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May 25, 2009

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Chain reaction

Dave Dowling considers the issue of shift handover and how to ensure

that it does not become the weakest link in an organisation’s safety

management procedures.

The shift handover is an important area of focus for accident investigators, and for good reason. A research study carried out in 1996 on behalf of the HSE1 identified a number of major accidents, which highlighted failings in the shift-handover procedures.

The 1988 Piper Alpha explosion and fire is probably the most prominent event where the shift handover is referred to as one of the main contributing factors to the disaster. Here, details about the replacement of a pressure safety valve with a blank flange, and instructions not to use it, failed to be communicated during the shift handover.

In 1991, at a vitrification plant at Windscale, shield doors designed to protect people from the effects of radiation, were left open during a hazardous part of a process. Details concerning a temporary override were not properly logged and carried forward from shift to shift. Post-incident investigation also highlighted an over-reliance on one-way written communication.

More recently, in 2007, failings in the shift-handover procedures were cited in a report from the US Chemical Safety and Hazard Investigation Board on the BP Texas refinery explosion.2 The report into the incident, which led to 15 deaths and 180 people injured, revealed that limited written information was recorded in the shift log and verbal communication was insufficient.

Procedures and standards
The expectations for an effective shift handover are set out in a report published in 2007 following the work of the Buncefield Standards Task Group.3 It recommends the minimum provision of a procedure or standard that specifies simple and unambiguous steps for effective communications at shift changes.

National occupational standards (NOS) are used as the building blocks for many vocational qualifications, and specific ones have been established for personnel who work shifts in industry, and include safety elements such as a shift handover.

Intended as a competency-based tool, NOS are statements of the skills, knowledge and understanding needed for an individual to carry out a particular job role or function. Individuals are subjected to a workplace assessment, which normally involves observation of a process or procedure, as a means of confirming competent performance. Quality assurance is achieved by seeking accreditation for a vocational qualification by an awarding body, which is itself regulated by a Sector Skills Council (SSC).

Cogent, a SSC for the chemicals and pharmaceuticals, oil and gas, nuclear, petroleum, and polymer industries, has developed a web-based competence self-assessment tool to meet the needs of companies in these fields. It represents a total systems-check, assisting organisations by revealing what they don’t know about their own procedures and systems. The result is a confidential self-examination of organisation-wide competence.

A procedure or policy should be regularly monitored for effectiveness and this may be achieved by reviewing the contents of logs, checking understanding of information, and collating trends and patterns where safety events result in minor or ‘near-miss’ events. Procedures should also be periodically reviewed to ensure that the content is current and accurate, taking account of internal or external experiences. An independent audit or peer review is an effective method of identifying and sharing good practice.

Responsibilities and arrangements
Communication of systems and processes during the shift handover can be further complicated by the fact that one person is unlikely to be available to clarify misunderstandings or correct actions once they have left the workplace at the end of their shift.

It is therefore vital that all personnel involved in the shift-handover process are fully aware of their roles and responsibilities, as outlined below:

  • outgoing personnel are responsible for ensuring the incoming personnel understand the status of the business, process and systems before leaving the workplace;
  • incoming personnel are responsible for ensuring they are in a position to carry out actions and make decisions before they allow the outgoing personnel to leave the workplace;
  • people returning from a long break need a more comprehensive handover; and
  • care is required when an experienced person is handing over to someone with less experience.

A positive safety culture should encourage an effective shift handover where misunderstandings are queried. HSG 48 Reducing error and influencing behaviour provides guidance on human factors in industrial safety and HSG 256 Managing shift work provides advice on arrangements that can ensure effective shift handovers take place.

Arrangements for reviewing the effectiveness of the shift-handover process will ensure good practice is maintained and the systems support changes in knowledge, technology, and the environment.

The following list is presented as good practice when preparing for, and carrying out, a shift handover.4

  1. Allow sufficient time for the handover;
  2. Conduct the handover face to face;
  3. Eliminate distractions;
  4. Ensure the person leading the handover
    i.    gives an overview of the handover content,
    ii.    makes positive statements about safety issues,
    iii.   talks through the log items, and
    iv.   summarises the handover at the end;
  5. Ensure feedback takes place to seek clarification and confirmation; and
  6. Ensure the person receiving the handover takes notes.

Effective communication
In dynamic industries, there is a disproportionate number of errors and accidents that occur after shift handover.5 Good communication is imperative and a checklist to aid its effectiveness is presented below:

  • identify information that needs to be communicated, and cut out unnecessary information;
  • use aids, such as structured log sheets, display board, computer displays, diagrams and reports;
  • use a combination of written and verbal communication methods to convey the message;
  • encourage two-way discussion;
  • use effective questioning techniques;
  • appreciate that deviations from the norm (routine) can cause a differing interpretation of a situation;
  • invite a witness from the oncoming shift (expert, or experienced in the area of work) to attend the handover where complex situations are being explained;
  • add context and explanation to subjects — do not read out a list; and
  • ensure hand-written information is accurate and legible.

History suggests that important information can be missed in the rush for workers to get home once their shift is finished. In some cases, it would not be unusual for shift workers to leave the workplace before their shift officially finishes if their relief has already arrived. To mitigate the risks of poor communication and instruction at this juncture, many companies pay an allowance for an additional period at the end of the shift to ensure flexibility if the need arises.

Contents of an effective shift handover
A review was carried out in 1994/95 to examine the practice of shift handovers in the oil industry and make recommendations for improvement.6 The findings used interview data, in conjunction with log-book content, to derive a set of mandatory and discretionary categories. The table below presents a modified list of subjects, which may be considered in the development of a local procedure.

 Mandatory categories Discretionary categories
 Staffing levels Environmental matters
 Emergency roles Severe weather warnings
 Safety issues Technical problems
 Maintenance in progress Welfare issues
 Vehicles and equipment out
of service
 Complaints
 Business abnormalities External events
 Security status Support arrangements
 Status of safeguarding
installations and systems
 Actions taken during the shift
 Visitors and contractors
in attendance or expected
 Routine duties
 Work outstanding Records
 Permits in force Repairs
 Access restrictions    Inspections
  Tests

   

Specific checklists exist for different organisations and can be used to substitute many of the topics in the table above.

References

  1. Health & Safety Executive (1996): Effective shift handover — A literature review, (Offshore Technology Report — OTO 96 003), prepared by The Keil Centre, Edinburgh
  2. US Chemical Safety and Hazards Investigation Board (2007): Investigation report: refinery explosion and fire BP Texas City, Texas, 23 March 2005
  3. Health & Safety Executive (2007): Safety and environmental standards for fuel storage sites, Buncefield Standards Task Group (BSTG), final report
  4. Parke, P and Mishkin, A (2005): Best practices in shift handover communication: Mars exploration-rover surface operations, proceedings of the International Association for the Advancement of Space Safety Conference, France
  5. Brazier, A (2008): Buncefield, www.andybrazier.co.uk/guides/handover.htm
  6. Lardner, R (1996): Safe communication at shift handover: setting and implementing standards, see www.hse.gov.uk/humanfactors/comah/standards.pdf

Dave Dowling is a fire and rescue manager at URENCO UK Ltd

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