100: No Change Assessment Performed
Definition/Typical Issues
Did personnel fail to perform a change assessment when it was required? Did personnel fail to realize that a change assessment was required?
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 EPA regulations.
Example 2
- A mechanic had to tie in a caustic line to a different location than indicated in the modification package. The mechanic identified that a change assessment was needed and requested that one be performed. The mechanic was told that the assessment was completed when in actuality it had not been performed. As a result, the line was tied in at an inappropriate location.
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.
Example 4
- A new supplier was selected to supply product barrels to the facility. Barrels from the new supplier were cheaper but only came in one color (black). This caused shipment problems because different-colored barrels had been used previously to easily identify the barrel contents. Purchasing did not realize the importance of the color coding. No management of change assessment had been performed.
Typical Recommendations
- Develop criteria for when a change assessment is required.
- Develop examples of situations that do and do not require a change assessment.
- Audit the change assessment process to identify situations that need additional clarification regarding the need to perform a change assessment.
- Provide awareness training and refresher training on the change control system.
Cross-References
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 97 | Change Review Issue |