Evaluations should include recognition that even simple changes to systems and conditions made for improving overall safety can have unforeseen impacts and require Subject Matter Expert involvement in planning. Enhancements were made to the Integrated Work Control Program procedures to address the issues identified with respect to the Dispatched Work process for screening, planning and execution in the field. This occurrence serves as reminder of the need for Facility Management ownership of all aspects of work on their systems including status of work at end of shifts, strict work control procedural compliance, ensuring proper engineering evaluations for configuration changes, and a questioning attitude from the initial planning to performing the work, including appropriate recognition of need for stopping work when conditions change or questions arise.
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