Process Safety — Manage The Only Constant: Change

Deliberate change occurred when one of the six reactors in the series was taken offline due to a leak and replaced with a temporary pipe section. This replacement allowed the process to continue operating, prioritizing production over safety considerations, although at the time, those involved may not have fully grasped the implications of their actions. Tragically, this pipe section failed catastrophically under pressure, releasing flammable liquid that ignited and exploded.

Simultaneously, the facility was also grappling with creeping change. Nearly six months before the incident, the plant's mechanical engineer left and no qualified replacement was hired, leaving the engineering department without any mechanical engineering expertise. While the facility had qualified chemical engineers in management roles, over the course of those six months, it became an accepted norm to operate without a mechanical engineer, leading to a gradual erosion of standards and a drift from previously established acceptable requirements. The absence of a mechanical engineer proved to be a contributing factor, as the mechanical stresses on the temporary pipe section were neither understood, analyzed nor properly managed.

Fast forward to today, we have established robust management-of-change processes that require subject matter experts to thoroughly assess and endorse any proposed changes before they are implemented. These processes cover both physical modifications and organizational changes, ensuring a comprehensive evaluation of potential risks and impacts. Additionally, we have established procedures in place to monitor and manage creeping changes actively, addressing gradual shifts or degradations that may occur over time.

However, the challenge we collectively face lies in how effectively these processes are utilized and integrated into our operations. We must remain vigilant in ensuring that we thoroughly understand the evolving risk profiles associated with changes and manage them appropriately, leveraging the expertise and insights of various stakeholders.

The Flixborough disaster serves as a reminder that process safety is a multidisciplinary field, requiring contributions from diverse disciplines and roles. No single individual or role possesses all the answers; we often do not recognize the gaps in our knowledge until it is too late. Effective collaboration and knowledge-sharing among different experts are crucial to gain a holistic understanding of potential risks and create safer workplaces.

I often talk about process safety being a team sport, where each person has different roles and skills, but they all work toward the goal of winning. Creeping change can be the enemy of a successful team, as we drift into the belief that we can manage the situation independently, and not seek help from others.

As we remember the 50th anniversary of Flixborough, it is useful to reflect on how change and competence are managed in your facility. How effective is your management-of-change process? How would you know if the system is being followed or bypassed? What systems do you have in place to identify, assess and manage creeping changes? How do you manage organizational changes to ensure that appropriate competence is maintained? What can you do each day to ensure you remain focused on having the right people in the right roles?

There is no escaping change, but to ensure our workplaces are as safe as possible, we must understand and manage it. 

Stay Safe