Page 123 - 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 101

Identifying the Critical Work—Management of Change 101

The need for thoroughness in reviewing planned changes is illustrated
by an incident involving a major health care facility. The hospital initiated a
planned change to utilize a new respiratory oxygen supplier. In the course of
implementing the change, the supplier installed a new oxygen tank and sup-
port equipment at the facility. The new installation included a section of hose
in the oxygen distribution system that apparently contained residue from a
chemical compound utilized to clean the hose. Several patients requiring res-
piratory care died in the days following their initial exposure to the new oxy-
3
gen system. Although the investigation did not conclusively correlate the
deaths with the change in oxygen supply, the public images of both the hos-
pital and oxygen supplier were unfavorably impacted. The point to be made
is that an in-depth review is required to successfully minimize the potential
for subtle, unintended problems resulting from process changes.
In many facilities, processing and manufacturing operations are period-
ically shut down to perform equipment maintenance or modifications. The
actions of shutting down the operation, managing the maintenance/modifi-
cation work, and restarting the operation following completion of the work
represent significant changes from the normal operating mode. Predictably,
an abnormally high percentage of serious incidents have occurred during
such periods. One study indicates about 24 percent of the total serious inci-
dents in petrochemical facilities occur when the operating mode is other
4
than normal. Certainly, we would expect most petrochemical operations
typically to be in the “other-than-normal” mode less than 10 percent of the
time. Thus, the probability of an incident occurring during a day when a fa-
cility is down for maintenance is likely to be several times higher than for a
day when operations are in the normal mode.
Such shutdowns for maintenance and modifications belong in a special
category of planned change. Management tools such as procedures, training,
contractor safety programs, and effective permit systems are particularly crit-
ical in sustaining incident-free operations during these nonroutine periods.

Management of Change in the Serious
Incident Prevention Process

Table 9-1 provides a listing of management tools that can be effectively
utilized to manage change. The serious-incident prevention process provides
an effective method for ensuring that critical work necessary to sustain seri-
ous-incident-free operations is identified and effectively executed. It is clear
that this work must include actions to effectively manage change. Successful
incident-prevention processes must ensure that all types of changes are ef-
fectively managed, including both unplanned and planned changes.