Page 119 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company

CH09pp096-102 4/10/02 12:50 PM Page 97

Identifying the Critical Work—Management of Change 97

Unplanned Changes

Entropy recognizes that, in the absence of compensating forces, all mat-
ter and systems tend toward disorder. With “change” being a potential
enemy of safe operations, the presence of naturally occurring degradation is
a significant concern.
Changes driven by entropy are of particular concern because they occur
slowly—often too slowly to be recognized by individuals who observe op-
erations on a daily basis. Even if these changes are recognized, individuals
may not have the expertise to determine when corrective action is required.
In operations such as aviation, petrochemicals, construction, and health
care, prompt identification and accurate evaluation of subtle workplace
changes are critical to sustaining operations free of serious incidents.
Changes related to naturally occurring degradation may at first glance be
primarily associated with mechanical failures from forces such as friction or
corrosion. A closer look confirms entropy is also at work in eroding the ef-
fectiveness of administrative processes. Major gaps in an organization’s pub-
lished safety processes compared to actual implementation can develop. For
example, with the passage of time, compliance with a facility’s safety permit
system may degrade to where individuals routinely authorize maintenance
work without conducting an adequate review of field preparations.
A process dependent upon general employee awareness to detect and
evaluate the significance of subtle, naturally occurring changes is inade-
quate. Recognizing and understanding the potential consequences of grad-
ual changes requires a comprehensive, systematic approach. Management
tools such as audits, inspections, equipment testing, instrument calibrations,
procedure reviews and training are needed. Many of us have experienced
the advantages of including “outsiders” in safety inspections. Rather than
comparing an operation to “how it looked yesterday,” knowledgeable out-
siders are more likely to compare the operation to “how it should be.”
Training courses on management of change typically focus on changes
that are planned and intentionally implemented. For planned changes, man-
agers and other personnel commonly have advance knowledge prior to im-
plementation. Management review is generally involved since approval of
expenditures or other authorization is usually required. Reviews for some
types of planned changes are also mandated by OSHA’s Process Safety
Management Standard. Obviously, planned changes must be properly man-
aged to prevent serious incidents. However, unplanned changes are equally
as critical while often receiving less scrutiny.
Examples of potential unplanned changes applicable to a chemical fa-
cility include drum filling equipment that has become unreliable in dis-