A Critical Shift: How Adding Structure Can Make Shift Handovers More Effective

  • March 12, 2012
  • News
March 2012
By Tom Plocher and Jason Laberge of Honeywell and Brian Thompson of Engen.
(All are members of ASM Consortium)
In the refining industry, control room and field operators document their daily activities using shift logs. At shift changes, these logs are an important part of the shift handover process. They are the mechanisms that help coordinate activities across shifts or teams. Industrial research has repeatedly argued for the benefits of imposing structure on shift handovers in the form of structured logs, checklists, and displays. Yet, an estimated 80 percent of the world’s industrial operations still lack a structured approach to shift handovers. The lack of structure dramatically increases the likelihood for missing critical information and misunderstandings occurring.  And such misunderstandings and missed information sometimes have disastrous results.
Repeated Themes
Examples of the pitfalls from not following a structured approach for shift handovers are evident throughout recent history. Case in point: On July 6, 1988, a large fire and explosion on the Piper Alpha offshore platform killed 165 and completely destroyed the facility. One of several root causes involved personnel starting a pump without knowing that it was missing relief valve in for service — all because no one recorded the information in the control room or maintenance logs. During shift handover, personnel discussed the status of the pump work, but no one mentioned the relief valve work. Upon restart, the pump leaked, producing a flammable hydrocarbon cloud that exploded.
On Oct. 30, 2002, a pipefitter at an undisclosed facility found himself exposed to a toxic chemical while replacing a section of pipe connected to a storage tank. Those on the previous night’s shift had only partially prepared the tank for maintenance, and personnel only vaguely documented this status in the shift log. No one fully communicated this during the shift handover. As a result, the subsequent shift believed the tank was ready for usage. When the pipefitter opened the pipe, he was exposed to the toxic chemical, rendered unconscious and fell through scaffolding onto a concrete pad.
More recently, on March 23, 2005, at a BP refinery in Texas City, a fire and explosion killed 15 people and harmed more than 170. The explosion occurred when a key piece of equipment overflowed during startup operations, creating a flammable vapor cloud. The incident investigation noted several root causes, including a failure to log key information, and an informal and unstructured shift handover process, which resulted in subsequent shifts not being aware of the previous shift’s startup activities. Upon the resuming of the startup process, the shifts didn’t consider the previous shift’s progress, which contributed to the flammable liquid overflow condition.
Common Failure Mode
These incidents all share a common failure mode: the inaccurate or incomplete communication of information from shift to shift. Specifically, all three incidents involved failures to effectively communicate information about maintenance actions in progress, but incomplete, at the time of a shift handover. Poor logbook design and poorly-conducted shift handovers are the two most common causes of such lapses in communication across shifts. The two problems are closely intertwined, and can have significant consequences.
When it comes to logbook design, operations shift logs can suffer from a myriad of problems. First and foremost, they often lack structure, providing no clear expectation to the operator about what to log and how to structure entries. For example, routinely documented elements, like the categories of plant information, and the level of recorded detail, can vary from shift to shift within the same unit — and from unit to unit within the same plant. 
Knowing what information is important to log becomes a critical operator task, but one that only the most experienced operators can be trusted to perform reliably. In the current industrial environment, marked by an increasingly inexperienced workforce, simply relying on operators to know what to report is an unnecessary risk. Electronic logs are now commonly available, but they are no panacea. In our many visits to refinery sites, we observed electronic shift logs that contained up to ten unique pieces of information in a single unstructured paragraph. Such logs are impossible to scan and search, which is essential for accurately and effectively presenting key events to an incoming operator during a shift handover. Unstructured logs foster a common lack of standardization and encourage lax reporting. 
In terms ofshift handovers, a similar lack of structure is also common. Shift handovers often occur without reference to the logbook. In such cases, most of the shift handover is based on what the outgoing operator can retrieve from his memory of the past 12 hours — which occurs when the operator is fatigued from a long shift, making his recollection of details even more challenging. And, when logbook use during a shift handover does occur, operators can often find that logbooks lacking key information needed to present to the incoming operator. In both cases, the failure to present a complete and accurate report on the situation is made even worse by time pressures and ineffective communication skills.
Best Practices
Effective communication is a two-way interaction. The outgoing operator presents information and looks for signs that the incoming operator understands. Ideally, the incoming operator asks questions, nods in understanding and summarizes information to provide feedback to the outgoing operator and indication that he understands. 
Five things that can potentially improve shift handovers include:
  • Use structured shift logs that clearly indicate what should be reported in the handover presentation. The shift logs should include key categories and subdivisions of information needed by the incoming second shift operator so he can have an accurate model of the current plant situation.
  •  Set clear expectations for complete and accurate shift handovers and for individual responsibilities. Require the outgoing first shift operator to routinely acknowledge every key category of information in the logbook during the shift handover, even if no new events have occurred in a particular category during his or her shift.
  •  Plan ahead and allow sufficient time to conduct a complete shift handover.
  •  Train operators in the skill of conducting effective shift handovers and in effective two-way communication.
  •  Emphasize to both first shift and second shift operators that they have a joint responsibility for effective communication of the situation.
Case in Point: Engen Petroleum Research Project
How important is structure for effective shift handovers? The Abnormal Situation Management (ASM®) Consortium funded a research project to answer that question conclusively. ASM teamed with Engen Petroleum, researchers from Honeywell and Nanyang University of Singapore to conduct a series of shift handover tests at the Engen refinery in Durban, South Africa. 
The tests entailed having experienced control room operators from the Engen refinery work through two difficult simulated emergency scenarios involving a steam pipe rupture and a power failure that caused pumps to fail. The tests focused on the shift handover between the first shift and second shift operators. The operators had to recognize the abnormal situation, shut down the affected unit and communicate the status of the situation to a second shift operator during a shift handover. The second shift operator had to understand the situation and safely bring the unit back into operation. 
In half of the test trials, the shift handover used a semi-structured logbook in which much of the information communicated was left up to the operator. The other half of the test trials relied on an experimental shift log designed using features from a handover checklist. This checklist-integrated shift log provided sub-categories of information and prompted the operator to acknowledge each detail even if the operator had nothing relevant to report. To ensure statistical robustness, the team performed and observed 10 test trials of the semi-structured handover and 10 trials of the structured handover.
Test results were conclusive. The checklist-integrated logbook generated higher-quality log entries as deemed by participating experts. By the end of each shift handover, the second shift operators who were briefed using the structured logbook were able to provide a more accurate and comprehensive account of the unit situation. As these operators worked to bring the unit back on line, test showed they were also better at answering questions and did not need to consult with supervisors and team members to answer them. This gain in situation understanding took little extra time, adding only one extra minute on average to the time spent on shift handovers conducted in a less structured way.
Putting It Into Practice
The conclusive results from the handover research prompted Engen to use the structured checklist, shown in the figure below, as the basis for a new electronic logbook. This was part of a bigger project at the plant to monitor operating envelope violations.  Engen implemented the content and structure of the checklist electronically, but limitations of the electronic logbook software application did not allow the implementation of “electronic checkboxes,” which, in the research, provided a medium for the incoming shift operator to formally acknowledge receipt of each information item.
Engen’s implementation and enforcement of effective shift handovers is challenging because the official 12-hour shift for operations staff does not include time for shift handovers, so personnel conduct them on their own time. The structured logbook was generally well-received, but it did encounter some issues. A major criticism, for example, was that the structured logbook was much longer than the previous electronic logbook due to the increased number of automatically populated data fields and manual input fields. 
In addition, adoption and usage assessments of the new log revealed that not everyone used the log as a structured handover tool to its fullest potential. For example, operators still use the “other” fields to communicate significant amounts of information.  As a result, Engen initiated an ongoing change management effort to address this. 
Engen also uncovered a need for follow up training to reinforce behavior change. It may also need to develop a separate shift handover report that is a distinct subset of the full reporting log. 
Overall, shift handovers are more effective when they are supported by clear, two-way communications and a structured checklist of key categories aimed at gathering important plant information. Using structured checklists reduces the chance of not communicating critical information during a shift change. They also help ensure clear, accurate and consistent communications between shifts to keep things running smoothly.

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