Accident Description

Accident: Management of Change

Location: Location: ,

Accident Occurred On: 11/25/1998 | Final Report Released On: 08/28/2001

Accident Type:

Investigation Status: The CSB issued this safety bulletin on August 28, 2001.

The U.S. Chemical Safety and Hazard Investigation Board (CSB) issues this Safety Bulletin to focus attention on the need for systematically managing the safety effects of process changes in the chemical industry. This bulletin discusses two incidents that occurred in the United States in 1998. Each case history offers valuable insights into the importance of having a systematic method for the management of change (MOC). 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.