Industrial accidents that involved poor handover
Handover time between individuals and teams is a critical moment in any operation. Sometimes a limited amount window of opportunity exists in which to communicate key information. And it is sometimes in this haste to communicate the story of a shift that vital information and intel doesn’t make it to the right person. And it’s in those vital moments when the information and intel doesn’t make it that tragedies can happen. Today we look at some of the worst industrial accidents where poor handover and shift communication practises contributed to the outcome.
Piper Alpha disaster, 1988
With the death of 167 personnel the Piper Alpha incident is still the worst offshore Oil platform disaster ever witnessed. At the time of the disaster the platform accounted for nearly 10% of the North Sea fields total output. Its loss was to have a profound, and lasting effect on attitudes to safety and maintenance in the industry. In the lead up to the explosion a pressure safety valve had been replaced with a blank flange, however explicit instructions not to use this valve were not communicated between rotating shifts. An extensive inquiry chaired by Lord Cullen reported that this handover failure was a key factor in the eventual disaster.
Texas City Refinery Explosion, 2005
On March 23 2005 a Hydrocarbon Vapour cloud ignited and exploded at BP’s Texas City refinery killing 18 and injuring more than 180. The City operation was the second largest refinery in the State, and the third largest in the US overall. Following the accident, the US Chemical and Safety Hazard Investigation Board found that poor communication between supervisors and operators had led to key information in relation to startup procedures not being included at shift handover time. It was further found that BP did not have a mandated shift handover requirement in place for its operations staff on site. The City refinery was eventually sold as part of BP’s efforts to address the fallout from another major accident, the Deepwater Horizon.
DuPont LaPorte Chemical Leak, 2014
A World War 2 era facility that was both a testament to its safety and a symbol of its owners fall from grace, the DuPont La Porte facility was a site where its workers had won national awards and recognition for their safe use of Chemicals. A catalogue of shift communication errors a number of days before the accident led to the eventual release of nearly 24,000 pounds of Methyl Mercaptan, a highly toxic chemical. Four workers died from toxic inhalation as a result of the leak. While poor procedures and actions undoubtedly contributed, DuPont themselves were heavily criticised for their role in the accident with the Occupational Safety and Health Administration board fining the company $372,000 stating that the facility had inadequate gas detectors, outdated alarms and broken ventilation fans.
Thankfully new technologies continue to make shift handovers safer experiences for all involved. Digital solutions like Relay allow workers on mobile devices to do on the spot note taking. Instant notifications can alert key stakeholders when particular events happen and digitally stored handovers allow vital shift intelligence to be analysed by management to spot trends and patterns.
At iHandover we work tirelessly to deliver digital handover solutions that enhance team safety. If you would like to know more about Relay, and how it can help protect your teams please fill out the form below.
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