Management of change is one of the key ingredients in an effective safety program. It is a requirement of SEMS and PSM. Now from the nuclear industry comes a fresh reminder of how important, but little understood, management of change is.
Cat owners have long turned to kitty litter to control feline “bombs” and, as it turns out, the nuclear industry uses kitty litter to control its own potential bombs. The litter helps stabilize radioactive sludge for storage or shipping.
Unfortunately an effort to “‘go green’ by using organic kitty litter backfired. The Los Alamos National Laboratory changed over to the organic litter as the mixing agent for its waste, but the chemical process is different from the old clay-based litter. Now storage drums are bursting their seams, bubbling and even catching fire! The storage facility has been closed since February, but the agency just reported its finding last week. Here is a link to a good story about it.
The management of change lesson here is that the time you need to use your MOC process is when you don’t think you have to. We don’t know whether the people at Los Alamos thought they were making an environmentally-friendly improvement or just found a cheaper brand of kitty litter. But they overlooked some pretty fundamental laws of chemistry and physics. If they had applied an MOC checklist to make sure they weren’t missing anything, they would probably have avoided this whole problem.
On the subject of MOCs, here is another take on the need to focus attention on management of change. We usually think of MOCs as either the way we avoid an unintentional safety or environmental consequence or the way we ensure that we have thought through the training procedural and other items that come with change. This article from the Harvard Business Review looks at business change management, but the message carries over into safety: Change fails when leaders don’t follow through to make sure it happens.
Does your change management procedure ensure that people are responsible for implementing the change according to plan? If not, it is just so much…..kitty litter.