The Silent Killer: Why Ignoring "Management of Change" Is Gambling with Lives
We change a valve, update software, or reorganize a team, thinking "it's just a small tweak." But in complex systems, small changes can have catastrophic, unforeseen consequences. The most dangerous sentence in industry is: "It's just a temporary fix." Here is why Management of Change (MOC) is the most critical process you are probably ignoring.
It happens every day in every industrial facility, from a chemical plant in Germany to a shipyard in Korea. A pump is vibrating excessively. A Maintenance Supervisor says: "Let’s swap it out for the spare pump. It’s a slightly different model, but the flange fits." A chemical feedstock is out of stock. A Process Engineer says: "Let’s use this alternative supplier. It’s chemically similar, just 2% more acidic." A Shift Supervisor retires. The HR Director says: "Let’s not replace him immediately. The junior team can absorb his workload to save costs."
These decisions feel small. They feel efficient. They feel like proactive problem-solving. But in the world of Process Safety and High Reliability Organizations (HROs), they are Russian Roulette.
We suffer from a cognitive bias called Linear Thinking. We assume that a Small Change = Small Consequence. But industrial plants, ships, and logistics networks are Complex Adaptive Systems. In a complex system, the relationship between cause and effect is Non-Linear.
A small change in temperature can change a liquid to a gas, increasing pressure by 1,000 times.
A small change in valve closure speed can create a hydraulic shockwave that ruptures a pipe 2 kilometers away.
A small change in staffing can destroy the transfer of critical information during a shift handover.
When we bypass the formal Management of Change (MOC) process because "it takes too long" or "it’s just a simple fix," we are removing the safety margins that were painstakingly engineered into the system. We are flying blind into a storm we created.
Part 1: The Ghost of Flixborough (The High Cost of "Temporary")
We cannot talk about Management of Change without honoring the dead of Flixborough. On Saturday, June 1, 1974, the Nypro chemical plant in England exploded. The blast was equivalent to 15 tons of TNT. It killed 28 men, injured 36, and leveled every building on the site.
The Cause: Two months earlier, a reactor (Reactor 5) had developed a leak. To keep production running (the eternal pressure), the site engineers decided to remove Reactor 5 and install a temporary bypass pipe to connect Reactor 4 to Reactor 6. Because it was a "temporary repair," they didn't treat it as a major design change.
They didn't do a full stress analysis.
They didn't calculate the bending moments on the pipe bellows.
They didn't consult a metallurgist. They just built it on a workshop floor using chalk drawings, fitted it, and turned the plant back on.
The Result: The bypass assembly was structurally unsound. Under operating pressure and temperature, the pipe buckled (the "squirm" phenomenon). It ruptured, releasing a massive cloud of cyclohexane vapor. When the cloud found an ignition source, it erased the plant from the map.
The Lesson: The engineers at Flixborough weren't stupid. They were pressured. They were focused on Production Availability, not System Integrity. They fell into the trap of thinking that "Temporary" means "Low Risk." History teaches us the exact opposite: Temporary changes are often HIGHER risk because they bypass the standard quality controls of permanent design. If you are installing a "temporary fix" (a clamp, a jumper wire, a bypass) without a rigorous MOC, you are building your own Flixborough.
Part 2: The "Like-for-Like" Trap
The most common lie in maintenance and engineering is: "It’s a like-for-like replacement." This phrase is used to bypass the MOC process. If it's "like-for-like," we don't need to evaluate the risk, right?
Wrong. True "Like-for-Like" is incredibly rare in the real world. Vendors change specs. Materials change. Software evolves.
Case Study: The Valve Replacement
The Change: A maintenance team replaces a 4-inch valve with another 4-inch valve from a different manufacturer. They call it "like-for-like."
The Difference: The new valve has a slightly different trim characteristic. It closes 0.5 seconds faster than the old one.
The Consequence: That 0.5-second difference creates a "water hammer" (pressure surge) that exceeds the design pressure of the upstream piping. The pipe bursts.
Case Study: The Software Update
The Change: IT updates the control room SCADA software to the latest version. "Just a security patch."
The Difference: The new version changes the default color of a "Low Priority Alarm" from Yellow to Blue.
The Consequence: The operator, conditioned for 10 years to ignore Blue (informational) messages, misses a critical warning signal during a crisis.
If you don't run every substitution through an MOC filter to ask "What is different?", you are introducing unknown variables into your equation. And unknown variables tend to explode.
Part 3: Organizational Change (The Brain Drain)
MOC is not just for hardware. In fact, the most dangerous changes in the modern economy are often Organizational.
When a company announces a "Restructuring," a "Downsizing," or an "Optimization Program" to save costs, executives look at the salary spreadsheet. They rarely look at the Cognitive Risk.
The Hidden Cost of Firing "Old Bob": Let's say you fire "Old Bob," the Senior Maintenance Technician who has been there for 30 years. He costs €60,000 a year. You replace him with a junior tech costing €30,000.
Financial Saving: €30,000. (The Board applauds).
Knowledge Loss:
Bob knew that Pump B vibrates in winter and needs a specific grease.
Bob knew that the fire water valve is stiff and needs a wrench to open.
Bob knew the history of why a certain interlock was installed in 1995.
This is Corporate Amnesia. When you remove key people without a formal Organizational MOC, you lobotomize the organization. You remove the "safety net" of experience. You assume the procedures (Work as Imagined) are perfect. But Bob was the one bridging the gap between the procedure and reality (Work as Done). Without him, the gap becomes a trap.
Organizational MOC Rule: Before you delete a role or merge two departments, you must ask: "What does this person know that is not written down? Who will catch the balls they drop?"
Part 4: The "Cumulative Change" (Boiling the Frog)
Sometimes, a single change isn't dangerous. But 100 small changes over 5 years are fatal. This is the phenomenon of "Creeping Change" or "Drift."
Imagine a chemical plant:
Year 1: We increase the pump throughput by 2% to meet targets. (Safe).
Year 2: We switch to a cheaper gasket material to save money. (Safe).
Year 3: We reduce inspection frequency from monthly to quarterly. (Safe).
Year 4: We lose the experienced supervisor and don't replace him. (Safe).
Year 5: BOOM.
No single MOC triggered the alarm. Each change was evaluated in isolation. But the accumulation of changes eroded the safety margin until it vanished. We boiled the frog. Effective MOC requires a periodic "Cumulative Impact Review." We need to step back and ask: "How different is our plant today compared to its original design intent?" If the answer is "Very," you are operating outside your design envelope.
Part 5: The "Temporary" Trap (Normalization of Deviance)
There is an old saying in engineering: "Nothing is as permanent as a temporary fix."
We install a clamp on a leaking pipe "just until the shutdown." The shutdown gets delayed. The clamp holds. We forget about it. Two years later, the pipe corrodes under the clamp and bursts.
We install a jumper wire to bypass a faulty alarm "just for the night shift." The shift changes. The handover is poor. The jumper remains. A week later, the alarm is needed, but it is silenced.
This is the Normalization of Deviance. When a temporary fix survives without failure, we accept it as the new normal. We stop perceiving the risk. Every temporary change is a degradation of the system's integrity. It is a loan taken out against safety. Eventually, the debt must be paid.
Part 6: The Solution – A Rigorous MOC Protocol
How do we stop the chaos? We cannot freeze the plant; change is necessary for survival. But we must manage it. We need a disciplined, non-negotiable MOC protocol.
1. The "Stop" Rule
This is cultural. The moment someone says:
"Let's just tweak this..."
"Let's bypass that..."
"Let's try this alternative..."
"Let's reorganize this team..."
The immediate response from everyone in the room must be STOP. Initiate the MOC. Yes, it involves paperwork. Yes, it slows you down. Safety is a brake. Brakes are annoying when you want to drive fast, but they are essential when you are approaching a cliff.
2. Multi-Disciplinary Review (The "Blind Spot" Check)
Never let a Mechanic approve a mechanical change alone. They have tunnel vision. An MOC must be reviewed by a diverse team:
The Electrician: "If you increase the pump size, will the motor draw more current and trip the breaker?"
The Operator: "If you move that valve, can I still reach it in an emergency?"
The Safety Officer: "Does this new chemical require different PPE or fire suppression?"
The Process Engineer: "Does this change the pressure relief requirements?"
We all have blind spots. A diverse team covers them.
3. The "Sunset Clause" for Temporary Changes
If you approve a "Temporary Repair" (e.g., a clamp, a bypass, a jumper), it must have a Hard Expiry Date written on the tag and in the system.
"This clamp is approved for 7 days. Expires: Dec 12th."
On Dec 12th: The system alerts. If the fix hasn't been made permanent or removed, the plant shuts down. If you don't set a hard sunset clause (a "kill switch"), the temporary clamp becomes a permanent fixture.
4. Update the Documentation (Closing the Loop)
A change isn't finished when the bolt is tightened. It is finished when:
The P&ID (drawing) is updated.
The Standard Operating Procedure (SOP) is updated.
The Training is delivered to the operators.
If you change the physical world but don't update the paper world (Work as Imagined), you create a trap for the next person who relies on the drawing to make a decision. "The job isn't done until the paperwork is dead accurate."
The Bottom Line
We live in a corporate culture that celebrates "Agility," "Pivoting," and "Speed." But in high-hazard industries, Agility without Analysis is Suicide.
We must respect the complexity of the machine. We must respect the complexity of the organization. Don't be the cowboy who makes a "quick fix" at 3:00 AM to be a hero. Be the professional who demands an assessment.
If you change it, you own the risk. Make sure you understand it first.
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