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Good afternoon Before I start to talk about change it is quite appropriate that I need to point out my phone number has changed since I originally wrote my paper. I can assure you that my mobile and email have stayed the same. I think most people will acknowledge that change is the new stability, and companies that do not keep changing probably won’t survive. Over recent years a fair amount of my work has been evaluating changes that companies have recently completed or planning to make in the near future. Obviously as a consultant I have the opportunity to be critical and pick holes, safe in the knowledge that I will never have to implement my recommendations. The reality is that I generally find that companies are often weak in managing change, especially where human and organisational factors are concerned. The intention of this presentation is to give you some idea of the general issues I encounter.
The Flixborough disaster in 1974 gave our industry a clear message that change can be risky. An ill conceived and implemented plant modification resulted in the death of 28 people. I know the process industry did learn many lessons from Flixborough and I doubt there are many companies in the industry that do not have some form of plant modifications procedure in place as a result. However, my opinion is that most systems and procedures are focussed hardware and on change control rather than change management, and this is a potentially serious weakness.
There are three topics I want to cover today. They are 1. The drivers of change 2. People and organisational changes 3. The difference between change control and change management
From a managerial perspective, there are two drivers of change. Either an external force such as regulation, obsolescence or demands from stakeholders requires change; or an opportunity is recognised, often related to advances in technology that may allow new products to be made or costs to be reduced. However, you do need to bare in mind that these drivers are usually quite removed from the people at the sharp end who either need to implement the change or are those most likely to be affected by them. Management consultants say that when people are uncomfortable with a situation their behaviour will automatically change. For example if the temperature in this room were uncomfortably hot we may take our jackets off, and someone may get up and change the setting on the thermostat. We must recognise that most employees are quite comfortable with the status-quo, and very resistant to change. Having systems that control change are unlikely to address everything we need to successfully manage change.
All changes have potentially positive and negative consequences. The positive ones are the reason we want change to happen. Some of the negatives are inevitable, and some are difficult to predict, but in managing change we need to do what we can to at least balance the equation. This is another interesting issue regarding managing change. My experience suggests that companies often have only sketchy ideas of the benefits they expect and then assume it will be successful. It is rare that objective evaluations are made during and after change programs about whether the benefits are being achieved or whether the negative consequences outweigh the benefits. Studies have shown this to be the case, pointing out it is rarely in the interest of people managing to change to collect data that may reflect badly on themselves.
OK. Up until now I have talked about change in very general terms. I now want to get more specific. The HSE refer to the 4 Ps of premises, plant, procedures and people as potential sources of hazard when assessing risks, and I find these classifications useful when considering what can be affected by change. Now I am fairly confident that most companies have some form of modification procedure that addresses premises and plant. To a certain extent quality systems cover procedures and things like COSHH cover materials and substances. I am much less happy with the ability of most existing systems to address human and organisational factors.
In order to illustrate my opinions regarding management of change I am going to talk through a selection of types of change that I have been involved in evaluating as a consultant. In each case I will refer to HSE guidance and research documents that are available to assist in evaluating changes and can feed into a management programme.
There is no doubt that technology is changing our control rooms. As well as affecting the operators interface on the plant, it is also providing opportunities to change how plants are operated, including the number of people required, the nature of the job and the location of the control room.
There are many positive consequences of the changes taking place in our control rooms. The safety element is interesting because moving control rooms away from the plant certainly makes them safer if there is a problem, but we have to be sure that the changes do not make those problems more likely. For the operator, modern control rooms generally give them less direct methods of evaluating how the plant is operating. Replacing wall mounted panels where you could see the whole plant at a glance with screens that only show part of the plant at any time can have a major affect. And the operators are less likely to be able to be able to hear, feel or even smell the plant. Automation means operators have less to do most of the time, and possibly far more complex situations to deal with when the automation can’t manage. Also, the divide between control room and field operators can widen considerably, both in geographical terms but also in the nature of the job. I know the result is generally that plants run more steady and have less disruption, but I am concerned that the changes can mean that the consequences when control is lost can be more significant.
In managing changes, we have to remember that control rooms are where operators receive data about how plant is operating so that they can detect and diagnose events quickly and accurately, and hence implement appropriate action. Now contrast this with my experience interfaces are designed on modern control systems. Graphics generally recreate a simple representation of the plant and equipment. Combined with alarm systems that cause frequent over load of operators, the operator is being made to work much harder to understand what is happening on their plant. Control rooms are also centres of communication, and their location can have a big impact on the opportunities people have to communicate face to face. Many of the over sights I see in control rooms represent a failure to manage the introduction of the new technology. Often this is because people simply assume that the gizmos must be more effective, but without making any realistic assessment of what they expect to improve and checking to ensure it has been achieved. Also, operators are often never told how to use the new technology, and so it is not used as intended or at all. There are also difficult issues to address. For example, it is possible that your existing workforce may not be able to adopt the new ways of working. Difficult to deal with, but cannot be ignored. This HSE report gives an insight into these issues, and I would certainly suggest that you should look at this when considering change, and to evaluate you current arrangements.
One of the changes I get involved in very often is in staffing arrangements. De-manning is frequently the objective, often following the introduction of new technology. Organisational changes may also be required to accommodate the change, which does tend to complicate things more than most people envisage.
There are clear potential cost savings achieved through de-manning, and it can be an opportunity to simplify the organisation. and acts as an impetus to implement other changes that may have been more difficult if things had stayed as they were. However, many companies have found that the negative outcomes are worse than they expected, with the effects not always being apparent for some time. The main thing to realise is that it is generally unusual circumstances including emergencies when reductions in manning and loss of expertise have the greatest impact. As plants have become more reliable, we have less opportunities to test the ability of individuals and teams to cope.
The important thing to consider when planning, implementing and reviewing changes to staffing arrangements is the ability for your teams to detect, diagnose and respond to high demand situations reliably and effectively. In my experience, in modern plants it is rarely the number of people available that has the biggest impact. Rather, it is ensuring a level competence within a team and the ability of individuals to work together with each other and with the technology provided. Research report 348/2001, commonly known as the staffing assessment methodology, has been used widely in evaluating staffing arrangements. It provides a degree of objectivity to issues that are often very subjective.
It seems to have become unfashionable over recent years to talk about supervision in industry. We are more likely nowadays to have team leaders and coaches, and many companies have moved towards self-managed teams. In my experience, the main driver of change has been staffing reductions, rather than improvements in supervision. I am concerned that levels of supervision have been reduced, and that this can impact on safety.
There is no doubt that supervision within traditional, hierarchical organisations has its problems, and different arrangements can improve communication, decision making and even job satisfaction. However, removing a supervisor generally requires more people, or even the whole team to take on some of supervisory role. There is little doubt in my mind that this makes implementing supervision more difficult, and takes some considerable time to establish the necessary change in culture. Whilst the new types of organisation probably work well in low hazard industries, I am not sure they can work within the constrains of major hazard industries.
It is clearly not my place to say what types of team structure you can or cannot use. All I can say is if you are making changes, you need to be very clear how supervision as a management function is going to be delivered. Given that more people may be involved in its delivery, you also need to be very clear about how people will become and maintain competence in the necessary supervisory skills. Research report 292 gives a comprehensive definition of what constitutes supervision and provides a method to evaluate how supervision is delivered at the management, team and individual level that you can use to see how this will be affected if you change your organisation.
This is that last example I am going to look at briefly. Over recent years I have examined the changes companies have been planning to shift patterns. Again this is often because team sizes have reduced or the demands of the job have changed. People tend to think it is only the length of shift that makes the difference. This is not the case, and certainly when comparing 8 and 12 hour shifts my conclusion is that it is a relatively minor difference.
The key point about shift patterns is that there is no one pattern that is better than all the others. All have pros and cons and so it is important that shift work is properly managed. Also, when making changes it is important to remember that it is not only the worker that is affected, but also their family and friends. There are few things more contentious than changing a shift pattern, and it is great example of the need to include the people effected in any evaluation, and that the change needs to be sold to them very well.
People are rightly concerned about fatigue, but this is affected by more than shift length and includes the time a shift starts, the breaks during a shift and between sets of shifts. However, there are more factors to consider beyond fatigue including cover for sickness and holiday absence, and having flexibility to accommodate life in general However, it is also important to recognise that a good shift pattern is no use if no ones actually works it in practice, and so the actual hours worked including overtime and swaps need to be recognised. CRR 254/1999 is widely known as the fatigue index, and is useful in evaluating shift patterns when implementing change. Unfortunately it does not cover all the other aspects of shift work that you need to consider in managing changes.
I started by saying that change is the new stability, and I hope to have demonstrated that most changes ultimately affect people and the way they are organised. This includes plant modifications, especially the adoption of new technology, whether it has a direct impact on the way people work or as a knock on. For example if t means less people are needed to operate. I am fully aware that most companies in our industry have plant modification systems, but my observation is that they are far more concerned with controlling change rather than managing change. Whilst this may be seen as the safe option, the reality is that it does not fit into the current business climate. Either companies that cannot manage change will go out of business, or change will be implemented by bypassing either the spirit or letter of the system.
I want to finish by looking at the underlying process of change. In my view this applies to all types of change, although clearly I am more familiar with human and organisational changes. The first step in the process requires change to be recognised. The challenge being that anyone in your organisation may do something that results in change. It may be a manager reorganising their department through to a contractor substituting a part during maintenance. Having identified a change is likely to occur, it is important to carry out a realistic evaluation. My experience is that quite major changes are often made without a clear idea of what benefits are expected. Also, in considering risks it is important to recognise that there are many informal arrangements in place that may be affected. You then need a plan for implementation that addresses the action required to implement the change and risks during transition. It should also ensure the change is sold to the people likely to be effected, and that these people need to buy-in if the benefits are to be achieved. The more end users are involved in implementing a change, the more likely you are to achieve the benefits you hope for. Following implementation it is important to formally accept the change. At this point we need to avoid the temptation of assuming success. Achieving acceptance from people affected is import before moving on to recommission the affected system. An important part of this is ensuring everyone has achieved at least a minimum level of competence in using the changed system. Again this can not be assumed. Finally, it is vital that changes are reviewed. This should not simply rely on checking whether accidents or incidents have been reported. Instead it should look for objective evidence that the expected benefits have been achieved and the predicted risks avoided. Talking the people who use the system should be part of this. By looking at the change in this way you can then check whether you current change systems are supporting the underlying process. In my experience, most address few of the human and organisational factors. In many cases the systems hinder the process through buraucracy.
So to close. I suggest you look at change as a hazard. It has the potential to cause harm, and so generates risks that need to be managed. This management process is quite generic, and applies to all types of change. Most systems in my experience are more related to control rather than management. As with all management systems, performance measurement and review is arguably the most important stage, and the one we usually overlook. Remember success is not guaranteed, and we can learn a lot from reviewing how change occurs. Thank you
In simple terms, managing risks involves identifying hazards, determining potential harm and likelihood (i.e. assessing the risks), identifying possible controls and implementing those required to achieve risks that are As Low As Reasonable Practicable (ALARP) and then reviewing and repeating the process continuously to ensure the controls are adequate. I classify change to be a hazard in its own right. How do I justify that? Well, the definition from OHSAS 18001 (Safety system specification) defines a hazard as a source or substance to cause harm. If we think about Flixborough the hazardous material was already present, but not causing harm. It was the only following the change to the plant that harm was experienced. Following this line of thought, we can then start to consider what the consequences of a change could be and how likely it is that they will occur. This actually works for both the positive and negative outcomes from a change, as we know that 100% success is never guaranteed. So having established that change is a potential hazard we need to understand what can change and hence what needs to be managed. The HSE refer to the 4Ps as elements of work that need to be considered when managing risk. These seem to apply equally well to change.
2006 Hazards - Managing change presentation
Tel: 01492 879813 Mob: 07984 284642
Managing the risks of change
New phone number
The drivers of change
The effects on people
The difference between change control and
Drivers of change
External force Opportunity
Consequences of change
Cost to change
Risk in transition
Cost to change
Risk in transition
What changes? – 4 Ps
Ad hoc systems
Examples of changes affecting people
Cheaper maintenance and modification
Automation gives improved productivity
Lower costs because less people required to operate
Smaller ‘window’ on the plant + fewer senses can be
used to monitor – slower to detect excursions
Less hands-on experience operating the plant
Can divide control room and field operators
Incidents less likely – but higher consequenceIncidents less likely – but higher consequence
Managing control room changes
Understand what plant data operators use and
how that may be affected by the changes
Understand how people communicate and how it
may be affected
Make sure you are able to get the benefits from
the new technology
Acknowledge operations are becoming a higher
HSE Contract research report 432/2002HSE Contract research report 432/2002
Freeze on recruitment.
Lower wage bill
Lower training expense
Not enough people for high demand situations
Loss of technical competence
Loss of practice experience
Difficult to cover absence
Normal operation not a reliable indicationNormal operation not a reliable indication
of maximum workloadof maximum workload
Managing staffing changes
Know what high demand situations can occur
Understand how they are detected, diagnosed
and responded to
Demonstrate that there will be enough people in
the right place at the right time
Demonstrate that teams will operate effectively
HSE Contract research report 348/2001HSE Contract research report 348/2001
Fewer levels of hierarchy
Improved communication within teams
Improved decision making
Improved job satisfaction
More people need supervisory competence
Lack of leadership in emergencies
Takes a long time for people to becomeTakes a long time for people to become
comfortable with the new stylecomfortable with the new style
Managing supervisory changes
Who will perform the supervisory roles?
Defining workload, allocating work priorities & manpower
Communicating operational information
Problem solving/decision making
Assessing competence & training requirements
Measuring team performance & appraising team members
Implementing first-level discipline
Providing leadership in emergency situations
How do they become and stay competent?
HSE Research report 292HSE Research report 292
Longer or shorter shifts (8 vs 12 hour)
Breaks between shifts
Breaks between sets of shifts
Breaks for holidays.
Better cover absence
More consistent themes
Shift work does not only affect work lifeShift work does not only affect work life
Managing shift pattern changes
Identify any fatigue peaks
How will sickness absence be covered?
How will holidays be covered?
How will family/weekend events be covered?
What hours will people actually work?
HSE Contract research report 254/1999HSE Contract research report 254/1999
There are many changes taking place across
industry that affect people and the way they are
This includes many engineering/technology driven
Multiple and continuous change are common
Current change management systems are often
inadequate for addressing all the issues
More emphasis on change control rather than
Underlying process for managing change
when change will occur
Assess benefits & risks
Confirm change complete
‘Everyone’ needs to be
able to recognise change
‘Sell’ change & get buy-in
End user involvement
Consider change to be a hazard
It doesn’t matter what is changing, the
underlying process should be the same
Start to think more about change management
rather than simply change control
Post change review is vital
Success is not guaranteed
Change is a learning exercise
Thank youThank you
Change = hazard
Implement & review
During change &
Review during & after
Must have systems in place
People reviewing change must be competent to
assess all risks and identify suitable controls
Resources to manage a change must be
commensurate with risk
Need to account for fact that multiple minor
changes can introduce high levels of risk
Need good communication to inform and involve
people likely to be affected
Record actions and decisions in a transparent
and audible fashion
Recognise there is uncertainty in change