Effective Communication During Shift Handovers - Essay Example

Effective Communication During Shift Handovers: Problems and steps which can be taken to ensure effective shift handovers Introduction Shift continuation is vital for smooth day-to-day continuous process operations like the offshore oil and gas sectors. These sectors comprise of numerous oil platforms and artificial oil and gas islands distributed over several kilometres of wide area. The platforms and artificial islands each have multiple wells containing several barrels of oil produced per day. A major environmental concern with offshore oil and gas activities is the potential for oil spills and gas leaks. Due to such high risk factors, offshore operators and workers have to be tested for states of readiness and response capabilities, as well as their knowledge and understanding of the individual leak and spill response plans. In order for these operators to perform their duties efficiently and up-to-date every time, communication and coordination is assumed to be of crucial importance especially for continuity across shift changes via shift changeover. This changeover includes a period of grounding by outgoing personnel, shift changeover where incoming and outgoing workers communicate to exchange task-related information and cross-checking of information by incoming personnel as they assume responsibility for the task [3, 11]. The goal of shift handover is the accurate, reliable communication of task-related information across shift changes, thereby ensuring continuity of secure and efficient working in the plant. 2. Monitoring complex offshore operations Offshore gas exploration and oil production are constantly operating at 24 hours, 7 days a week and 365 days throughout a year. Personnel typically have to reside on the offshore installation plant for 3-4 week periods, working alternating 8 or 12-hour shifts. Their goal is to maximise exploration, operation or support maintenance functions without compromising health and safety requirements. Complex technical systems place demands on the operator's information-processing and decision making skills. The operator may be physically remote from the system and rely on an internal system-state model to understand and control the invisible process [5]. The accuracy of this model determines how effectively operators' start-up, monitor, adjust and shut-down the operational process. Successful control requires three components to be present (i) clear specification and understanding of the future goals of production, (ii) an accurate mental representation of the current state of the process and (iii) an accurate internal model of process dynamics. Many continuous process tasks are characterised by long system response times between process alterations and effects. Actions may not have their effects until subsequent shifts. Without adequate communication of information at shift handover, diagnosis of effects resulting from actions on previous shifts is problematic. Amongst the distinctive features of offshore facilities are their geographical isolation and unusual shift patterns. All or part of the crew may leave the facility in a short period of time. Clarification of issues not adequately recorded or communicated at shift handover is therefore potentially problematic. Significant fluctuations in alertness and performance have been observed over two-week offshore shift cycles, the most marked and adverse effects occurring during the shift-change phase [10]. Furthermore, offshore workers can be exposed to high noise levels, both on and off-duty, which increases potential for misunderstood verbal communications [1]. 3. Problems to ensure effective shift handovers: A Survey Approach A recent survey of permit-to-work systems in 5 medium-sized UK offshore oil refinery and gas plants [11] identified communication at shift handover as a problematic issue. 25 maintenance fitters, supervisors and managers were interviewed. One of the survey questions concerned the sequence of events at shift changeovers. When asked whether work should carry on over the shift change with an existing permit, the majority of fitters and supervisors replied that a new permit should be issued. In contrast, the majority of managers were of the opinion that work should carry on with the existing permit. A lack of clarity about how to keep incoming personnel informed of the current work situation was evident. The survey report recommended that a formal procedure for both maintenance and production shift handovers be developed, which included face-to-face communication between in-coming and out-going supervisors and a means of informing the incoming shift of work in progress. Formal shift handover procedures and two-way face-to-face communication were evident when production supervisors and managers in a gas reprocessing plant were observed during shift changeover and their handovers tape-recorded. Considerable time and effort was devoted to preparation for shift handover by outgoing personnel. During their shift information was collected, verified and recorded in a written log which summarised plant status. This log had a pre-determined structure to ensure that key items of information pertaining to safety, production and technical problems (ongoing and resolved) were included. The process of collation and checking intensified towards the end of the shift. Information was collated from a variety of sources including other written logs, face-to-face discussion with colleagues and personal inspection of the plant. All handovers occurred face-to-face with the shift log present, providing an opportunity for the incoming participant to give feedback or ask for clarification. The content of the shift log was used to structure the verbal handover, which elaborated upon the written log entries. During the handover, outgoing personnel gave information and opinions. Incoming personnel gave their colleagues passive and active feedback. The crucial importance of a two-way discussion at shift handover was demonstrated by detailed analysis of sixteen taped handover conversations and written logs. A total of six instances of misunderstandings arising during conversation were identified. The majority of these misunderstandings occurred during discussion of deviations from normal working. Four of these misunderstandings related to safety issues. On each occasion the misunderstanding was identified and repaired by the potential victim of the misunderstanding taking an active part in the handover by asking for confirmation, clarification and repetition. When incoming personnel had been absent for a ten-day rest period, additional effort was expended by outgoing personnel when preparing for such handovers. A summary of important events which had occurred during the incoming participant's absence was prepared and included in the verbal handover. The average ten-day handover took longer to complete. Significantly more information was given during ten-day handovers. The difference in length was accounted for by the outgoing participant giving additional historical information to bring the incoming participant up-to-date with current plant status. Following a ten-day handover, incoming personnel read through the logs covering the period of their absence to update their knowledge and cross-check this with the information given to them by their colleague. Management procedures pertaining to shift handover recognised the importance of face-to-face communication, specifying that handovers must be conducted in this fashion. The problematic nature of ten-day handovers was also recognised and it was expected that such handovers would take longer to complete than normal handovers. A thirty-minute shift overlap was allowed for all handovers. 4. Case Study: Personnel Incident due to Poor Communication Many offshore oil and gas accidents refer to ineffective broken communication (or miscommunication) as being amongst the underlying causes to human and equipment fatalities. In high-hazard domains, productive objective-oriented communication set apart successfully resolved safety critical incidents from those which were less effectively administered. The point of change at work which unavoidably accompanies shift-working has been linked to an increase of accident rates. Several researches into this effective communication studies have reported an increase rate of accidents surrounding particularly in shift changeovers yearly [3], with the highest incidental occurrences during the start and end of a shift. The Health and Safety Executive (HSE) [6] identifies some sudden and unpredictable major accidents, resulting in a considerable number of incidences, injuries and millions worth of freight, supplies, property damage and environmental impact which occurred at or following operator or worker shift changeover. However, the main reasons for the higher incidence events at or near shift changeover are not known as investigations into these areas are limited in resources and proofing. Below is a sample investigation into incident where failure of operator-to-maintenance personnel communication at shift handover was held to have been a contributory fundamental factor. This was a major accident resulting in actual loss of human life. This incident was heavily subjected to close scrutiny. It should be strongly stressed that the following incident described as a case study, poor and ineffective communication at shift handover formed part of a complex permutation of design and operational failures. This study is just a relevant example from many highly publicised incidents reported by HSE that make up the numerous unpublished or undisclosed production incidents or close missed accidents caused by possible failures of communication at shift handover. Offshore Maintenance Accident Health and safety guidance on how offshore operators and workers can help facilitate the expansion and improvement of health and safety includes a case study on communication failure during shift handover [9]. A man was seriously injured while repairing a broken valve along a high pressure line. The accident occurred when workers on one shift isolated a valve by shutting one valve on each end of the line and opening the drain-line between both valves. They knew the isolating valves were not functioning properly so they closed the drain-line again. They left a clear notice in the log book to inform the next takeover shift that the valves must be re-opened first to blow the line down. Isolation Certificate and the permit to work did not describe the appropriate method of isolation in precise detail. During the actual shift handover, the message was somehow not passed on to the next worker. Based on regular maintenance schedule, a fitter (who was unfamiliar with the worker's job) removed the clamp bolts holding the pressure pipe flanges together, instead of just loosening them and cracking a line joint. As a result, pressure had built up in the pressure line again and a coupling blew apart. The fitter received very fatal permanent head injuries and will never recover fully ever again. Analysis of case study The above study can be analyzed in terms of communication theory [2], these unforeseen maintenance incident forcibly demonstrate the consequences of (i) failing to take into consideration of the inherent uncertainty of natural human language, (ii) the impending increase for misunderstanding when workers hold different working knowledge and system states of plant status, (iii) failure to look into the information needs of others and provide ways to capturing key information intended for others and (iv) over dependence on only means of communication such as one-way written communication. In this incident, means of communication via written communication failed as the intended message was misinterpreted or simply not read. To summarize this case study, the incident described above identifies risk areas at shift handover (i) involving planned maintenance work, (ii) planned maintenance work continued over a shift change. Thorough communication of such work should be afforded a very high priority, (iii) operator supports (logs) were not designed to capture key information reliably, (iv) a lack of procedures which specified how to conduct an effective shift handover was evident and (v) inaccurate and unreliable carry-forward of written information from shift to shift was evident. 5. Ensuring effective shift handovers via effective communication The manner in which effective shift handovers can be ensured among operators and workers between the various functions such as operations and maintenance depends much on the assistance and barriers to establishing effective communication among themselves. Most of this communication factors can be achieved from reviewing concepts found in communication theory [2] and organisational behaviour [12]. In order to assist effective communication, it must first be encoded and physically broadcasted as a communiqu signal and may be in any written or spoken form. For effective shift handovers, the message incurred has to be repeated by more than one communication channel and medium through traditional means of writing (in log-books) and speaking. The accuracy of communication for handovers may also increase due the availability of feedback from workers. Two-way communication with this feedback is essential at shift handover. Qualitative aspects of speech such as comprehension speaking assessment, outspoken confidence, speaking competence gained via pace, phrasing of words, hesitancy to express oneself and language fluency all play a major role in effective communication. Verbal face-to-face communication at both shift and functional handover is desirable. Misunderstanding from miscommunications is most likely to occur when system states held by outgoing and incoming personnel differ widely. This can occur during deviations from normal operational working, plant maintenance, following a lengthy absence and between both experienced and inexperienced staff. A more accurate alignment of system states with actual system states depends on successful communication. Successful communication is facilitated by shared system states. In order to achieve shared system states, handovers can be expected to take longer at such times. Operator or worker logs intended information into computer for the next personnel at shift handover are assumed the likelihood to furnish accurate and reliable communication. Logging in information via writing is facilitated by document form format based on the needs of user. This has to be supported by Supervisors to implement the inclusion of relevant categories and types of information into the handover form to support effective communication. Barrier towards effective communication may take the form of the intended message being buried in irrelevant, unwanted information, which requires time and effort to extract and interpret to the next handover. Important information needs to be specified, presented and irrelevant information excluded for successful handover. Since natural human language is inherently confusing, additional effort needs to be applied to reduce any doubt on the information perceived by (i) carefully specifying the information to be communicated e.g. specifying a plant item and tag, (ii) facilitating two-way communication which permits clarification of uncertainty, e.g. which plant item are you referring to Also transmission of this language with information is limited by the capacity of the communication channel and medium. Eliminate unnecessary information for effective handovers. Misunderstandings between two human communications are unavoidable and extra effort needs to be expended to identify, minimise and mend misunderstandings. Effective handover is achieved by two-way communication, with e.g. both first and second shift operators, taking responsibility for achieving accurate communication. People and organisations frequently refer to communication as unproblematic, implying successful communication is easy and requires little effort. Over-confidence and complacency are common. Effort needs to be expended by organisations to address complacency by (i) emphasising the potential for miscommunication and its possible consequences, (ii) setting standards for effective communication and (iii) developing the communication skills of organizational members. The review of communication theory indicates that to ensure effective shift handover communication organisations should (i) give effective shift handover communication a high priority, (ii) pay particular attention to handovers which occur when operators have returned following a lengthy absence from work, during plant maintenance, during deviations from normal working, and when handovers take place between experienced and inexperienced staff (iii) specify key information needed by the incoming operator to update their system states of plant status, (iv) use operator supports (logs, displays etc.) designed on the basis of the operator's information needs, (v) include communication skills in their selection criteria for shift-workers and (vi) develop the communication skills of all existing staffs. Individual shift handovers should (i) be conducted face-to-face, (ii) be two-way, with both operators/workers taking joint responsibility for ensuring accurate communication, (iii) use verbal and written means of communication and (iv) be given as much time as necessary to ensure accurate and efficient communication. 6. Conclusion The basic importance of shift handover in ensuring safe and effective continuity of work on continuous process offshore oil and gas industries has been discussed. Apparent unbiased conclusions can be drawn about the responsibilities targeting both companies in oil/gas sectors and continuous process employees. To summarize above, the workers must (i) make a point of giving effective communication via shift handover a high priority, (ii) include communication skills in their selection criteria for shift-workers, (ii) develop the communication skills of existing staffs, (iii) provide procedures which specify how to conduct an effective shift handover, (iv) place greater reliance on written communication when longer 12-hour shifts are in operation and (v) allow for longer shift handovers. More effort is needed to brief personnel who have been absent for longer periods where possible, plan maintenance work to be completed within one shift, thereby eliminating the risk of miscommunication of maintenance issues at shift handover. Sufficient information is available to provide general guidance on how to conduct an effective shift handover, which should be (i) conducted face-to-face, (ii) two-way, with both participants taking joint responsibility for ensuring accurate communication, (iii) via verbal and written means, (iv) based on a pre-determined analysis of the information needs of incoming operator/worker and (v) given as much time as necessary to ensure accurate communication. Sufficient information is also available to provide guidance on how to assess and improve current practice. This includes (i) specification of key information needed by incoming operators to update their system states of plant, (ii) status, (iii) design of operator supports (logs, displays etc.), based on the operator's information needs and (iv) involvement of end-users when implementing changes to established methods of communication at shift handover, thereby facilitating their acceptance and use. Further research which compares best practice described in this report with current practice offshore would help to identify areas for improvement. A second area meriting further research is how to ensure accurate and reliable and unambiguous carry-forward of written information from shift to shift. Information technology offers a possible solution. REFERENCES [1] B. C. Ross (1978). Noise on offshore platforms in Occupational Health. Vol 30, No 11 pp 524-527. [2] C. E. Shannon and W. Weaver (1949). The mathematical theory of communication Champaign. IL: University of Illinois Press. [3] C. Grusenmeyer (1995). Shared functional representation in cooperative tasks-The example of shift changeover. International Journal of Human Factors in Manufacturing. [4] D. Hunns (1986). Human Factors in Reliability and the Psychology of Communications. International Journal of Quality and Reliability Management, pp 22-37. [5] H. Kragt and J. Laandweerd (1974). Mental Skills in Process Control. in Edwards, E and Lees, F, (eds) The Human Operator in Process Control. London: Taylor Francis [6] Health and Safety Executive (1986) Safety Audit of BNFL Sellafield 1986, Vol 1 & 2 [7] Health and Safety Executive (1987). Dangerous maintenance: a study of maintenance accidents in the chemical industry and how to prevent them. London. HMSO. [8] Health and Safety Executive (1991). Human factors in industrial safety. London : HMSO [9] Health and Safety Executive (1994). Play Your Part: How offshore workers can help improve health and safety. London: HMSO. [10] K. R. Parkes (1993). Human factors, shift work and alertness in offshore oil industry. Report OTH 92 389 London: HMSO [11] R. Lardner (1992). Do you know what I know: A field study of shift handover in a safety critical industry. MSc Thesis, University of Sheffield, unpublished. [12] S. R. Axley (1984). Managerial and organisational communication in terms of the conduit metaphor. Academy of Management Review, pp 428-37. [13] The Human Factors in Reliability Group (1991). The guide to reducing human error in process operations. Warrington: The SRD Association. Read More