Asset Integrity Management

Topic: Management of Change

- Prepared By
Kashyap Patel

Presentation Overview
What is Management of Change? Why do We Need MOC?

What is Change?
Change vs. Replacement Types of Changes Permanent vs. Temporary Change MOC Program Training Information Management System

Auditing
Success of MOC Case Study of Sector 5 Flash Fire Incident

What is Management of Change?

Pipeline system & surrounding in which pipeline operates are often dynamic and need changes depending upon operational or other requirement

Prior to implementing changes, there shall be a system to ensure that prospective changes such as design, operation & maintenance etc. are evaluated for their potential risk impacts to pipeline integrity along with impact on the environment
MOC program is used to ensure all changes to a process are properly reviewed and any hazards introduced by the change are identified, analyzed, and controlled before resuming operation

Example: Upgrading of SR from B-50 to B-200 due to frequent UPSO due to increase in downstream consumption Change in PRS skid because of change in pressure values of GSPL at CGS terminal

Why Do We Need MOC?

It has been determined that 80% of all large scale accidents in the process industries trace their origins back to Change. By successfully managing change we can reduce the number of incidents while still allowing, even encouraging, change to occur. MOC can be a helpful system for communication of changes made in any asset of the company & can be utilized for central monitoring

Why Do We Need MOC? Case Study:

Macondo Blowout and Explosion, 2010

Why Do We Need MOC?

Cause:
In the offshore sector -BP, Transocean, industry associations, and the regulators systems for managing the safety of process changes were inadequate. The plan to complete and temporarily abandon the Macondo drilling operation was changed five times during the week before the disaster and decision made for temp. abandoning the well was based on wrong interpretations & test results To conduct the test, rig personnel purposely reduced the hydrostatic pressure inside the well. If the barriers were effective, there should be no flow into the well (or pressure buildup) from the formation during the test. But in actual, LCM spacer has plugged the flow and there was no flow recorded into the well. Thus rigger primarily focused on the fact that no flow is coming out from the well regardless of pressure built-up and decided to start temporary abandoning process. Thus seawater was circulated down the drill pipe to displace the mud from the marine riser and from the well. This had the effect of reducing the hydrostatic pressure in the well below the reservoir pressure. Because the cement and mechanical barriers did not have sufficient integrity (as discussed below),

hydrocarbons began to flow from the formation into the well and resulted into massive blowout.

Why Do We Need MOC?

Learning:
Decision to temporary or complete abandoning the well was changed five times in a week. This shows poor and ineffective system of decision making. Investigation team did not find any document that could describe that the decision taken to temporary abandoning the well was routed through proper management of change procedures and hazard assessment prior to implementation. If proper MOC could have been placed, monitored & analyzed at different stages then this could have prevent the decision failure in a series of decision failure that has resulted into massive blowout.

Why Do We Need MOC?

MOC Pyramid

5-10 Potential High Risk

50-100 Requires MOC

1000 Work Orders

What is Change?
Change is an alteration or adjustment to any component, variable or property within an existing system (except those within clearly defined boundaries or responsibilities). The most difficult part of management of change is recognizing that a change is taking place. It is essential that employees can distinguish between when the MOC procedure is required and when it is not. (For example, the replacement of a valve with an identical valve would not require approval through the MOC system, while the addition of Globe valve in place of ball valve would.) It is also important to be able to recognize the difference between safety critical and non-safety critical changes

Change vs. Replacement

Change is an alteration or adjustment to any component, variable or property within an existing system A replacement that satisfies the design specifications. Replacement is not subject to MOC They are equipment and procedural alterations that do not vary from the documented design specifications. Its the replacement of a component with an identical part or an equivalent part approved and specified by the applicable engineering standard. Replacement will require written documentation in accordance with the maintenance procedural guidelines (i.e. work orders).

They are equipment and procedural alterations that vary from the documented design specifications.

Change requires MOC

documentation, written procedures in accordance with MOC Plan

Change vs. Replacement

Examples: 1. Changes that alter pressure values of NG in GSPL line at CGS terminal 2. Changes involving safety relief or vent systems 3. Changes associated with decoration of material due to corrosion 4. Changes related to up gradation of DRS or Service Regulators due to increase in downstream consumption Examples: 1. Increasing the pressure values of DRS Active, Monitor, SSV, CRV within safe operating envelope Replacing pressure gauge or temperature indicator on PRV system as per specification Repairing PE line due to third party damage Replacing GI pipe or domestic meter meeting the same specification as the original Painting

2.

3. 4.

5.

Types of Changes
1. Change of Process Technology: When facility was initially design, safeguards were built in to keep the process from exceeding safe operating limits. If the parts of the process are changed then a review should be conducted to ensure that it does not compromises process safety 2. Change of Facility: The introduction of new equipment could also introduce hazard or increase risk 3. Organizational Change: Occur through transfer of employee to new assignments or through reduction/increasing the staff. It is very important that this to be recognized as change and the employee gets safety related knowledge required to carry out the new responsibility 4. Variance Procedure: Occurs when operation supervisor/engineer/manager wishes to deviate from the standard procedures. A review of the procedure should be conducted and appropriate approval received before the variance took place

Permanent vs. Temporary

Generally it is assumed that it will be a permanent change in MOC but it can be of temporarily type also & MOC is also used to control temporary changes Temporary change must have a specified time limit & if the time limit is to be extended then a new review to be conducted MOC will keep track of temporary changes and ensure that they are returned to their original condition Temporary changes do not have same requirements as per permanent (e.g. no change in P&ID).

Examples of Temporary Changes: 1. Temporary not providing the UPS system at CNG station due to repairing/maintenance work 2. Temporary running transformer without vacuum circuit breaker unit 3. Temporary disconnecting second stream of PRS system due to maintenance 4. Replacement workers

MOC Program

I. II. III. IV. V.

Proposal Review of Proposal Approval Execution Documentation

I. Proposal
1. Identification Identification of the changes required is the most difficult part & thus extremely important part of MOC system Systemic approach for identification can be used. The employee can use the list as a check-list to determine if the modification falls under any of the categories. Developing a clear, written, definitions of a system boundaries and what constitutes change for effectively identifying change requirement
Example: Suppose a downstream network of 3000 SCMH DRS has been expanded over a period of time and more & more commercial & domestic customers are connected through this DRS. Now daily monitoring, recording and analyzing the pressure values of upstream and downstream of DRS at peak flow condition can be helpful for identifying whether change or modification or replacement of DRS with higher capacity is required or not.

I. Proposal
2. Plan for situation Step by step plan preparation of executing a change Steps to be taken to control the change, MOC guide for employee Defining time limit for executing permanent or temporary change Define technical or non technically staff involved in the process. Helps in assigning responsibilities during MOC

3. Control Mechanism

4. Time Limit

5. Staff involved:

II. Review of Proposal

1. Evaluation Evaluating the reasons for changes required

Define whether change is technically benefited or commercial benefited or whether change is necessary for continuing the operation
Develop a form or template for recording the reason of change

Example: To determine the causes of not up grading the installed DRS or evaluate installation of new DRS based on cost incurred and revenue generation

II. Review of Proposal

2. Risk Ranking:

Risk ranking based on hazard level & potential severity associated with change. Yes/No questionnaires type format can be developed and based on score, risk matrix to be developed to determine over all risk level

III. Approval
1. Permission & Communication:

Permission/authorization of third parties or other to be affected through MOC plan

2. Safety Review & Approving Authority:

Whether 5 approval signatures and a thorough hazard analysis or 1 approval signature and no formal risk assessment required? Risk ranking system to determine authorization level

IV. Execution
1. Work Permits: Obtaining work permit as per work permit matrix before executing job

2. Monitoring:
Monitoring the parameters of system like pressure, temp. etc for a specified time to determine functionality of changes applied

3. Implications: Study the outcomes as per checklist or a form of expected changes in system in order to determine success level of MOC plan

V. Documentation
Documentation of entire MOC plan in a uniform format Completion Report

Older Version of documents withdrawal from use

Training
Training is important achieve the success of a MOC program as it will only function on the level that employees are trained to properly use it. Process safety could be put at risk during a MOC execution by the unintentional actions of one untrained individual. Employees must possess the proper respect for management of change and they can only acquire this through training. Anyone who could affect a change must be aware of and conform to the policies and procedures of change control. It is equally important for both management and regular staff to receive program awareness training as they all play an active role in the MOC process.

Information Management system

Used to account for the status of all changes currently under review. The system should ensure that: - The most up to date information is available when considering a change, and; - All changes are incorporated in the same database which is accessible to everyone. (like SAP system utilization) This prevents two inter-related changes from occurring concurrently without being aware of one another. The system must include a list of all documentation that must be reviewed and revised when a change occurs like operating procedures, P&IDs, maintenance and testing procedures etc

Auditing
Audits are used to ensure that the MOC system is working as effectively as possible. No matter how good a system is, there is always room for improvement, and audits are a way of continuously improving the MOC program. The audits determine whether all changes are assessed for their impact on safety and whether the documentation of the change is accurate and complete. If a MOC system is new then more frequent audits should be performed during the initial stages to ensure all the bugs are found.

Success of MOC
Management Support Implementation more than documentation Understanding & utilizing developed procedures Training & Awareness

Case Study: Flash Fire Incident At Sector-5 CNG Station Gnagar

Background: In the last week of May13, GSPL communicated to GSPC GAS that they are contemplating to increase the inlet pressure to GSPC Gas facility to 35 bar from current 26 bars. In order to prepare our system to work at 35 bar, it was decided to carry out functional test of PRS installed at sector 5, Vijay Petroleum and Sector 24 CNG station. At Vijay petroleum, CNG O&M team carried out functional test but it did not work and team discontinued work and came to sector -5 CNG station.

Case Study: Flash Fire Incident At Sector-5 CNG Station Gnagar

Sequence of Events: 1. 2. 3. 4. Pressure from system was released and purged with N2 from the outlet of the filter DP valve tapping stem Pressure was raised to 35 bar using N2 The pressure was kept on hold for 2-3 minutes and checked the inlet & outlet of PRV and found 35 bars and 18 bars respectively After this, N2 was being vented out through P.G. manifold after PRV and installed the PG in the manifold and confirm pressure to be zero in skid & took the decision to remove the nitrogen cylinder Before any action could be taken to remove nitrogen cylinder hose, a flash fire occurred and travelled through the venting passage of the system and damage the weak portion like Tee, Elbows of the system in the path Three people got burn injury in this incident

5.

6.

Case Study: Flash Fire Incident At Sector-5 CNG Station Gnagar

Causes of incident: 1. Presence of Oxygen in N2 cylinder which has created air gas mixture inside the isolated system 2. Improper procedure for purging & venting of the gas (Non use of regulator and not ensuring venting point in upstream and downstream of PRV)

3. The air gas mixture in the filter of the skid rushed due to depressurization in the downstream of the system and the impurities in the filter ignited the mixture. (most possible cause for ignition)

Case Study: Flash Fire Incident At Sector-5 CNG Station Gnagar

Role of MOC
Sr.
1

Steps
Identification

Descriptions
As it was clear instruction from GSPL, we had a proper reason to identify changes required in the system in order make our system compatible with the pressure of transmission line This part could have clearly evaluated that what is to be done in order to incorporate the changes. Like was it really necessary to check the system? which process to be adopted?, Could there have been any other better method than functional test?

Evaluation

Plan for Situation

Step wise planning have been made to carry out functional test of all facilities which are going to be affected due to increase in pressure in GSPL line

Case Study: Flash Fire Incident At Sector-5 CNG Station Gnagar

Role of MOC
Sr.
4

Steps
Control Mechanism

Descriptions
Work flow procedure plan could have been prepared based on policy and procedures of company to carry out functional test like deciding venting points, purging point, use of regulators etc in order to control the process Determining the time limit for completing entire job at all three location. As per permit taken for the job we can see that all three locations functional test were planned in a single day. Thus this could have serve as a checkpoint whether the time limit planned is sufficient or it requires more time

Time Limit

Case Study: Flash Fire Incident At Sector-5 CNG Station Gnagar

Role of MOC
Sr.
6

Steps
Staff Involved

Descriptions
This could have help in deciding the staff involved in procedure such that other operations could not have affected. Clearly defines the roles and responsibilities of each person involved in the operation Based on the potential severity and hazard associated with the hazard associated with the functional test & N2 purging ,risk ranking could have been done to determine overall risk level. This could have been check point for determining percentage of N2 present in the cylinder and risk associated with filter cartridge Based on risk rating it could have been determined the level authorization required to execute the change. Like whether GA head approval or GM-T approval or AGM HSE approval were required before executing the job

Risk Ranking

Approving Authority

Case Study: Flash Fire Incident At Sector-5 CNG Station Gnagar

Role of MOC
Sr.
9

Steps
Work Permit

Descriptions
Based on authority level of approval, this have helped in taking signatures of all approving authority so that they can be awaked about the operation is under progress. This can have serve as a checkpoint of all compliance and procedures

10

Permission or Communication

It might have helped in deciding whether third party information or communication was required or not like communication to CNG vehicle customers as a safety precautions before job execution

Case Study: Flash Fire Incident At Sector-5 CNG Station Gnagar

Role of MOC
Sr.
11

Steps
Monitoring

Descriptions
Functional test gone unsuccessful at Vijay Petroleum. Thus continuous monitoring was necessary of the system and its parameters in order to eliminate any malfunction that could have resulted because of the test Based on expected results, yes no type checklist might have been prepared to analyze the success of MOC Documentation of entire MOC plan and procedure. This must have included step wise approved procedures to be executed, signed & approved P&ID diagram defining venting & purging point during test, tool box talk, risk rating, hazard identification & steps taken to mitigate hazards associated with test, list of staff involved with clear roles and responsibility etc documents

12 13

Analysis of Implications Documentation

Bibliography & Webliography

Draft Integrity Management system published by PNGRB

Fire Incident Report of GSPC GAS

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