Shift Handover series:

Part 1: Shift-Handover: 5% of Operations Time, 40% of Incidents

Part 2: Shift-Handover: Structured Logbook Design

Introduction

In our previous article looking into the challenges of shift handover and the significant impact that Mental Modelling has on the shift handover process, we identified that whilst shift handovers take up only a small portion of an operator’s time, they are the significant contributor to plant incidents.

In the research from Yin and Laberge 2010, we saw that operators place a significant emphasis on leveraging their personal mental model when making decisions. This is problematic because in most cases an operator's mental model is highly personalized and specific to them as an individual,  since their model has been an accumulated development over years of personal experience.

Thus, what we see is that during the shift handover process there is a fundamental underlying assumption that - when knowledge is being transferred - the same meaning is being received by the other party. But, as illustrated in the figure below, the message sent can be at times (maybe even often times), different from the message that is received. 

When we delve deeper into the research, the reason for this is identified as even if the outgoing operator gives his or her best effort to anticipate and communicate the crucial information required by the incoming operator during shift handover (i.e. necessary for the incoming operator to know in order to operate the plant safely), this anticipation is based on their own personal mental model -- and the updates that have occurred to their mental model throughout the shift.

In our first article (which can be found here) we concluded that by adhering to simple communication strategies during the shift handover process, ensures that the clarity and validation of the intended message is tremendously improved (i.e. risk of operator error and loss in efficiency is greatly reduced).

In the second section of this series, we dive deeper into the content and structure of operations log books, how they are utilized, and their most effective design.

Logbooks

According to Yin and Laberge, over 80% of production logbooks are of an unstructured style. Typically, an unstructured logbook is a standard A4 notebook or diary in which operators are free to write anything that they feel is pertinent information to the incoming shift, and of course this is based on their personal judgement and individual mental model.

This unstructured approach is relatively simple and easy for operations staff to conduct, requiring little effort, time or impact on operations. But, one study at Nanyang Technological University of Singapore has identified that a significant volume of critical content is accidentally being missed using this method; more specifically that 18% of the expected contents are not included in typical logbooks and shift handover reports. (This figure is based on analysis conducted with senior operations staff. This percentage could presumably be lower or higher in junior operational staff, depending on personal opinion)

Additionally, both the Piper Alpha and BP Texas City investigation reports clearly stated that despite the best of intentions by the operation teams, the lack of logbook information and the informal/unstructured shift handover processes where key failures in the lead up to both incidents.

So, it’s clear that whilst operators give their best effort in transferring the required knowledge to the incoming operations team, significant portions are still being missed,for various reasons.

So, what can be done? How can we improve this situation?

It was identified by The Keil Center that operations teams are very much aware of the minimum and necessary information that is required to operate the facility safely and effectively,however,with the pressure and rush of day-to-day operations it is simple to forget key elements during shift handover.

During testing, The Kiel Center implemented a structured template for use during the shift handover preparation, with the goal being to catch and clarify the small (even miniscule)  changes and events that later may have the potential for significant impact.It was proved that by leveraging the structured template, operators were prompted to recall all important and relevant information that would have otherwise  been forgotten, or been left to fall through the cracks. 

As operators, all of us have experienced reported incidents that were a direct result of undocumented or incomplete maintenance preparations, overrides, and deviations from SOP.

Based on this research the final message of the The Kiel Center was that clear and quantifiable benefits can be achieved by moving from unstructured logbooks to logbooks with a structure – inevitably driving the improvement of the shift handover process.

As seen in the figure below, a structured logbook clearly outlines each of the key information categories that operations staff are expected to provide to the incoming shift,thus acting as a prompt for the operator to ensure they are clearly thinking through each of the key knowledge areas.

The Kiel Centre identified via an operator survey that this change to structured logbooks resulted in a 71% improvement in the content of the completed logbooks; combined with a 66% improvement in the shift handover process.

Nanyang has taken this research one step further to quantify the benefits, in terms of actual operator knowledge improvement via identifying that operators gained a 9% improvement in the ability to recall information; and 8% improvement in correct responses to probe questions.

Our first article in this series is available here: Shift-Handover: 5% of Operations Time, 40% of Incidents

References:

The Kiel Center: http://www.hse.gov.uk/humanfactors/topics/standards.pdf
Yin and Laberge 2010: http://pro.sagepub.com/content/54/23/1946.abstract
Nanyang Technological University: http://link.springer.com/chapter/10.1007%2F978-3-642-21741-8_36