The standard’s content

Risk Assessments Some of the examples posted require risk as-

sessments at several stages of the change activity. The intent is to achieve and maintain acceptable risk levels throughout the work. Thus, risk assess- ments should be conducted as often as needed as changes occur—and particularly when unexpected situations arise. SH&E professionals who become skilled risk assessors can offer a significant value- added consultancy.

Risk assessment is the core of ANSI/ASSE Z590.3, Prevention Through Design: Guidelines for Ad- dressing Occupational Hazards and Risks in Design and Redesign Processes. The standard’s content is applicable to MOC whether the contemplated change involves new designs or redesign of exist- ing operations. Of particular interest are sections on supplier relationships, safety design reviews, hazard analysis and risk assessment processes and tech- niques, and the hierarchy of controls.

Risk Assessment Matrixes Z590.3 recommends use of a risk assessment

matrix, and stresses that all involved agree on the definitions of ferms used in the matrix. An adden- dum in Z590.3 provides several sample matrixes. The example presented in Figure 1 (p. 39) was pre- ferred by operating employees involved in the risk assessment process. They indicated that first es- tablishing a mental relationship between numbers such as 6 and 12 helped them more readily under- stand the relation between terms such as moderate risk and serious risk.

The Significance of Training CCPS (2008) emphasizes the significance of

training in achieving a successful MOC system: Training for all personnel is critical. Many systems failed or encountered severe prob- lems because personnel did not under- stand why the system was necessary, how it worked and what their role was in the imple-

. mentation, (p. 58)

The culture change necessary to implement a successful MOC system is impossible without a training program that helps supervisors and work- ers understand the concepts to be applied. Where the MOC system applies to many risk categories (occupational, public, environmental, fire protec- tion and business interruption, product quality and safety), training must be extensive.

Oocumentation An operation must maintain a history of opera-

tional changes. All modifications must be recorded in drawings, prints and appropriate files; they be- come the historical records that would be reviewed when future changes are made.

Comments that “changes made were not re- corded in drawings, prints and records” are too common in reports on incidents with serious con- sequences. Examples of unrecorded changes in- clude the following:

•The system was rewired. •A blank was put in the line. •Control instruments were disconnected. •ReUef valves of lesser capacity had been installed. •Sewer Une sensors to detect hazardous waste

were removed.

On the MOC Examples As noted, the 10 MOC examples covered in the

following discussion are posted in the PS Extra sec- tion of the ASSE website (

To demonstiate the substance and variety of ac- tual MOC systems, few changes were made in the examples. In some cases, terms used are not read- üy understandable. However, these terms are Ukely understood within the organization that developed the system, so they are presented as-is to empha- size that the terminology included in an MOC pro- cedure must reflect the language commonly used within an organization and must be understood by all involved in an MOC initiative.

These examples vary greatly in content and pur- pose. Some are one page; others take several pages to cover the complexity of procedures and exposures. Some procedures have introductory statements on policy and procedure, others do not. Nevertheless, these examples show that an MOC system need not meet a theoretical ideal to provide value. These examples are intended as references; none should be adopted as is. An MOC system should reflect an organization’s particular needs and its culture.

Example 1: Producing Mechanical Components This prejob planning and safefy analysis system

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