In the oil & gas industry, hazards are inevitable and if they are not identified properly, they may lead to regrettable situations such as disasters. Continuous process in the oil & gas industry demands people who carry out operations and maintenance of oil & gas plants, usually within 24 hours, 7 days a week. Therefore, workers are frequently rotated on a routine basis within a cycle refereed as shift work. Within continuous process, shift handover is required between those who are on shift works. Shift handover is defined as transferring responsibilities and tasks from one individual to another or a work team and it is one of the best known types of safety critical communication.
Shift handover is a critical activity with a direct impact on production and safety. Poor shift handover is known to cause operation problems such as plant upsets, unplanned shut downs and product reworks, which can result in considerable revenue loss. Research by one oil & gas company revealed that while start-up, shutdown and changeover periods account for less than 5% of an operation’s staff time, 40% of plant incidents occur during this time . In fact, every second incident or accident in the process industry is related to communication errors that occurred during shift handovers.
This article will examine the key challenges in shift handover and illustrate how shift handover became one of the contributing factors in some major incidents in the oil & gas sector. We’ll also provide recommendations on how to have a robust and effective shift handover process.
THE ROLE OF SHIFT HANDOVERS IN MAJOR INCIDENTS
The importance of shift handover was highlighted in such major oil & gas incidents as Piper Alpha, Texas City, Buncefield and Deepwater Horizon. The Cullen report following the Piper Alpha disaster inquiry clearly mentioned, as one of many factors that contributed to the incident, the failure of transferring information in shift handover. In fact, information that a pressure safety valve had been removed and replaced by a blind flange was not communicated between shifts. In addition to that, there was no written procedure for shift handover and information that was written in a shift handover logbook was left to the lead operator’s discretion.
An explosion at a Buncefield oil storage depot was another incident where shift handover was one of many contributing factors that led to disaster. The Buncefield incident investigation team revealed that effective arrangements for shift handover were not in place and there was confusion between supervisors about which tank was being filled, and the shift logbook was only used to capture information about one of the pipelines. Furthermore, the logbook only had information about the plant situation during end of the shift, not events occurring during the shift. Finally, it was revealed that allocated time for handover between shift supervisors was not sufficient.
The Texas City Refinery explosion in 2005 is an example of total failure of shift handover management, in addition to a range of technical failures that contributed to this incident. The investigation team found out there were no procedures being used during shift handover. The absence of a lead operator during shift handover, miscommunication, unclear information and lack of required details in the shift handover logbook were also evident. Working operators in a shift pattern for 30 consecutive days in such a hazardous facility led to excessive fatigue among personnel and demonstrated a lack of required policy for shift work. Even though shift handover management and lessons learned from BP’s Grangemouth refinery incident in 2000 (which was similar to the Texas City Refinery explosion) were available, BP’s Texas City management did not appear to learn from the lessons of the Grangemouth study.
Communication is at the heart of every aspect of our lives. All communication is prone to error and misunderstandings are an inventible feature of human communication. Reliable communication is highly critical to safety, and shift handover falls into this category. Effective communication during a shift handover provides a strong layer of protection in preventing major incidents. Good communication between management, supervisors and workers at an informal level is a feature of low incident plants.
People tend to underestimate the complexity of the communication process, and consequently overestimate their ability to communicate effectively. Communication failures are probably under-reported and most of the time have been ignored during incident investigations. Checking that information has been received and understood is equally critical. As playwright George Bernard Shaw once said, “The single biggest problem in communication is the illusion that it has taken place.”
Unreliable communication can result from a range of issues, including:
• Missing information.
• Unnecessary information.
• Inaccurate information.
• Poor quality of information.
BARRIERS TO EFFECTIVE COMMUNICATION IN SHIFT HANDOVERS
A shift handover is effectively the transfer of knowledge from an outgoing staff member to an incoming staff member, typically thought to be a unidirectional process in which the outgoing operator decides which information is of importance for transferring, so that the incoming staff can effectively operate the facility. When operators write shift handover reports, the reports are based on one assumption—one BIG assumption! The assumed fact is that all staff members have a shared thought process and common understanding. This assumption leads to miscommunication, lack of a common understanding and potential incidents. An outgoing operator will typically write anything that they feel is relevant to the incoming shift, based on personal judgment.
The lack of structure, poor legibility and insufficient information often found in shift logbooks has been well documented. A literature review indicated that 80% of oil & gas production facilities’ logbooks are in unstructured style and do not capture key information; what’s more, they sometimes include unnecessary information, while key information is buried in the content.
A review of the Piper Alpha and Texas City incident investigation reports by indicate that lack of logbook information and the informal/unstructured shift handover processes were key failures in the lead up to both incidents. Both company teams were aware of the minimum and necessary information that is required to operate the facility safely and effectively; however, with the pressure and rush of day-to-day operations, it is simple to forget key elements during shift handover.
HIGH-RISK SHIFT HANDOVERS
It is very important to pay special attention to certain circumstances during shift handover, such as maintenance or abnormal situations. Miscommunication of maintenance issues over a shift change can have serious safety implications. When plant maintenance carries over during a shift change, there is a high likelihood of miscommunication occurring between incoming and outgoing personnel.
A clear picture of all activities needs to be presented to incoming shift, otherwise all activities would be based on an inaccurate understanding and incomplete information. In addition to this, shift handovers between experienced and inexperienced staff, or during periods when some staff have been absent for long period of time, or when the plant’s safety system has been overridden for some reason are all considered to be high-risk shift handovers. Therefore, where practical, maintenance should be completed within one shift, which would eliminate the risk of miscommunication during shift handover.
Following major incidents, most regulators look closely at shift handover management and defined requirements for shift handover systems. When the UK’s Health and Safety Executive agency examined 16 offshore oil & gas companies, they discovered the following issues in relation to shift handover:
• Did not clearly define responsibilities and information needs.
• Did not provide written guidance.
• Did not mention it in their safety case.
• Lacked risk awareness among their operators.
• Provided little or no training.
• Did little monitoring or auditing.
• Had accidents that involved miscommunication at shift handover, e.g., maintenance or plant status.