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Changes are an inevitable part of the production process, but accidents caused by such changes are not rare, which means the risks associated with changes are high. In response to the requirements of regulatory authorities, companies have come to understand change management and have begun to implement standardized approaches for managing changes. However, change management still cannot be effectively implemented in many companies. What are the reasons? Based on my personal experience, I share this for your reference. I. The responsibilities and procedures for change management are unclear. The change management system cannot be implemented, and the responsibilities of company departments are unclear, resulting in a redundant structure. The staff are unclear about how to initiate changes, what steps and procedures are required, as there are no rules to follow. II. Insufficient ability to identify change risks. Without tools for risk identification and assessment, relying solely on brainstorming methods is insufficient to fully identify change risks. The personnel involved in risk identification are limited in number and lack the necessary professional expertise; as a result, it is not possible to fully identify the risks that may arise from changes. Changes sometimes involve multiple specialties, and one or two specialties alone are not sufficient to thoroughly identify and assess all risks. III. Lack of leadership attention. Regarding some of the procedures for making changes, some leaders consider them troublesome and unnecessary. The leaders’ lack of attention resulted in the changes losing their environment to survive. Even the leadership’s sense of authority is changed at will, which will surely cause problems for the company. IV. Staff do not understand change management. Especially in some small and medium-sized enterprises, empiricism and risk-taking are severe; they fail to understand the need for and role of changes, considering them to be unnecessary complications. Technical upgrades are carried out solely based on enthusiasm and experience, which often results in situations where what was fixed before ends up causing new problems. V. It is unclear regarding the communication of information after the changes, as well as training and closed-loop management for acceptance. After the change, the risk control measures were not implemented or were not implemented properly. For example, modifications to operating procedures, training on the changes, and notification of updated safety information. After the changes were completed, there was no inspection, and archived materials such as updated drawings and the list of safety and production information were not filed. If operations are still carried out as they were before the change, it would be nonsensical, like trying to find a sword by marking its position in the water; it’s abnormal for no accidents to occur. VI. Weak risk awareness. There is no understanding of the core concept that managing safety means managing risks; empiricism leads to underestimating the risks associated with changes, or even complete ignorance of such risks. VII. Changing the information is cumbersome and inconvenient to implement. Some companies simply copy the forms in Annex 3034 or those used by other companies; they end up with lots of signatures, numerous forms, and a huge pile of documents, which is intimidating. Three elements need to be changed: first, the plan content and risk assessment; second, approval; third, closed-loop tasks such as training and acceptance. On this basis, other requirements can be set according to the actual situation of the enterprise, without the need to imitate others blindly. It is best to combine this with the company’s usual management practices and adapt it to the specific circumstances of one’s own enterprise; it should not be copied verbatim.