Change Request Form

Change Request No: Date Registered:

Change Title:

STEP 1: Initiation
Change Initiator: Change Owner:

Site(s) Concerned: Plant Area:

Relevant Drawings and
Documents:

Present Situation:

Proposed Change:

The Change is: Permanent Temporary – Removal or Review Date:

Supporting Reasons:

Cost of Change (normally estimated by the Change Initiator)

Estimated Cost: $

Type of Expenditure: Operations Capital Project Code/Cost Centre:

Notes:
1. The Change Owner shall be the Manager whose area of responsibility is affected by the change. If there is
more than one person whose area of responsibility is affected, then they are to be designated as reviewers.
2. If the change is not endorsed, the remainder of the form need not be completed. However the Change
Request Form must still be registered in the Document Control System.

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Change Request Form
Review Checklist (Change Initiator and Change Owner to review together)
Physical
Is any plant item being modified?
Is any safeguarding equipment
modified?
Are critical alarms or trips affected?
Is process control system changed?
Is any Registered Plant modified?
Is new equipment being installed?
Is equipment being removed?
Are structures or supports
changed?
Are excavations being performed?
Fire fighting equip modified?
Neighbouring properties being
altered?
Does it involve working at heights?
Will the security system be
changed?
Changes in office, facility layout?
Change in component material or
construction?
New technology being introduced?
Other - provide details
Endorsement (by Change Owner)
Position
LNG Ops Manager
Further Review Required?
Target Completion Date:    
Registration (by Document Controller)
Position Title
Technical
Documentation
Procedural & Process
Change in method of operation?
Change to Safe Work Instructions
or Standing Orders
Change to SCADA operator
interface?
Changes impacting key
documentation?
Introducing new substance?
Changes to drawings
(e.g. P&IDs, Schematics)?
Changes to critical controls (e.g. ESDs,
manual overrides)?
Introduction of hazardous goods?
Change to Emergency response
procedures?
Change in raw materials?
New standards, codes or legislation?
Major change in plant performance?
Traffic management changes?
Other - provide details
Name Endorsed
Yes No
Yes (Nominate reviewers in Step 2)
No (Provide justification, then proceed to Step 4 - Approval)
Name
Management & Organisation
Is a Plant Outage required?
Change staff levels or shift roster?
Change in or new policies?
Change to Safety Case documents?
Will the Hazard Register be
impacted?
Change to Hazardous Area Dossier?
Contract personnel filling positions?
Organisational structure changes?
Contract company changes?
Delegation of critical responsibilities?
Staff training required?
Human factors (e.g. fatigue, harmony,
morale, cultural preferences)?
Have stakeholders been contacted?
Other - provide details
     
Signature Date
     
Signature Date
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 Change Request Form

STEP 2: Review
Reviewers (nominated by Change Owner)

Disciplines Involved: Reviewers

HSE Yes      
Electrical Engineering Yes      
Mechanical Engineering Yes      
Process Engineering Yes      
Instrument and Controls Engineering Yes      
Technical Services Yes      
Operations Yes      
Commercial /Finance Yes      
Legal or Regulatory Yes      
Human Resources Yes      
Procurement/Purchasing Yes      
Consultants Yes      
Other: Yes      
Other: Yes      

Reviewer 1 Name:       Position:      

Comments:
     

Change is supported: Yes No Signature: Date:      

Reviewer 2 Name:       Position:      

Comments:
     

Change is supported: Yes No Signature: Date:      

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 Change Request Form

Reviewer 3 Name:       Position:      

Comments:
     

Change is supported: Yes No Signature: Date:      

Reviewer 4 Name:       Position:      

Comments:
     

Change is supported: Yes No Signature: Date:      

Reviewer 5 Name:       Position:      

Comments:
     

Change is supported: Yes No Signature: Date:      

Reviewer 6 Name:       Position:      

Comments:
     

Change is supported: Yes No Signature: Date:      

STEP 3 Formal Assessments

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 Change Request Form

Formal Assessment Requirements (as determined by Change Owner and/or Reviewers)

Form of Standard Risk Assessment HAZOP Review of Relevant
Assessment: Legislation & Standards
Financial Analysis Engineering Design Other
Review

Assessment comments and special requirements:

Standard Risk Assessment (Guidelines in Section 5 of OH & S manual) – Attach Risk Assessment

Risk Assessment Facilitator:       Risk Assessment Date:      

Summary of Findings:

Highest Residual Risk: (after the change is made or involved in implementing the change)
     
Residual Risk Category: Extreme (1-5) High (6-10) Medium (11-17) Low (18-25)

Other findings:

HAZOP (attach HAZOP Minutes if conducted.)

HAZOP Facilitator:       HAZOP Date:      

Summary of Findings:
     

Other Assessment (attach documentation for any other assessment conducted)

Summary of Findings:
     

Financial Analysis - please attach relevant Financial Analysis.

TOTAL Cost: $       Capital AFE #      
(attached)
Type of Expenditure: Project Eng Services Operations Health & Safety
Commercial Environmental Other

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 Change Request Form

STEP 4a: Endorsement

Assessment Endorsements (only applicable positions need sign)
Position Title Name Endorsed Signature Date
Technical Authorised       Yes No N/a      

Engineering Authorised       Yes No N/a      

HSE Authorised       Yes No N/a      

Other authorised (specify)       Yes No N/a      

     

STEP 4b: Approval

Change Approval Signoff
Position Name Approved Signature Date
Manager       Yes No      

Regional Manager       Yes No N/a      

General Manager       Yes No N/a      

Operations
Managing Director       Yes No N/a      

Note:
The level of approval required is determined by the cost of the change (AFE cost) and by the level of
residual risk being signed off in accordance with Table 1 of the OH&S Manual– Hazard and Risk
Management.

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 Change Request Form

STEP 5: Change Completion

Completion Checklist
Actions Required for Completion Applicable Comments
Is the work complete and available for service? Yes No      
Have all relevant drawings have been updated and Yes No      
entered into the Document Control System?
Have Critical Controls changes been implemented and Yes No      
documented?
Has the Safety Case or other regulatory documents Yes No      
been updated?
Has site Hazard Register been updated? Yes No      

Has Hazardous Area Dossier been updated? Yes No      

Have all procedures, policies and guidelines been Yes No      

updated, including relevant HSE documents?
Has training of relevant personnel been completed? Yes No      

Have HAZOP and Risk Assessment recommendations Yes No      

and controls been implemented?
Have all reporting obligations to relevant regulatory Yes No      
authorities been fulfilled?
Has the Emergency Response Plan been updated? Yes No      

Has the Pronto Maintenance System been updated? Yes No      

Has all controlled documentation been updated? Yes No      

Have all internal and external stakeholders have been Yes No      
informed/ familiarised?
Have MSDSs been updated for any new materials Yes No      
introduced?
Have all codes and regulations been complied with? Yes No      

Have plant labels, markings or placards been updated? Yes No      

Other:       Yes No      

Completion Sign off (by Change Owner)

Name       Date      
Work Completed Communications completed All actions carried out:

Date:       Position:       Signature:

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