Why Poor Shift Handover Can Lead to Serious Oil & Gas Incidents

Effective communication during a shift handover provides a strong layer of protection in preventing major incidents.In the oil & gas industry, hazards are inevitable and if they are not identified properly, they may lead to regrettable situations such as disasters. Continuous process in the oil & gas industry demands people who carry out operations and maintenance of oil & gas plants, usually within 24 hours, 7 days a week. Therefore, workers are frequently rotated on a routine basis within a cycle refereed as shift work. Within continuous process, shift handover is required between those who are on shift works. Shift handover is defined as transferring responsibilities and tasks from one individual to another or a work team and it is one of the best known types of safety critical communication.

Shift handover is a critical activity with a direct impact on production and safety. Poor shift handover is known to cause operation problems such as plant upsets, unplanned shut downs and product reworks, which can result in considerable revenue loss. Research by one oil & gas company revealed that while start-up, shutdown and changeover periods account for less than 5% of an operation’s staff time, 40% of plant incidents occur during this time . In fact, every second incident or accident in the process industry is related to communication errors that occurred during shift handovers.

This article will examine the key challenges in shift handover and illustrate how shift handover became one of the contributing factors in some major incidents in the oil & gas sector. We’ll also provide recommendations on how to have a robust and effective shift handover process.

THE ROLE OF SHIFT HANDOVERS IN MAJOR INCIDENTS

The importance of shift handover was highlighted in such major oil & gas incidents as Piper Alpha, Texas City, Buncefield and Deepwater Horizon. The Cullen report following the Piper Alpha disaster inquiry clearly mentioned, as one of many factors that contributed to the incident, the failure of transferring information in shift handover. In fact, information that a pressure safety valve had been removed and replaced by a blind flange was not communicated between shifts. In addition to that, there was no written procedure for shift handover and information that was written in a shift handover logbook was left to the lead operator’s discretion.

An explosion at a Buncefield oil storage depot was another incident where shift handover was one of many contributing factors that led to disaster. The Buncefield incident investigation team revealed that effective arrangements for shift handover were not in place and there was confusion between supervisors about which tank was being filled, and the shift logbook was only used to capture information about one of the pipelines. Furthermore, the logbook only had information about the plant situation during end of the shift, not events occurring during the shift. Finally, it was revealed that allocated time for handover between shift supervisors was not sufficient.

The Texas City Refinery explosion in 2005 is an example of total failure of shift handover management, in addition to a range of technical failures that contributed to this incident. The investigation team found out there were no procedures being used during shift handover. The absence of a lead operator during shift handover, miscommunication, unclear information and lack of required details in the shift handover logbook were also evident. Working operators in a shift pattern for 30 consecutive days in such a hazardous facility led to excessive fatigue among personnel and demonstrated a lack of required policy for shift work. Even though shift handover management and lessons learned from BP’s Grangemouth refinery incident in 2000 (which was similar to the Texas City Refinery explosion) were available, BP’s Texas City management did not appear to learn from the lessons of the Grangemouth study.