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