CSB Safety Bulletin Says "Managing Change" Is Essential to Safe Chemical Process Operations

August 28, 2001

(Washington, DC - August 28, 2001): In industry, as elsewhere, change often brings progress. But it can also increase risks that, if not properly managed, create conditions that may lead to injuries, property damage or even death.

A new Safety Bulletin from the U.S. Chemical Safety and Hazard Investigation Board (CSB) released today concerning "Management of Change" (No. 2001-04-SB, August 2001) discusses two incidents (one in Maryland and the other in Washington State) that occurred in the United States in 1998. The first incident involved a November 25th fire at an Equilon Enterprises oil refinery in Anacortes, Washington. The fire in the delayed coking unit caused six fatalities. The second incident on October 13th involved a reactor vessel explosion and fire at the CONDEA Vista Company detergent alkylate plant in Baltimore, Maryland that injured four people and caused extensive damage.

Each case history offers valuable insights into the importance of having a systematic method for management of change (i.e., managing changes in chemical processes using a formal Management of Change [MOC] program). An MOC methodology should be applied to operational deviations and variances, as well as to preplanned changes --- such as those involving technology, processes, and equipment.

The CSB MOC Safety Bulletin explains that lack of time for safety decision-making was not a factor in causing the incidents. According to the Bulletin:

"Neither the Equilon Enterprises oil refinery nor the CONDEA Vista Company explosion and fire involved emergencies that required rapid decision making. In each instance, time was available to look into the circumstances more thoroughly. Each situation could have been avoided with a more analytical and structured approach to problem solving."

The CSB found that there were numerous contributing factors that caused these incidents. However, the CSB believes that properly conceived and executed MOC programs could have helped to prevent or mitigate the effects of both events.

Both the Occupational Safety and Health Administration's (OSHA) Process Safety Management standard and the U.S. Environmental Protection Agency's (EPA) Risk Management Plan require facilities to manage changes in covered processes handling highly hazardous materials using a formal MOC program. However, the Bulletin states, "it is good practice to do so, irrespective of the specific regulatory requirements."

The CSB urges organizations to review their MOC policy to be sure it covers operational variances in addition to physical changes. If your organization doesn't have a systematic method for handling changes, develop and implement one.

To maximize the effectiveness of your MOC system, the Bulletin suggests that the following activities be included:

- Define safe limits for process conditions, variables and activities --- and train personnel to recognize significant changes. Combined with knowledge of established operating procedures, this additional training will enable personnel to activate the MOC system when appropriate.

- Apply multidisciplinary and specialized expertise when analyzing deviations.

- Use appropriate hazard analysis techniques.

- Authorize changes at a level commensurate with risks and hazards.

- Communicate the essential elements of new operating procedures in writing.

- Communicate potential hazards and safe operating limits in writing.

- Provide training in new procedures commensurate with their complexity.

- Conduct periodic audits to determine if the program is effective.

The complete CSB Safety Bulletin on Management of Change may be viewed or downloaded from the CSB website at http://www.chemsafety.gov/bulletins/2001/moc082801.pdf.

CSB Safety Bulletins offer advisory information on good practices for managing chemical process hazards. Actual CSB case histories provide supporting information. Safety Bulletins differ from CSB Investigation Reports in that the Bulletins do not comprehensively review all the causes of an incident.

The CSB is an independent federal agency whose mission is to ensure the safety of workers and the public by preventing chemical incidents. The CSB is a scientific investigatory organization, not an enforcement or regulatory body. The Board determines the root causes of accidents, issues safety recommendations, and performs special studies on chemical safety issues.



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