Safety critical communication. Overview. Communication. Andy Brazier

Transcription

1 Safety critical communication Andy Brazier Tel: (+44) Mob: (+44) Overview Communication is a two way process Critical communication includes: Shift handover Permit to work Between management and employees 2. 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. 3

2 4 Quantas Maintenance Logs P: 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. 5 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. 6

3 A Accurate A-B-C of communication B Brief C - Clear 7 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. 8 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. 9

4 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. 10 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. 11 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 12

5 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). 13 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? 14 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. 15

6 Buncefield Standards group - effective shift/crew handover communication arrangements must be in place to ensure the safe continuation of operations. 16 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 HSG48 Second Edition 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. 18

7 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. 19 Status at Handover All alarms are functioning properly Yes No All fire main drain valves are closed Yes No All bund drain valves are closed Yes No Vapour recovery unit is operating Yes No Outgoing shift Incoming shift I confirm that I believe the incoming shift has received and I confirm I have received and understood all necessary understood all necessary information and will be able to act information and will be able to act safely. safely. Signature Signature 20 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. 21

8 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 22 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. 23 Copies of a week s logs 3 ½ kg of paper All hand written Multiple formats Contents reviewed Offshore study 24

9 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 25 Other studies using data from log books Component reliability 1 Hours of operation, failure and repair time Economic operation 2 Model of plant breakdown and identification of items critical to system reliability Reliability 3 Development of a fault tree used to identify plant modifications References 1 Moss Campbell Galyean et al 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. 27

10 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. 28 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