We have all been there… the auditor identified several “physical changes” during their walk-thru of the process, and when it comes time to audit the MOC element, they begin asking for completed MOCs (and PSSRs). And like everyone before us and mostly after us, we will have made changes that needed a MOC, but we failed to perform one. This leads to an audit finding and much consternation among the facility personnel as to how they address the audit finding. For me, it is a three-stage action plan:
Stage 1
Take the specific changes that were made without an MOC and perform an MOC. NEVER EVER back-date documents; just put a note at the top of the MOC that this is related to Audit Finding #___ and is being done after the fact. This is NOT a paperwork exercise to satisfy some audit findings; this is a true MOC with all the Hazard Reviews and EHS reviews to ensure the change that was made was indeed safe to make in the manner in which it was made. We may get lucky if the change was minor in size and scope and all turned out well; however, the changes that are often identified by a 3rd party auditor are usually larger in scale – like a new storage tank, new process vessel, etc. In my experience, these are usually overrun with errors, and if I wanted to run the numbers up on the audit, it would be quite easy to do with one of these large-scale changes. We almost always find significant issues that were not considered in the project, and this can lead to a lengthy “to-do list” in order to satisfy the MOC/PSSR reviews and documentation.
Once we have completed Stage 1 regarding all the specific changes that the audit identified during the 3-5 days, we move to Stage 2.
Stage 2
Here, we dig deeper – way deeper than what the audit team had to time while they were on site. We have to realize that an auditor was able to identify ___ number of changes that were made over a period that we failed to identify. This auditor is looking at our process(s) as a snapshot in time, and if he/she is capable of finding changes in those 3-5 days on-site, we have to realize there are probably more changes that were missed. It is incumbent upon us to perform a formal review to identify any other sleeper changes that were missed.
This can be a lengthy exercise to perform as it requires a multidisciplinary team from operations, maintenance, engineering, and EHS. The review MUST BE DONE with the understanding that it is NOT an exercise to identify personal failures but to find changes that had been made without an MOC. People must feel secure in speaking freely about what they know, and any patterns by individuals will be addressed later and OUTSIDE of this group.
Stage 3
While Stages 1 & 2 are happening, management MUST devise a corrective action plan to ensure we are not doing Stages 1 & 2 again in 3 years (Audit) and/or 5 years (PHA). Where Stages 1 & 2 are looking back, Stage 3 is all about looking forward. This requires some deep and oftentimes difficult discussion regarding how we got where we are and what we need to do to ensure that once we climb out of this hole we have dug we fill the hole with concrete! Obviously, at varying degrees, our MOC process was broken. This could be a cultural issue, a technical issue, and/or a training issue. In my experience, I have found all three played a role in my MOC problems. But know this: many of you will find some patterns of poor MOC performance around certain individuals and if we have trained these folks properly and they have chosen to make changes without a MOC there needs to be some accountability for their decisions/behaviors. But we also find serious deficiencies in how the program is written, who we have asked to perform certain functions, time demands, etc.
Bottom line, YES, we need to go back and perform a MOC on those changes that have already been made – knowing good and well there will be an action list of documents to be created and updated. But also knowing that on some occasions, we may need some drastic measures to ensure process safety while the process continues to run. I have had several instances where the system within the process had to be shut down immediately due to a lack of proper design and/or construction. Again, NEVER NEVER NEVER back-date documents – just make a note on the MOC. But the path forward (Stage 3) is as critical as Stages 1 & 2. These MOC audit findings can be a bear to close, but closing them properly with a PLAN is key to our success.