Presented 2018 via Skype to process safety professionals in Pakistan

Poor communication at shift handover was identified as one of the causes of the Piper Alpha disaster. The operators decided to start the standby condensate pump but did not realise its relief valve was not in place. The inquiry into the disaster found no evidence to suggest that the people involved had done this intentionally and concluded that they made decisions that, in hindsight, were clearly wrong because they did not have a full and accurate understanding of equipment status and condition.
Unfortunately, in the 30 years since Piper Alpha there has been relatively little effort put into improving shift handover across industry. This is despite subsequent major accidents where problems with shift handover failures have been identified.
This paper summarises the issues of shift handover and the challenges with achieving improvement. It refers to work carried out at a client’s site to improve shift handover, which has had a very positive effect on shift workers and their managers.

Published in Loss Prevention Bulletin June 2018

Incident investigations often conclude that one of the causes was either that people did not follow a “good” procedure or that procedures were not fit for purpose. These findings are often based on an inflated opinion of what procedures can achieve. The reality is that procedures appear very low on the hierarchy of risk control and will only ever make a fairly modest contribution to safety. Avoiding hindsight bias when considering the role of procedures in incidents can mean that more effective recommendations can be made, leading to a set of procedures that provide effective support to competent people.

Published in Loss Prevention Bulletin December 2018.  Available as a free download at

Removal of an isolation was identified as one of the causes of the Piper Alpha disaster. The operators did this to start a pump without realising its relief valve had been removed for maintenance. The underlying cause was that the pump isolation was not cross referenced with the removal of the relief valve.
This paper summarises several issues with process isolations based on the events at Piper Alpha, namely use of shared isolations and management of change. Process isolation is a critical and complex subject, and this paper only touches on the subject. A key message is that people can often perceive an isolation as guaranteeing safety when the reality is that it is only a means of reducing rather than eliminating a risk.

Published in Loss Prevention Bulletin June 2018