The Effect Of A Simple Meeting At Shift Change-over

June 9th, 2009

On the night of July 6, 1988, an explosion and fire aboard the Piper Alpha oil drilling platform killed most of the crew. The disaster began with a routine maintenance procedure. On the morning of the 6th of July, a backup propane condensate pump (which removed liquids from the natural gas) in the processing area needed to have its pressure safety valve checked. The work could not be completed by 18h00 and the workers asked for and received permission to leave the rest of the work until the next day.

The men said later that they had notified a supervisor that nobody should turn on the back-up pump for the time being. The tube was sealed with a plate.

Later in the evening during the next work shift, the primary condensate pump failed. None of those present were aware that a vital part of the machine had been removed and decided to start the backup pump. Gas products escaped from the hole left by the valve.

Gas audibly leaked out at high pressure, ignited and exploded, blowing through the firewalls. The fire spread through the damaged firewalls, destroyed some oil lines and soon large quantities of stored oil were burning out of control.

There were many reasons for the accident, including deficiencies in the permit-to- work system. But one of the findings from the investigation was that employees relied on too many informal communications and communication between shift changes was lacking. If the shift change system had been implemented properly, the initial gas leak probably would not have occurred.

The Piper Alpha disaster happened more than twenty years ago – and yet today we still come across instances where failures occur because of shift-change meetings not being conducted properly.

At a cement plant recently, an operator came on shift, saw that one of the main screw conveyors was switched off, and turned it on. Unbeknown to him, a maintenance worker was working on it and was killed when the machine was turned on. In the subsequent inquiry, it was found that the isolation and permit-to-work procedure had not been followed. In addition, the meeting that was required at every shift change-over was not being held at all!

A problem solving team at a plastic component manufacturing company found that the defects on one of their machines increased drastically after a shift change. On further investigation, it was found that the incoming and outgoing operators didn’t even see or talk to each other!

One of the findings of the Chemical Safety Board (CSB) into the causes of the 2005 BP Texas City Disaster was that the shift change-over in the control room was poorly conducted.

Why do people stop taking these meetings seriously?

The Piper Alpha investigative team suggested that the ability to communicate clearly with fellow workers during the handoff of work to another shift is an important and underrated skill.

It is easily underrated by those who think that working hard implies only traditional type of activities, such as typing hard on a keyboard or running a power tool or driving a truck. The once accepted attitude of “It’s not going to happen on my watch” is clearly not justifiable anymore, not when so many tasks cross from one shift to another.

So it comes down to making sure that meetings are attended and properly conducted. It will probably require that the minutes of the meeting or at least a summary is kept on record, and that management read the minutes or summary carefully. An irritating detail – but the alternative is a strong possibility of a disaster.