A large UK oil refinery stabilises in excess of one million barrels per day of crude oil. A five-shift rota system with a 35-day shift cycle was in operation.
Effective shift handover is an important requirement of most shift-working operations. The change-over of tasks and staff can give rise to problems with the transmission or non-communication of critical information. Failures of communication or misunderstanding at shift handover were identified as contributory factors in certain recent industrial accidents, such as the Piper Alpha disaster, and a beach contamination incident at Sellafield.
A project was initiated to address concern about current shift handover practice. While there had not been any specific incidents where failures of communication at shift handover had been a causal or contributory factor, management had noted potential for improvement in this 'core' site activity.
The project involved collecting information on current shift handover procedures and practice by focusing on one typical area of the refinery. A structured approach with several data collection methods was used, to examine current policies, procedures, documentation and work behaviour, including:
The review identified the following areas for improvement:
Most shift log books were unstructured A4 ruled books. There was a lack of guidance on what information should be included, thus style and content varied between individuals. Log book content was mainly historical, with little content indicating what should or might happen in the future. There was no specific reference to safety issues.
The existing training programme for new recruits included shift handover, but there was no agreed standard against which to assess the adequacy of the trainees' knowledge or behaviour.
None of the handovers observed had all of the behavioural features present which would define an effective and safe shift handover. For example, in 20% of the handovers observed, there was no evidence of collation of information or making notes in preparation for handover. Many handovers suffered from distractions, in the form of other handovers being conducted simultaneously nearby. Only one of the recipient personnel observed made notes during the handover.
The main recommendations from the review were:
Following several weeks in use, a number of improvements resulting from the introduction of structured logs were noted. More information on maintenance and technical problems was being recorded, safety issues were being flagged up, and timings of events were being recorded more consistently. The information in the logs was also easier to access and read, as operators learned to look for categories in certain positions on the page.
The training programme was well-received by both apprentices and experienced personnel.
During site-wide evaluation of the changes, 70 people were interviewed, representing 22% of those personnel affected by the project: 76% of those people interviewed believed that the introduction of structured logs had led to improvements in how log books were completed; 56% believed that it had led to improvements in how handovers were conducted. Furthermore, 66% of the staff interviewed during the survey felt that there had been a need to improve standards of shift handover, as relevant information had often been lost, missed, or not recorded.
In general, the introduction of structured logs was well received, and helped to facilitate desired changes in behaviour at shift handover. In particular, involving post-holders in the process achieved a degree of commitment which may not have resulted from other methods.