Tel: (+44) 01492 879813 Mob: (+44) 07984 284642andy@abrisk.co.ukwww.abrisk.co.uk

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Safety critical communication

Andy Brazier

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Overview

Communication is a two way process

Critical communication includes:

Shift handover

Permit to work

Between management and employees

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Communication

.

There were 20 sick sheep, one died, how many were left?

“Send reinforcements we are going to advance”

“Send 2 and 4 pence we are going to a dance”

Error is an integral part of communication.

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Quantas Maintenance LogsP: Left inside main tire almost needs

replacement.

P: Something loose in cockpit.

P: Dead bugs on windshield.

P: Evidence of leak on right main

landing gear.

P: DME volume unbelievably loud.

P: Suspected crack in windshield.

P: Aircraft handles funny.

P: Target radar hums.

P: Mouse in cockpit.

P: Noise coming from under

instrument panel. Sounds like a

midget pounding with a hammer.

S: Almost replaced left inside main

tire.

S: Something tightened in cockpit.

S: Live bugs on back-order.

S: Evidence removed.

S: DME volume set to more

believable level.

S: Suspect you’re right

S: Aircraft warned to straighten up, fly

right, and be serious.

S: Reprogrammed target radar with lyrics.

S: Cat installed.

S: Took hammer away from midget.

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Why is communication critical

Railway research - miscommunication

Major role in 38% of track working incidents

Major role 11% & minor role 25% of SPADs.

50% involved movement of trains

Main error is failing to communicate

Wrong information communicated

Wrong information transmitted

Right information misunderstood

A third of all serious incidents are partly caused by communication errors.

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A-B-C of communication

A – Accurate

B – Brief

C - Clear

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Planning communication

PPPPPP

Proper Planning Prevents Poor Performance

Planned communication is

More likely to include relevant information

Less likely to include irrelevant information

Accurate and brief

Only needs to take a few seconds, but makes a big difference.

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Planning communications

Know your goal

What the other person needs to understand

How to start the communication

What information to exchange

If a long message, break it down into small chunks

Ending the communication

Making sure the other person understands correctly.

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Verbal communication

Giving a message

Speak slowly

Pronounce words clearly

Be aware of background noise

Receiving a message

Make sure your assumptions are correct

Sound interested

Ask questions

Repeat the message in your own words.

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Taking the lead in communication

People need to take responsibility for the communication they are involved in

Identifying who is involved

Listening

Questioning

Challenging

Correcting

Calming

Repeating back

Concluding.

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Emergency messages

M-E-T-H-A-N-E

M- my name, job role etc.

E - Exact location

T - Type of incident

H – Hazards involved or present

A – Access arrangements

N – Number of casualties

E – Emergency services/actions required

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General principles

Face-to-face is best

Written is not as good

No opportunity to feedback

Useful as a backup for face-to-face

Most people over-estimate their ability to communicate

‘Receiver’ needs to achieve the understanding intended by the ‘transmitter’

Error is an integral part of communication

Many unintended messages are received (e.g. body language).

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Shift handover

Shift handover is a complex, error prone activity, performed frequently

High risk

It can’t be ‘engineered out’

Partly driven by systems and procedures

Highly dependent on behaviours of people involved

Rarely cited as a root cause of accidents.

But is anyone looking for it?

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BP

Texas

City

BP’s own report - “there was no written expectations with explicit requirements for shift handover.

CSB report – “the condition of the unit – specifically, the degree to which the

unit was filled with liquid raffinate – was not clearly communicated from night shift to day shift.”

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Buncefield

Standards group - “effective shift/crew handover communication

arrangements must be in place to ensure the safe continuation of operations.”

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Not a new Discovery

Other accidents

Piper Alpha 1988 – status of condensate pumps not known

Sellafield 1983 – presence of radio active material in tank pumped to see

Ronny Lardner publications 1992-96

HSG48 Second Edition 1999.

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We know there is room for

improvement but….

People underestimate its complexity and hence overestimate their ability at shift handover

Who has the incentive to put in additional effort?

Person finishing their shift – want to go home

Person starting their shift – don’t know what they don’t know

Managers – rarely present

Seems to have fallen into the “too hard” category

for many.

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Improving handovers

Make it very clear what needs to be communicated

Minimise unnecessary communication

Use structured logs and handover reports

Use a combination of face-to-face and written

communication

Set a high standard and encourage good

communication.

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Status at Handover

Vapour recovery unit is

operating

� Yes � No

All bund drain valves are

closed

� Yes � No

All fire main drain valves are

closed

� Yes � No

All alarms are functioning

properly

� Yes � No

Vapour recovery unit is

operating

� Yes � No

All bund drain valves are

closed

� Yes � No

All fire main drain valves are

closed

� Yes � No

All alarms are functioning

properly

� Yes � No

Incoming shiftI confirm I have received and understood all necessary

information and will be able to act safely.

Signature

Outgoing shiftI confirm that I believe the incoming shift has received and

understood all necessary information and will be able to act

safely.

Signature

Incoming shiftI confirm I have received and understood all necessary

information and will be able to act safely.

Signature

Outgoing shiftI confirm that I believe the incoming shift has received and

understood all necessary information and will be able to act

safely.

Signature

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Handover management system

Clear procedure with additional written guidance

Training

Monitor and audit

Involve personnel in developments

Consider handover performance in incident and accident investigation.

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Take care of high risk handovers

Ongoing maintenance

Deviations from normal operation

Safety systems overridden or unavailable

Individual returning after long absence

Involving individuals with significantly different levels of experience

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Looking for other angles

Tackling behaviours head on is not easy

You will only get the quality of handover you ask for

There may be ways of making the data used at shift handover a more integral part of the business.

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Offshore study

Copies of a week’s logs

3 ½ kg of paper

All hand written

Multiple formats

Contents reviewed

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Information being recorded

Human errors

Valve ‘inadvertently’ closed, missing parts and information, tasks not complete

Minor incidents

Small releases, equipment failures

Routine tasks

120 operational tasks recorded

Solutions to problems

Release pressure, manually manipulate valve, use sealing compound

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Other studies using data from log

books

Component reliability1

Hours of operation, failure and repair time

Economic operation2

Model of plant breakdown and identification of items critical to system reliability

Reliability3

Development of a fault tree used to identify plant modifications

References

1 – Moss 19872 – Campbell 1987

3 – Galyean et al 1989

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Findings from these studies

Data from log books could be very useful

It is relevant to safety and reliability studies

Allows models to be developed

Supports expert judgement

Difficult to achieve

Handwritten

Not structured with data collection in mind

Concerns about consistency.

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Maximising the value of data

Improving the quality of data

To get the full picture, it is usually necessary to have input from more than one area of the business

It is useful to be able to consider logged information alongside the relevant ‘hard’ process data

Information may be required in different formats for different purposes

Supporting the operator in collecting the data

Making it as easy as possible

Making it very clear what is required

Using the data.

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Practical aspects

Operators need to be involved in development

Log book design

For the full benefits operators need to accept change

Computerised solution can only support and not

replace a well thought out handover system

A culture of open communication and continuous learning are required

As with any intervention there are potential negative outcomes

People still need to talk to each other

Some computer literacy is required.

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