Shift handover

Risk engineering position paper

Risk engineering position paper

01
Executive Summary 4

02
Specific requirements 5

03
Auditing 9

04
Reference to industry losses 10

05
Appendix A 12

06
Further reading 13

Contents
4

1
Executive
summary
While effective communication is important
in all organizations, it is particularly important
for continuously operating plants during shift
changes. Clear and effective communication
during a shift handover provides a key layer of
protection in the prevention of major incidents.
The objective of this shift handover position paper is to promote accurate and
reliable communication of relevant information across shift changes, thereby
ensuring the continuity of a safe and effective working environment. An effective
handover consists of three steps:

• Preparation by the outgoing personnel for handover.

• Performing the handover in which the outgoing and incoming personnel
communicate to exchange relevant information.
• Cross-checking of information by the incoming personnel as they assume
responsibility.

A lack of effective information transfer has led to serious incidents in the process
industry. This has included the Piper Alpha offshore platform incident and the
Texas City refinery incident, which are outlined in the Reference to Industry Losses
section of this report.

In this position paper, we define the standards that would be rated by Marsh
as “very good” for a shift handover system in the oil, gas, and petrochemical
industry. These attributes reflect those in the Marsh energy risk ranking criteria
which can be used to determine risk improvement opportunities and provide
detailed advice to organizations seeking to improve their shift handover systems.

This paper includes guidance on the formal

routine for the handover of communication
from one shift to another, the rotational
shift handover that occurs offshore, and
the compilation of shift logs to aid in these
handover processes.
Risk engineering position paper

2
Specific
requirements
POLICY AND PROCEDURE
There should be a comprehensive written local policy and procedure
governing shift handover. Any corporate expectations for shift handover
should be available to all operating sites and incorporated into local
procedures as appropriate.

The procedure should clearly define:

• The standards required for an effective shift handover.

• The contents and structure of the shift logs used in the shift
handover process.

SHIFT HANDOVER
It is as important to consider the way in which the handover takes place as it
is to consider what information needs to be communicated.

What makes an effective shift handover?

An organization needs to ensure that shift handover communication is given
a high priority and the consequences for miscommunication are clearly
understood (see also Appendix A).

For a handover to be considered effective, it should be conducted:

• At the normal place of work, such as the shift office, control room, or field
operator stations. For example, it should not take place in the changing
room or car park.
• Face-to-face, using clear language.
• Without interruption.
• As a two-way communication with feedback. Both participants are taking
joint responsibility for ensuring the accurate transfer of information.
6

This means: Additional or special handover

– Developing the communication skills of risks to be considered
existing staff with appropriate training. An organization should consider how to manage
– Ensuring that communication skills are additional or special risks associated with:
considered in the recruitment of shift-workers
and are included in the training and training • Any non-standard or higher-risk handovers, such
validation process for new employees. as during a plant run down for a turnaround,
during a turnaround event, or on plant re-start
• Both verbally and in written format. It should after a turnaround. Other examples could
meet the information needs of incoming staff, include major project construction or
which will mean giving consideration to: commissioning activity.
– The design of operator supports, usually a • A lengthy absence from work, which could be
shift log book. due to:
– The input from operators on the design of – Illness.
these supports.
– Shift patterns: If the shift cycle includes
Note: It is not good enough to just leave the shift rostered leave periods, then special
log for the oncoming shift to read. arrangements should be made to extend the
handover to ensure that the returning shift
• With as much time as necessary to ensure
team is properly updated. Some sites
accurate communication of information.
prepare a special set ofhandover notes for
This includes:
these situations based on a compilation of
– Sufficient time to prepare the shift the logs over the absence period. In other
handover log. cases, specific shift team members are
– Sufficient time to complete the handover, required to return to work one day early to
which is typically 10-15 minutes for field/panel receive an update and/or attend a team
operators and up to 30 minutes for area team safety briefing.
leaders and shift managers. – Offshore crew change: Most crews have two
– Additional time when the handover involves to three weeks off between work periods.
less experienced staff, periods of high activity, This places significant additional emphasis
following the undertaking of complex tasks, or on a good quality handover, as during the
where shifts are 12 hours long. intervening period there will have inevitably
been loss of awareness for the oncoming crew,
while the outgoing crew will be fatigued and
may be focused on travel requirements.
• Unmanned operational facilities: Areas or
facilities that are not normally manned should
be provided with a log book that is completed by
any person visiting the area. This is to register
their attendance, log their activities, and provide
information on the status of the operation in that
area. Key information from these visits should
also be reported into the central log system for
the operation. Typical facilities in this category
are unmanned offshore platforms, substations,
and remote pipeline facilities, such as metering or
pumping stations or jetties that are not manned
unless they are occupied by a vessel.
• Noncontinuous shifts: Not all shifts require
continuous 24-hours- a-day coverage. For
example, the shift pattern might not have a
night shift but could have two day shifts of eight
hours each. Consideration would then need to
be given to how the oncoming day shift would
receive a shift handover if verbal communication
is not possible.
Risk engineering position paper

SHIFT LOGS
Format of a shift log However, paper versions of logs can be
equally valuable, and are commonly used
The shift log should NOT be a blank book, for field operator positions.
in which the content is left to the discretion
of the off-going shift personnel. It should Input from the operating team is important
follow a set format that reflects not only when designing the required content for the
the basic information that the shift crews shift logs. Ultimately, the shift log is a key
need to perform their roles, but also the vehicle for leadership to show their priorities
information that site leadership require to be in running the site, both in terms of what is
discussed to ensure the key systems of work included and the order in which it appears in
(including process safety elements) are being the log.
monitored adequately.
Shift logs should be retained for a designated
The scope, content, and level of detail in a period of time, as any information recorded
shift log should be predefined. This may may be useful in the future, such as during
vary depending upon the shift roles and incident investigation.
should be tailored to the specific shift
position in question. Preparation of a shift log
For example, a shift manager’s log should During the shift handover process, a shift
contain high-level information to ensure that log is the usual means of recording the
the oncoming shift manager is fully apprised information that has been exchanged
of the overall status of the site operation, between the incoming and outgoing shifts.
matters that require their attention, and Each member of the outgoing shift will need
situations that they may need to take into to prepare a shift log and use this to conduct
account when responding to emergencies or a shift handover with the incoming shift.
making decisions. A field operator’s log may
Relevant information will need to be
contain some of the same information, but it
communicated in advance of shift log
is likely to contain low-level information more
preparation to other roles within the shift
relevant to the role he/she is performing.
team to ensure that the correct information
Shift logs may be handwritten or electronic, is entered. The shift manager should be
and this may vary from shift role to shift aware of all key information. This may require
role. In any instance, shift logs for each role individual discussions with personnel prior
should have a set format and content to to shift log completion. The diagram below
ensure that relevant information is captured illustrates how the communication network
and handed over to the oncoming shift may look in a simplified shift team structure.
teams. The information required should
be clearly understood and obtainable. The
log should be logical, easy to understand,
intuitive, and user friendly. It should include
Outgoing shift Incoming shift
information not only on what has happened
but why, and what actions have been taken. Shifttamanager
erhT Shifttamanager
erhT
The shift logs could include checklists, area
maps, process diagrams, and color coding
of risks.
Panel
taoperator
erhT Panel
taoperator
erhT
Typically, the shift manager’s log is produced
electronically, although this is not necessarily
a requirement. Often electronic logs can Fieldtoperator
aerhT 1 Fieldtoperator
aerhT 1
be designed to import information from
other databases that may be available, such
as the process information system, product
quality monitoring system, work order Fieldtoperator
aerhT 2 Fieldtoperator
aerhT 2
system, electronic permit to work system,
and the incident and accident database.
This reduces the amount of input required Fieldtoperator
aerhT 3 Fieldtoperator
aerhT 3
from the author.

Communication prior to shift handover log prepapration

Shift handover communication
8

Depending upon the size and complexity of the – Key equipment status and changes: It is
operation, it may be appropriate for the organization good practice to maintain a “white board”
to have a shift team meeting after the shift handover register to show the status of trips/bypasses,
process has been completed. This is typically led by safety system impairments, cooling water
the shift manager, based around the content of their configuration, steam and power configuration
shift log, and attended by the relevant team members and operating mode, flare header
to ensure that all key information has been clearly configuration, backup equipment, and any
and effectively communicated and any plans for the temporary operating arrangements.
forthcoming shift are coordinated.
– Equipment out of service.

What should be included in – Product quality results, including any actions

taken to remedy out of specification material.
a shift log?
• Maintenance:
Key information for routine shift logs will vary by role.
Information that should be considered includes: – Status of work orders that are in progress,
planned, or raised.
• Shift role being handed over.
– Preparation required for future maintenance
• Identity of outgoing and incoming shifts: activity and permit preparation.
– Shift name. • Any environmental excursions taking place.
– Shift rotation; morning, afternoon, night (time • Staffing issues such as illness, any on-shift
and date). training, and any cover requirements.
• Personal and process safety: • Daily instructions, including procedure
– Incidents, accidents, and reported hazards, changes, management communication, and
plus any steps taken in response. special instructions.

– Status of work permits, with particular • Routine duties: Records of any routine tests and
emphasis on extensions, incomplete work, and checks performed by shift personnel on a periodic
isolations. basis for the area, such as status of rotating
equipment, checks on fire protection (monitors,
– Any special permits to prepare, such as hydrants, foam, active systems settings, and auto-
confined space entry. start status of firewater pumping systems), and
– Status of emergency control systems, with the testing of alarms, detectors, and monitors.
particular emphasis on bypasses or defeats • Comments: A comment area can be provided to
(including gas detection, fire detection, relief detail any other points not covered, but should be
valves, emergency shutdown, fire water a small part of the overall handover log.
systems, etc.).
• Signatures: The log should be signed and dated
– Alarm status. by the incoming and outgoing shift roles.
– Temporary operating arrangements, such as For periods of special hazard, such as before, during,
air hoses on hot-spots, use of bypasses, or or after a plant turnaround, a differently structured
manual valve settings. shift log may be required to reflect the ongoing risks
– Temporary plant modifications. and status of relevant activity.

• Operations status: Specialized logs will also be required for marine

terminals and reception/dispatch facilities (road,
– Unit operating status, operating rates,
rail, and pipeline) where the information is related
plant out of service, deviations from target,
to the vessels and consignments rather the
deviations from operating envelope, and any
process operation. Information logged in these
operating limitations.
areas is generally required for the official transfer
– Events such as changes in operation, tanks documentation associated with the vessels and
switches, upsets, and recoveries (include times consignments in question. Nevertheless, a log of the
of events). essential information equivalent to that described
– Summary of operating problems and actions in the list above should also be maintained for
taken to resolve. handover, as well as a formal record of events.
Risk engineering position paper

Auditing
Each site should audit its shift handover
process on a periodic basis, with audits
completed for selected shift roles. The audit
should be performed by a local manager
knowledgeable in the standards required, with
the output reported to site management to
follow-up on any actions.
An audit process would typically include:

Observations of a shift handover taking place. This will establish

if the handover standards are being followed and if there are any
problems in the transfer of information.

An evaluation of the quality of a random selection of completed

historical shift handover logs, in order to establish if the logs
are being provided, the extent to which information is being
completed, and the relevance of the information detailed.

In addition to establishing whether the shift handover process is fit for

purpose, an audit further reinforces an organization’s continuing commitment
to demonstrating that shift handover is a safety critical system of work.

“ The audit should

be performed by
a local manager,
knowledgeable
in the standards
required.”
10

4 Reference to
industry losses
INCIDENT SUMMARY #1
Piper Alpha – 1988
Piper Alpha was a North Sea gas production platform. During a routine restart
following maintenance, a hydrocarbon cloud formed and subsequently
ignited, killing 167 workers. Unknown to the personnel starting the pump, a
relief valve in the pump discharge had been removed for service and a blank
had been loosely installed in its place on the piping flange (which was not
readily visible from the pump vicinity). When the pump was restarted, this
flange leaked, producing a flammable hydrocarbon cloud, which subsequently
found an ignition source.

The Cullen report concluded that one of the contributing factors to the Piper
Alpha disaster was the failure to communicate information at shift handover.
During shift handover, the status of the pump work was addressed, but the
relief valve work was not mentioned or recorded in the shift logs. There was
no written procedure for shift handover in place, and there was no structure
as to what items to include in the handover.
Risk engineering position paper

INCIDENT SUMMARY #2
Texas City refinery fire and explosion – 2005
In this incident, a splitting tower was overfilled after start-up from a maintenance outage,
resulting in a flammable vapor cloud and a subsequent explosion, killing 15 people and
injuring 180. Financial losses were reported to have exceeded US$1.5 billion, with houses
damaged as far as 1.2 kilometers from the refinery.

The US Chemical Safety Board investigation noted that supervisors and operators poorly
communicated critical information relating to the start-up during the shift handover, and
no shift handover communication requirements for operations staff were in place. This was
deemed to have been a contributing factor leading to this incident.
12

5 Appendix A
SELF ASSESMENT CHECKLIST
The following checklist is a quick tool that a
site can use to test its existing processes for
good practice.

Item

Procedure

Does the site have a formal written shift handover procedure?

Supporting infrastructure

Does the PHA process define the roles and responsibilities of the
key people who operate the process:
Y N Partial

Have staff been appropriately trained in how to conduct a shift

handover?

Does the process recognise the need for shift logs (written or
electronic) to be in place for the handover?

Is sufficient time given to prepare and deliver the handover?

Are higher risk non-standard handovers considered, such as at

turnaround or during project activity?

Is account taken of additional handover requirements that may

be required after a lengthy absence?

Is a log book provision made for unmanned operational

factilities?

Has consideration been given to units where noncontinuous

shifts may be in place?

Does each role on shift complete a shift handover with a

handover log book?

Are the contents of the log book clearly defined for each role?

Is a post-shift handover team meeting needed?

Stewardship

Are shift handover log books retained?

Is there an audit process to ensure shift handover is being

appropriately conducted?
Risk engineering position paper

Further
reading
Health and Safety Executive (HSE) website: http://www.hse.gov.
uk/humanfactors/topics/shift-handover.htm

HSE website: Extract from inspectors human factors toolkit –

Safety critical communications http://www.hse.gov.uk/
humanfactors/topics/common3.pdf

HSE (1996) Effective Shift Handover. OTO 96 003

http://www.hse.gov.uk/research/otopdf/1996/oto96003.pdf

HSE (1999) Reducing Error and Influencing Behavior HSG48, HSE

Books, London, UK (free to download) http://www.hse.gov.uk/
pubns/priced/hsg48.pdf

Andrew Brazier and Brian Paccitti, Improving Shift Handover and

Maximizing its value to the business Symposium series no 154,
6
IChemE 2008

HSE Improving Communication at Shift Handover, Prepared by

The Keil Centre for HSE http://www.hse.gov.uk/humanfactors/
topics/shifthandover.pdf

Department of Energy (1990) The Public Enquiry into the Piper

Alpha Disaster Vols 1 & 2 Cm 1310 London: HMSO

US Chemical and Hazard Investigation Board, Investigation

Report, Refinery Explosion and Fire (15 killed, 180 Injured), Report
No 2005-04-I-TX March 2007
Risk engineering position paper
Contacts

Jasper Clark
Risk Engineering Hub Leader (UK)

+44 (20) 73575421

[email protected]

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