The 'Small Change' Trap
The changes that cause incidents are rarely the large, obviously reviewed ones — they're the substitutions, temporary fixes, and 'like-for-like' replacements that seem too minor to trigger a formal review.
A surprising number of serious incidents trace back to a change that technically should have gone through MOC but was judged, informally and incorrectly, not to need it.
Making MOC Something People Actually Use
MOC systems that are fast for genuinely low-risk changes and rigorous for genuinely high-risk ones tend to get used honestly; systems that treat every change identically train people to find workarounds.
The clearest sign an MOC program is failing isn't a lack of submissions — it's a suspiciously low rate of changes being flagged as anything other than routine.
