98: Change Control Issue

Node Change Control Issue

Definition/Typical Issues

Was a change assessment performed? Was there a delay in performing the change assessment? Was the change assessment improperly or inappropriately performed? Was control of design/field changes inadequate?

Note 1: Change control issues address the OSHA process safety management (PSM) management of change element.

Examples

Example 1

  • A modification to a flare system needed to be performed because of an instrumentation failure. Although maintenance identified the change, no change assessment was performed prior to the modification being installed. As a result, the flare instrumentation was rendered inoperable for 11 hours, contrary to OSHA requirements.

Example 2

  • A new oil cooler was installed. The management of change assessment did not consider the impact on the overall cooling system. Because many coolers had been installed without considering the impact on the overall cooling system, it was overloaded on the first hot day.

Example 3

  • The management of change policy requires safety reviews of all process changes, but during an overnight emergency, a failed gate valve was replaced with a ball valve. No change assessment was performed to save time. The valve subsequently ruptured when peroxide that was trapped in the ball decomposed.

Typical Recommendations

  • Train all employees to understand the difference between a change and a replacement-in-kind.
  • Develop examples of situations that do and do not require a change assessment to be performed.
  • Provide a list of issues that should be considered during a change assessment.
  • Enforce requirements to have change assessments completed prior to performing the modification.
  • Establish and implement procedures to manage changes.
  • Assign someone as the "owner" of the management of change system to routinely monitor its effectiveness.
  • Create a system to address management of change action items and to document their completion.

Cross-References

Version 10 Element(s)
Node ID Node Name
102 Change Not Identified

 

PSM Element(s)
14

 

RBPS Element(s)
Management of Change

 

Maritime Element(s)
Node ID Node Name
95 Change Control Issue
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