32 Occupational safety
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The role of poor shift handover in oil and gas incidents I
n the oil and gas industry, hazards
Research has revealed that whilst start-ups,
which occurred during a shift. Finally, it was
are inevitable and if they are not identified properly, they may lead to incidents. When it comes to continuous
shutdowns, and changeover periods account for less than 5% of engineers’ time, 40% of plant incidents occur during these instances.
also revealed that there was an insufficient amount of time allocated for the handover between supervisors.
processes, engineers are required to be available 24/7 to carry out operations or maintenance. Workers are therefore frequently rotated on a routine basis
Role of shift handovers in major incidents The importance of shift handovers has been
The BP Texas City Refinery explosion in 2005 is another example of the total failure of shift handover management. The explosion
within a cycle of shifts and conduct a handover between teams at the end of each shift. A shift handover is defined
highlighted by major oil and gas incidents such as Piper Alpha, Texas City, Buncefield, and Deepwater Horizon. The Cullen report
occurred when a flammable vapour cloud was created by liquid overflow from a blowdown stack. The investigation team found that there
as transferring responsibilities and tasks from one individual or team to another and it is the best-known type of
published following the Piper Alpha disaster clearly mentioned, as one of many factors, that the failure of transferring information
was no procedure to follow when conducting a shift handover. The absence of a lead operator during handover, miscommunication, unclear
safety critical communication. The goal of a shift handover is to communicate “accurate, reliable, task relevant
during shift handover contributed to the incident. Specifically, information about a pressure safety valve which had been removed
information and a lack of detail in the logbook were all evident. Operators were working in shift patterns for 30 consecutive days at a
information across shift changes, thereby ensuring continuity of safe and effective working.”
and replaced by a blind flange was not communicated between shifts. In addition to that, there was no written procedure for shift
time which led to excessive fatigue among personnel and demonstrated an ineffective policy for shift work. Even though shift
handover and information that was written in the shift handover logbook was left to the lead operator’s discretion.
handover management issues and the general lessons learned from BP’s Grangemouth refinery incident in 2000 were available, the BP Texas City management did not appear to learn from the Grangemouth incident.
This article describes the key challenges in shift handovers and illustrates how poor handovers contributed to some of the oil and gas industry’s worst disasters, before offering some recommendations on how to implement robust and effective shift handover management.
Elsewhere, the Buncefield oil storage depot explosion and fire in 2005 was also partially caused by poor shift handover. The incident investigation team revealed that effective
Communication matter The UK Health and Safety Executive (HSE)
A shift handover is a critical activity with a direct influence on production and safety. Poor shift handover is known to cause operational problems such as plant upsets, unplanned shutdowns and product reworks, all of which
arrangements for shift handover were not in place and there was confusion between supervisors about which tank was being filled. The shift logbook was also only used to capture information about one pipeline and only had information about the plant’s situation
guidance document HSG48 clearly states that reliable communication is highly critical to safety. Effective communication during a shift handover provides a strong layer of protection against major incidents. People tend to underestimate the complexity of the
can result in considerable revenue loss.
during the end of a shift and not about events
communication process, and consequently
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