What do a leg amputation and a large fire loss have in common? Although the direct cause of an accident is related nearly 100% of the time to an unsafe behavior or unsafe condition, an often-overlooked “root cause” of these incidents is an organization’s failure to manage change.

Here’s an example: During his daily mixing operation routine, a manufacturing company employee followed the procedure developed for Mixing Machine A. The instructions called for an even spread of the chemical additive along a horizontal metal grate, performed while standing on a protected platform, to ensure complete mixing.

Later, the operation and operator were moved to Mixing Machine B – and while the mixing machine was different, the procedure was not changed accordingly.

Mixing Machine B’s design had a funnel top rather than a horizontal grate. The operator made assumptions to evenly spread the material into the mixer and removed the funnel guard. This exposed the mixing blade and the employee slipped, leading to the amputation of his lower leg.

Viewpoints from Chuck Yorio

At first glance, one may assume the root cause of the accident was the employee’s failure to follow the rules reviewed during his orientation training.

The root cause analysis for this unfortunate loss would lead us to question why the employee chose to remove the guard. Was he properly trained at hire? Was the guard in the way? Was the operation of removing the guard a common practice? Were the rules adequately enforced? Many more questions arose – and all of them uncovered problems that led to physical and administrative improvements to prevent further disaster.

Upon closer investigation, the root cause of this accident was the change in the process (the machine) without the necessary change in procedure.

When clear expectations are not communicated, it is human nature to make assumptions. One of the corrective actions was to implement a change management plan.

In an unrelated event, an automatic welding process was altered over time to improve the quality of the product.

This involved removing a guard above a hydraulic cylinder. The automatic welder stopped over the now-unprotected hydraulic cylinder (while still burning), causing a fire and significant loss. The company put a formal change management plan in place after this occurrence.

A common definition of change: “A change in the technology of manufacturing, chemicals, and process equipment, or a change in the procedures of operating the process and related equipment, or in the organization of the department that can affect safety, the environment, quality, or efficiency.” This definition applies to manufacturing and pilot plant operations, as well as application and research laboratories.

A typical policy might say: “(COMPANY)’s Management of Change (MOC) system is intended to ensure that the safety, health, and environmental impact of all modifications to processes, equipment, chemicals, organizations and procedures are identified, reviewed, approved and communicated prior to the implementation of the change.”

Procedures will vary and likely include a safety assessment when a change is implemented. As with any preventive and planning program, Management of Change (MOC) policies should be included. A great broker/consultant will be on top of this for you.


EPIC offers this material for general information only. EPIC does not intend this material to be, nor may any person receiving this information construe or rely on this material as, tax or legal advice. The matters addressed in this document and any related discussions or correspondence should be reviewed and discussed with legal counsel prior to acting or relying on these materials.


Our Leaders

Chuck Yorio Headshot
Chuck Yorio

Principal, Vice President Risk Control – Pittsburgh, PA