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

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
Introduction
Presentation in two parts
Andy Brazier – theory
Brian Pacitti – practical

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
Buncefield
Standards group - “effective shift/crew handover communication
arrangements must be in place to ensure the safe continuation of operations.”

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.

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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
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
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
Offshore study
Copies of a
week’s logs
3 ½ kg of paper
All hand written
Multiple formats
Contents
reviewed

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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

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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

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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.

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Putting these ideas into practice

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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

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Minimum effort required
A few mouse clicks
Automated events
Operator has more time to record the ‘value
added’ information

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Logging an Event

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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
Automating Log Entries
Opralog Events
Database
Financial
DCS
Plant Historians
Maintenance

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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

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Templates provide flexibility

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Templates provide flexibility

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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

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Sharing information

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Reporting

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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

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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.