System Safety for the 21st Century, 2nd Edition

CHAPTER 18Change Analysis

Change is a necessary ingredient of progress. It can be a positive factor that improves the effectiveness, efficiency, and/or safety of an organization or operation. However, change is almost always a causal factor in accidents, many times a very significant causal factor. Whether the change is a friend or foe depends largely upon the manner in which changes are planned, managed, and controlled.

Change analysis is one of the techniques associated with the Department of Energy’s management oversight and risk tree (MORT) approach to system safety. Unlike the MORT chart itself or some of the other tools and techniques associated with the MORT program, change analysis is a very simple, straightforward process that is relatively quick and easy to learn and apply.

Well‐designed and engineered systems can rapidly become ineffective, inefficient, and/or hazardous without effective change controls.

Change analysis is a technique for evaluating changes and determining the need for counterchanges to keep the system in balance.

Change analysis has applications in both accident prevention and accident investigation. It is recommended for both.

PURPOSE

The purpose of change analysis is to list and examine all changes systematically, determine the significance or impact of the changes, and recommend appropriate counterchanges to ensure that the safety of the operation is not adversely affected by the changes.

Change analysis, as a preventive tool, provides an excellent ...