One of my most debated topics at SAFTENG is my writings/ramblings about the critical role that a Management of Change (MOC) plays in ALL of safety, not just PSM. I’ve been involved in numerous non-PSM/RMP accidents that can be traced to poor or non-existent change management.
One fatal event last year involved simply moving a machine from one department to another, literally just on the other side of a wall. This machine had an accurate LOTO procedure in its original location; however, when it was moved, the energy control procedure was never updated for its new location. Months later, an employee lost their life on this machine as the LOTO SOP was not even close to being accurate, and NONE of the isolation devices were identified in the field. It was pure luck this incident did not happen much sooner, and to any of the 14 operators who had locked out this machine “the best they knew how”.
This was not a PSM/RMP facility, but it did have an SMS (on paper only) that included an MOC for changes. The MOC program was over 10 years old, and not a single (1) MOC had been completed. Management wanted to label the root cause as “operator error” rather than “management system failure” (i.e., Latent Organizational Failure). Sound familiar? This was IN NO WAY an Operator Error event; sure, the operator made an error because the management system failed to provide an accurate LOTO procedure for the machine’s new location. To compound this even more, a Supervisor had done an “inspection” on this machine and LOTO procedure after the move and before the accident, and failed to identify the procedure as NOT EVEN CLOSE to being accurate. To my knowledge, this supervisor has not received any action for his clear “pencil-whipping.”
So often, I get the evil eye when I mention MOC to non-PSM/RMP facilities. But how do they manage their PRCS program when a new space is introduced, the Respiratory program when a new respirator is added, the LOTO program when a new machine/equipment is installed, etc.? MOC has been part of QMS for as long as I have been a safety professional. In fact, OSHA stole the concept for the PSM standard from the QMS model, much like all the other SMS elements! It’s not only for PSM/RMP facilities; it can bring tremendous value to non-PSM/RMP workplaces.
MOC is a TOOL to help us MANAGE our changes. It’s not an evil entity that haunts our places of business! It’s not “paperwork” standing in the way of an engineer completing his/her project. But I think I will dress up again this year as an MOC for Halloween and scare the crap out of everyone!
