Misuse of management of change 

The Regulator I Issue 3 I October 2021

NOPSEMA is concerned duty holders may be failing to properly manage change following several instances where the management of change (MoC) process was used to justify deviations from accepted permissioning documents without regard for the increase in risk.

NOPSEMA recognises that it may be appropriate for duty holders to use the MoC process to facilitate temporary change, where equivalent or better controls, and/or alternative ways of working are put into place in the interim.

It is important for duty holders to ensure that any change implemented through the MoC process continues to reduce safety and environment risks to as low as reasonably practicable and environmental impacts to an acceptable level. Duty holders should also consider if the change in risk will impact on any other regulatory requirements, such as the requirement to submit a revised permissioning document to NOPSEMA for assessment and acceptance.

NOPSEMA has identified instances where duty holders have used the MoC process to justify a significant deviation from their accepted permissioning document and/or implement a change without adequately considering the increase in risk. For example: 

• Rather than fix a leak in the hydraulic system designed to operate a subsea isolation valve on a gas flowline, an operator used the MoC process to bypass the hydraulic control system and lock the valve in the open position rendering the valve incapable of functioning as intended.
• An operator used the MoC process to defer maintenance and replacement of the passive fire protection on a hydrocarbon pressure vessel, stating it was not safety critical. However, the fire protection had degraded to such a point that it couldn’t provide the necessary protection in a fire scenario.

In each of the examples above, NOPSEMA determined the changes resulted in a significant increase in risk to the health and safety of the workforce. NOPSEMA took compliance action by requiring each operator to ensure the risk were adequately addressed. This resulted in both operators reversing the changes implemented. 

A failure to properly manage change can significantly increase the risk of major accident event. It is for this reason that NOPSEMA is committed to addressing the issue by using the full range of its regulatory powers and, where necessary, to test the boundaries of the legislation to ensure the protection of the workforce and environment.

Recently, the Department of Industry, Science, Energy and Resources (DISER) published an Offshore Oil and Gas Safety Review policy framework where it referred to instances where operators used their MoC process to address the loss of safety-critical controls without understanding the increase in risk.

NOPSEMA supports DISER’s proposed amendments to the safety regulatory framework that will require operators to identify and document control measures, which if lost or removed, will require a revision to the accepted safety case. Through this proposed revision the operator must justify to NOPSEMA that the risks have been identified and adequately controlled before the change can take place.

NOPSEMA recognises that such amendments will assist in removing any ambiguity around when a revision to an accepted safety case is required and when the MoC process can be used. The proposed introduction of a civil penalty regime will also provide a disincentive to non-compliance.

If duty holders are unsure about whether a proposed change can be implemented using the MoC process or if a revision to the accepted permissioning document is required, NOPSEMA strongly recommends you contact your facility’s focal point inspector for guidance.