In 1974, a temporary 20-inch bypass pipe was installed to keep production running while a reactor was repaired. Then it failed under pressure, released 30 tons of cyclohexane, and killed 28 people. 1.Apply strict time limits to temporary changes - Set a hard expiration and a named owner. 2.Require the same hazard review for temporary work as permanent work - Production pressure is exactly when shortcuts feel justified and are most dangerous. 3.Confirm the people designing the change are qualified to design it - At Flixborough, the bypass was installed by personnel who weren't professionally qualified engineers.

If the MOC isn't a technical review this could still have dire consequences when production is established. 1.Pressure-test the technical basis of every change against its protective systems - The question isn't "does this work?" but rather "what does this change isolate, defeat, or bypass?" 2.Put a fresh set of eyes on overpressure protection - Isolation from a PSV is one of the most common and lethal review misses. 3.Don't confuse a thorough process with a thorough analysis - A signed MOC with a flawed hazard review is more dangerous than no MOC, because it creates false confidence.

We've heard it before and it is a common thread. Incidents have different decades, different chemicals, different industries, same root cause: a change that wasn't properly identified, reviewed, documented, or communicated. 1.Stop treating MOC as paperwork - It is the management system that prevents uncontrolled change from becoming unacceptable risk. 2.Recognize the pattern repeats across all contexts - Imperial Sugar was a dust explosion from conveyor modifications; MOC applies far beyond classic PSM chemical processes. 3.Audit your program against recurring failure modes - Unmanaged temporary change, ignored organizational change, inadequate hazard review, and incomplete documentation/PSSR.

Welcome to the Bear Process Safety Training Hub. This space is for EHS, PSM, and process safety leaders and engineers at high‑hazard facilities who want practical training that goes beyond paper compliance. To get the most value, follow these three steps: Step 1 – Watch the “Start Here” onboarding Go to Classroom → Start Here: Welcome & Orientation and watch the short intro. It will walk you through the trainings and which path fits your role. Step 2 – Introduce yourself Comment below with: - Your name - Your role and facility type (e.g., PSM engineer at chemical plant) - Your top focus area right now: PHA, HAZOP, MOC, or “overall PSM program” Step 3 – Choose your first training - If you’re newer to process safety or PHAs, start with Introduction to PHA. - If you participate in studies, add Intro to HAZOP Methodology. - If you manage change, add Intro to MOC. If you lead or plan to lead PHAs, your next step after the intros is the PHA Facilitator’s Course in the Classroom. Use the community to ask specific questions, share lessons learned, and get clarification on how to apply this in your facility. The more you engage, the more you’ll get out of this hub. https://www.skool.com/bear-process-safety/classroom/60e141e5?md=d337ca678f62493db06334f56050a8c0