Abstract Management of change (MOC) is a critical process safety control used to govern engineering and organizational modifications in safety‐critical systems; however, despite widespread procedural adoption, it often underperforms in practice. This study identifies the organizational and managerial mechanisms that erode the practical authority of MOC and provides insight into strengthening change governance. A qualitative explanatory study was conducted in a safety‐critical gas distribution organization. Twenty‐two semi‐structured interviews with managers, supervisors, and HSE and technical experts were analyzed using inductive content analysis, followed by realist synthesis based on context–mechanism–outcome configurations. Findings show that MOC degradation is primarily driven by governance erosion rather than isolated procedural gaps. Organizational conditions triggered mechanisms such as managerial disengagement, discretionary enforcement, formalistic compliance, and risk‐signal dilution, leading to outcomes including informal change implementation, bypassed HSE review, superficial documentation, and incomplete closure. Training and documentation gaps were identified as downstream consequences of weakened decision authority. Overall, MOC underperformance is best understood as a gradual loss of practical authority rather than a simple compliance issue. Improving effectiveness requires embedding MOC as a mandatory approval gate within managerial decision‐making and reinforcing accountability and consistent enforcement.
Saei et al. (Mon,) studied this question.