2008 hazards - shift handover
TRANSCRIPT
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Improving shift handover and maximising its value to the
business
Andy Brazier
Tel: +44 1492 879813 [email protected]
Brian Pacitti
Tel: +44 1224 [email protected]
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Introduction
Presentation in two partsAndy Brazier – theoryBrian Pacitti – practical
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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.”
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Buncefield
Standards group - “effective shift/crew handover communication arrangements must be in place to ensure the safe continuation of operations.”
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Not a new Discovery
Other accidentsPiper Alpha 1988 – status of condensate pumps not knownSellafield 1983 – presence of radio active material in tank pumped to see
Ronny Lardner publications 1992-96HSG48 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 proceduresHighly dependent on behaviours of people involvedRarely cited as a root cause of accidents.
But is anyone looking for it?
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We know there is room for improvement but….
People underestimate its complexity and hence overestimate their ability at shift handoverWho has the incentive to put in additional effort?
Person finishing their shift – want to go homePerson starting their shift – don’t know what they don’t knowManagers – rarely present
Seems to have fallen into the “too hard” category for many
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Looking for another angle
Tackling behaviours head on is not easyLog books used at handover contain a wealth of informationCould this be used more widely?
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Offshore study
Copies of a week’s logs3 ½ kg of paperAll hand writtenMultiple formatsContents reviewed
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Information being recordedHuman errors
Valve ‘inadvertently’ closed, missing parts and information, tasks not complete
Minor incidentsSmall releases, equipment failures
Routine tasks120 operational tasks recorded
Solutions to problemsRelease 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
References1 – Moss 19872 – Campbell 19873 – Galyean et al 1989
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Findings from these studies
Date from log books could be very usefulIt is relevant to safety and reliability studiesAllows models to be developedSupports expert judgement
Difficult to achieveHandwrittenNot 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 dataImproving the quality of data
To get the full picture, it is usually necessary to have input from more than one area of the businessIt is useful to be able to consider logged information alongside the relevant ‘hard’ process dataInformation may be required in different formats for different purposes
Supporting the operator in collecting the dataMaking it as easy as possibleMaking it very clear what is required
Using the data
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Minimum effort required
A few mouse clicksAutomated eventsOperator 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
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Automating Log Entries
Opralog Events Database
Financial
DCS
Plant Historians
Maintenance
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Structured logging
Balance between structure and flexibilityUse of pre-defined ‘Event Hierarchies’Each event can have its own template
Additional information to be capturedInformation shared with other logs and reportsOther 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 visibleIssues effectively escalated
Quick searching and reportingTaking data from multiple logsHistorical 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 developmentLogs are very easy to configureFor 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 outcomesPeople still need to talk to each otherSome computer literacy is required
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ConclusionOpralog has been used with great success
User bases in the 100sAcross multiple sites
Has resulted in more consistent logsInformation is being used moreCultural improvements
People understand the need for high quality logsReadily available information means people ask more insightfull questions at handovers
A management system that support handover, but has many other uses.