Improving shift handover and maximising its value to the ...

1 Institution of Chemical Engineers 2008 Improving shift handover and maximisingits value to the businessAndrew Brazier1and Brian Pacitti21 Consultant, Llandudno, UK2 Infotechnics Ltd, Aberdeen, UK0260-9576/08/$ + PREVENTION BULLETIN 20421handover. This meant operators started a pump that wasnot in an operational state. And before that, followingthe discharge of highly radioactive material from thenuclear processing plant at Sellafield in 1983, it wasfound that failures of communication between shiftscreated confusion regarding the contents of a particulartank that was pumped to a number of accidents have identified shifthandover as a contributory cause, it seems likely thatthis is an under-reported issue.

2 Put simply, because therehas not been much attention paid to shift handover andrelatively little information published on the subject,people have not been looking for evidence of failureswith shift handover when investigating incidents problems with shift handoverThe Health and Safety Executive s guidance documentHSG485states that reliable communication is highlycritical to safety, and that shift handover falls into thiscategory. Failures of communication occur for a numberof reasons. In general either the information beingcommunicated is incomplete or inaccurate; or the personon the receiving end misunderstands the meaning of theinformation they are given.

3 There are many reasons whythis can occur, with information being presented poorlybeing the underlying all communication is error prone, the morecomplex the situation the more likely errors are to shift handover , situations such as duringmaintenance and deviations from normal working areconsidered to be high-risk because errors are likely andtheir consequences can be shift handoverHSG48 provides advice for Improving shift includes carefully specifying information that needsto be communicated, using aids such as log booksIntroductionContinuous operation requires people to work safety and efficiency requires criticalinformation to be communicated between these communication is prone to error.

4 This makes shifthandover a highly critical activity that is performedfrequently with little opportunity to engineer outpotential caused by poor shift handoverThe role of shift handover has been highlighted in anumber of recent high profile, major the 2005 Texas City refinery explosion, BP released their internal investigation report to thepublic1. This identified that poor shift handover was a contributor to the accident, citing the failure tocommunicate the failure of a hard-wired high levelalarm between shifts as a contributing event. By way of an explanation the report stated that there was nowritten expectations with explicit requirements for shifthandover.

5 The subsequent inquiry carried out by theChemical Safety Board2agreed with these finding,stating that the condition of the unit specifically, the degree to which the unit was filled with liquidraffinate was not clearly communicated from nightshift to day shift . In the UK, whilst at the time of writing this paper the full facts of the case were still not known, it seemsclear that shift handover had a role in the 2005 explosion at the Buncefield oil storage terminal. One of therecommendations from the Buncefield Standards TaskGroup (BSTG)3was that effective shift /crew handovercommunication arrangements must be in place to ensurethe safe continuation of operations.

6 Further details onthis subject were provided in the BSTG s final this is not a new discovery. The inquiry into the1988 Piper Alpha disaster found that prior to theaccident critical information about the status of thecondensate pumps was not communicated at shiftLOSS PREVENTION BULLETIN 20422 They need to be willing to challenge what they havebeen told; They need to be able predict what someone elseneeds to know; They need to show that they are interested in whatthey are being told; They need to make time for the procedure or management system can addressthese issues directly. Whilst guidance can be provided tohelp people understand what is expected of them, therewill be a requirement for continuous supervision andcoaching to ensure bad habits are avoided and to drivecontinual improvement.

7 Given the pressures of work, itis unlikely that this will happen automatically. Shifthandover practices are likely to evolve over this will result in improvement, but at othertimes short cuts and bad practice may be the challenges to Improving handoverAs well as shift handover being a particularly complexactivity, there are other reasons why makingimprovements are difficult. In particular, we mustrecognise that the individuals involved may not alwayshave incentives to put in the effort most important person in any handover is the person finishing their shift . The quality of theinformation they provide and their communication skills will have the greatest influence on how wellinformed the person starting their shift is.

8 However, atthe end of an eight- or twelve-hour shift even the mostconscientious person will be interested in getting , some may have the attitude that any problemsthey leave are going to be dealt with by someone else( the incoming shift ).It is true that the person starting their shift caninfluence the quality of the handover they questions and being interested will tend toimprove the quality of the handover . However, they arenot in a particularly powerful position because they donot know what questions to ask, especially if key datahas not been , we must recognise that the people typicallyresponsible for Improving performance are often notpresent ( managers) or busy themselves ( ) when handovers are taking place.

9 Mosthandovers will be carried out alternative perspectiveChanging behaviours is always difficult, especially whenthe individuals may not perceive a direct handover , using more than one communicationmedium (for example, both written and verbal),allowing sufficient time and developing communicationskills and advice in HSG48 is good and has beenreemphasised by the final report from the BuncefieldStandards Task Group. However, despite its importanceand the occurrence of numerous incidents influenced bypoor shift handovers, it is quite a surprise that there isnot more advice available. The reasons for this are notclear, but it is easy to surmise that it is a soft andintangible subject that has probably fallen into the too hard category for many theoryIn the absence of specific advice regarding shifthandover, there is plenty for communication in generalthat should be applicable to shift thing is clear.

10 People tend to underestimate howcomplex the communication process is and consequentlyoverestimate their ability to communicate reality is that error is a natural and inevitable aspectof communication because language is inherentlyimprecise and successful communication is one where a personreceiving a message achieves exactly the sameunderstanding of that message as the persontransmitting it intended. However, the following factorscan interfere with this process6:1. It is not possible to transfer meanings from oneperson to another directly. Rather, the receivercreates meaning in his or her mind;2. Anything is a potential message, whether it isintended or not;3.