14d • General discussion
"Let's fix this now before the review is done, I don't want to have to start an MOC"
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.
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"Let's fix this now before the review is done, I don't want to have to start an MOC"
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