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2008 Hazards - Shift handover

IChemE Hazards conference. Improving shift handover and maximising its value to the business.
Presentation in conjunction with Infotechnics

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2008 Hazards - Shift handover

  1. 1. 1 Improving shift handover and maximising its value to the business Andy Brazier Tel: +44 1492 879813 andy.brazier@gmail.com www.andybrazier.co.uk Brian Pacitti Tel: +44 1224 355260 sales@infotechnics.co.uk www.infotechnics.co.uk
  2. 2. 2 Introduction Presentation in two parts Andy Brazier – theory Brian Pacitti – practical
  3. 3. 3 BP Texas City BP’ own report - “there was no written expectations with explicit requirements for shift handover. CSB report – “the condition of the unit – specifically, the degree to which the unit was filled with liquid raffinate – was not clearly communicated from night shift to day shift.”
  4. 4. 4 Buncefield Standards group - “effective shift/crew handover communication arrangements must be in place to ensure the safe continuation of operations.”
  5. 5. 5 Not a new Discovery Other accidents Piper Alpha 1988 – status of condensate pumps not known Sellafield 1983 – presence of radio active material in tank pumped to see Ronny Lardner publications 1992-96 HSG48 Second Edition 1999.
  6. 6. 6 The problem Shift handover is a complex, error prone activity, performed frequently High risk It can’t be ‘engineered out’ Partly driven by systems and procedures Highly dependent on behaviours of people involved Rarely cited as a root cause of accidents. But is anyone looking for it?
  7. 7. 7 We know there is room for improvement but…. People underestimate its complexity and hence overestimate their ability at shift handover Who has the incentive to put in additional effort? Person finishing their shift – want to go home Person starting their shift – don’t know what they don’t know Managers – rarely present Seems to have fallen into the “too hard” category for many
  8. 8. 8 Looking for another angle Tackling behaviours head on is not easy Log books used at handover contain a wealth of information Could this be used more widely?
  9. 9. 9 Offshore study Copies of a week’s logs 3 ½ kg of paper All hand written Multiple formats Contents reviewed
  10. 10. 10 Information being recorded Human errors Valve ‘inadvertently’ closed, missing parts and information, tasks not complete Minor incidents Small releases, equipment failures Routine tasks 120 operational tasks recorded Solutions to problems Release pressure, manually manipulate valve, use sealing compound
  11. 11. 11 Other studies using data from log books Component reliability1 Hours of operation, failure and repair time Economic operation2 Model of plant breakdown and identification of items critical to system reliability Reliability3 Development of a fault tree used to identify plant modifications References 1 – Moss 1987 2 – Campbell 1987 3 – Galyean et al 1989
  12. 12. 12 Findings from these studies Date from log books could be very useful It is relevant to safety and reliability studies Allows models to be developed Supports expert judgement Difficult to achieve Handwritten Not structured with data collection in mind Concerns about consistency.
  13. 13. 13 Putting these ideas into practice
  14. 14. 14 Maximising the value of data Improving the quality of data To get the full picture, it is usually necessary to have input from more than one area of the business It is useful to be able to consider logged information alongside the relevant ‘hard’ process data Information may be required in different formats for different purposes Supporting the operator in collecting the data Making it as easy as possible Making it very clear what is required Using the data
  15. 15. 15 Minimum effort required A few mouse clicks Automated events Operator has more time to record the ‘value added’ information
  16. 16. 16 Logging an Event
  17. 17. 17 Logging an Event ST run up held in manual due to steam inlet rate of change alarm. Held for 5 minutes until alarms cleared
  18. 18. 18 Automating Log Entries Opralog Events Database Financial DCS Plant Historians Maintenance
  19. 19. 19 Structured logging Balance between structure and flexibility Use of pre-defined ‘Event Hierarchies’ Each event can have its own template Additional information to be captured Information shared with other logs and reports Other documents attached or referenced Ensures the same events are logged the same way each time
  20. 20. 20 Templates provide flexibility
  21. 21. 21 Templates provide flexibility
  22. 22. 22 Making the information readily available Events automatically shared between different logs Critical information becomes highly visible Issues effectively escalated Quick searching and reporting Taking data from multiple logs Historical information Logs become a live repository of data
  23. 23. 23 Sharing information
  24. 24. 24 Reporting
  25. 25. 25 Practical aspects Operators need to be involved in development Logs are very easy to configure For the full benefits operators need to accept change Computerised solution can only support and not replace a well thought out handover system A culture of open communication and continuous learning are required As with any intervention there are potential negative outcomes People still need to talk to each other Some computer literacy is required
  26. 26. 26 Conclusion Opralog has been used with great success User bases in the 100s Across multiple sites Has resulted in more consistent logs Information is being used more Cultural improvements People understand the need for high quality logs Readily available information means people ask more insightfull questions at handovers A management system that support handover, but has many other uses.