Management of Change: Replacement-In-Kind
We continue our discussion to do with the challenge of defining ‘change’ in the context of Management of Change (MOC). Previous posts in this series are:
‘In-Kind’ Changes
The concept of ‘In-Kind / Not-In-Kind Change’ is frequently used to determine if a proposed change should be handled by the MOC system. ‘In-Kind’ changes are generally do with replacement and repair activities. If a replacement part is made to the same specifications as the original item then the change is ‘In-Kind’, and so the MOC process need not be implemented. On the other hand, if equipment is being added, modified or removed, then the change is ‘Not-In-Kind’ and the Management of Change process should be followed.
The catch is that, strictly speaking, no two equipment parts will ever be truly identical. Any replacement, even if it built to the same specification, will differ from the original part to some degree. The replacement part was probably made at a different time, by different workers (possibly in a different factory) and stored in a different warehouse for a different length of time. When evaluated rigorously in this manner all changes are ‘Not-In-Kind’.
Of course, it is important not to push this argument too far. For example, if a piece of equipment is to be repainted, it is theoretically possible that the new paint could contain a hazardous chemical that could affect the workers. However few companies would seriously consider conducting an MOC on a repainting project just because a different brand of paint is being used.
But ― and there’s always a ‘but’ ― changes that are ‘obviously’ Not-in-Kind may turn out to be significant.
The following incident report is an expansion of a story introduced in Chapter 1.
A worker was changing out a filter in a section of pipe containing a highly flammable light hydrocarbon. This was a routine operation that he had done many times. He shut in the filter housing, drained the filter and piping, opened the filter, pulled out the old filter cartridge, and installed the new cartridge. He then replaced the gasket at the top of the filter, closed up the filter and opened the valves in the piping in order to restart the flow.
Immediately, the new gasket failed and large quantities of hydrocarbon sprayed out in all directions. The operator’s clothing was drenched in flammable hydrocarbons. Close to the filters was a fired heater.
The operator did just the right thing ― he ran away. Moments later the leak did ignite. The subsequent fire did immense damage; sections of the refinery were shut down for weeks. But no one was injured.
There are two lessons to be learned from this incident. First, ‘If a man’s not there, he can’t be killed’. Had the operator tried to control the leak or fight the fire it is likely that he would have been killed or seriously injured.
Subtle Changes
The second lesson is to do with MOC. The incident investigation found that the wrong gasket had been installed. The operator picked up what he thought was the correct gasket from the warehouse. However, the wrong part had been put in the storage location. It was a subtle, but near-fatal, management of change failure in the warehouse. An inadvertent change had occurred in the supply chain process.
