Follow Up to the Incident Report: MOC Training
Take the quiz
Yesterday we asked ChatGPT to write a story of a young engineer who is asked to investigate the causes of a serious incident. She determines that a root cause was a failure of the Management of Change (MOC) program.
There is no value in conducting an incident investigation without effective follow-up. Therefore, I asked ChatGPT to help create a follow-up training program to do with MOC that could help all employees.
Here is the response and follow-up quiz.
Learning Objectives
Explain how to apply the 5 Whys technique to a process safety incident.
Identify typical failure points in a Management of Change system.
Describe the consequences of informal or incomplete MOC.
Suggest safeguards to prevent recurrence of similar events.
What went right in this incident?
How could the MOC process have prevented the event?
Who should be responsible for ensuring an MOC is completed?
What role should operators and maintenance personnel play in verifying changes?
Have you seen a similar situation at your site — where a design or procedural change caused an incident?
Quiz
Circle the correct answer for each multiple-choice question. Only one answer is correct.
1. What is the primary goal of the '5 Whys' technique?
A. Assign blame for an incident
B. Identify surface-level errors
C. Determine the root cause of a failure
D. Record operator actions
2. What was the immediate cause of the vapor release?
A. A failed gasket on a flange
B. A pump seal leak
C. A faulty control system
D. A fire in the alkylation unit
3. What was the root cause of the incident?
A. Instrument miscalibration
B. Operator error
C. MOC system breakdown
D. Equipment malfunction
4. Why did the maintenance team use the wrong gasket?
A. The parts list was not updated
B. They were undertrained
C. They were rushed by management
D. They misread the label
5. What process safety step was skipped during the project?
A. Pressure testing
B. Pre-Startup Safety Review (PSSR)
C. Lockout/Tagout
D. Area classification
6. What key principle does the MOC process enforce?
A. Routine maintenance tracking
B. Safe implementation of changes
C. Alarm management
D. Emergency response planning
7. Who should be involved in the MOC process?
A. Only operations staff
B. Corporate finance
C. Engineering, operations, and maintenance
D. The legal department
8. What role did Jodi play in the incident investigation?
A. Maintenance supervisor
B. Witness to the leak
C. Team leader using root cause analysis
D. External consultant
9. What safeguard could have prevented the incorrect gasket installation?
A. Firewater system
B. PSSR (Pre-Startup Safety Review)
C. Lockout/Tagout
D. Air monitoring
10. Why was this incident considered a “near miss”?
A. It occurred during a drill
B. No fire or injuries occurred
C. It was a permitted release
D. It was detected during routine inspection
Answer Key
C
A
C
A
B
B
C
C
B
B
