INTRODUCTION Any facility or operation is subject to continual change. Changes often are made in e uipment!

materials and processes to increase producti"ity or to correct ha#ards. In some cases! temporary adaptations! connections! bypasses or other modifications are made to the facility or process. $ystem administrators may decide to mo"e employees %ithin a specific process! %hich could eliminate or create positions %ithin the facility or process. All of these changes ha"e the potential to create ne% %or&place ha#ards! some of %hich are not immediately recogni#able. Although some changes are more critical than others! each modification should be analy#ed for inherent ha#ards that may result from the change. Although change usually is proposed for a good reason! changes made to impro"e one aspect of an operation actually may increase the potential for ha#ards in other areas of the same operation. To assess the impact of change and to monitor its implementation! it is essential to ha"e a policy and procedure for 'anagement of Change ('OC). 'OC seems decepti"ely simple! but it can be one of the most difficult elements of *$+ management to implement effecti"ely. 'OC in"ariably impacts other elements of a *ealth! $afety and +n"ironment 'anagement $ystem once it is implemented. Therefore! to be truly effecti"e! 'OC needs to be integrated into all aspects of the system! and the in"ol"ement of e"eryone in a facility needs to be encouraged. Commitment from company management creates a climate that empo%ers people to initiate needed change! and pro"ides a supporti"e structure for the implementation of change. +mployee participation is essential. Those on the line often are the first to notice problems! and in"ol"ement in the design of the 'OC program fosters commitment and o%nership. Commitment at all le"els is crucial. No matter ho% %ell designed an 'OC program is! it %ill be ineffecti"e if it is not used. It is impossible to describe a single! uniform method for managing change. The uni ue circumstances and needs of each facility re uire that a system be designed specifically to meet those needs. This course is not offering to teach a generic 'OC program, it is designed to loo& at the elements of effecti"e 'OC and present ideas that can be used to design a facility-specific program that %or&s.

Definations

Change
Is the result of a conscious decision to e.change! substitute! con"ert! alter! add! modify or "ary a component of an e.isting process! its e uipment and/or control and management systems. Change can be administrati"e! organi#ational and/or technical.

Administrative Change
Administrati"e changes are modifications to %or& procedures. An e.ample might be decreasing the fre uency of inspection or maintenance in one section of an operation. The section in"ol"ed may not "ie% the change as significant, ho%e"er! the conse uences of this change may seriously affect other parts of the operation.

Organizational Change
'odifying the structure of an organi#ation! regardless of its si#e! is a major change! and re uires appropriate impact analysis. Typical organi#ational changes include0 decreasing or increasing the number of super"isors decreasing or increasing the number of hours that employees %or& contracting instead of using company personnel changing operating philosophies

Technical Change
Technical changes affect the operating process. Adding or deleting e uipment or materials! or reno"ating or changing process techni ues are e.amples of technical change. Technical changes often are implemented to increase production and profits or to decrease ha#ards. 1et they can increase the potential for ha#ards.

MOC Policy
A public statement of the company2s commitment to implement change in a safe manner. The company needs to communicate its 'OC 3olicy to all its %or&ers. The 'OC 3olicy pro"ides a "alues-based frame%or& for addressing change in the company2s facilities and operations. The 'OC 3olicy must be applied to all acti"ities that fall under the umbrella of change.

MOC Program
A component of an *$+ management system. A systematic program is necessary to ensure that changes are managed in such a %ay that they do not compromise the safe design and operation of a facility.

MOC Procedure
The appro"ed se uence through %hich changes are initiated! e"aluated! authori#ed! implemented and follo%ed up. The intention of an 'OC procedure is to ensure that changes are re"ie%ed and appro"ed by people %ith appropriate &no%ledge and e.perience. These people %ill then be accountable for effecti"e implementation of the changes.

4enefits of 'OC

Safety
$afety is the most important reason for implementing an 'OC program. An effecti"e program %ill result in fe%er incidents in the follo%ing areas0

Fewer hazardous releases

As %e ha"e seen from the 3iper Alpha disaster! uncontrolled releases of ha#ardous materials %ill ha"e the most serious and sometimes catastrophic *ealth! $afety and +n"ironmental conse uences.

Less hazardous repair and maintenance

3roblems created by uncontrolled change often lead to e uipment stress and damage! and repair and maintenance of such e uipment can be ha#ardous to personnel. $ome e.amples of these ha#ards are "essel entry! climbing on and mo"ing hea"y machinery! and %or&ing on high "oltage electrical systems.

Fewer operational incidents

Uncontrolled (une"aluated) change may mo"e operating conditions into an unsafe range! encouraging or often re uiring operators to o"erride built-in safety systems. In some cases! uncontrolled change means that personal protecti"e e uipment must be discarded or physical safety de"ices! such as pressure relief "al"es and fire %ater systems! must be temporarily o"erridden.

Economic considerations
+conomic considerations are another compelling reason for implementing an 'OC program.

Production
3roduction rates should increase because of fe%er direct losses. 3roduction uality and capacity should increase and energy costs decrease because there %ill be less need to recycle or reprocess off-spec materials.

Assets
5e%er incidents %ill lead to fe%er losses.

Operations
Reduced do%n time for maintenance and repair and fe%er injuries %ill result in increased profit.

Company reputation
A company that has a reliable *$+ record satisfies its customers shareholders employees local residents go"ernment agencies ban&s The company then can attract in"estment capital! generate sales of its product! and a"oid legal e.penses.

Con"ersely! dissatisfaction amongst customers may lead to lost sales. Anger amongst members of the public and the %or&force may result in costly la%suits or disciplinary actions by go"ernment regulatory bodies. If these problems tarnish the company2s reputation! it may e.perience difficulty in attracting in"estment capital.

Change process

Identify problem or opportunity

The change process begins %hen a problem or opportunity re uiring change is recogni#ed. 5or continual impro"ement to ta&e place! it is essential that all personnel in"ol"ed in an operation are acti"ely encouraged to become part of the 'OC process. 'anagement and senior technical people must be %illing to listen to the ideas of %or&ers at all le"els! including temporary and contract %or&ers. 6ac& of education and e.perience do not mean that a person cannot come up %ith useful insights and suggestions.

Evaluate proposed change

The ne.t step is to decide if the change is practical! and if the desired outcome can be achie"ed by using e.isting systems more efficiently. +.amples are refresher training for employees and impro"ed document/communication management. If possible! correcti"e actions should be ta&en %hile operations continue. If the desired outcome cannot be achie"ed merely by increasing the efficiency of e.isting systems! a more thorough analysis is re uired.

Analyze root causes

A detailed team e"aluation is designed to identify the true! underlying causes of the problem and the areas in %hich change can be most effecti"e. Note: Root Cause Analysis will be addressed in greater detail during a later module of the HSE Management Training Program.

Obtain approval
4efore a change can be implemented! plant management must formally appro"e it. Update

information
3rior to implementation of the change! safety information needs to be updated. This may include the creation of ne% procedures! training %or&ers in the ne% procedures! and updating dra%ings.

otify all involved

4efore implementation! all affected parties need to be notified of the proposed change and gi"en an o"er"ie% of %hat is being done! the reason it is being done! and %hat the outcome is e.pected 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 ma.imi#e the effecti"eness of the 'OC program can be lost. 'onitoring change in"ol"es ongoing ha#ard/ris& assessment and follo%-up to ensure re uirements are being met. 3ost-change assessment is a "aluable method of identifying additional need for impro"ement. It is only in monitoring and follo%-up of implemented change that the system can continue to be e"aluated and impro"ed.

WHE !" #A A$E#E T OF CHA $E %E&'!%E()

'any changes occur in the e"eryday operation of a facility. *o%e"er! not all of these changes re uire the scrutiny of an 'OC procedure. Only initiated change (conscious decision to change) can be analy#ed and e"aluated for its potential ha#ardous conse uences and! therefore! managed. Reacti"e! spontaneous or co"ert (hidden) change cannot be managed because it cannot be anticipated. These &inds of changes must be managed %ithin other elements of the *$+ 'anagement $ystem! for instance! *a#ard Identification and 'echanical Integrity. Consideration of the follo%ing criteria should help to determine if the 'anagement of Change procedure needs to be follo%ed in a particular case. *o%e"er! as a general rule! if the proposed change affects one or more of the other elements in the *$+ management system! the 'OC procedure %ill probably need to be follo%ed.

!ypes Of Change
!n*+ind, ot !n*+ind change
If it is proposed to replace a piece of e uipment %ith another that is functionally identical and of the same specifications! the change is In-7ind and does not re uire an 'OC process. CA'T!O - Always consider that a replacement !n +ind may .e ot !n*+ind in many respects/ i0e0/ it may made .y di11erent people/ made with di11erent machinery/ made at a di11erent time/ stored 1or di11erent lengths o1 time in di11errent conditions/ or installed .y di11erent people0 7eeping the abo"e points in mind! e uipment replacement is considered In-7ind if it meets the follo%ing criteria0 'aterial specifications (dimensions! %eight! etc.) are the same. The ser"ice for %hich the e uipment is being used remains unchanged. All process conditions must remain the same as for those of the original item. Inspection and maintenance re uirements should not change. The replacement is part of routine maintenance. The In-7ind item is being replaced because it has a &no%n life span. Replacing In-7ind e uipment that is failing %ithout &no%n cause re uires in"estigation and 'anagement of Change. The ne% item is e ui"alent to the original one! not an impro"ed model or from a ne% supplier. Upgrades or ne% "endors should be assessed using the 'anagement of Change process. +"en a seemingly minor change in any of the specifications may impact some aspect of the process in some %ay.

Critical change
A critical change is one that could create a serious incident if it is mismanaged. Critical changes should recei"e more thorough scrutiny than those considered non-critical. CA'T!O - The criticality o1 a proposed change is not always o.vious without a detailed evaluation within the #OC process0 8hen a proposed change is deemed to be critical but also e.pensi"e! the proposal should be subjected to a 9uantitati"e Ris& Analysis (9RA). The story of the 3iper Alpha disaster illustrates such a need. The decision not to install blast %alls bet%een the oil separation unit and gas inta&e lines! because they %ould ha"e been too e.pensi"e! pro"ed to be a fatal mista&e. A 9RA %ould ha"e sho%n that the conse uences/probability/ris& e uation

%arranted the e.pense of the blast %alls. Note: RA has been mentioned in the Pro!ess Ha"ards Analysis #PHA$ %ortion of the training& and will be dis!ussed in more detail in a later session of the training.

"mall,large change
6arge changes usually in"ol"e many modifications to e uipment! instrument systems and administrati"e procedures! and therefore should recei"e a full 'OC re"ie%. *o%e"er! small changes may not be re"ie%ed %ith the same rigor because they can be implemented uic&ly and do not appear to ma&e a significant impact on the %ay a plant operates. 'OC re"ie%s! at least through a chec&list! should accompany e"en small changes. CA'T!O - Plant e2perience shows that it o1ten is the small changes that ultimately lead to serious incidents0 3ecause they are small/ they may not .e su.4ected to the scrutiny they really deserve0

Emergency change
+mergency change is one that has to be made "ery uic&ly %hen someone in authority decides that the dangers of doing nothing are greater than those possibly associated %ith the proposed change. An emergency change may be justified for reasons such as the follo%ing0 danger to personnel potential for major e uipment damage potential for major operational loss serious en"ironmental impact serious community complaint regulatory "iolation +"ery effort must be made to minimi#e the number of emergency changes! because they bypass the normal systems for ha#ard identification. After the fact! e"ery emergency change should be re"ie%ed by the formal 'OC procedure to ensure that no unforeseen problems e.ist 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 &eep an operation running %hile a piece of e uipment is repaired or replaced. A temporary change should have an automatic termination date. A temporary change of e"en a short duration should go through at least a $afety Re"ie% Chec&list (see Appendi.) by at least t%o or three people. A ne% procedure should be %ritten and an emergency response prepared in case the modification does not %or& properlyCA'T!O - 3ecause o1 the short duration o1 some temporary changes/ there can .e a temptation to .y*pass the 1ormal #OC procedure0 "ome o1 the most serious incidents have occurred .ecause o1 temporary changes0 We saw in the introductory session video how a temporary change that was not thought through or reviewed was the cause o1 the catastrophic accident in Fli2.orough/ England in 56780

!n1re9uently repeated change

Infre uently repeat changes are those that ha"e occurred at least once before and are repeated at infre uent inter"als. If a change has been carried out before! and if it %as properly managed! the 'OC process generally %ill not need to be repeated. *o%e"er! it needs to be stated in the 'OC records that this is the case.

!nstrumentation change

4ecause computeri#ation of instrument systems and the introduction of process simulations has allo%ed 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 re uires a formal 'OC appro"al.

PHA recommendations 1or change

One of the most important roles of an 'OC program is to manage the recommendations arising from a 3rocess *a#ard Analysis such as a *A:O3 study. These recommendations could fall into any of the already described types of change and! li&e any proposed change! each recommendation must be e"aluated and managed. +"en if a proposed change has resulted from a 3*A! an initial re"ie% may indicate the need for another 3*A or a Root Cause Analysis in order to identify hidden ha#ards caused by this specific change. 8ithout such an analysis! the uic& solution may focus on the symptoms rather than the real cause. *ence! the problem could recur.

#OC POL!C: A ( P%OCE('%E

Management of MOC
+ach company or facility de"elops its o%n policy and 'OC procedure %ithin the o"erall *$+ 'anagement system. 8hen designing such a policy and procedure it is important that the system reflects the e.isting culture and the %ay in %hich people in a facility actually %or& and interact %ith one another. In particular! the system should recogni#e that informal discussions and con"ersations are a feature of "irtually all aspects of change management! and that these informal communications should be encouraged and! %here possible! recorded and attached to the 'OC form. It is often in the informal communications that "aluable insights can be gained.

!eam approach
A team of people should al%ays carry out the 'anagement of Change process. The benefits of fresh ideas and increased commitment to the process ma&e the e.tra time that this may ta&e %orth%hile. 'ore than one person should uestion the impact of e"en a small! uic& change (along the lines of the Decision Analysis Tree already discussed). 4ecause it is often the small! uic& changes that ha"e not been thought through that cause incidents! if the change %arrants a formal 'OC re"ie%! it should be done. This being said! it is important not to ma&e the procedure so cumbersome that %or&ers %ill be tempted to bypass the process.

"ormal structure of MOC

Once a suggested change has been discussed informally and the decision made to commit it to the 'OC form! the formal process has begun. It is important that the 'OC procedure and form be easy to use %hile also ensuring that a thorough re"ie% ta&es place before the change is implemented. Designing the procedure and the 'OC form is al%ays a challenge %hen first implementing a 'anagement of Change 3rogram. The follo%ing sections pro"ide a basic structure that addresses all the issues that should be co"ered%hen recommending and e"aluating change and around %hich your o%n policy! procedure and 'OC record form can be designed.

MOC Coordinator#s responsibilities

The *$+ 'anager usually is responsible for ensuring that the policy and procedures are follo%ed and that all appropriate documentation and authori#ations are in place before the proposed change is implemented. In larger facilities! a separate 'anagement of Change group often carries this responsibility.

!he eight steps of the MOC process

50 !nitial re9uest
The person %ho ma&es the initial re uest is called the Initiator. Usually the Initiator is a manager! a super"isor or an engineer. *o%e"er! all employees and contractors should feel free to propose changes they feel %ill ma&e the facility safer! cleaner or more profitable. 3articipation of all employees is crucial if continual impro"ements are to be made. It should be recogni#ed that! by suggesting the change! the Initiator is demonstrating that he or she cares enough about the plant to %ant to ma&e it better. $o! for an 'OC program to encourage other %or&ers to ma&e their o%n suggestions! it is important that the Initiator be &ept in"ol"ed in the discussions that ta&e place once the proposal for change has been submitted. If the Initiator has proposed a solution! it should be considered along %ith suggestions solicited by the 'OC Coordinator from others in the operation. ;0 First review 4efore the formal 'OC process is initiated! the proposed change needs a uic&! commonsense reality chec& from people the Initiator &no%s and trusts. If it turns out that the idea is impractical! not much time %ill ha"e been %asted and the Initiator %ill not ha"e been made to loo& foolish in front of his management or colleagues. Regardless of ho% the 'anagement of Change system is organi#ed! it should be recogni#ed that the first re"ie% process %ill happen any%ay! and so it should be incorporated into the 'anagement of Change process. The first re"ie% should accomplish t%o things. a) 'a&e an initial assessment of the problem and the proposed solution and add rele"ant information and suggestions based on &no%ledge and e.perience. b) Determine if the change is In-7ind/Not-In-7ind. If the decision is made that the change is In-7ind! the necessary action can be ta&en %ithout further re"ie% or analysis! and the formal 'anagement of Change process is not pursued. The ;In-7ind/Not-In-7ind< decision is critically important and is the most challenging aspect of managing change. If a supposed In-7ind change turns out to be Not-In-7ind after all! a serious incident may occur. 4ecause of the criticality of this decision! super"isors and lead operators need to be thoroughly trained in the criteria for deciding %hether a change should be In7ind or Not-In-7ind! particularly since the choice of In-7ind change offers a tempting %ay of by -passing the %hole 'anagement of Change process. The #OC Form- "ection A < %e9uest 1or Change 8hen the re uest is formulated! it is entered in the first section of the 'OC form. This part of the 'OC form is completed by the Initiator and the 'OC Coordinator. (In a smaller organi#ation or facility! the $afety 'anager usually acts as the 'OC Coordinator for the duration of the 'OC process. In a larger facility or organi#ation! there usually is a dedicated! permanent 'OC Coordinator.) The 'OC Coordinator assigns an 'OC record number to the suggestion! and trac&s the form2s progress as it mo"es through the 'OC process. The 'OC Coordinator also is usually part of the 'OC Committee in the final appro"al process. The first section of the form should contain the follo%ing information0

Administrati'e information The first part of the form pro"ides all the administrati"e information and the basis for the proposed change and should include the follo%ing0 name of the Initiator and the date change category (technical! organi#ational or administrati"e) process system and facility location e uipment and process identification criticality (ris& ran&ing) of the problem %hether the change is deemed emergency! permanent or temporary and! if temporary! its time frame related 3*A information if the change is a recommendation arising from a study Te!hni!al basis for the !hange(des!ri%tion of the %roblem The person(s) re uesting the change should clearly define the problem to be sol"ed or outline the opportunity for impro"ed performance. This %ill be the basis for other e"aluations of the situation. To the e.tent that the Initiator is familiar %ith the historical bac&ground of the change scenario! it should be described at this point. In particular! if pre"ious solutions to similar problems %ere attempted! and failed! a description of %hat happened should be pro"ided. *ere! also! the Initiator should e.plain %hy he belie"es action must be ta&en. This could be for any combination of the follo%ing reasons0 safety en"ironment operations increased production increased producti"ity/efficiency reduced energy consumption/losses maintenance reduced maintenance costs reduced spare parts in"entory public relations public response other plants in the area other companies using similar technology regulatory re uirements ris& "ulnerability (refers to those changes that are made to reduce ris&! e"en if an incident has not yet ta&en place) "ee pages =8 and => 1or sample #OC 1orm0 =0 (etailed Evaluation After the first re"ie%! if it is decided that the proposed change should be pursued! it %ill proceed to the ne.t stage of the process! the detailed e"aluation. This e"aluation is performed by a team representing different disciplines and specialties according to the nature of the change. The detailed e"aluation Re"ie%ers ha"e three tas&s. a? Con1irm the pro.lem i) Can the problem be sol"ed by using e.isting controls more efficiently= ii) Does the situation under consideration ta&e the %or& process into an

unsafe range= .? Analyze the pro.lem i) Thoroughly understand the problem. ii) Use Chec&list! Root Cause Analysis or 3*A if necessary. c? !denti1y possi.le solutions i) 4rainstorm. iii) Thin& out of the bo.. Note: )ater in the HSE Management Training Program& the identifi!ation and sele!tion of solutions will be !o'ered in more detail. Evaluation Team +ach change is the responsibility of the 'OC Coordinator. 5ollo%ing the same steps as for 3*A preparation! his ne.t tas& is to see& out and select appropriate e.perienced and technically &no%ledgeable Re"ie%ers. $omeone on the Team also should ha"e an understanding of the organi#ational issues! such as economics and plant politics/ri"alries! related to the proposed change. The Re"ie% Team needs to be sensiti"e to these issues and adjust the proposal accordingly. The follo%ing are the minimum selection criteria for the 'OC Re"ie% Team0 E2perience- 'embers should ha"e &no%ledge of the process under re"ie% and &no%ledge of similar problems that occurred in the past and actions that %ere ta&en to sol"e them. +nowledge- Collecti"ely! the Team members should ha"e multidisciplinary technical &no%ledge in areas such as chemical! mechanical and instrumentation engineering! materials of construction! e uipment reliability and *ealth! $afety and +n"ironment. $omeone %ith &no%ledge of regulations! codes and engineering standards should re"ie% the final recommendations for compliance. Creativity- >ust as for a 3rocess *a#ards Analysis! at least some of the Re"ie%ers need to be able to thin& ;out of the bo.< to generate ne% ideas. Esta.lishing time schedule and planning wor@ 1low *a"ing selected the Re"ie% Team! the ne.t step for the 'OC Coordinator is to plan the %or& flo% and establish a schedule that %ill ma&e sure the e"aluation stays on trac& %hile also ma&ing sure that people ha"e enough time to thin& about %hat is being proposed. $cheduling may re uire coordination %ith other departments or functions. 5or e.ample! if the change re uires that the plant be shut do%n! and a full turnaround is scheduled for the near-term! the change re"ie% needs to be completed before that turnaround so that the %or& re uired by the change can be incorporated into the o"erall turnaround program. Loc@ed list If it is important that people %ith e.pert &no%ledge in a specific area are part of the +"aluation Team and that they re"ie% the information in a predefined se uence! the Re"ie%er list can be loc&ed. In this %ay the named Re"ie%ers must ha"e input to the e"aluation and analysis of the change in a certain order. Technical in1ormation coordination The Re"ie%ers usually %ant access to technical documents in order to conduct their e"aluations. The 'OC Coordinator! %here possible! should ma&e sure hehas ready access to documents that are li&ely to be re uested by the Re"ie%ers.

3ro"iding a single source of information increases efficiency! and reduces the time needed for the re"ie%. $uch documents fre uently include the follo%ing0 process and instrumentation diagrams (3?IDs) e uipment and material data sheets en"ironmental and safety regulations plot plans other pertinent documents Change Evaluation- "ection 3 o1 #OC Form Ap0=8? Once the Re"ie%ers ha"e completed their analyses! each should sign off as being in agreement or disagreement %ith the proposed change and attach comments to the 'OC form. The Coordinator should collect all of the comments and ideas that ha"e been generated! and summari#e and analy#e them. Along %ith the Initiator! he then decides on %hat action should be proposed. This is %ritten up in a report! %hich forms the basis for the recommendations that %ill be presented to management.

80 Formal Approval
4efore a change can be implemented! it must be formally appro"ed and accepted by the plant management. The 'OC form and appro"al pro"ide a paper trail in case there is an incident in %hich the change is implicated as a possible cause. #OC Committee 'ost facilities use a permanent 'anagement of Change Committee to e"aluate the proposed change on behalf of the company2s management! and! assuming that it agrees %ith %hat has been proposed! and if more than one solution is presented! selects the most appropriate of those presnted. The 'OC Committee usually has permanent representati"es from Operations! 'aintenance! Technical! +ngineering Construction and +n"ironmental and 3rocess $afety. Other speciali#ations can be added on an as-needed basis. +ach of the Committee members should sign off onthe 'OC form once they are satisfied that the change is safe and %or&able. The change should be gi"en an implementation timeframe! and the responsible person from management should sign the formal authori#ation. Process Hazards Analysis APHA? One of the most important decisions that the 'OC Committee has to ma&e is %hether or not to re uire that a 3rocess *a#ards Analysis be carried out. 8ith regard to most proposed changes! the follo%ing fi"e guidelines can pro"ide assistance in determining %hether or not a 3*A is needed. a) If the change %ill be large and e.tensi"e! a 3*A helps to identify systems problems. 5or e.ample! if the change %ill modify or adapt the process and/or layout of a facility! as it did in the 3iper Alpha e.ample! the effect on the rest of the facility needs to be considered. b) If the change in"ol"es input from many disciplines and departments! then a 3*A may help in the identification of accident scenarios that result from potential interdepartmental misunderstandings. c) If the conse uences of the change could lead to a serious incident! a 3*A should be carried out. d) If the proposed change in"ol"es adjusting critical operating parameters! such as reactor temperatures! it should be e"aluated %ith a 3*A.

e) If ne% technology or a brand ne% process arrangement is proposed! a 3*A should be carried out in order to help identify currently unforeseen e"ents. (Thin& of 3iper Alpha.)

>0 !n1ormation 'pdating

Once the change has been appro"ed! any ne% $afe Operating 6imits must be defined! and engineering and other documentation updated before start-up. +"eryone affectedby the ne% "alues must be informed and trained in %hat to do if the ne% limits are e.ceeded. 3rocess $afety Information (3$I)! such as operating and maintenance procedures, process and instrumentation diagrams (3?IDs), training and mechanical integrity documentation! must be updated before the change is completed! other%ise there is a good chance that these paper%or& issues %ill be deferred indefinitely. !n1ormation 'pdating < "ection C o1 the #OC Form Ap0=>? The 'OC form should pro"ide an information chec&list that must be completed by those responsible from each area before start-up.

B0 oti1ication
4efore the change is implemented! e"eryone %ho could be affected by the conse uences of the change should be notified. It is the 'OC Coordinator2s responsibility to ma&e sure that rele"ant personnel are told of the proposed change date! along %ith a brief o"er"ie% of %hat %ill be done! %hy it %ill be done! and %hat the impact on the process is li&ely to be.

70 !mplementation
4efore large changes/modifications are implemented! a 3re-$tartup $afety Re"ie% (3$$R) should be performed. 4ecause there can sometimes be a considerable time lag bet%een the 3*A/formal appro"al and the implementation of the change! there is a danger that uncontrolled changes may occur during the inter"ening period. On smaller projects! e"ents usually mo"e uic&ly! and the 'anagement of Change Committee2s formal re"ie% of the change usually is ade uate. *o%e"er! management must be satisfied that the change cannot be modified bet%een appro"al and implementation. C0 Follow*'p Once the change has been implemented! there should be a follo%-up super"ised by the 'OC Coordinator to ma&e sure that all precautions and preparations %ere handled properly and that the change has actually achie"ed the desired results of impro"ed safety or operability. A follo%-up should include the follo%ing considerations. a) 8as the change management procedure follo%ed= b) 8ere all the other elements of process safety properly e"aluated to ensure that there %ere no une.pected side effects= c) 8as the change itself implemented properly! and do the operators ha"e an understanding of the ne% operating limits and %hat to do if those limits are e.ceeded=s