MOC Form for Permanent Change

A. Change initiation
Plant/Department: Date
Change Owner MOC No.
Title
Reason for change
Technical Change: Chemical Technology/Process Equipment Facility
Change category Procedural Change
Organizational Change
Description/Sketch of change (please add attachments in case more space is required)

Expected completion date Estimated cost

B. Evaluate the EHSQ Impact

 EHS Impact - Question list 1: If any of the below items is YES, the level of hazard assessment and approval is Level 3.
Does the change have the potential to impact the following critical aspects? Yes No
1. Will a protective device (e.g. safety relief valve, rupture disk, Safety Instrumented Function (Z-interlock), safety relevant
orifice, etc.) be changed, added or removed?
2. Does the change have the potential to impact an existing protective device (e.g. relief scenario, interference, etc.)?

3. Will a highly exothermic reaction be introduced or having the potential to impact existing reaction?

4. Will unstable substances with highly exothermic decomposition potential be introduced?

5. Does “the change” take the process outside “allowable operating condition”, i.e. P, T, flow, rpm, catalyst, conc., corrosion/
erosion rates etc.?

 EHS Impact - Question list 2: If any of the below items is YES, the level of hazard assessment and approval is Level 2. Otherwise it is Level 1.
Does the change have the potential to impact the following sections? (*No also includes low impact) Yes No*

Environment Protection
 Environment-related permits, certificates and approvals
 Emission to air (quantity, composition, treatment method, downstream purification equipment, GHG emissions, etc.)
 Emissions to water (soil/groundwater, wastewater stream, wastewater treatment facilities, water protection concept, etc.)
 Generation and handling of wastes (categorization, collection, storage, disposal, etc.)
 Influence on neighboring community (fence line noise, unpleasant odor, etc.)
 Consumption of energy (use of energy-efficient equipment, monitoring of key energy consumer, etc.)
 Skills, specific roles, certified qualification, etc.
 Processes, procedures and manuals, standards and documentation

Health / Occupational Safety

 Health / Occupational Safety-related permits, certificates and approvals
 Organization of work (job-related training, SOP, shift patterns, work coordination, etc.)
 Workplace design (working spaces, slip/trip/fall, traffic routes, etc.)
 Ergonomics factors (heavy physical work, unfavorable working poster, etc.)
 Exposure to mechanical (moving part, hydraulic pressure, etc.) and electrical hazard
 Exposure to hazardous substances (respiratory, eye/skin contact, etc.)
 Physical impacts (noise, vibration, radiation, heat/cold stress, etc.), mental stress
 Skills, specific roles, certified qualification, number of employees, etc.
 Processes, procedures and manuals, standards and documentation

Process Safety
 Process Safety-related permits, certificates and approvals
 Hazards posed by substance (flammable, corrosive, toxic, etc.)
 Hazards posed by chemical reaction (exothermic reaction, decomposition, reactant accumulation, etc.)
 Hazards posed by physical effects (pressure, temperature, flow, density, phase separation, etc.)
 Change of process (operating window), alarm/interlock, protective functions
 Fire prevention, explosion protection, emergency response, siting
 Skills, specific roles, certified qualification, etc.
 Processes, procedures and manuals, standards and documentation

Product safety/ transportation safety/ security

  New chemical substance registration, trade control, SDS, etc.
 Logistics Service Provider management, securing & lashing, etc.
 Security concepts, including IT security

EHS Impact Level 1 Level 2 Level 3

 Quality Impact - Question list 3: If any of the below items is YES, the level of hazard assessment and approval is Level 2. Otherwise it is Level 1.
Does the change have the potential to impact the following sections? (*No also includes low impact) Yes No*
Quality
 Quality parameters, specifications (e.g. impurities / components, even at trace levels)
 Materials, equipment and other aspects impacting product quality, e.g. filter systems
 Sampling and analysis methods
 Skills, specific roles, certified qualification
 Processes, procedures and manuals, standards and documentation

Quality Impact Level 1 Level 2

MOC Level Level 1 Level 2 Level 3

Name Signature Date
Assessed by

C. Hazard assessment and control measures

 C1 Determination of hazard assessment methods and approver(s)
Hazard assessment method
EHSQ impact Participants Approver
EHS Quality
Plant staff alone (minimum two persons) To be defined by
Level 1 MOC Assessment Dialogue
Contributors: optional site/plant
Multi-discipline team discussion with Contributor To be defined by
Level 2 Simple EHS Review Quality Assessment in the respective impact section site/plant
Multi-discipline team discussion with Contributor To be defined by
Level 3 Formal EHS Review NA
from PS expert additionally site/plant
Note: Level 1 corresponds to No/Low impact in G-GD-PRS 005. Level 2 corresponds to combination of Medium and High impact in G-GD-PRS 005 and
follows the stricter requirement for High impact. Level 3 offers special involvement from process safety expert.

 C2 Hazard assessment (EHSQ)

For Level 2/3: Attach finalized EHS Review and Quality Assessment documents
 For technical change, please use MOC Risk Assessment Checklist for Technical Change
 For organizational or procedural change, please use Evaluation Checklist for Organizational and Procedural Change

For Level 1(No/Low) : Directly input assessment dialogue result in the below form
EHSQ Assessment Dialogue Result
Potential EHSQ risk Control measures if needed

Name Signature Date

Assessed by
(minimum two persons)

 C3 Pemits and approvals

Responsible Signature/
Items Yes No Target date
person Completion date
Permits and approvals to be updated/applied before start-up.

☐ ☐

☐ ☐

Permits and approvals to be updated/applied after start-up.

☐ ☐
 ☐ ☐

 C4 Communication and training

Responsible Signature/
Items Yes No Target date
person Completion date
Information to affected persons before change execution ☐ ☐

Training or information to affected persons before start-up ☐ ☐

 C5 Documentation to be updated
Responsible Signature/
Items Yes No Target date
person Completion date
Mandatory documentation to be updated before start-up.

Operation Instruction (SOP) ☐ ☐

P&I Diagram ☐ ☐

List of alarm and trip points ☐ ☐

Material Safety Data Sheet (MSDS) ☐ ☐

Emergency Response Plan/Alarm Rule ☐ ☒

Safety Instrumented System Documentation (SRS, Proof testing

☐ ☐
documentation, etc)
Explosion Protection Document, hazardous area classification
☐ ☐
drawings
Relief device (PSV, rupture disc, over & under pressure protection)
☐ ☐
design calculations

Raw Materials and Product Specification ☐ ☐

Product Quality Plan ☐ ☐

Others: ☐ ☐

Documents that can be completed after start-up

Process description /Process Flow Diagrams (PFD) ☐ ☐

Equipment list ☐ ☐

Instrument list ☐ ☐

LC/LO、CSC/CSO checklist ☐ ☐

Preventive maintenance plan ☐ ☐

Equipment Data Sheet, technical information and drawings ☐ ☐

Electric/ Logical/Instrument diagram ☐ ☐

Piping Isometric Drawings ☐ ☐

Pipe Service Index, Pipe Line List ☐ ☐

Layout plans (equipment arrangement, site map, plant layout, ☐ ☐

underground drawings, etc.)

HIRA/Job Safety Analysis ☐ ☐

EHS Manual ☐ ☐

Training matrix/plan ☐ ☐
 Organizational Chart ☐ ☐

Job Description ☐ ☐

SAP data (Bill of Material, Functional location, etc.) ☐ ☐

Others: ☐ ☐

D. Sign. Date
Plant/Dept. Mgr.装置/部门经理: (Mandatory 必须)
签字 日期
pprovals (Issued for Sign. Date
Head of Prod.(Mandatory 必须)
Design) 签字 日期
批准(签发批复,开始 Sign. Date
Head of ME Dept. ME 部门总监(Mandatory 必须)
设计) 签字 日期
Sign. Date
GM.（总经理）（>1,000,000RMB）
签字 日期
Nominated MOC
Sign. Date
responsible person
签字 日期
变更指定负责人
Sign. Date
Plant/Dept. Mgr.装置/部门经理: (Mandatory 必须)
签字 日期
Approvals (Issued for Sign. Date
Head of Prod.(Mandatory 必须)
Design) 签字 日期
批准(签发批复,开始 Sign. Date
Head of ME Dept. ME 部门总监(Mandatory 必须)
设计) 签字 日期
Sign. Date
GM.（总经理）（>1,000,000RMB）
签字 日期
Nominated MOC
Sign. Date
responsible person
签字 日期
变更指定负责人
Change approval for execution
Approval decision Approved for execution Returned for revision Rejected
Approved by Name Signature Date
To be defined by site/plant

To be defined by site/plant

Rationale in case of return/rejection

E. Review before Go-live

Name Signature Date
Mechanical completion confirmed
(for technical change)
All control measures mandatory before
start-up completed (Ref: section C)
All PSSR actions mandatory before
start-up closed
(for level 2/3 technical change)

F. Approval and Go-live (not required for level 1 change)

1. All mandatory actions before start-up from hazard assessments completed. (Ref: C2) Yes NA
2. All mandatory permits and approvals required before start-up updated/applied (Ref: C3) Yes NA
3. All affected personnel briefed about the hazards and/or received operational training (Ref: C4) Yes NA
4. All mandatory documentation before start-up updated (Ref: C5) Yes NA
5. All mandatory actions before start-up from PSSR resolved & implemented (Ref: PSSR Checklist) Yes NA
Approved by Name Signature Date
To be defined by site/plant

G. MOC Close Out

1. All actions from hazard assessment completed (Ref: C2) Yes NA
2. All required permits and approvals updated/applied (Ref: C3) Yes NA
3. All identified documentation updated (Ref: C5) Yes NA
4. All actions from PSSR resolved & implemented (Ref: PSSR Checklist) Yes NA
Confirmed by Name Signature Date
Change Owner
MOC Coordinator