We have seen a significant decline in Process Safety over the past five years. It seems PSM was infected with COVID-19, and it has Long COVID-19 illness! In the past five years, we have battled facility management and corporate legal teams over one significant issue… Training personnel on the PSM/RMP Management of Change Program. All of these businesses had a written program and usually a lovely MOC Checklist – ON PAPER! But we find they are rarely used on changes that are not even controversial changes. So when we find over a dozen changes during an audit that did not have an MOC to support/manage the change, we begin to wonder why. And 99.999% of the time, we are told that OSHA or EPA requires personnel to be trained on the MOC program. And they would be correct (see below). I am not talking about training on changes the MOC is trying to manage – I am talking about WHO, WHAT, WHEN, WHERE and HOW an MOC is needed and executed within the facility. The written program addresses this, but no one in recent years has been trained on the MOC management process. And their response is… OSHA/EPA does not require it, so please remove the finding, hence why SAFTENG has a rash of 1-and-Done clients over the past 5 years! We do NOT compromise our values to make a client happy; just fire us and we will move along.
1910.119(l) Management of change.
1910.119(l)(1) The employer shall establish and implement written procedures to manage changes (except for "replacements in kind") to process chemicals, technology, equipment, and procedures; and, changes to facilities that affect a covered process.
1910.119(l)(2) The procedures shall assure that the following considerations are addressed prior to any change:
1910.119(l)(2)(i) The technical basis for the proposed change;
1910.119(l)(2)(ii) Impact of change on safety and health;
1910.119(l)(2)(iii) Modifications to operating procedures;
1910.119(l)(2)(iv) Necessary time period for the change; and,
1910.119(l)(2)(v) Authorization requirements for the proposed change.
1910.119(l)(3)Employees involved in operating a process and maintenance and contract employees whose job tasks will be affected by a change in the process shall be informed of, and trained in, the change prior to start-up of the process or affected part of the process.
1910.119(l)(4) If a change covered by this paragraph results in a change in the process safety information required by paragraph (d) of this section, such information shall be updated accordingly.
1910.119(l)(5) If a change covered by this paragraph results in a change in the operating procedures or practices required by paragraph (f) of this section, such procedures or practices shall be updated accordingly.
With all that said, OSHA/EPA missed the boat on this one. Not requiring personnel who are expected to manage and participate in the change to be trained in the MOC process is just “crazy talk”. And rather than waking up to this failure, management and legal are more concerned with the finding itself than its impact. This is a perfect example of Reason’s “Latent Organizational Failure”.
"latent organizational failures" are dormant, systemic issues such as poor procedures, inadequate training, or flawed system design that lie hidden within an organization and, when aligned with active failures (front-line human errors), create holes in safety defenses, ultimately leading to accidents.