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Incidents arising from shift handover

Hydrocarbon Engineering,

In a recent report, Honeywell suggests that the industrial world has long recognized that the discontinuities of shift handover are among the most common and potentially serious sources of problems. These can range from minor impacts on operational efficiency to the most serious safety incidents; all incur corresponding levels of economic cost.

Several industrial accidents emphasis the importance of effective logging and shift handover: On 23 March 2005, fifteen people were killed and more than 170 injured as the result of a fire and explosion in the isomerization unit at the Texas City refinery. The explosion occurred when a flammable vapur cloud formed following liquid overflow from the blowdown stack during operation of the raffinate splitter. Among the root cause of the accident was a failure to log pertinent information, as well as an informal and unstructured shift handover process.

Problems with existing processes

Honeywell highlights that most process plants already have a shift handover logging application of some sort, however they frequently make use of ad hoc or standalone data logging tools such as spreadsheets, email or custom databases. Ad hoc tools may provide only limited access to daily operating information for the rest of the organisation, or be inconsistently applied. In addition, ‘homegrown’ solutions can be difficult to keep up to date when the process changes.

Personal spreadsheets are generally not subject to the same rigid control standards as other IT applications, therefore errors and omissions can occur, impacting the accuracy of information used to implement shift handover procedures. Without a central data repository, different individuals may apply different data as the basis for reporting and decisions.

Additionally, Honeywell emphasises that some handover logs are no more than simple notebooks that operators complete during their shift. These have obvious and serious limitations, such s illegible handwriting, the difficulty of searching through a mass of entries across numerous books to find a particular entry, and the inability to identify or correlate common or recurring issues.

For more on how to overcome these risks, see also 'The advantages of an electronic operations logbook'.

Adapted from a report by Emma McAleavey.

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