END-OF-SHIFT-REPORT

Effective Communication and the End-Of-Shift-Report

Effective Communication and the End-Of-Shift-Report

Introduction

Continuous operation requires people to work shifts. Ensuring safety and efficiency requires critical information to be communicated between these shifts. All communication is prone to error. This makes end of shift report, a highly critical activity that is performed frequently with little opportunity to engineer out potential errors. The end of shift report is an important process in all companies with operations. It is obvious that the quality and efficiency of this process for the overall system operation is critical. Poor shift handovers are a source of conflict. The reasons for this are obvious. During the end shift report, the essential information for the operation of working group to group and between the operational levels is passed.

Accidents Caused by Poor end of Shift report

The role of shift handover has been highlighted in a number of recent high profile, major accidents. Following the 2005 Texas City refinery explosion, BP released their internal investigation report to the public. This identified that poor shift end report was a contributor to the accident, citing the failure to communicate the failure of a hard-wired high level alarm between shifts as a contributing event. By way of an explanation the report stated that 'there were no written expectations with explicit requirements for shift handover.' The subsequent inquiry carried out by the Chemical Safety Board agreed with these finding, stating that '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 (S&ES, 2007).'

In the UK, whilst at the time of writing this paper the full facts of the case were still not known, it seems clear that shift handover had a role in the 2005 explosion at the Buncefield oil storage terminal. One of the recommendations from the Buncefield Standards Task Group (BSTG) was that 'effective shift/crew handover communication arrangements must be in place to ensure the safe continuation of operations.'

Whilst a number of accidents have identified end of shift report as a contributory cause, it seems likely that this is an under reported issue. Put simply, because there has not been much attention paid to shift end reports and relatively little information published on the subject, people have not been looking for evidence of failures with shift end reports when investigating incidents and accidents (Brazier, 1996).

The Problems with End of Shift Report

The Health and Safety Executive's guidance document HSG485 states that reliable communication is highly critical to safety, and that shift end reports falls into this category. Failures of communication occur for a number of reasons. In general either the information being communicated is incomplete or inaccurate; or the person on the receiving end misunderstands the meaning of the information they are given. There are many reasons why this can occur, with information being presented poorly being the underlying factor.

Whilst all communication is error prone, the more complex the situation the more likely errors are to ...