Management of Change: The Risks We Create Without Realising It

Most organisations understand the need to manage major change.

Install new equipment, modify a process, alter a facility or introduce a new chemical, and a formal Management of Change process will usually be triggered. Engineering reviews are completed, hazards are assessed, drawings are updated, approvals are obtained and affected personnel are informed.

The obvious changes are generally visible.

The more interesting question is what happens when the organisation changes without recognising that it has changed.

A senior supervisor retires and responsibility is redistributed across the remaining team.

A maintenance contract is retendered and a new contractor takes over. Headcount is reduced. A project schedule is accelerated. Employees begin travelling to a new country.

A digital workflow replaces a familiar manual process. Two departments are reorganised.

An experienced engineer moves into another role. Procurement changes a supplier. A temporary arrangement remains in place for six months longer than originally intended.

Individually, none of these changes may look like a traditional HSE modification.

Collectively, they can fundamentally alter how risk is controlled.

That is why Management of Change should not be viewed simply as an engineering procedure.

It is an organisational capability.

And one of the biggest weaknesses in many MOC systems is not that changes are assessed badly.

It is that significant changes are never recognised as changes at all.

Change Alters the Assumptions Behind Risk

Every risk assessment contains assumptions.

There will be enough competent people available. Equipment will operate within defined parameters. Maintenance will occur at appropriate intervals. Supervisors will have manageable spans of control. Contractors will understand the work. Procedures will remain relevant. Emergency resources will be available.

Controls are designed around these assumptions.

Then the organisation changes.

Perhaps the control itself remains exactly the same on paper, but the conditions supporting it have changed.

Consider a supervisor responsible for verifying several safety-critical activities. The organisation restructures and the same supervisor becomes responsible for twice as many people across a larger geographical area.

No procedure has changed.

No equipment has changed.

The critical control may not have changed either.

But the supervisor's ability to verify that control may have changed significantly.

The original risk assessment may therefore no longer represent reality.

This is the fundamental purpose of Management of Change: to identify when a change invalidates, weakens or modifies the assumptions on which existing risk controls depend.

We Are Better at Seeing Physical Change

Physical changes are comparatively easy to recognise.

A new pipe is installed. Equipment is replaced. A process parameter changes. A new substance is introduced. A facility is modified.

Something tangible is different.

For high-hazard facilities, formal MOC processes have long recognised the importance of reviewing modifications before implementation. Process-safety frameworks such as OSHA's Process Safety Management standard explicitly address management of changes to process chemicals, technology, equipment, procedures and facilities.

The challenge is that organisations change in many other ways.

A reporting line changes.

A technical authority leaves.

A business function is outsourced.

A contractor replaces experienced personnel.

A new software platform changes how information is communicated.

A project enters a different phase.

Working hours increase.

A temporary operating arrangement becomes semi-permanent.

These changes may never reach the engineering MOC system because nothing physical has been modified.

Yet they can alter risk just as effectively.

The organisation therefore needs a broader understanding of change.

Organisational Change Is HSE Change

Restructuring is usually managed primarily as a business or human-resources activity.

Organisational charts are revised. Positions are combined. Reporting lines change.

Employees are reassigned. Cost savings are calculated.

The HSE consequences can receive much less attention.

But organisational structures are part of the risk-control system.

Who makes decisions? Who provides technical oversight? Who supervises the work?

Who responds during an emergency? Who verifies critical controls? Who has authority to stop an activity? Where does specialist knowledge reside?

Change those relationships and you may change the effectiveness of the system.

This becomes particularly important during downsizing.

Removing ten positions does not necessarily remove ten equal units of organisational capacity.

One departing employee may hold decades of experience, specialist knowledge, informal relationships and organisational memory that are difficult to replace.

A spreadsheet may show that the role has been transferred.

Reality may be more complicated.

Good organisational MOC therefore asks more than whether responsibilities have been reassigned.

It asks whether the organisation still has the capability to perform them.

The Departure of One Person Can Be a Significant Change

Most organisations have people they rely upon more heavily than the organisational chart suggests.

They are the person everyone calls when unusual equipment fails. They understand the history behind an old facility. They know why a particular procedure contains an unusual requirement. They remember the previous incident that caused a control to be introduced.

Much of this knowledge is tacit.

It may never have been formally documented.

When that person leaves, the position may be filled immediately, giving the appearance that organisational capability has been maintained.

But the replacement does not automatically inherit twenty years of experience.

This creates a particular vulnerability in mature organisations with ageing workforces or significant turnover.

Succession planning should therefore be considered part of risk management.

Which individuals hold safety-critical knowledge?

Where does the organisation rely heavily on one person's expertise?

What knowledge would be difficult to replace?

How long would it take a successor to develop equivalent capability?

These are not simply HR questions.

They are questions about operational resilience.

Contractor Changes Need MOC Thinking Too

Changing contractors provides a good example of organisational change that can be underestimated.

Commercially, the transition may appear straightforward. One contract expires and another begins.

Operationally, much more may be changing.

Different people arrive. Different supervisors take control. Equipment changes.

Procedures differ. Organisational relationships need to be rebuilt. Site knowledge is lost. Informal communication networks disappear.

Even where the incoming contractor is technically stronger, the transition itself creates vulnerability.

The organisation needs to recognise this as a period of change rather than simply a procurement event.

What knowledge needs to be transferred? Which activities require additional supervision during transition? Are safety-critical competencies equivalent? Which interfaces will change? What assumptions in existing risk assessments are no longer valid?

The new contractor may ultimately improve performance.

That does not mean the transition is risk-free.

Schedule Change Is Risk Change

Projects regularly change schedule.

Activities are accelerated. Milestones move. Work is resequenced. Additional crews are introduced. Shifts are extended. Simultaneous operations increase.

These decisions are often discussed primarily in terms of productivity and commercial impact.

But schedule is also an HSE variable.

Compressing a programme can increase workforce density, create additional interfaces, reduce recovery time, increase fatigue and place greater pressure on supervision.

Again, no formal safety standard may have changed.

But the environment in which those standards must operate has.

This is particularly important during schedule recovery.

When a project falls behind, the response is often to add resources or perform more activities simultaneously.

Both actions can be reasonable.

Both can also change the risk profile substantially.

A mature project should therefore ask: What new HSE risks are created by the recovery plan itself?

That question should be answered before the revised schedule becomes the new normal.

Temporary Changes Have a Habit of Becoming Permanent

Some of the most dangerous words in operational management are:

“It's only temporary.”

Temporary changes often receive less scrutiny because exposure is expected to be short.

A temporary bypass is installed. A temporary office is established. A role is covered by another employee. Equipment is operated under temporary arrangements. A temporary access route is created.

The arrangement works.

Then the expected completion date moves.

Three months becomes six months.

Six months becomes a year.

People become familiar with the temporary arrangement and its unusual characteristics gradually stop feeling unusual.

This is why temporary changes need expiry dates, ownership and review.

If a temporary control remains necessary beyond its intended period, the organisation should deliberately reassess it rather than allowing temporary status to become permanent by default.

Time does not make an inadequate arrangement safer.

It simply makes it familiar.

Digital Change Is Becoming a Major MOC Issue

Digital transformation is changing how organisations manage HSE.

Paper permits become electronic. Inspections move to mobile applications. Artificial intelligence supports analysis. Remote monitoring replaces some physical presence.

Dashboards aggregate information automatically. Procedures move into cloud-based systems.

These changes can create significant benefits.

They also create new dependencies.

What happens when connectivity fails? Can employees access critical information offline? Does automation remove a useful human verification step? Are alerts so frequent that people begin ignoring them? Does the new interface make an important control harder to see? Has responsibility become unclear because the system automatically routes decisions?

Technology can change human behaviour even when the underlying procedure remains unchanged.

Digital MOC therefore needs to consider more than cybersecurity and technical functionality.

It needs to consider how the technology changes the work.

A digital process that is technically successful but operationally cumbersome may encourage workarounds just as easily as a poorly designed paper process.

Change Can Accumulate Quietly

Individual changes are usually assessed independently.

The organisation may therefore miss their cumulative effect.

Imagine that over twelve months a business unit loses several experienced employees, changes contractor, introduces new software, reduces administrative support and expands its scope of work.

Each change may have been considered manageable.

But what is the combined effect?

The organisation that exists at the end of the year may operate quite differently from the organisation whose risks were originally assessed.

This is sometimes referred to as change saturation.

People have limited capacity to absorb new systems, responsibilities, technologies and expectations simultaneously.

Eventually, even beneficial changes begin competing with one another for attention.

This is particularly relevant during mergers, acquisitions, rapid growth and major organisational transformation.

Management should therefore periodically look across the portfolio of change rather than assessing every modification in isolation.

The question is not only, “Is this change manageable?”

It is also, “How much change is this part of the organisation already managing?”

MOC Should Happen Before the Decision Becomes Irreversible

One of the common weaknesses in Management of Change is timing.

The commercial or operational decision is effectively made first.

HSE is then asked to assess the change.

At that point, the purpose of the assessment can quietly shift from evaluating whether the change is acceptable to finding a way to make the predetermined decision work.

Sometimes that is unavoidable.

Usually, it is poor governance.

HSE considerations should enter the decision while alternatives still exist.

If a restructuring is being considered, evaluate the safety-critical responsibilities before finalising the structure.

If a new contractor is being selected, consider transition risk during procurement.

If a schedule is being accelerated, evaluate the implications before committing to the revised milestone.

MOC is strongest when it informs decisions.

It is considerably weaker when it merely documents them afterwards.

Not Every Change Needs a Committee

There is a danger here.

If organisations interpret MOC too broadly, almost everything becomes a formal change requiring extensive documentation and approval.

That would recreate bureaucracy.

The answer is proportionality.

A minor administrative change should not require the same assessment as a major process modification or organisational restructuring.

The organisation needs sensible screening criteria.

Could the change introduce a new hazard? Could it weaken an existing control? Could it affect a safety-critical role? Could it change exposure? Could it affect emergency response? Could it invalidate an existing risk assessment?

If the answer is no, the change may require little additional HSE assessment.

If the answer is yes, investigate further.

The purpose is not to create paperwork around change.

It is to prevent important changes from bypassing risk assessment simply because they do not fit the traditional definition of an engineering modification.

The People Doing the Work Need to Be Involved

Change looks different depending on where you sit in the organisation.

Management sees the revised organisational structure.

The supervisor sees three additional responsibilities.

IT sees the successful deployment of new software.

The employee sees that a task that previously required three clicks now requires twelve.

Project management sees schedule recovery.

The workforce sees additional simultaneous operations.

This is why consultation matters.

The people affected by change often identify consequences that are invisible to those designing it.

Their involvement should not be limited to communicating the final decision.

Ask them what will become harder.

Ask which controls depend on the existing arrangement.

Ask what information they will lose.

Ask what new interfaces will appear.

Ask what they are concerned about.

Not every concern will justify changing the decision.

But every credible concern deserves understanding.

Post-Implementation Review Is Where Learning Happens

A Management of Change process should not end when the change is implemented.

That is when assumptions finally meet reality.

Did the new organisational structure work as expected?

Did the new contractor integrate successfully?

Did the digital system improve the process?

Did the revised shift pattern create fatigue concerns?

Did the new equipment introduce unexpected maintenance issues?

A post-implementation review closes the loop.

Without it, organisations assess what they think a change will do but may never systematically determine what it actually did.

This is particularly valuable because unexpected consequences are not always negative.

A change may produce improvements that were not anticipated.

Those lessons are worth capturing too.

MOC should be a learning process, not simply an approval process.

Leaders Need Visibility of Significant Change

Senior leaders should understand where significant organisational and operational changes are occurring.

Not because executives need to approve every modification.

They need visibility because major change can alter the organisation's risk profile faster than historical performance indicators can reveal it.

An executive dashboard may remain green throughout a restructuring.

Injury statistics may remain unchanged during a contractor transition.

Nothing may appear unusual while experienced personnel gradually leave.

Lagging indicators are particularly weak at detecting emerging risk created by change.

Leadership should therefore ask forward-looking questions.

Where are we changing fastest?

Where are we losing experience?

Where are new interfaces being created?

Which critical controls depend on roles or systems currently changing?

Where is the organisation experiencing change fatigue?

These questions help leaders see vulnerability before an event exposes it.

Change the Way We Think About Change

Management of Change is sometimes treated as a specialist process belonging to engineering, operations or HSE.

It should be broader than that.

Change occurs continuously across organisations.

People change. Contractors change. technology changes. Business models change.

Work locations change. Organisational structures change. Schedules change. Risk changes with them.

The objective is not to prevent change.

Organisations that cannot change cannot survive.

The objective is to change deliberately.

Understand what assumptions are being altered. Identify which controls may be affected. Involve the people who understand the work. Make decisions while alternatives remain available. Verify that the change produced the outcome expected.

Most importantly, learn to recognise change before it becomes an incident investigation finding.

Because the most dangerous change is not necessarily the largest.

It is the one that quietly alters the conditions supporting safe work while everyone continues operating as though nothing has changed.

References and Further Reading

International Organization for Standardization (ISO). ISO 45001:2018 – Occupational Health and Safety Management Systems. Includes requirements for identifying hazards and assessing OH&S risks associated with planned or proposed changes, together with operational requirements for controlling temporary and permanent changes.

US Occupational Safety and Health Administration (OSHA). Process Safety Management of Highly Hazardous Chemicals – 29 CFR 1910.119. Includes formal Management of Change requirements for changes affecting process chemicals, technology, equipment, procedures and facilities.

UK Health and Safety Executive (HSE). Organisational Change and Major Accident Hazards – Chemical Information Sheet CHIS7. Guidance addressing the planning, assessment and management of organisational change in major-hazard industries.

UK Health and Safety Executive (HSE). Managing for Health and Safety (HSG65). Guidance addressing organisational change, competence, risk profiling, implementation, monitoring and review as elements of effective health and safety management.

Energy Institute. Guidance on Human Factors Safety Critical Task Analysis and Human and Organisational Factors resources. Industry resources supporting consideration of human performance, organisational arrangements and changing operating conditions within high-hazard environments.

International Association of Oil & Gas Producers (IOGP). Operating Management System Framework for Controlling Risk and Delivering High Performance in the Oil and Gas Industry. Industry framework addressing management of risk, organisational capability, change, operating controls and continual improvement.