Am looking to refresh a fairly straight-forward presentation on MOC with some real life experience for shop-floor workers, so am wondering if anyone would suggest their most compelling case studies on change-related incidents. The focus here is on plant/engineering type change and not so much on organisational change, although any suggested cases would be appreciated.  I know that Flixborough is a well-known one, but any others appreciated, especially day-to-day shop floor cases.

Also, any links to resources such as 'MOC key questions to ask' or such-like.

I am not clear what YOU mean by management of change. Usually it refers to how an organisation breaks the bad news to employees that they are all going to have their jobs reassessed and some will be made redundant. To a certain extent it is weasel words but unfortunately it something that people are having to go through more and more. I did myself and based on my own experience and the training that was delivered at the time, I was able to produce a decent enough presentation for people in my current employer who were going through a very similar process.

What you seem to be referring is reorganising your current operations, without actually redeploying/losing staff. I’d have thought in most organisations such change was an ongoing process. Why would you need something special to deal with such a change?

You may want to look at the Human Factors Engineering in the change mangement process...so rather than getting new examples of it look how the HFE tools can help...you may already have it but good information on RSSB, Step Change etc...

You will have these already but Texas City, Valero McKee factory LPG Fire 2008 are a couple of examples...there are two HSE research reports - 509 and 823 - which are about managing ageing plant but they contain good information on the importance of the MoC process...

If I think of any more I will drop you a note... :)

Originally Posted by: A Kurdziel

Usually it refers to how an organisation breaks the bad news to employees that they are all going to have their jobs reassessed and some will be made redundant.

It really doesn't.

To the OP, there are some further case studies at the bottom of this page:

http://www.hse.gov.uk/comah/sragtech/techmeasplantmod.htm

But you can also invent a hypothetical scenario related to the company/industry you are in 

MOC is either part of 45001 or the OSHA PSM Regulations in which it acts as one of the 14 elements that make up the regulations. either way, both are about managing changes and ensuring that the change has been assessed and does not create additional risks during or after implementation.

Case wise, look at pretty much any major accident around the world and 90% will mention MOC, specifically look the at CSB site.

I've opted for two kinds of cases, for your interest....

First, a very simple example that our Fitters can identify with. Paint and thinners being used by workers on the shop floor, possibly near to ‘hot work’ (welding / grinding) operations that could set them on fire. As a result of MOC, a ‘Best Practice’ document was created that said; “When touch up painting is in progress the area is "CAUTION" taped off and a warning sign posted stating "Painting in progress, NO welding or grinding allowed". The Permit To Work controls for shielding the hot work areas with screens / fire blankets will be discussed also. 

Secondly, the 1987 BP Dalmeny Crude Oil Tank Fire. A team of contractors was cleaning a crude oil storage tank at a refinery. One company employee was present, outside the tank. The risk of an explosive atmosphere was not considered sufficient to merit either forced ventilation or monitoring of the vapour concentrations within the tank. As a precaution, the workers were required to wear airline-breathing apparatus. Some of the things that had changed but were not managed; Several workers disregarded basic safety procedures, resulting in a lit cigarette being dropped inside the storage tank. More of these workers were contractors rather than company staff. A change in the experience, competency & attitudes of workers on site had not been acted upon, e.g. lack of policing the ban on smoking materials, lack of supervision / communication of safety risks at the work site. No forced ventilation of the tank to reduce the flammable vapour concentration was considered necessary. But a change had in fact happened; just because the tank had been drained of fluid did not mean it was free of flammable vapours that were present and may even have been agitated into the atmosphere by the cleaning work. The HSE said that the management of the contractors and the contracting company by both the contractor and the site operator was inadequate.

The second case very much brings home some horrendous human factors. Shockingly, the HSE reported that the controls on smoking materials (that were to be surrendered at the gate of this COMAH site) were neglected. The poor supervision which didn't detect the smoking inside the tank was also defective. The case resonates as we are seeing a fair bit of change in personnel at our site, with contractors coming in and out almost on a daily basis just now. 

Many thanks again.