(159b) Managing the Risk of MOC

During the execution of a change using Management of Change (MOC), the risk to the facility is increased because things are in flux until the change is completed, documented and personnel trained. During this time P&IDs, SOPs, and other procedures are being developed or changed. Construction or tie-ins in preparation, or as part of the change, are going on. Thus, during the change until it is complete, the potential for error, and therefore the risk, is increased. This potential for error emanates from the use of not-yet implemented P&IDs (which already have red marks), use of unapproved procedures (or use of old procedures after the change), and unintended connections and flows from or to piping which contains hazardous materials. Additional risk results from an incorrect workflow where the appropriate individuals were not included in the review of the technical basis and the safety aspects of the change, or the necessary approvals are bypassed. Another, less common but possible risk, is unknowingly impacting an existing safeguard by changing related equipment. This is typically due to the inability to conduct a good search of the PHA or the MOC system itself.

Thus, the MOC process needs to be carefully managed, not only for an individual MOC but the aggregate of all the MOCs that are being worked on at the same time. The MOC system needs to provide easy simultaneous access to all personnel and be fully searchable. This enables seeing at any point in time what equipment is undergoing changes, or that has recently changed and is being started up. The longer it takes to complete a change the higher the risk and the MOC system needs to be monitored for late and/or undocumented MOCs. Metrics (preferable with graphs) that show the open and past due MOCs in any period of time, as well as the level of activity of opening and closing MOCs should be part of the system. To ensure proper review and approval there should be pre-configured workflows for the different kinds of changes. Approvals should be independent of reviews. The workflows should be easily configurable and editable as needed. It is important to have a system that is easy to use as this removes one more barrier to doing good MOC as complexity leads to error and even avoidance or bypass of the MOC system. Names, responsibilities and dates of all actions, including approvals, should be automatically captured, addition of information files or links to them should be a feature, as well as the creation of emails that automatically include the required action. Such a system will be illustrated.