L - MoC
Management of Change
Effects of Change
Change alters the basic relationship between
components in a system (configuration) and
introduces new modes of failure.
Process
Plant
All changes must be
managed to ensure that
system integrity is not
compromised.
People
Examples of Change
New regulations
New facilities
New procedures
New tools and equipment
Increased job scope
Altered work sequence
Replacement parts
Inexperienced workers
Inclement weather
Deteriorating materials
Organisational Change
Potential Risks
1) Are new or unknown failure modes introduced?
2)
Are existing failure modes altered as a result of
this change?
3)
Are existing controls adequate for dealing with the
new failure modes?
4) Have changes been made in the organizational
infrastructure?
Management of Change System
System to ensure that all changes are thoroughly
scrutinized prior to implementation.
Rational basis required to initiate the process.
All changes evaluated, communicated and
coordinated prior to execution.
Applies to physical plant, chemicals, operating
conditions, staffing
Special provisions for spare parts, training, drawings etc.
Case History - CH11
Flixborough - 1974
Case History 11-Flixborough
1974 Nypro Caprolactam Plant, Flixborough, UK
Large site for caprolactam production by oxidation of
cyclohexane
Two months plus prior to incident:
- Cyclohexane leaking from Reactor No. 5
- Plant shutdown. Reactor removed for repair
OK to run with 5 reactors, bypass installed between Nos 4 & 6
Powerful explosion and fire killed 28, seriously injured 36
Process Description
6 Reactors 160 C, 120
psig (8.3 barg) - above
atm boiling point
12 ft (3.7 m) Dia x 16 ft
(4.9 m) high
Carbon steel with
stainless steel cladding
14 in (36 cm) elevation
change between reactors
The Incident
What Happened
Collapse of the temporary bypass caused release
of cyclohexane
Main cause of failure was effects of shear
forces caused by internal pressure
1/8 of liquid flashed off as pressure was reduced
to atmospheric, the remainder was carried
upward as a dangerous spray
One Theory of Why It Happened
Sudden pressure surge caused the pipe to fail
No. 4 reactor was equipped with an agitator
Heel of water was left in the reactor after
shutdown
On reheating during startup, temperature rose to
boiling at the hydrocarbon-water interface
Two phases mixed and created sudden evolution of
vapor and a pressure surge strong enough to rupture
the bypass arrangement
Damage Details
People: 28 deaths, 36 seriously injured
Environment: Onsite & offsite contamination
Business: Plant totally destroyed, Nypro
ruined
Reputation: 1,821 houses, 167 shops damaged
Major Lessons Learned
All changes require
competent design & careful
review.
The report of the Court of
Inquiry stated:
There was no overall
control or planning of the
design, construction,
testing or fitting of the
assembly nor was any
check made that the
operations had been
properly carried out.
Man
agem
e
nt o
f Ch
ange
Baglan Bay Ethylene Cracker Cold Box
HPSEPARATOR
35 barg
LEVEL CONTROL
VALVE IS HP/LP
INTERFACE
RELIEF VALVE
SET AT 3 barg
PROTECTS HEAT
EXCHANGER SHELL
& LP SEPARATOR
LP SEPARATOR
3 barg
SHELL OF HEAT
EXCHANGER
DESIGNED FOR
3 barg
New block valve installed
HPSEPARATOR
35 barg
LEVEL CONTROL
VALVE CLOSED
AS NO LEVEL IN
HP SEPARATOR
LP SEPARATOR
3 barg
NEW BLOCK
VALVE INSTALLED
AND CLOSED
Unit starts up
HPSEPARATOR
35 barg
LP SEPARATOR
3 barg
NEW BLOCK
VALVE CLOSED
PRESSURE IN
HEAT EXCHANGER
RISES TO 35 barg
LEVEL CONTROL
VALVE OPENS AS
LEVEL BUILDS IN
HP SEPARATOR
Lessons learned
Pro
ce
ss
Pro
ce
ss
Sa
fe
ty
Ris
Process safety information
contains process equipment
specification data
In
for
m
ati
o
kA
sse
ss m
en
t
Ma
na
ge
me
nt
of
Ch
Op
an
ge
er
ati
ng
Pro
ce
du
res
n A simple HAZOP would
have predicted the outcome
All changes require
competent design and
Careful review
Operating procedures
should have required
the new block valve to
be LOCKED OPEN
Pre-Startup Safety Review
Pre-Startup Safety Reviews
A disproportionate number of incidents occur
during startup and shutdown.
First time quality/integrity verifications prior
to startup. Critical checks on subsequent
startups.
Initial pre-startup review is very intense. It
examines all aspects of design, construction
and quality.
Pre-Startup Safety Reviews
What is a PSSR and
how is it different from a Pre-Startup PHSSER?
Pre-Startup Safety Review = Structured process
to ensure a facility is safe to startup.
Pre-Start Up PHSSER is a much wider Project
Review
Part of which should confirm the adequacy of
facilitys completed PSSR but should not
duplicate the scope
Pre-Startup Safety Reviews
Required every time feed is introduced into
system or positive process conditions are
established.
Operational readiness examines condition of
equipment, passage through lines, instrument
calibration, blind lists, procedures, utilities and
suitability of people. Sign off is required.
Minimum conditions of acceptance should be
documented.
What are the requirements to halt a
startup?
Pre-Startup Safety Reviews
Equipment considerations
What are some of the hazards and risks?
Cleanliness
Service testing (hydro test, flow test)
Refractory dry out
Purging
Calibration of instruments
Blanketing
Dewatering
Process line up (valves and circuits)
Pre-Startup Safety Reviews
Procedural considerations
All actions complete, including HAZOP
All PSI updated
Operating procedures written
Training complete
Maintenance procedures written and spare
parts available
Emergency response plans updated
Pre-Startup PHSSER: Key Activities
Recommendations from PHSERS, HAZOPs, etc
Design integrity maintained?
Readiness of P&IDs and other documentation
Hand-over system for project to plant control is in place
Procedures for startup up, shutdown, normal
operation, emergency shutdown of the facilities
Safe work practices procedures
Facility staffing adequate for startup?
Competencies and skills for safe operation
Punch listing is in place and that all high priority
items have been completed
Loop Checks and Trip Checks completed?
Pre-Start Safety Review??
