The hidden hazards of end-of-shift handoffs

by on September 29, 2011 · 0 Comment POSTED IN: Workplace Safety Network
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You’ve probably faced this situation: A crew is supposed to complete safety-sensitive procedures in one shift. But the crew doesn’t finish in time. They must pass on the work – right in the middle of things – to another shift. If you’re like most safety directors, you provide communications protocols so the second shift knows what safety procedures remain undone.

But protocols arent always enough. Here’s a case that shows how a company that engaged in rigorous safety planning, including communications, still failed to prevent an accident.

Facts of the case
A valve-replacement project required two shifts of work. The night shift was tasked with draining pressurized steam piping from the system; the day shift was tasked with replacing a leaky valve once the system was fully drained.

The night shift was unable to complete the drainage job during its shift. When the night-shift supervisor turned over the project checklist to the day-shift supervisor, he highlighted about two dozen procedures that had been completed.

Handwritten notes on list
Only four more valves needed to be opened and drained. Problem was, two of these valves were the last two items on the checklist.

The other two were near the top of the checklist – with a handwritten note next to them saying these two valves needed to be opened.

The night-shift supervisor also verbally communicated to the day-shift supervisor about all four valves during the shift handoff.

Later, the day-shift supervisor forgot about the night supervisor’s warning and overlooked the handwritten notes on the checklist. He only instructed his crew to drain two valves, not four – which would leave the line pressurized.

Add inexperience …
There were still two more chances to catch the error, though.

First, the workers could have noticed that when the two valves were opened, no steam came out. But an inexperienced worker was given the task. He didn’t see the lack of steam as a warning sign.

Second, the day supervisor checked the open valves, saw no steam coming out and assumed the system had been fully drained. He issued a permit for a contractor to replace the leaky valve.

So the crew missed both opportunities. A contract worker cracked open the seal on the leaky valve, and he and two other workers were engulfed in pressurized steam. One worker spent six weeks in the hospital with burns over 60% of his body.

What to watch out for
You can see how tricky these types of accidents are. Everybody thought they were following the right protocols, but communication broke down anyway.

The mistakes started with the handoff and were compounded by a novice worker who didn’t notice the signs of a problem and a supervisor who didn’t debrief the worker.

Here are some do’s and don’ts for strengthening communications during work handoffs:

  1. 1. Don’t assume one-time communication is enough. Even a checklist and a conversation between supervisors is not enough for complex projects. In general, the more complicated the task, the more likely you need ongoing communication.Example: The first shift supervisor could have placed green markers on opened valves and red markers on closed valves. That way, the second supervisor, with a quick scan, would see something was amiss. He would not have issued the permit to break the seal on the leaky valve.
  2. 2. Do keep the previous supervisor on call. Supervisors should not be reluctant to take and receive calls so any questions get answered and concerns clarified. In some cases, you may want to request upper management to spring for overtime to keep someone “in the know” on the current status of a project available for ongoing communication.
  3. 3. Don’t assume simple tasks can be done by anybody. Assigning inexperienced workers to an easy task (open a valve) is tempting. But if the simple task involves spotting crucial warning signs of problems – the lack of steam venting – you want a veteran to complete or oversee the task.
  4. 4. Do verbally debrief people who complete safety-sensitive tasks. On safety-sensitive work, supervisors should confirm for themselves what happened at the moment a warning sign should have appeared. The day-shift supervisor could have asked a worker (even a veteran one), “Did any steam come out of the valve after you opened it?” If the answer was, “No,” that would have meant something was wrong and needed further investigation.

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