SlideShare verwendet Cookies, um die Funktionalität und Leistungsfähigkeit der Webseite zu verbessern und Ihnen relevante Werbung bereitzustellen. Wenn Sie diese Webseite weiter besuchen, erklären Sie sich mit der Verwendung von Cookies auf dieser Seite einverstanden. Lesen Sie bitte unsere Nutzervereinbarung und die Datenschutzrichtlinie.
SlideShare verwendet Cookies, um die Funktionalität und Leistungsfähigkeit der Webseite zu verbessern und Ihnen relevante Werbung bereitzustellen. Wenn Sie diese Webseite weiter besuchen, erklären Sie sich mit der Verwendung von Cookies auf dieser Seite einverstanden. Lesen Sie bitte unsere unsere Datenschutzrichtlinie und die Nutzervereinbarung.
Good afternoon. I am Andy Brazier – a risk consultant specialising in human factors in major hazard industries The paper submitted to SPE was written by myself and Brian Pacitti from Infotechnics. It refers to a case study from Scottishpower. We realised you would probably be most interested in hearing from the horses mouth, so Martin Sedgwick will be presenting instead of Brian.
So this presentation is a double act. I will make the case that most companies need to improve the way they communicate, with shift handover being an example of where this is particularly critical Martin will tell you about what Scottishpower has done to improve shift handover as part of their aim to prevent process safety incidents The underlying message is that there is now technology available that, if used properly, can support improved communication. An example is the Opralog, which makes logging of information and access to it easy across the business.
In some ways, I am quite disappointed that this paper was accepted for this conference. Not because I did not want the opportunity to talk to you, but because I had hoped that problems we have known about for years may have been solved by now. I think the problem is that, whilst people see communication including shift handover as important, they don’t really understand the risk. Communication in its own right is not hazardous and I doubt it ever directly harmed anyone, so perhaps it never gets high enough on the list of priorities
The Deepwater Horizon/Macondo incident illustrates the world we live in. Despite the technology involved, it relies on people (lots of them) to operate safely. To do that they need know what is going on.
But modern ways of working have made this difficult. We have multiple companies, resulting in different lines of reporting. There may be commercial sensitivities. So people may feel they cannot talk to others. The danger is that no one really knows what is going on. They make decisions based on incomplete information. And we know what can happen.
It is not just at the cutting edge where we have problems. Transferring oil products from site to site is not conceptually very complicated and is certainly nothing new. The clearest link between Buncefield and Deepwater Horizon is that both were dealing with flammable hydrocarbons. In this case, because people did not know what was going on they did not realise a tank was being filled, so they were not monitoring its level and it overflowed.
We have had other major accidents where communication and shift handover have been identified as contributing factors. But when I talk to my clients they don’t seem to recognise it as a priority problem for them. I don’t think it is because they don’t believe it to be a problem, but because they don’t really know what to do or it simply fits into the ‘too hard’ category
I think communication often does not happen because people do not know what information needs to be passed on. This is because the transmitter does not know what the receiver needs. As Donald Rumsfeld said, it is the unknown unknowns that cause us the most problem. One reason people do not know what to communicate is because we have not provided them with suitable systems. But there is a significant behavioural element. If you think of shift handover, the person finishing their shift will inevitably want to leave as soon as they can, and so has little incentive to stay on to make sure all the important information has been communicated.
I’ll say something along the lines of I had concluded that making data more useful to the business would give an incentive for everyone to improve handovers. I’d looked at what companies were doing and found there was still a lot of reliance on handwritten logs, and where computerised it was usually a word or excel file. Infotechnics contacted me. When we met I had a lot of questions, and Opralog seemed to have the answer to them all.
2011 SPE - Electronic logging to improve safety
Using Electronic Shift Logging to
Tel: +44 1492 879813
Tel: +44 1224 355260
Two part presentation
1. Companies need to improve critical communication
processes, including shift handover
2. Case study from – role of shift logging in
preventing process safety incidents
Underlying theme – technology is available to assist
improvement (e.g. Opralog from Infotechnics)
Is there a link between safety and communication?
Is communication hazardous?
Did it ever kill anyone?
Deep water drilling in the Gulf of Mexico is:
At the edge of our technical capabilities
The people involved have to know what is going on
Day by day
Hour by hour
Minute by minute
They need to communicate. But…
The work for different companies
They report to different people
They are restricted in what they can say
The result is
No one has the full picture of what is going on
Bad decisions are made
Transferring oil products between sites is:
The people involved have to know what is going on
They may not know a
tank is being filled
They won’t know it
needs to be monitored
It may overflow
And don’t forget:
BP Texas City
What is the problem?
1. Knowing what to communicate
There are known knowns; there are
things we know we know.
We also know there are known
unknowns; that is to say we know there
are some things we do not know.
But there are also unknown unknowns –
the ones we don't know we don't know.
2. Inadequate systems
3. Inappropriate behaviour
What can you do?
1. Tell people they have to communicate
2. Train people to communicate better
3. Specify/guide what has to be
4. Make sure they are communicating
5. Make sure communication is effective
6. Identify problems
7. Drive (continual) improvement
Making it easy to log information that is then
readily accessible to anyone who may need it
What is the problem?
Incorrect information given
All of the above
What can you do?
Tell people they have to communicate
Train people to communicate better
Specify/guide what has to be communicated
Make sure they are communicating
Make sure communication is effective
Drive (continual) improvement
Shift handover is a complex, error prone activity,
It can’t be ‘engineered out’
Partly driven by systems and procedures
Highly dependent on behaviours of people
Rarely cited as a root cause of accidents.
But is anyone looking for it?
We know there is room for
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
Managers – rarely present
Seems to have fallen into the “too hard” category
Looking for another angle
Tackling behaviours head on is not easy
Log books used at handover contain a wealth of
Could this be used more widely?
Copies of a
3 ½ kg of paper
All hand written
Information being recorded
Valve ‘inadvertently’ closed, missing parts and
information, tasks not complete
Small releases, equipment failures
120 operational tasks recorded
Solutions to problems
Release pressure, manually manipulate valve, use
Other studies using data from log
Hours of operation, failure and repair time
Model of plant breakdown and identification of items
critical to system reliability
Development of a fault tree used to identify plant
1 – Moss 1987
2 – Campbell 1987
3 – Galyean et al 1989
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
Not structured with data collection in mind
Concerns about consistency.
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
Supporting the operator in collecting the data
Making it as easy as possible
Making it very clear what is required
Using the data