Safety-critical communication

When appropriate means of communication are not in place, not in working order, not utilised or not utilised appropriately

Examples of system failures include:

• the absence of a formal or effective process for shift handover to ensure the oncoming shift are fully aware of plant status and operational issues
• an inadequate system to record plant information (e.g. log books) or failure to use record keeping systems
• inadequate radio coverage of plant area or insufficient communications equipment available.

When the means of communication exists, but the information that needs to be communicated is not communicated, or is communicated inaccurately

Examples of content failures include when:

• lack of clarity leads to incorrect assumptions about required actions
• inappropriate level of detail is provided (too much or too little)
• assumptions are made about each person’s knowledge or availability of information
• there is an inconsistency between tone or method of delivery of message and the nature of action required.

When the means of communication exists and the necessary information is delivered; however, it is not received on time or is misunderstood, misinterpreted or disregarded

Examples of reception failures include when:

• intended recipients don't receive the message
• radio communication is done in noisy plant areas
• hand written messages are illegible
• voice messages are not listened to in full
• volume of messages is excessive or inadequate e.g. alarm messages on plant control systems during start up, shutdown or emergency conditions.

For an effective start of shift or shift handover that reduces the likelihood of an incident arising during the shift, consider:

• providing procedures describing key information that needs to be exchanged, the method for doing so and order of priority
• allowing sufficient time for handovers to remove time pressure and other distractions
• developing procedures for information sharing during higher risk handovers:
  • during shutdowns, unusual operating conditions and emergency breakdowns
  • during work which involves complex permits and/or isolations
  • when people have had extended absences from the worksite
  • when there are inexperienced workers on the job
  • when there is handover between experienced and inexperienced workers
• worker competency in effective implementation of handover procedures
• regular auditing of the quality and effectiveness of the handover process, including consulting with the workforce on their experience of shift handover communication
• where possible, planning handovers so they are completed face-to-face and allow for crews to openly discuss issues to reduce the possibility of misunderstandings
• allow for two-way communication during shift handover; that is, in addition to providing information to workers, encourage questions and feedback from workers
• the effectiveness of shift handover communication during any incident investigations and make alterations where necessary
• checking that the content of handover communication is relevant, so as not to obscure the information with irrelevant detail
• reducing environmental interference such as noise and insufficient lighting.

Permit to work procedures (systems) provide a safe framework for work to take place by ensuring that hazards are identified and controlled. For example, adequate isolation of hazardous energy sources, provision of fire extinguishers and decontamination. Permits to work are required for different types of activities in normal operations, construction and maintenance. For example, excavation, confined space entry and hot works.

Operations: Permit to work and isolation procedures enable the operations teams to identify hazards, implement the required controls, and effectively isolate and prepare the correct equipment in a timely manner to enable servicing, maintenance and repair tasks to be safely performed.

Maintenance: Effective communication during maintenance requires all parties involved in the work to be included in the information sharing. This includes representatives from all work fronts and interfaces whether that is operations or maintenance. In particular, make sure that there is clear agreement whether an item of equipment is available for operation or under maintenance. It is vital that operations and maintenance personnel are clear at all times on the status of equipment which is being maintained or has undergone maintenance.

The term “owner” is used to define the department, team or person that is in charge or control of an item of equipment, system or plant. The owner has the authority to authorise an individual or work team to operate the equipment and/or perform maintenance work on the equipment or within the work area(s) they are accountable for. Having an owner assists with effective communication. Establishing who the “owner” at any point in time is critical to prevent the accidental operation of equipment under maintenance and the maintenance of equipment which is still operational (or capable of being operated).

There are a range of methods that can be used to communicate who the “owner” is, including:

• identifying “on shift” personnel and their area of accountability on plant or equipment status boards in control rooms
• requiring all non-process personnel to report to a control room to obtain approval prior to entering the plant
• a permit to work procedure or system which formally transfers “ownership” and control of plant or equipment to enable a defined scope of work to be performed
• appointing permit coordinators who are responsible for issuing permits to work authorising performance of work on plant and equipment
• a procedure for the management or transfer of permits during shift handover (workers will need to be trained and deemed competent in this process).

There is a tendency for permit to work procedures, systems and forms to become complex as they mature and it is important that personnel working with the system are adequately trained (and periodically retrained) in the requirements to ensure they remain competent. Similarly, permit to work procedures that have been adjusted and become more complex over time, should be reviewed for effectiveness and useability.

Without regular review, it is likely that degradation of the permit and isolation system will only be identified when an incident occurs.