Abstract
Management of Change (MOC) is a process for evaluating and controlling modifications to facility design, operation, organisation, or activities. It is one of the most important elements of Process Safety Management (PSM). In chemical process industries (CPI), MOC is required to ensure that safety, health and environment are controlled. In recent years, the number of accidents related to MOC failure is significant and caused by the lacks of MOC management, organisation safety culture, design failure, incompetency, human factor and etc. From the accident statistics published by Chemical Safety and Hazard Investigation Board (CSB-US), European Major Accident Reporting System (EMARS-European), Failure Knowledge Database (FKD-Japan) and Accident Reporting Information Analysis (ARIA-France), MOC contributes significantly to the occurrence of accidents and its percentage contribution to accident rate is not decreasing over the past 20 years. In this paper, the contribution of MOC failure to accidents and their main failure factor are identified from the study of over thousands of accident cases and analysed with data mining method. Study revealed the major factor of MOC failure are the lack of organisation commitment, lack of experience, limitation of resources, inadequate of HAZOP study, human factor, safety culture and etc. Good practice of MOC has to be inculcated in CPI through learning from past accident and continuous improvement of MOC system.
