It’s just a temporary change. I’ll remember to reverse it – Management of Change Gone Bad
Changes in operations occur all the time in our industry. Whether it is an operational requirement, an upgrade to the process equipment, a change to the process itself, a temporary fix, or any other reason, changes happen all the time. You might say that change is the only constant.
Accepting that change is a fact of life does not mean that changes should be uncontrolled. Changes can have a significant impact on production, safety, or the environment. And not always a positive impact.
Sys-Tech http://sis-tech.com/ in their current news letter posted a summary of the case study by the CSB (US Chemical Safety Board) on a toxic gas release in Petrolia Pennsylvania in 2008. This report details a “temporary change” that resulted in a toxic gas release with community-wide impact, with 1 person injured, the plant, 2500 citizens in local towns evacuated; and roads closed.
All this from a “temporary emergency” power supply installation twenty-eight years prior to the event.
In this case the temporary fix unintentionally became permanent. One of the contributing factors causing this incident was that Management of Change was not followed and and key plant documentation was not updated. Thus the temporary change was not reversed, nor when it became permanent where the procedures updated.
This started me wondering: how many “temporary” changes are now part of the permanent process? How robust is your control of changes? Are you confident in your ability to identity & reverse those “temporary changes? Is your change management solution integrated into the actual change process?
If you need to
- Manage and streamline changes to products, procedures, processes, and equipment.
- Monitor and organize reviews, approvals and other actions necessary to implement the change (for example, update documentation, training materials, or master data).
- Ensure employees follow company/industry-specific change procedures to ensure safety compliance and reduce incidents.
Then SAP Management of Change provides a highly flexible and fully auditable solution for monitoring, implementing, and reporting changes
You can read the full CSB report here