In the 80s time-travel classic, Back to the Future, a teenage Marty McFly accidentally travels 30 years into the past in a DeLorean time machine built by eccentric scientist Dr Emmett Brown (Doc).
The unforeseen consequences of his actions while there see him almost erased from existence and spending the remainder of the film – and two sequels – in a race against time trying to repair the damage he has inadvertently caused.
That’s because, as he learns, whether you’re introducing an organisational or procedural change, or simply just figuring out the capabilities of a technological innovation like the flux capacitor – with its potential to “unravel the very fabric of the space-time continuum” – robust management of change (MoC) is crucial.
A key element in managing process safety, MoC’s scope is any change that isn’t a “like-for-like” replacement, and considers physical equipment, and organisational or procedural changes which may be either permanent or temporary. It is the process whereby changes are assessed to ensure that they do not inadvertently introduce new hazards and unknowingly increase risks.
Not so simple
As with time travel, MoC sounds simple in theory, but its implementation has proven to be anything but. Similar to the plot of Back to the Future, change rarely goes to plan and must be carefully managed.
Despite rarely following the rulebook on MoC, Doc does seem to have some appreciation of the importance of effective change management; evidenced when he commands Marty, upon his arrival in 1955: “You must not leave this house. You must not see anybody or talk to anybody. Anything you do can have serious repercussions on future events.”
When it comes to the implementation of MoC, it’s not just large-scale, multi-million-pound changes we’re talking about. Accidents have occurred in major hazard industries due to the unforeseen consequences of minor changes being made too.
Chemical process safety expert Trevor Kletz made this point in his 1985 book What Went Wrong, with the second chapter containing dozens of bite-sized examples of modifications that have resulted in incidents. Many were made with the best of intentions, including alterations made during startup and operations, as well as creeping and organisational changes.
There are similar instances in Back to the Future, such as when Marty accidentally interferes with his parents’ first meeting. In the scene, his future dad, George, is nearly knocked over by a vehicle driven by the father of his future mum, Lorraine. Confused yet? With the best of intentions, Marty pushes George out of the way before being hit by the car himself.
Then, when nursing Marty back to health, Lorraine becomes (temporarily) infatuated with him, the consequences of which, as Doc explains, would have been disastrous: “They don’t meet, they don’t fall in love, they won’t get married and they won’t have kids.”
So, how do we more robustly manage change?
Once a change is raised, it should be clearly described so that it can be understood by everyone. The MoC process also asks for a suitably-robust risk assessment to be carried out where new or impacted hazards are identified, and possible side effects spotted. Personnel will be directed, perhaps using checklists as a guide, to select the appropriate risk assessment technique which, for larger technical changes, may involve HAZOP and LOPA. The documentation that is required to be reviewed and updated as part of the change will be identified by the MoC process. This will, of course, all occur before the change is made.
MoC is not complete once the physical change has been made; it’s only once it has been fully implemented that this can be claimed. This includes informing all stakeholders, providing the necessary training, and updating the required documentation and maintenance routines.
One might draw another parallel with Back to the Future here, in that none of the above happens. For example, it’s only when Marty arrives in 1955 with an empty fuel tank that Doc informs him: “I’m sure in 1985, plutonium is available in every corner drugstore, but in 1955 it’s a little hard to come by.”
Had a thorough risk assessment been completed by Doc when designing the time machine, I’m sure there would have been a spare cannister of the radioactive chemical onboard, in preparation for anyone accidentally travelling to a different decade.
Measuring performance
There ought to be a means of measuring how the MoC process is performing too. Key performance indicators, such as the number of open MoCs, or the time taken to close out MoC actions, may be good indicators as to the overall health of the process and whether it is performing effectively. When Marty’s efforts to spark romance between his future parents at the Enchantment Under the Sea Ball works, the reappearance of his siblings in a family photo is a measure of his success.
Management too has a pivotal role to play in the MoC process and in ensuring that changes made do not have a detrimental effect on safety. There should be personnel with relevant knowledge and competence available, and they need to be given the necessary time and resources to follow the process.
Putting this into Back to the Future terms, attempting to implement change without the necessary time, resource and competencies would be equivalent to handing Biff a copy of Gray’s Sports Almanac, the keys to the DeLorean and the money to place his first bet.
Of course, there may be situations where an “emergency” change needs to be completed quickly – but this should not shortcut any part of the MoC process. Further, the rest of the management system must be in good shape as well, or the effectiveness of MoC could be undermined.
Appropriate training should also be given to all staff that may be involved in the process. One, so they can understand that it is essential to safety, and two, so they make sure it is used for any change they are involved in. They should also understand that they must not make any changes outside of the MoC process.
In short, there may be instances where a team wishes it could travel back in time to before an original change was made. But since we don’t have time machines – and certainly not ones as stylish as a DeLorean – we don’t have this luxury. MoC needs to happen correctly the first time, and a change must not be allowed to have a detrimental effect on safety.
The flying cars or hoverboards promised to us in Back to the Future might not have materialised, but we do have the power to influence process safety and make a positive impact. As Doc remarks in Back to the Future III: “Your future is whatever you make it. So make it a good one!”
This article was originally published in the Chemical Engineer https://www.thechemicalengineer.com/features/the-greatest-teacher-accidents-are