In my first job out of school at a chemical process plant, I was assigned the task of determining why a tank of Dowtherm would periodically empty itself. After investigating, I discovered the outlet valves were not configured properly. I flagged down an instrument technician and we made the changes to the valve controls, and the problem was solved. I was very proud of myself, but my boss was horrified. We had completely bypassed the "Management Of Change" (MOC) procedure, which I viewed as pure bureaucracy, but he saw as a necessity for preventing accidents. Through the years, after witnessing and cleaning up after many well-intentioned changes, I've come to see the wisdom of managing change. This excellent article by Sam McNair explains why MOC is important, and how to deal with cultural resistance to it.
My favourite points include:
As many as 80% of serious major accidents in industry are related to uncontrolled change.
The most difficult part of MOC is recognizing change.
Just as there is nothing in the world as permanent as a temporary tax; there is no more permanent change than a temporary one. Temporary changes are the most frequent cause of accidents and incidents.
No one likes to discipline people for breaking the rules, especially when they do it in the spirit of improvement. But it is infinitely worse to have to tell a family that someone won't be coming home tonight.
Do not confuse the authority to make a decision with possession of the knowledge necessary to make that decision.
The 2015 version of ISO 9001 contains more references to managing change than the 2008 version. I would speculate that the next version of ISO 9001 will be even more heavily focused on change management. API Spec Q2 and Q1 both require a MOC procedure. MOC is already a critical, formal process in IT and HSE. Just as "risk management" is now the tool de jour (and rightly so), I think MOC will become the next big thing in Quality.