99: Change Identification Issue
Definition/Typical Issues
Was there a failure to identify the change to the system? Was the definition of change less than adequate? Did personnel fail to understand the definition of "change" versus "replacement-in-kind"?
Examples
Example 1
- SO2 (a toxic gas) was released because a stiffer gasket was installed in an SO2 line. The gasket installed could last longer in this chemical service, but would not seal properly using previous torque settings. The management of change system defined "replacement-in-kind" as use of "similar or better" materials. Because the maintenance department considered the new gasket material superior, a change review was not performed.
Example 2
- A field modification to an instrument air line had to be made to route the line around a water line that was not on the drawings used by the designer. This reroute created a low point in the air line where contaminants collected. The field modification was not identified as a change that required a review.
Example 3
- A batch of product was ruined because of improper mixing of the components. Purchasing had switched suppliers to reduce costs. The feed material was now purchased at twice the concentration as before. The management of change system did not identify it as a change because the same material was purchased from both suppliers.
Typical Recommendations
- Ensure that authorization signatures are obtained from key personnel before design/field changes can be implemented.
- Train employees on how to initiate a request for change.
- Provide specific examples of what is and is not a change requiring review.
- Train all employees to understand the difference between a change and a replacement-in-kind.
- Ensure that all newly installed and/or modified equipment is included in a hazard review prior to startup.
- Involve design personnel in field reviews of the fabrication and installation of equipment.
- Allow field fabrication and installation personnel to have access to design personnel to resolve problems encountered in the fabrication and installation process.
- Empower personnel with the ability to initiate change assessments.
- Define the technical scope of the management of change system so that types of changes to be managed are certain and sources of changes are monitored.
- Define the management of change roles and responsibilities of various types of company/facility personnel.
- Develop specific examples of changes and replacements-in-kind for each category of change to be evaluated, and use these in employee awareness training in order to minimize the chance that the management of change system is inadvertently bypassed.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 102 | Change Not Identified |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 96 | Change Not Identified |