Reinventing Management of Change: Lessons from 30 Years of Digital Process Safety – Part 5
Executive Summary
Over the past three decades, organizations have invested heavily in digital platforms to improve Management of Change (MOC). Many of these platforms are technically sophisticated, highly configurable, and aligned with regulatory requirements.
Yet incidents, audit findings, and recurring deficiencies in MOC execution persist.
The root cause is rarely technological.
In practice, the effectiveness of MOC is determined less by software capabilities and more by how people interpret, prioritize, and execute the process. Process safety engineers and plant managers understand this intuitively: a well-designed system can still fail if it does not align with human behavior, operational pressures, and organizational incentives.
To improve MOC outcomes, organizations must address the human dimension of change with the same rigor they apply to technical risk.
MOC in the Context of Operational Pressure
Industrial facilities operate under constant pressure to maintain production, manage costs, and respond to operational disruptions. In this environment, MOC is often perceived as an administrative burden rather than a risk management tool.
Common operational realities include:
- Production schedules that discourage delays
- Maintenance backlogs that compress planning cycles
- Engineering resources stretched across multiple initiatives
- Contractors working under tight timelines
- Competing priorities between safety, reliability, and throughput
When these pressures collide with MOC requirements, individuals naturally seek the path of least resistance.
This is not a failure of character. It is a predictable outcome of organizational design.
The Behavioral Failure Modes of MOC
Across industries, several recurring behavioral patterns undermine MOC effectiveness.
1. Under-Scoping of Change
Engineers and operators may classify changes as “minor” to avoid triggering extensive reviews. Over time, this leads to a systematic underestimation of risk.
2. Procedural Compliance Without Critical Thinking
Users may focus on completing required fields and approvals rather than critically evaluating hazards. The MOC process becomes a checklist rather than an analytical exercise.
3. Reliance on Informal Knowledge
Experienced personnel often rely on tacit knowledge rather than documented analysis. While expertise is valuable, it is not a substitute for structured risk evaluation.
4. Fragmented Accountability
When responsibilities are distributed across departments, no single individual feels fully accountable for the integrity of the change process.
5. Normalization of Deviance
Over time, deviations from formal MOC procedures become normalized if they do not immediately result in adverse outcomes.
These patterns are not unique to any single organization; they are systemic.
Why Traditional MOC Metrics Are Misleading
Many organizations measure MOC performance using indicators such as:
- Number of MOCs processed
- Cycle time from initiation to closure
- Percentage of overdue actions
- Audit compliance scores
While these metrics are useful, they provide limited insight into the quality of decision-making.
A facility can process thousands of MOCs efficiently while systematically failing to identify critical hazards.
For plant managers, this creates a false sense of assurance. For process safety engineers, it obscures the true effectiveness of the MOC program.
To address the human factor, organizations must move beyond quantitative metrics toward qualitative indicators of risk awareness and analytical rigor.
Aligning MOC Systems with Human Behavior
Effective MOC systems are designed not only to enforce procedures but also to guide human judgment.
Key design principles include:
- Risk-based prompts that encourage deeper analysis for high-impact changes
- Contextual information that connects changes to historical incidents and hazards
- Clear visibility of responsibilities and dependencies
- Structured decision points that require explicit justification
When systems are aligned with how people think and work, they reduce the likelihood of superficial compliance.
The Role of Leadership in MOC Effectiveness
Technology cannot compensate for weak governance.
Plant managers and senior leaders play a critical role in shaping how MOC is perceived and executed. Their actions influence whether MOC is treated as:
- A bureaucratic requirement, or
- A core element of operational discipline
Leadership behaviors that strengthen MOC include:
- Visible engagement in high-risk changes
- Consistent reinforcement of MOC expectations
- Balanced decision-making that values safety alongside production
- Accountability for both outcomes and process integrity
Without leadership commitment, even the most advanced MOC systems will fail to deliver meaningful risk reduction.
From Human Behavior to Organizational Learning
The ultimate purpose of MOC is not merely to control change but to enable organizational learning.
Every change generates insights about system vulnerabilities, procedural gaps, and operational constraints. When these insights are systematically captured and reused, organizations move from reactive compliance to proactive risk management.
However, this transformation requires more than data collection. It requires cultural and structural mechanisms that translate individual experiences into institutional knowledge.
Looking Ahead: From Human Factors to Digital Intelligence
In Part 6 of this series, we will examine how artificial intelligence and advanced analytics can support—but not replace—human judgment in Management of Change, and how organizations can safely integrate these technologies into their process safety frameworks.
