
Cook, J.L., (1998). Standard operating procedures and guidelines. Fire Engineering Books & Videos.
10

15. Barriers
• Designing management of change procedure
to act as barriers to major offshore accidents
-Designing
-MoC • Safety barriers (barriers) are physical or non-
-Procedure
-Barrier physical means planned to prevent, control, or
-Major
offshore
mitigate undesired events or accidents. Barriers
accidents
may be passive or active, physical, technical, or
human/operational systems.
Sklet, S., (2006). Safety barriers: Definition, classification, and performance. Journal of Loss Prevention in the Process Industries, 19:
494-506.
11

16. PSA, Management regulation, #5 Barriers
-Designing
-MoC
-Procedure
-Barrier
-Major
offshore
accidents
http://www.ptil.no/management/category401.html
12

17. PSA, Management regulation, #5 Barriers
• Barriers shall be established that:
a) reduce the probability of failures and hazard
and accident situations developing,
-Designing
-MoC b) limit possible harm and disadvantages.
-Procedure
-Barrier
-Major
offshore – Where more than one barrier is necessary,
accidents
there shall be sufficient independence
between barriers.
http://www.ptil.no/management/category401.html
12

18. PSA, Management regulation, #5 Barriers
-Designing
-MoC
-Procedure
-Barrier
-Major
offshore
accidents
http://www.ptil.no/management/category401.html
13

19. PSA, Management regulation, #5 Barriers
– The operator or the party responsible for
operation of an offshore or
onshore facility, shall stipulate the strategies
-Designing and principles that form the basis for design,
use and maintenance of barriers, so that the
-MoC
-Procedure
-Barrier
-Major barriers' function is safeguarded throughout
offshore
accidents the offshore or onshore facility's life.
http://www.ptil.no/management/category401.html
13

20. PSA, Management regulation, #5 Barriers
-Designing
-MoC
-Procedure
-Barrier
-Major
offshore
accidents
http://www.ptil.no/management/category401.html
14

21. PSA, Management regulation, #5 Barriers
– Personnel shall be aware of what barriers
have been established and which function
they are intended to fulfil, as well as what
-Designing performance requirements have been defined
in respect of the technical, operational or
-MoC
-Procedure
-Barrier
-Major organisational elements necessary for the
offshore
accidents individual barrier to be effective.
– Personnel shall be aware of which barriers
are not functioning or have been impaired.
– The responsible party shall implement the
necessary measures to remedy or
compensate for missing or impaired barriers.
http://www.ptil.no/management/category401.html
14

22. Objective of lecture
1. Give an understanding of the elements included
in the title; Designing management of change
procedure to act as barriers to major offshore
accidents
2. Shortly describe experiences from major
accidents
3. Give an understanding of the different steps in
designing a management of change (MOC)
procedure
15

23. Texas City accident,
Baker panel, five root causes:
1. inadequate training/qualification of
personnel,
2. inadequate review against technical
standards,
3. inadequate operational discipline and
attention to detail,
4. inadequate management of change
reviews,
5. lack of an effective management
review system.
Baker, J., Bowman, F., Erwin, G., Gorton, S., Hendershot, D., Leveson, N., (2007). The report of the BP U.S. Refineries independent safety
review panel, Washington DC.
16

24. Objective of lecture
1. Give an understanding of the elements included
in the title; Designing management of change
procedure to act as barriers to major offshore
accidents
2. Shortly describe experiences from major
accidents
3. Give an understanding of the different steps in
designing a management of change (MOC)
procedure
17

25. Change or replacement-in-kind?
• Replacement-in-kind (RIK)
– An item (equipment, chemicals, procedures,
organizational structures, people etc.) that meets
the design specifications, if one exists of the item it
is replacing.
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
18

26. Example, replacement and concern
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
19

27. Example, replacement and concern
• Replacement-in-Kind?
– Replacing rotating equipment with new equipment of the
same material, capacity, flange rating, seal design, driver
type, horsepower, etc.
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
19

28. Example, replacement and concern
• Replacement-in-Kind?
– Replacing rotating equipment with new equipment of the
same material, capacity, flange rating, seal design, driver
type, horsepower, etc.
• Change:
- Increasing the impeller size
- Using a single seal to replace a tandem seal in a pump
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
19

29. Example, replacement and concern
• Replacement-in-Kind?
– Replacing rotating equipment with new equipment of the
same material, capacity, flange rating, seal design, driver
type, horsepower, etc.
• Change:
- Increasing the impeller size
- Using a single seal to replace a tandem seal in a pump
• Example concern with change
- Downstream equipment may not accommodate potentially
increased flows. Increased head lifts downstream PSVs
- Different spare parts and maintenance requirements
- Greater potential for seal leak
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
19

30. Example, replacement and concern
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
20

31. Example, replacement and concern
• Replacement-in-Kind?
– Replacing the current maintenance contractor with
another qualified contractor
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
20

32. Example, replacement and concern
• Replacement-in-Kind?
– Replacing the current maintenance contractor with
another qualified contractor
• Change:
– Changing from centralized maintenance to decentralized
maintenance
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
20

33. Example, replacement and concern
• Replacement-in-Kind?
– Replacing the current maintenance contractor with
another qualified contractor
• Change:
– Changing from centralized maintenance to decentralized
maintenance
• Example concern with change
– Need to address issues such as:
• Responsibility for training
• Standardization of procedures and practices
• Potential that mechanics will spend a greater percentage of
their time in closer proximity to process hazards
• Need to train more mechanics on process overviews,
chemical hazards, MOCs, etc.
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
20

34. Main steps – designing MOC
• Establish Consistent Implementation
• Involve competent personnel
• Evaluate possible impact
• Manage all sources of change
• Keep MOC practices effective
• Emergency change
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
21

35. Establish Consistent Implementation
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
22

36. Establish Consistent Implementation
1. Establish and implement formal procedures to
manage changes, excluding Replacements-in-
kind (RIKs),
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
22

37. Establish Consistent Implementation
1. Establish and implement formal procedures to
manage changes, excluding Replacements-in-
kind (RIKs),
2. Assign a job function to be the "owner" of the
MOC system and to routinely monitor MOC
effectiveness,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
22

38. Establish Consistent Implementation
1. Establish and implement formal procedures to
manage changes, excluding Replacements-in-
kind (RIKs),
2. Assign a job function to be the "owner" of the
MOC system and to routinely monitor MOC
effectiveness,
3. Define the technical scope of the MOC system/
Identify potential change systems,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
22

39. 3 Identify potential change systems
• Process safety management system
• Plant layout or equipment location/
arrangement
• New chemicals
• Software
• Procedures
• Chemical specifications and suppliers
• Job assignments (individual, shift, or staff)
• Organization
• Policies
• Building locations and occupancy patterns
• Other
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
23

40. Involve competent personnel
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
24

41. Involve competent personnel
4. Define the MOC roles and responsibilities for
various types of company/facility personnel,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
24

42. Involve competent personnel
4. Define the MOC roles and responsibilities for
various types of company/facility personnel,
5. Provide awareness training and refresher training
on the MOC system to all employees and
contractors,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
24

43. Involve competent personnel
4. Define the MOC roles and responsibilities for
various types of company/facility personnel,
5. Provide awareness training and refresher training
on the MOC system to all employees and
contractors,
6. Provide detailed training to all affected employees
and contractors who are assigned specific roles
within the MOC system,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
24

44. Evaluate possible impact
7. Ensure that the written MOC procedures include
the use of an MOC review form and that the
following items are addressed prior to any
change:
– Technical basis for the proposed change
– Impact of the proposed change on safety and health
– Authorization requirements for the proposed change
8. Use appropriate analytical techniques, including
qualitative hazard evaluation methods, to review
the potential safety and health impacts of a
change,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
25

45. Manage all sources of change
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
26

46. Manage all sources of change
9. For each type/category of change to be
evaluated, develop specific examples of changes
and RIKs for each category for use in employee,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
26

47. Manage all sources of change
9. For each type/category of change to be
evaluated, develop specific examples of changes
and RIKs for each category for use in employee,
10.Update all process safety information (PSI) prior
to startup of the change. If this is not possible,
facilities should use temporary records,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
26

48. Manage all sources of change
9. For each type/category of change to be
evaluated, develop specific examples of changes
and RIKs for each category for use in employee,
10.Update all process safety information (PSI) prior
to startup of the change. If this is not possible,
facilities should use temporary records,
11.Communicate changes to potentially affected
personnel, including contractors,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
26

49. Keep MOC practices effective
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
27

50. Keep MOC practices effective
12.Keep a summary log of all MOC reviews,
including the items that must be included on an
MOC review form, to aid day-to-day management
of the MOC process,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
27

51. Keep MOC practices effective
12.Keep a summary log of all MOC reviews,
including the items that must be included on an
MOC review form, to aid day-to-day management
of the MOC process,
13.Establish and collect data on MOC performance
indicators and efficiency indicators,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
27

52. Keep MOC practices effective
12.Keep a summary log of all MOC reviews,
including the items that must be included on an
MOC review form, to aid day-to-day management
of the MOC process,
13.Establish and collect data on MOC performance
indicators and efficiency indicators,
14.Provide input to internal audits of MOC practices
based on learnings from the MOC performance
indicators,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
27

53. Emergency Change
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
28

54. Emergency Change
• A change needed in a situation where the time
required for following the normal MOC procedure
could result in unacceptable safety hazard, a
significant environmental or security incident, or
an extreme economic loss.
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
28

55. Simple generic MOC work flow
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
29

56. ISO 31000:2009 - Risk management
-- Principles and guidelines
30

57. MOC performance indicators, example
• Number of incidents having MOC failure as a
contributing factor or root cause,
• Percentage of changes within the MOC system
that were reviewed incorrectly,
• Percentage of MOCs that were reviewed but were
not properly documented,
• Percentage of changes that were properly
evaluated but did not have all of the required
authorization signatures on the change control
document,
• Percentage of changes that were processed on an
emergency basis,
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
31

58. 32

59. What went wrong?
• “Sometimes there is no systematic
procedure, sometimes the procedure is not
thorough or is not followed, and sometimes
the change is so simple that a formal review
seems unnecessary. There is also a
reluctance in many companies to look in the
literature for reports of similar situations.”
• Kletz, T.A., (2009). What went wrong?: case
histories of process plant disasters and how they
could have been avoided. Gulf Professional Pub.,
Burlington, MA.
33

60. Successfully implementing MOC
procedure
• Keep it simple, yet fit for duty
• Obtain widespread acceptance and commitment
• Field test the system prior to its official
implementation
• Provide adequate training
• Periodically monitor the effectiveness of the MOC
system
• Use audits and management reviews
• Demonstrate management leadership and
commitment
Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.
34

61. Recommended reading
• Center for Chemical Process, S., (2008).
Guidelines for the Management of Change for
Process Safety. John Wiley & Sons, Inc.
• Baker, J., Bowman, F., Erwin, G., Gorton, S.,
Hendershot, D., Leveson, N., (2007). The report of
the BP U.S. Refineries independent safety review
panel, Washington DC.
35