RESEARCH & DISCOVERY PROJECT...research & discovery project research and review of industry best practice – grid mesh, barricading & shift handover final report 1 december 2012

PREPARED BY: IBIS BUSINESS SOLUTIONS & PEOPLE KNOWLEDGE CONSULTING 1

PREPARED FOR: Steve Emery, Senior Project Manager John Holland Group Pty Ltd

PREPARED BY: Ibis Business Solutions Pty Ltd (ABN: 16 094 816 029) & People Knowledge Consulting (ABN: 87 080 157 902)

RESEARCH & DISCOVERY PROJECT

RESEARCH AND REVIEW OF INDUSTRY BEST PRACTICE – GRID MESH, BARRICADING & SHIFT HANDOVERFINAL REPORT 1 DECEMBER 2012

RESEARCH & DISCOVERY PROJECT: GRID MESH, BARRICADING AND SHIFT HANDOVER FOR: JOHN HOLLAND GROUP PTY LTD2

REVISION HISTORYVERSION AUTHOR SIGNED REVIEWER SIGNED DATE

1.0 Brett Mayze Neil Isles 30/11/12

Greg Stuart Tony Trajanovski

Tony Trajanovski

tony.trajanovski

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tony.trajanovski

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CONTENTS EXECUTIVE SUMMARY 4Grid Mesh 5Barricading 5Shift Handover 6

INTRODUCTION 7Grid Mesh 8Barricading 8Shift Handover 8

METHODOLOGY 9Industry Standards 10Industry Consultation 11Literature Review 12

FINDINGS & DISCUSSION 13Grid Mesh 14Barricading 17Shift Handover 22

CONCLUSION & RECOMMENDATIONS 39Grid Mesh 40Barricading 41Shift Handover 44

REFERENCES 46Grid Mesh 47Barricading 47Shift Handover 47

APPENDICES 50Appendix A: Shift Handover 53


EXECUTIVE SUMMARYJohn Holland Group Pty Ltd engaged Ibis Business Solutions (Ibis) in partnership with People Knowledge Consulting (People Knowledge) as experts to research, review and report industry leading practice in relation to grid mesh, barricading and shift hand over processes.

This research involved a world-wide literature review (including peer review journals and industry specific publications), industry consultation (seeking internal standards, procedures, processes and practices that describe differing organisations management of the research topics) and review of legislative and other requirements (including quality standards, codes of practices, guidance and advisory materials).


GRID MESHWith regard to the installation, removal, inspection and auditing of grid mesh installations, key findings outline:

• Twospecificregulatorydocumentswerefoundtoberelevant to the selection and installation of grid mesh; the Western Australia Health and Safety Regulations and AS/NZS 1657 (1992).

• Therearetwomaintypesofgridmeshavailableonthe market for flooring use, Expanded Metal Mesh and Grid Grating.

• FactorstoidentifywhichstyleofGridMeshismostsuitableforinstallationincludelocation,trafficvolume,possiblevehiclemovementandloadbearingcapacity.

• Securinggridmeshusingaminimumnumberoffasteningpointsisrecommendedbyonemajorsupplierandwhethersecuredbyweldsorclips/clampsisbasedonthecriteriafortheselectionofthestylesuitability.

• Whereanyworkisundertakenongridmesh,whetherinstallation,fixingorremovalwork,itwasidentifiedthatthemajorityofparticipantsensurethattheworksactivitiesareconductedunderaworkspermittoensurethattheworksareconductedinaccordancecompanyproceduresanddonotintroducenewhazardstotheworkplace.

Anumberofkeyareasthathavebeenidentifiedasensuringbestpracticeinclude:

• Ensuringthatallactivities,includinginstallation,fixingand removal of grid mesh are conducted under a workspermitissuedbyacompetentandauthorisedcompany representative.

• AriskassessmentorJobHazardAnalysisistobecompletedspecifictotheactivityandworkareapriortoanyworkactivitycommencing.

• Allpersonnelinvolvedinthegridmeshworkactivitiesaretrainedinworkingatheightsandinusingtherelevant equipment, and in the company processes and proceduresforthegridmeshworkactivity.

• Amethodforensuringthatgridmeshinstallationsareclearlyidentifiedashavingbeeninspected,whetherbyapplicationofaninspectionplateorsomeother mechanism.

BARRICADINGAreviewoflegislation,codes,standards,guidelinesandpublishedliteratureshowedthatthereisverylittleinthewayofdocumentedindustrystandardsthatspecificallyrelatetotheselectionandinstallationofbarricading.TheoneexceptiontothiswasthecodeofpracticedevelopedbyAbuDhabiEHSCentre(2012).

Also,theliteraturereviewdidnotidentifyanyspecificresearchassociatedwiththeselectionandinstallationofbarricading.Theonlyarticlesidentifiedrelatedtotheuseand effectiveness of signage in general.

In contrast, the industry consultative process revealed that the majority of organisations that had actively participated had either:

• Adedicatedstandardthatidentifiedtypesofbarricadingtobeused,outlinedtheselectionprocessfortheuseofbarricadingandinstallationandremovalprocedures;or

• Therequirementsassociatedwithbarricadingwereaddressed (to varying degrees) in other standards relatingtohazardspecificactivitiessuchasworkingatheights and / or system manuals.

Thereareanumberofkeyareasthathavebeenidentifiedasensuringbestpractice.Theseareasinclude:

• Clearlydefiningthetypesofbarricadesandspecificrequirements for their selection, installation, use and removal.

• Documentingandcommunicatinginstallationandremoval procedures.

• Havingclearsignagethatisvisible,recognisedandunderstoodbyall.

• Useofinformationtagsthatcommunicateclearandconciseinformationregardingthebarricadeandresponsibleperson.

• Considerestablishingremovalchecklistprocedures/permitswherelifemaybeendangeredwithoutwarning.

• Implementgeneralawarenesstrainingforallpersonnelandcompetencybasedtrainingforpersonnelwithkeyresponsibilitiesforbarricading.

• Implementanauditandinspectionprogram.


SHIFT HANDOVERWith regard to the shift handover process, key findings outline:

• Shifthandoverissensitivetocontextandaccordinglyis hampered in achieving a standardised approach to handover content.

• TherearespecificreferencestoshifthandoverobligationsinAustralianminingregulationsbutlimitedguidancematerialsorstandardsavailableinhowtobestconduct or structure shift handovers.

• Leadingindustries(e.g.Healthcare,Oilandgas,andAviation) have commissioned significant research in the topic of shift handover and have documented practices, guidelinesandproceduresthatarewelladvanced.

• TypicallyshifthandoverplanningformsthatwerereviewedfromAustralianconstructionandheavyindustrieswerehighlygenericandconsistedmainlyoffree form fields.

• Commonlyshifthandoverisconductedfacetofacebetweensupervisorsorsuperintendentswiththeoutcome of the handover fed into the oncoming shift’s pre-startmeeting,contrarytoNASA’sresearchedbestpractice of face to face, team to team.

• FromAustralianconstructionandheavyindustriesproceduresreviewed,shiftlogorplodbooksarerarelymentioned or used and rarely do current procedures reviewedreferencewheretheshifthandovershouldbeconducted.

• Theinclusionofauditingarrangements,analysisofshifthandover records and the inclusion of communication skillsinselectioncriteriacouldnotbeevaluatedfromthematerials provided.

• Oneorganisationhasmadesignificantinvestmentandadvancementintheuseoftechnologyalignedwithbestpracticesapproachedinitsengagementwithshift handover.

Key findings outline that current advancements to standardise shift handover in several industries are challenginggiventhedifferingriskprofilesofactivitiesbeinghanded over and sensitivity of shift handover to context. Basedonawiderangingreviewofshifthandovermaterialsand research, it is suggested that:

• Thereshouldbeprovisionofclearprocedures/writtenguidancedescribingthekeyinformationtobeexchangedduringshifthandover,withastructurefortheconversationandsuggestionsonhowthishowthisshouldbedone.

• Shifthandoversshouldbeconductedface-to-face,crewtocrew.

• Thereshouldbetwo-wayshifthandovers,withbothparticipantstakingjointresponsibilityforensuringaccurate communication and understanding.

• Handoversshouldincludebothverbalandsupportinghandoverartefactswhichbestpracticecurrentlypointstowardsasbeingvisualtechnologiesofsite.Thesehaveimprovedfromelectronicstaticdatabasesandhandwrittenlogorplodsheets.

• Trainingshouldbeprovidedtoensurethatemployeesare competent to use handover procedures, logging, plodsheets,databaseorassociatedtechnologiesthataccompany shift handover processes and have the opportunity to develop their presentation, facilitation and communication skills.

• Shifthandoverrecordsshouldbemaintainedandanalysed for learning opportunities.


INTRODUCTIONJohn Holland Group Pty Ltd engaged Ibis Business Solutions (Ibis) in partnership with People Knowledge Consulting (People Knowledge) to conduct research into, and review, current safety practices and requirements in the Australian construction industry and internationally. This research involved a world-wide literature review (including peer review journals and industry specific publications), industry consultation (seeking internal standards, procedures, processes and practices that describe differing organisations’ management of the research topics) and review of legislative and other requirements (including quality standards, codes of practice, guidance and advisory materials). The focus of the research was to identify industry leading practice in relation to grid mesh, barricading and shift handover processes as outlined in this report.

This report sets out the findings and recommendations of the research undertaken and details all practices researched and reviewed. Recommendations for industry leading practice are specified and the justifications for selection of these recommendations as industry leading practice are provided for each of the processes.


GRID MESHResearch,reviewandreportindustryleadingpracticeinrelation to grid mesh standards, practices and procedures to identify:

• Documentedindustrystandardsfortheselectionandinstallation of grid mesh,

• Documentedinstallation,fixingandremovalprocedures.

• Installation,fixingandremovalchecklistproceduresincluding permitting requirements.

• Industrytraininginrelationtotheuse,installation,fixingand removal of grid mesh.

• Industryacceptedauditingprocessesforensuring compliance.

BARRICADINGResearch,reviewandreportindustryleadingpracticeinrelationtobarricadingstandards,practicesandproceduresto identify:

• Documentedindustrystandardsfortheselectionandinstallationofbarricading.

• Typesofbarricadingincludingselectioncriteriaandfitness for purpose.

• Documentedinstallationandremovalprocedures.

• Barricadingsignagerequirements.

• Installationandremovalchecklistproceduresincludingpermit requirements.

• Industrytraininginrelationtotheselection,installationandremovalofbarricading.


SHIFT HANDOVERResearch,reviewandreportindustryleadingpracticein relation to shift handover standards, practices and procedures to identify:

• Industryaccepteddefinitionof“shift handover”.

• Criteria(typeofproject,typeofactivity,etc.)totriggershift handover requirement.

• Documentedindustrystandardsandproceduresforthedocumentation of shift handover including:

– method of shift handover,

–items/issuestobediscussedandincludedinshift handover,

– communication of information at shift handover.

• Industrytraininginrelationtoshifthandovermethodsand communication.



METHODOLOGYThe purpose of the review was to examine current practice and make recommendations based on leading approaches and standards to identify the most comprehensive, accurate and safe procedures in the areas of grid mesh, barricading and shift handover. The commencement and project planning for this review began in the week of September 3rd, while the formation of the project team and data collection commenced on Monday September 10th. In total, the research project had a seven week window with submission of this report on Monday October 29th.

At the outset the research team identified a three pronged methodology as the most appropriate and effective way of maximising data collection within the project timeline. This multi front approach sought maximum involvement of industry through personnel (namely safety professionals) most affected by any changes in current practice while simultaneously engaging with peak bodies, industry collaborative forums, safety authorities, regulators and legislative guardians. Underlying this consultative data collection more passive documentation including written materials, industry publications, empirical studies, journal articles, books, conference proceedings and the internet were also searched for relevant best practice material and findings. A detailed explanation of each approach taken to collect and maximise research materials across these three different fronts is outlined in the following sections.


INDUSTRY STANDARDSForeachofthethreeprocessesunderreview(gridmesh,barricadingandshifthandover)allformsofrelevantAustralian legislation, codes of practice, regulations, rules andstandardswereresearched.Theseweresourceddirectlyandindirectlyfromavarietyofbodiesincludingstate regulators and government departments, Standards Australia,industryassociations,peaksafetybodiesandconsultationwithsafetyprofessionals.MaterialscollectedforreviewincludedstatebasedOccupational Health and Safety Acts, relevant regulations and mandatory standards, codes of practice and non-mandatory standards and specific guidance material. Each of the collected materials wasreviewedandcomparedinitscontentrelevantsectionin the “findings and discussion” section of this report.

It is important to note at this point, that this paper does not discussandcontrastdifferentsafetylegislationworldwide,nordiscussthecurrentchangeswithharmonisationofworkplacehealthandsafetylegislationinAustralia.Rather,thecontributionofthissectionofthereviewistoprovideastarting point for the various minimum standards imposed onoperatorsinrelationtothethreesubjectprocesses(gridmesh,barricadingandshifthandover).Theseminimumobligatorystandards,guidelinesorrulesprovidethebaselinefromwhichthevariousapproachestothethreepracticesunderreviewcandevelopandexpand.Effectively,reviewfromthissectionprovidestheframeworkfortheminimumlevelofcompliancewhileguidancematerialprovides insight into general thinking and suggested innovation in industry approaches, if any.


INDUSTRY CONSULTATIONInadditiontoareviewoflegislationandtheexistingstandards and guidance materials the project team also soughttoengagearangeofsubjectmatterexperts,industryassociationsandcollaborativebodiesandorganisations.Acontactlistwasdevelopedtoidentifyrelevant sources that could provide information, insight, and specific materials around their internal policies, standards, procedures, processes and practices in the threeprocessesunderreview.Thiscontactlistincludedmore than 70 organisations across various sectors in Australiaandoverseas.ThecontactlistwasprovidedtoJohnHolland’sProjectManagerforreviewandinputpriortocommencementofconsultation.Wherepossiblelargemultinationalorganisationsweretargetedtogainaccesstooverseaspractices,whilethefinalcontactlistincludedinvolvementfromthefollowingindustries:

• BuildingandConstruction

• MiningandMineralProcessing

• EngineeringandConstructionManagement

• Oil,EnergyandGas

• HeavyManufacturing

• MaintenanceServices

• WaterandWasteServices

• HigherEducation

• HealthCare

Industryengagementwasintendedtobebroaderthantheconstructionsectortogainabroaderviewofbestpracticebyengagingorganisationsandindividualswithexperienceandexposuretothethreeprocessesunderreview.

Contactwithorganisationswastargetedthroughkeyindividuals, usually safety professionals at senior levels withintheorganisation.Thesecontactsthereforehaddelegationsthatenabledthemtoagreetoparticipateintheresearchonbehalfoftheirorganisationandhadtheaccess and resources to provide the requested materials. Consultationwasconductedusingasemistructuredinterviewprocesswithinitialcontactmadeviafacetofaceortelephoneandafollowuprequestformaterialsviaemail.Acopyofthesemistructuredinterviewguideisprovidedinthe Appendices.

Responsestoourrequestwerevariableacrossthethree processes, though generally limited to less than 20 companies(roughlya27%responserate)intotalwhichprovideddocumentationwithintheprojecttimeframe.Eachindustrysectorwasrepresentedbyatleastoneexample.Themajorblockagesfororganisationsnotbeingabletocontributeincluded:

• Keypersonnelbeingunabletobecontacted,returncalls or redirect queries for requests for materials due to existing operational commitments and/or travel.

• Inabilitytoprioritiserequestsformaterialsinthegiventimeframe due to existing or unforeseen commitments.

• Citingalackofexistence,lackofhavingdocumentedformal, or immature existing procedures and systems for the three processes requested.

• Concernsaroundintellectualpropertyordetrimenttotheir competitive advantage.

Astructuredapproachforthedatacollectedwasusedtoexamine current policies, procedures, documentation, and allinformationsourced.Thesematerialswerereviewedfromadesktopstandpointasnoopportunitywasavailableto gauge implementation, effectiveness or practicality of these systems.


LITERATURE REVIEW Reviewofexistingliteratureincludedsearchesforrelevantmaterialsongridmesh,barricadingandshifthandoverandinvolvedsearchingarangeofmediaincludingbutnotlimited to:

• Peerreviewedjournals.

• Librarycatalogues,eBooksandbookreviews.

• Electronicdatabasesandpublicationresources.

• Industrypublications,journals,newspapersand magazines.

• Conferenceproceedings,presentationsandacademic theses.

• Theworldwideweb.

Thisdocumentationwassystematicallycollatedandevaluatedforeachofthespecifictopicsunderreviewandtheirrelevanceforinclusion.Applicablearticlesandpapersusedinthereviewareforthepurposeofidentifyingorjustifyingbetterpracticeandarereferencedinthisreport.


FINDINGS & DISCUSSION


GRID MESHThroughoutthisreport,GridMeshwillbereferredtoforusein flooring materials as its sole application. No reference or identification for the installation, use or auditing of other applicationsofGridMeshproductsisintendedtobeincludedaspartofthisreview.

DOCUMENTED INDUSTRY STANDARDS FOR THE SELECTION AND INSTALLATION OF GRID MESH

Legislation (Acts & Regulations), Codes, Standards, Guidelines

Followingreviewofthelegislation,codes,standardsandguidelinesapplicabletogridmeshglobally,fourcriteriawerefoundtoberelevanttotheselectionandinstallationofgrid mesh.

AS/NZS 1657 (1992) documents the requirements for ensuring that grid mesh used in a flooring application must meetthefollowingcharacteristics:

• Gratedfloorsshallbeconstructedinsuchaformaswillprovide a slip-resistant surface.

• Thesmallerdimensionofanyopeningshallnotexceed40mm and the area of any opening shall not exceed 5000mm2.

• Anygapbetweenadjacentmadeupsectionsofgratedfloorsshallnotexceed10mmandmaybeofanylength.

• Wheretheslopeofawalkwayexceeds1in8(7degrees),thewalkwayshallbeof(a)grating(expandedtypemetal,metalgrating);(b)metalplatefittedwithcleats;(c)timbercomplyingwithClause2.2.3.1fittedwithcleats;or(d)otheracceptablematerial.Wheregratingisused,itshallbesubjecttoacceptancebytheauthority having jurisdiction.

The Western Australia Health and Safety Regulations state thatapersonwho,ataworkplacethatisaconstructionsite, is the main contractor, an employer or a self-employed person must ensure that if grid mesh or checker plate flooringpanelsarebeinginstalledattheworkplaceeachpanelissecurelyfixed,inaccordancewithmanufacturer’sspecifications,toasupportingstructurebeforethesupportstructureisplacedintopositiononthebuildingorstructureunderconstructionandwherethisisnotpracticable,theneachpanelissecurelyfixedtothebuildingorstructureunder construction immediately after the panel is placed into position.

Industry Consultation

Therearetwomaintypesofgridmeshavailableonthemarket for flooring use. These are identified as Expanded Metal Mesh and Grid Grating.

Anumberoffactorsareusedtoidentifywhichstyleofgridmeshwouldbemostsuitableforeachinstallation,includinglocation,trafficvolume,possiblevehiclemovementandloadbearingcapacity.

Expanded Metal Mesh is manufactured from solid sheets ofcarbonsteel,galvanisedsteel,oraluminiumandother metal/alloys. In the expanding process, the sheet is simultaneously slit and stretched, expanding the slits into diamond-shaped holes of uniform size, shape and regularity. No metal is lost in the expanding process and the final product is stronger per kilogram and lighter per metre thantheoriginalsheet.Thenewlyformedstrandsandknuckles of the diamond-shaped trusses are at an angle to the original plane of the sheet, adding strength and rigidity.

Fromconsultationwithmanufacturersandsuppliersgenerally,theexpandedmetalmeshisconsideredtobemore slip resistant due to the angled diamond pattern creating ridges that provide a greater level of traction than standardgridgrating.However,theincreasedtractioncomes at the price of raised sharper edges on the mesh whichcancausemoreinjuryintheeventofafall.Whenselectingthestyleofgridmeshbasedonslip-resistanceitis critical to ensure that the increased exposure in the event of a fall is considered.

Grid Grating is a commonly used product in the manufactureofstairtreads,walkwayflooring,screensanddraincovers.Itisametalpanelmanufacturedbyweldingaseriesofloadbearingbarstoacrossbarpositionedat90degrees. This grid is then “banded”withametalflatbartoprovideadditionalrigidityandstabilitytotheloadbearingbars.Gridgratingisavailableaseitherhotdipgalvanisedoruntreated (ungalvanised) steel. Galvanised grid grating has adurable,abrasionresistantcoatingofmetalliczincandzinc-alloylayersmetallurgicallybondedtothesteelbaseinaccordancewithAS/NZS4680:2006.Gridgratingcanalsobemanufacturedinthreedifferentloadbearingbarsectionshapes,ineitherI-bar,flatbarorserratedbardependingonthe application.

When installing either style of grid mesh, accepted and recommended practice is to ensure that the manufacturer’s guidelinesforinstallationarefollowed.Thiswillincludemethods of securing and supporting the grid mesh. There aretwocategoriesofsecuringgridmeshthatareavailable–weldingandviaclips/clamps.


Fromreviewingmaterialssuppliedbythemanufacturersandsuppliersofgridmeshgratingproducts,ithasbeenidentified that one major supplier recommends using the followingnumberoffasteningpointsasaminimumwhensecuring grid mesh:

SPAN CLIPS / WELDS

500 to 1500mm 4

1500 to 3000mm 6

3000to4000mm 8

4000 to 5000mm 10

5000 to 6000mm 12

Whetherthegridmeshgratingpanelsaresecuredbyweldsor clips/clamps depends on the same factors as selection ofthegridmeshproductaswellashowoftenthegratingwillberequiredtobeliftedorremoved.

Expandedmetalmeshcanbesecuredbyeitherweldingor clamping methods depending on the frequency of the panelneedingtoberemoved.Whenusingweldingasthefixingmechanism,thepanelshouldbesecuredinaccordancewiththemanufacturer’sguidelinewhichisaweldeverythirdorfourthstagdependingontheproductbeingused.

Documented Installation, Fixing and Removal Procedures

There are no specific standards or legislation for the installationofgridmesh(onlyforthemanufacture)howeverthe installation must meet the requirements of AS/NZS 1657 (1992).

Followingreviewofthematerialssuppliedbyindustryparticipants,itwasidentifiedthattheinstallationprocessisbrokendownintothreesections.

The first section is the pre-installation activities that are completedbeforeworkactivitiescommence.Theseinvolveconductingjob/taskassessments,communicatingwithrelevantpartiesandobtainingaworkpermitfortheactivitiesbeingconducted.Itwasidentifiedthat66%ofcompanies undertaking grid mesh installation, fixing and removalactivitiesrequiredthatajobhazardanalysisorriskassessmentbecompletedbeforeactivitycommenced,howeveronlyonecompanystatedaspartoftheirprocedurethattheassessmentwastobeconductedforthespecificworklocation.

Inadditiontoconductingariskassessmentorjobhazard analysis, 30% of companies stated that the assessmentmustbeclearlydisplayedonnoticeboardsorformallycommunicatedtoallworkpartiesimpactedbytheworkactivitiesbeingconducted.Communicationwiththeimmediateworkpartyispartoftheacceptedassessmentprocess,however,theadditionalrequirement

tocommunicatewithworkpartiesintheaffectedareaensuresthatallpartiesareawareoftheworkbeingconducted on site.

For30%oftheproceduresprovidedbyindustry,itiscompulsoryforaworkpermittobeinobtainedinorderforanyworkactivitytobeconductedinrelationtogridmesh.Thepermitmustbespecifictotheactivityandlocationandmustbeissuedbyanauthorisedcompanyrepresentative.

The second section of the grid mesh process is in relation to the process of installing grid mesh.

In30%oftheproceduresreviewed,itwasarequirementthat,wherepossible,thestructuralsupportmembersweretobeinstalledandfullysecuredpriortotheinstallationofthe grid mesh.

Itwasalsoidentifiedthatguardrails,handrailsandkickboardsweretobeinstalledatthelimitsofthegridmeshinstallationactivitiesandthatfallarrestequipmentwastobeusedbyinstallerstoassistinthepreventionoffallsfromheight.Thiswasidentifiedasacceptedpracticebythe majority of the company procedures and processes reviewed.In30%oftheproceduresreviewedadditionalhardbarrierswererequiredtoisolatetheareadirectlyunderneath the installation area to prevent injuries from fallingobjects.

When conducting the installation of the physical panels, 30%oftheproceduresreviewedcalledfortemporaryfixingwithwiresorclampsduringtheemplacementprocesspriortobeingpermanentlyfixedinplacebyeitherweldingorfixingclamps/clips.Thiswastoensurethatthepanelscouldn’tbemovedornudgedoutofpositionwhileadjacentpanelsweremovedintopositionorthepaneldidn’tshiftwhilebeingsecuredintoplace.

Where, during the installation process there is an instance ofthepanelsnotfitting,30%oftheproceduresreviewedcalled for a cessation of all installation activities until remedialactionhadbeencompletedandthepanelswerefitting in place as designed.

Thefinalsectionofproceduralprocesswasinrelationtothe removal activities relating to grid mesh.

With regard to the removal of grid mesh, 33% of the proceduresrequiredaworkspermittobeinplacepriorto the commencement of any removal activities. In one instance,writtenauthorisationforthespecificworkzoneisrequiredinadditiontoholdingaworkspermitfortheremoval activity.

Inallproceduresreviewed,solidbarricadingisrequiredaroundtheextremitiesoftheworkzonewheregridmeshistoberemoved.Inaddition,in20%ofprocesses,theareabelowtheworkzonemustbehardbarricadedandsignednotifyingworksbeingundertakenoverhead.


In all instances of grid mesh installation, fixing and removal, trainingisrequiredtobecompletedasidentifiedinthesection in this report on industry training in relation to the use, installation, fixing and removal of grid mesh.

Installation, Fixing and Removal Checklist Procedures Including Permitting Requirements

Reviewoftheproceduresanddocumentationsuppliedbyparticipantshasidentifiedthefollowingareasasbeingofkeyconcernwhenperforminganinspectionofinstallation,fixingorremoval/re-instatementactivitieswithgridmesh:

• Loosepanels

• Looseormissingfixingclips/clamps

• Unsupportedloadbars

• Deformationordamagetopanels

• Triphazardsorpanelssittingupcreatingaraisededge

• Corrosion

Inoneinstance,acompanyhascreatedapostworkinspectionchecklistthatissignedoffbyanindependentinspectoroncetheworkactivityhasbeencompletedandinspected. The checklist ensures that the installation or reinstatementhasbeencompletedinaccordancewiththemanufacturer’s installation requirements and is safe for use.

Whereanyworkisundertakenongridmesh,whetherinstallation,fixingorremovalwork,itwasidentifiedthatthemajorityofparticipantsensurethattheworkactivitiesareconductedunderaworkspermittoensurethattheworksareconductedinaccordancewithcompanyproceduresanddonotintroducenewhazardstotheworkplace.

Industry Training In Relation to the Use, Installation, Fixing And Removal Of Grid Mesh

Currently,therearenostandardisedindustrytrainingcoursesavailablefortheuse,installation,fixingandremovalof grid mesh.

Discussionswithmanufacturersandsuppliersofgridmeshhaveindicatedthatthegeneraltrendisforthemtobesolesuppliersandnotbeinvolvedintheuse,installation,fixingor removal process.

Discussionswithindustryhasidentifiedthatitiscommonpractice for companies to train their personnel using internalproceduresforworkingwithgridmesh.Nationallycertified training is provided to support the use, installation, fixingandremovalprocessesinthefollowingareas:

• WorkingAtHeights

• FallArrest

• Rigging

AdditionaltrainingisalsoprovidedininternalPermittoWork systems as the majority of companies surveyed identifiedthatnoworkactivitiesinvolvinggridmeshweretobeconductedwithoutaPermittoWorkbeinginplace.

Industry Accepted Auditing Processes for Ensuring Compliance

Therearenospecificlegislativerequirementswithregardtoinspection of grid mesh.

Inliteratureavailableduringthisreview,itwasevidentthat regular inspection of grid mesh installations is highly recommended as there is a high incidence of injury andaccidentduetogridmeshpanelsbeingdamaged,corroded or unsecured.

All manufacturers and suppliers consulted indicated that therewasaneedtoensurethatregularinspectionsofgridmeshinstallationswereconductedbasedonthelevelofriskofaninstallation.Itwasindicatedthatthefrequencyofinspectionscouldbepushedouttoamaximumoffiveyears depending on the securing mechanisms, the level of traffic, environmental conditions and cleaning/chemical usage on grid mesh panels.

Inoneinstanceacolourcodedinspectionplatewassecured to the grid mesh panel indicating the date of inspectionandapprovaltoremaininservicefollowinginspection.Thisallowedallpersonneltoquicklyidentifywhichinstallationshadbeenassessedandwereconsideredsafetouseandwhichwerestilltobereviewed.

Documentationprovidedbyindustryindicatesthatinspectionsofgridmeshinstallationsaretoberegularlyconducted;howeverthefrequencyofinspectionisdependent on the perceived risk of the installation.


BARRICADINGAttheoutset,thetermbarricadinganditsrelevancetotheresearchundertakenneedstobeclarified.Forthepurposesofthisresearch,(basedonthedefinitioncontainedwithinAbuDhabiEHSCentre(2012))barricadingis defined as:

A temporary structure (rigid or flexible in nature) consisting of vertical and / or horizontal components (eg. mesh, tape, panels, rails etc.), or similar objects, used to create a restricted access area to prevent unauthorised entry into a particular work area or area where a hazard may exist.

Itshouldbenotedthatguarding/formwork/scaffolding/guardrailing/perimeterfencingorperimeterscreenswhichare used for the purpose of traffic management, machinery access/protectionorfallpreventioneg.workingonroofs-edgeprotection;multilevelbuildings-perimeterscreens;walkways;workplatforms;scaffolds;stairs;blastprotection;etc.werenotconsideredtofallunderthedefinitionofbarricadingforthepurposesofthisresearch.

DOCUMENTED INDUSTRY STANDARDS FOR THE SELECTION AND INSTALLATION OF BARRICADING

Areviewoflegislation,codes,standards,guidelinesandpublishedliteratureshowedthatthereisverylittleinthewayof documented industry standards that specifically relate totheselectionandinstallationofbarricading.TheoneexceptiontothiswasthecodeofpracticedevelopedbyAbuDhabiEHSCentre(2012).AbuDhabiEHSCentre(2012)definesrequirementsfortheuseofbarricadesincluding:

• Trainingandcompetencyneeds.

• Assessingtheneedforbarricades.

• Definingthedifferenttypesofbarricades.

• Installationofbarricades.

• Barricadingsignage.

• Useofbarricadingtape.

• Barricadingmaterials.

• Lighting.

• Preventionofunauthorisedaccess.

• Inspectionrequirementsforbarricading.

• Removalofbarricading.

Also,theliteraturereviewdidnotidentifyanyspecificresearchassociatedwiththeselectionandinstallationofbarricading.TheonlyarticlesidentifiedrelatedtotheuseandeffectivenessofsignageingeneralBrunerL.(2007),K.L.ChanAlanH.S.Chan(2011),ChanA.H.S.&NgA.W.Y.(2010),LaugheryK.R.&WogalterM.S.(2012)andTownsendD.(2008).Forasummaryofthefindingsofthisresearch, refer to the section titled Barricading signage requirementsbelow.

Itshouldbenotedthattheoppositeapplieswhenreviewingbarricadingassociatedwithhazardspecificactivities such as:

• Excavations–Occupational Safety and Health Regulations 1996 (2012)requiresthatsuitablebarriersare installed to protect persons at risk of injury from excavationwork.WorkSafeWesternAustralia(2009)statesthataplasticsafetymeshbarrier900mminheightattachedtostarpicketsisanacceptablealternativetoarigidbarricadeforprotectionaroundexcavations.

• Publicaccess–WorkSafe Western Australia (2009) statesthatthehorizontalguardrailistobebetween900mmand1100mmfromthegroundwhenitisnecessarytoexcludemembersofthepublicfromatemporaryconstructionsiteorworkarea.

• Workatheights/preventionoffalls–Australian Safety and Compensation Council (2008) and Workplace Health and Safety Queensland (2011) for example, outlinespecificrequirementsforbarricadingassociatedwiththepreventionoffallsatroofedges,mezzanineedges,walkways,stairways,roofstructures,shafts,pits, etc. Identified requirements relate to types of barricading,heightofguardrails,abilityofbarricadingtowithstandapredeterminedforceandsignage.


In contrast, the industry consultative process revealed that the majority of organisations that had actively participated had either:

• adedicatedstandardthatidentifiedtypesofbarricadingtobeused,outlinedtheselectionprocessfortheuseofbarricadingandinstallationandremovalprocedures;or

• therequirementsassociatedwithbarricadingwereaddressed (to varying degrees) in other standards relatingtohazardspecificactivitiessuchasworkingatheights and / or system manuals.


TYPES OF BARRICADING INCLUDING SELECTION CRITERIA AND FITNESS FOR PURPOSE

Therearevarioustypesofbarricadingthatcanbeusedintheworkenvironment.Thetypesofbarricadingcanbegenerallycategorisedashardorsoftbarricading.Forthepurposesofthisevaluation,hardandsoftbarricadingisdefined as:

• Hardbarricading–Providesasolid/rigidbarrierthatcannotbewalkedthroughandisgenerallyconstructedofscaffoldtube,mesh,metalorwoodenpostsorrails,etc.Hardbarricadesmayincludefences,buildingwalls,concrete structures, standalone A’frames, earthen berms,waterfilledplasticbarriers,etc.

• Softbarricading–Delineatesanareathathasrestrictedaccessduetoanactivitythatisoccurringorwarnsofahazard/dangerthatmayexist.Thebarricadedoesnotprovideasolid/rigidbarrierandcanbeeasilywalkedthrough.Softbarricadesmayincludecolouredrope/ribbon,bunting,cones,flagging,bollards,etc.

Based on the documented industry standards and industry consultation, the selection criteria and fitness for purpose astowhichtypeofbarricadingtobeusedwasdeterminedbyoneofand/orbothofthefollowingfactors:

• Assessedlevelofrisktoanindividualshouldtheybeexposed to the particular hazard / danger or activity beingundertaken.Forexample:

–Employersshallusesoftbarricadingtoprevententryofpersonnel and equipment as an immediate and short-termcontrolwhereariskassessmentindicatesthattheassociatedriskislow;andusehardbarricadingto prevent entry of personnel and equipment to areas whereariskassessmentindicatestheuseofsolidbarricadestoprovideaphysicalbarrier.

–Softbarricadesaretobeusedforareasoflowriskwhereitisintendedonlytoidentifythattheareaisnotgenerallysuitableforpersonnelaccessonatemporarybasis;andhardbarricadesaretobeusedforareasofmediumtohighriskwherethereisarequirementfor personnel to remain clear, or not enter, due to an active process or specific danger.

• Theparticularactivitybeingundertakenwithinthebarricadedareaorthetypeofhazard/dangerthatwaspresent.Forexample:

–Hardbarricadingshallbeusedtoprovidephysicalprotection for high risk hazardous areas / activities wherepersonsareworkingatheight,elevatedworkareas,vehicle/pedestrianinteraction,aroundexcavations,steelerection,slewingmobileplant/equipment, etc.

–Hardbarricadingshallbeusedtoprotectemployeesfromimmediateriskbypreventingentrytoahazardsuch as open hole conditions or dangerous ground conditionsthatmaybeundetectablethatwillendangerlifewithnowarning.

Otherconsiderationsfortheselectionofbarricadingincludedfamiliaritywiththehazard,visibilityofthehazardsand the amount of clearance from the hazard.

Someofthestandardsdevelopedandusedbyorganisations contained a matrix that identified certain scenarios / activities / hazards and the specific types of barricadingrequiredtobeimplementedforthatspecificsituationinaccordancewiththeirstandards.Thisservesasaquickandeffectivereferenceguideforpersonnelwhoneedtoimplementbarricading.

DOCUMENTED INSTALLATION AND REMOVAL PROCEDURES

AreviewofAbuDhabiEHSCentre(2012)andorganisationalstandardsdemonstratedthattherewerecommonrequirementsassociatedwithinstallationandremoval procedures. These included:

• Barricadesmustbeinstalledbeforethecommencementofworks.

• Thebarricadedareaistoencompasstheentirepotentially affected area of the hazard.

• Barricadingistobeinstalledatleasttwometresawayfromthehazard.Wherethiscannotbedone,ariskassessmentshouldbeundertaken.

• Barricadingistobemaintainedingoodconditionensuring that it remains effective.

• Ahardbarricadeshallhaveasolidtopandmidrail(e.g.scaffoldtubeorequivalent).Thetoprailmustbebetween900mmand1200mmhighandmidrailshallbenomorethan560mmfromthefloorifnotoeboardisfitted,with450mmbetweenrails.Itmustbeabletowithstandaforceof0.55–0.90kN(approximatelyequivalent to 55 – 90 kg) applied at any point.

• Hardbarricadingistobeaccompaniedatalltimeswithrelevant flagging / tape.

• Barricadingmaterialssuchasmeshand/ortapeshallbeinstalledwiththetopedgeataheightbetween900mmand 1200mm.

• Plasticmeshbarriersshallbeaminimum900mmhighsupportedbycappedstarpicketsorotherupright structures.

• Barricadesupportsshallbeatmaximumspacingofthree metres.

• Barricadesshallbemaintainedinatautandlevelposition to prevent sagging.


• Waterfilledplasticbarricadesareclassedasasuitablebarricadingmethod.Iftheyareusedwherethereispotentialforavehicleimpacttheyshallbelinkedtogetherand filled.

• Barricadingshallnotbetiedtovalvehandles,conduit,instrumenttubing,electricalgear,orotherfragileitems.

• Barricadesshallbeinstalledinsuchawayastoeliminateaccidentalentryintothebarricadedzone.

• Entrypointsinbarricadingshallbearrangedsuchthatpersonnelenteringtheareacannotwalkdirectlyintothe hazard.

• Whereabarricadewouldnotsupportaperson’sweight,itshallbeplacedsothatanypersonfallingthroughitwouldnotreachthehazard.

• Nopersonshallenteradangerbarricadeareaunlessauthorityisobtainedfromthebarricadeowneraslistedonthebarricadetag.

• Capsshallbefittedtostarpicketsorstakes.

• Warninglights,suchasamberflashingbeacons,areprovidedatappropriateintervalswheretheriskassessmentindicatestheneedtowarnpeopleofthepresenceofabarricadeduringdarkness.

• Barricadingsignageshallbeinstalledonallbarricadesinaccordancewithrequirementsoutlinedbelowunder“barricading signage requirements”.

• Barricadesaretoberemovedimmediatelyoncetheworkiscompletedorthehazardnolongerexists.

In summary, the majority of differences from one standard toanotherwereminimalwhenitcametoinstallationandremoval procedures.

BARRICADING SIGNAGE REQUIREMENTS

Legislation (Acts & Regulations), Codes, Standards, Guidelines

AbuDhabiEHSCentre(2012)requiresthatemployers ensure:

• Thatwheresolidbarricadesareusedtheyareaccompaniedwithsignstocommunicatethehazardinformation.

• Barricadingsignsareattachedinappropriatenumberstoensurevisibilityunderallcircumstances.

• Barricadingsignsshallprovidethenameandphonenumberofthecontactperson/responsiblesupervisorinadditiontotheexpecteddurationthatthebarricadingshallbeinplace.Whereappropriate,signsshallalsohave attached specific hazard information eg. - “Danger no access-persons working above”.

Standards Australia (1994) AS1319 does not specifically refertoorrelatetosignageforbarricadingbutdoes

specify requirements for safety signs in the occupational environment.Relevantcategorieswithinthestandardthatcanbeappliedtobarricadingsignageincluderegulatorysigns and hazard signs. The standard outlines specific requirementsforcolour,shape,layout,useofsymbols,useofwording,signsizeandlegibility,symbolandlettersize,sign material, sign construction, sign erection and removal, sign location, and sign maintenance. It also outlines specific requirements for the use of accident prevention tags. Relevanceofthisstandardtorequiredbarricadingsignagewilldependprimarilyonthepurposeofthebarricade,levelof risk and site conditions.

Itshouldbenotedthattheoppositeapplieswhenreviewingbarricadingassociatedwithspecificactivitiessuchas:

• Excavations–Occupational Safety and Health Regulations 1996 (2012)requiresthatsuitablesignsthatwarnoftheriskareerectedattheplacewheretheexcavationworkistobedone.

• Perimeterfencingworkatheights–Australian Safety and Compensation Council (2008) states that signage shouldbeerectedwhichwarnsagainstentrytothose areas.

Literature Search

Theliteraturereviewdidnotidentifyanyspecificresearchassociatedwiththeselectionandinstallationofbarricadingsignage. The only articles identified related to the use and effectivenessofsignageingeneralBrunerL.(2007),K.L.ChanAlanH.S.Chan(2011),ChanA.H.S.&NgA.W.Y.(2010),LaugheryK.R.&WogalterM.S.(2012)andTownsendD.(2008).

These articles outlined key points in relation to general signage:

• Ifyouhaveamultilingualworkforce,makesurethatthewordingonthesignsisintherelevantmultiple languages.

• Besurethatyoursignscomplywithanyregulatoryandother industry standards.

• Usecolourcodingtocomplywithmandatedregulatorystandardswhererequired.

• Graphicsonsignsshouldbecolourfulandboldandimmediately convey the message.

• Placeappropriatesignsatthepointofdanger.

• Consistentformatforsignsandlabelsshouldbeusedthroughout the facility for clarity.

• Createcustomisedmessagestoclearlyidentifyrequirements for entering a specific area or operating a specific piece of equipment.

• Materialsusedforsignsandlabelsshouldbeabletoenduretheenvironmentwheretheyareused.Speciallydesignedandtestedmaterialsareneededtowithstandharsh environments.


Theyidentifiedthatthecomprehensibilityofsafetysignswasbetterforthesignswhichwerefamiliar,concrete,simple,meaningfulandabletobeassociatedwiththeunderlying concepts.

LaugheryK.R,&Wogalte,M.S.(2012)foundthatthefactorsthathaveshownsignificanteffectsare:

• Location–placedwhereitislikelytobeencountered.

• Size–biggerisgenerallybetter.

• Colour–huedifferencesforprominence.

• Contrast–brightnessdifferences;blackonwhiteorviceversaforgreaterlegibility.

• Format–“chunked”textandoutline/bulletedlistsattractattentionbetterthanlargedenseparagraphsoftext.

TownsendD.(2008)statesthatforasigntobeeffectiveitmustbevisible,readable,noticeableandlegible.HealsooutlinesU.S.OSHArequirementsforsignageas:

• Dangersigns–usedonlywhereanimmediatehazardexists.Dangersignshaveredasthepredominantcolourfortheupperpanel;blackoutlineontheboarders;andawhitelowerpanelforadditionalsignwording.

• Cautionsigns–warnagainstpotentialhazardsorunsafepractices.Theyhaveyellowasthepredominantcolour,blackupperpanelsandborderswithyellowlettering.

• Safetyinstructionsigns–arewhitewithgreenupperpanelandwhiteletterstoconveytheprincipalmessage.


Standardsobtainedfromparticipatingorganisationsoutlinedsignagerequirementsbasedonthetypeofbarricadeandtheintendedpurposeofthebarricade. This included:

• Signageneededtoidentifydateandtimeerected,nameofresponsiblepersonwithphonenumberormeans of contact, duration of project and reasons for thebarricade(hazardpresent).Thisinformationwasrequiredtobegenerallyrecordedonaninformation/barricadetagthatisattachedtothebarricade.

• Allbarricadesshallhaveaninformationtagandsignageattached at all faces and designated access points. The intervalsofsignagewasnotspecifiedforthefaces.

• Therewerethreetypesofsignsidentified:

–Dangersigns–generallydenotedbyred,redandwhite,orredandblacksignsortape.

–Cautionsigns–generallydenotedbyyellow,oryellowandblacksignsortape.

–Information–generallydenotedbybluesignsortape.Theseweregenerallyusedforspecialactivitiessuchas commissioning, operational exclusion zones, etc.

• Signsshouldbelocatedwherethemessagesarelegible,andsothattheyattracttheattentionof,andareclearlyvisibletoallconcerned.

• Signsshouldbemountedascloseaspracticabletotheobserver’slineofsightandpositionedsoastogivetheviewerampletimetoheedthewarning.

• Signsshallbeconstructedanderectedsothattheydon’tcreateahazardandshallbemaintainedingoodcondition,keptcleanandwellilluminated.

• Themeaningofsafetysignsusedonasitemustbecommunicatedtotheworkforceattheinduction,toolboxmeetings and pre-start meetings.

INSTALLATION AND REMOVAL CHECKLIST PROCEDURES INCLUDING PERMITTING REQUIREMENTS

None of the standards (legislation, codes, standards, guidelinesandpublishedliteratureandindustryconsultation)reviewedrequiredtheuseofinstallationandremovalchecklistsoranypermittingrequirements.Oneorganisationalstandardrequiredthatforentrybeyondtheir “high risk level”barricade,anentrypermissionformwasrequired.Thehighrisklevelbarricadedenotedthattherewasanimmediaterisktoemployeessuchasopenholes,dangerousgroundconditionsetc.wherelifemaybeendangeredwithoutwarning.

Itshouldbenotedthatforotherspecificscenarios(notpart of the scope of this research), installation and removal checklists that include permit requirements exist such as removalofgridmesh,removalofguardrailsonwalkwaysandworkplatforms,etc.

INDUSTRY TRAINING IN RELATION TO THE SELECTION, INSTALLATION AND REMOVAL OF BARRICADING

Therearenoindustrytrainingpackagesavailablethatareassociatedwiththeselection,installationandremovalofbarricading.AbuDhabiEHSCentre(2012)statesthatemployeesaretrainedinthebarricadingofhazardsandunderstandtherisksassociatedwithusingtheequipmentandthecontrolmeasuresimplemented.AbuDhabiEHSCentre(2012)goesonfurthertosay:

• Trainingshallbecompetencybasedandinclude:

–Systemsofworkneededforthesafeuseofbarricades.

–Typesandselectionofcorrectbarricades.

– Barricade equipment.

–Care,maintenanceandinspectionofbarricades.


• Additionalretrainingshallbeconductedwhenevera periodic inspection reveals, or there is a reason to believe,thattherearedeviationsfrominadequaciesintheemployee’sknowledgeofbarricadinghazards.

• Employersshallconductadditionalretrainingwheneverabarricadingofhazardsprocedurefails.

• Employersshallensurethatwheresolidbarricadesareusedtheyshallbeerectedbyacompetentperson.

Lessthanonequarteroftheorganisationalstandardsreviewedrequiredsometypeoftraining/instruction.Thisvaried from completion of a site induction (the majority) that containsinformationonbarricades,signsandworkareademarcation to having a training package and competency assessmentbasedonthestandardforbarricading.

INDUSTRY ACCEPTED AUDITING PROCESSES FOR ENSURING COMPLIANCE

Onlyoneoftheorganisationalstandardsthatwerereviewedrequiredthatanauditprocessbeestablishedtoassessimplementationofbarricadingprocesses.Howeveritdidnotgointoanyfurtherdetailregardingfrequencies or scope.

Otherorganisationalstandards(lessthanonethird)requiredregularinspectionstobeconductedtoensurethatbarricadesarecorrectlyerectedandmaintainedtotherequired standard. The frequency of required inspections variedfrombeforeworkcommences,duringtheworkactivity,atthecompletionoftheworkactivity,attheendofeachshift,dailyandweekly.Theyalsorequiredthattheinspectionsberecordedeitherontheattachedhazardtagor in a formal inspection checklist.

AbuDhabiEHSCentre(2012)specificallystates:

• Barricadesshallbekeptinaconditionthatdoesn’treducetheireffectivenesswhichincludes:

–Signedappropriatelyandclearlyvisible.

– Effective at preventing accidental contact

–Visibleduringthehoursofdarknesswhererequired.

–Removedpromptlywhentheworkiscompletedorthehazardhasbeenremoved.

• Barricadecomponentsaretobeinspectedfrequentlyandthosewithdefectsshallbewithdrawnfromservice for repair or disposal and tagged or marked as “Dangerous, Do Not Use”.

• Asaminimum,aweeklyformalinspectionshallbeundertakenanddocumentedforallbarricading.

• Employersshallconsidertheuseofinspectiontagsfixedtoeachbarricade.Theinspectiontagcanbeusedtorecordthefollowinginformation:

–Identificationmarkofthebarricade.

–Thedatethebarricadingwasfirsterected.

–Dateofthelastinspection

– Result of inspection.

– Name of the person carrying out the inspection.


SHIFT HANDOVERShiftworkisdefinedbytheABSas“a system of working whereby the daily hours of operation at the place of employment are split into at least two set work periods (shifts), for different groups of workers” (Australia Bureau ofStatistics,2009).LikewiseBuxton(2003)notesthatshiftworkinvolvesthealternationofteamsofworkerseachworkingacertain“shift”(thehoursofwork),andwhousuallyperformthesameworkdutiessothatoperationscanbecontinuedforlongerthanallowedbyanysingleworker.

Shiftworkandextendedworkinghoursareincreasingin many industries and organisations in Australia. The ABS(2009)reportedthatinNovember2009,1.4millionAustralianemployeesusuallyworkedshiftworkintheirmainjobwhichaccountedfor16%ofallemployees.Theindustrieswiththehighestproportionofemployeeswhousuallyworkedshiftworkwere‘Mining’formen(52%)and‘Healthcareandsocialassistance’and‘Accommodationandfoodservices’forwomen(both32%).Theindustrieswiththenexthighestproportionswere‘Accommodationandfoodservices’formen(44%)and‘Transport,postalandwarehousing’,‘Mining’and‘Artsandrecreationservices’forwomen(all24%).Withanincreaseintheprevalenceofshiftworkthereisagrowingemphasisontheimprovement in shift related health and safety processes. Thetransitionofworkteamsor“shifts” is a defining aspectofshiftworkthatenablesittoachieveitsgoalofuninterrupted vocation, or provision of continuous service across the 24 hours in a day. Accordingly at the heart of shiftworkprocessimprovementeffortsisthefundamentalconceptofshifthandoverwhichdependingupontheindustry, is also referred to as shift changeover, handoff, sign out, sign over, turnover, and/or transfer.

INDUSTRY ACCEPTED DEFINITION OF “SHIFT HANDOVER”

Inindustrieswhichoperatecontinuousprocesses,continuity is maintained across shift changes as outgoing personneltransferaccountabilityfortheworkplacetotheincomingpersonnelresponsibleforperformingthesamedutiesonthesubsequentshift.Thegoalofashifthandoveristoaccuratelyandreliablycommunicatetaskrelevantinformationacrossshiftchanges,therebyensuringcontinuityofsafeandeffectiveworking(Lardner,1996).Howevertherearerelativelyfewcommonlyaccepteddefinitionsforshifthandover,anexampleofwhichisfoundin the healthcare industry:

“the transfer of professional responsibility and accountability ..... to another person or professional group on a temporary or permanent basis”

(AustralianCommissiononSafetyandQualityinHealthcare,2012;Manser&Foster,2011).

However,shifthandoverasatransferofresponsibilityisdefining an outcome and not the underpinning process of informationexchangewhichisfundamentaltotheactivitiesthatfollowinthesubsequentshift.Assuchshifthandoverencompassesallreportingmechanismsemployedwhenworkerschangeshifts,andwhilethecommunicationprocessesusedtoconveyinformationaboutthejobisan integral component, shift handover also performs a numberofotherfunctions.Theseincludeerrorcorrection,planningoffuturework,creationandreinforcementoflocalnorms and teaching and learning (Symons et al., 2012). Appreciation of the multiple functions of shift handover demonstratesthatitisnotjustaonewayinformationtransmissionbutateamactivitywithinteractionbetweenallparticipantsandsubjecttoalltheadvantagesanddisadvantagesofteamworking(Symonsetal.,2012).Accordingly a more rounded definition for shift handover includes the description of communication exchange and is listedbelowfromCohen&Hilligoss(2010)definitionwhichhasbeenadaptedfortheconstructionindustry:

“the exchange between shifts of information and risks relating specifically to the job or tasks being performed which accompanies either a transfer of control over, or of responsibility for, the work.”


This characterisation of shift handover emphasises the process of “exchange”andisalignedwiththeconstructionindustryprocedurescollectedthroughoutthisreview.Industrymaterialswhilenotdirectlydefiningtheconceptofshifthandovercommonlydescribeitasa“system for the relay of information”.SupportingthisdefinitionGrusenmeyer(1995)andLardner(1996) detail that an efficient shift handover should include three different stages: (1) preparing information to pass on, (2) executing the shift “handover”duringwhichtheoutgoingworkercommunicatestask-relatedinformationtotheincomingworker,and(3)matchingtheinformationhandedoverbytheoutgoingoperatortotheinformationtakenoffthesystembytheincomingoperator.LikewiseanauditmethodologydevelopedbytheKeilCentre(2006)consistentlyreferencestheimportanceofeffectivecommunicationinsuccessfulshifthandover.Accordingly,theexchangeofinformationtoestablishthecurrentstateoftheworkplaceanditscontextisanessentialelementofeffectiveshifthandover(Carroll,Williams,&Gallivan,2012;Cohen&Hilligoss,2010;Lardner,1999;Thompson&Plocher,2011;Wallis,2010)andourdefinitionofexchangehighlightsthisprocesswhilesimultaneouslyencompassingdifferentlylabeledinteractionsandthevariationsinthe their accompanying events and purposes.

However,animportantpointofdifferentiationshouldbemadebetweencommunicationeventsthatoccuratthestartofashift,namelyshifthandoverandpre-startmeetings.Whilebothfundamentallyrequireeffectivecommunicationofinformationdependentuponexecutionandinclusion,theymayinvolvesomeoverlapeventhoughtheirprimaryobjectivesdiffer.Ashifthandoverisabouttransferofsituationalawarenesswhileapre-startmeetingisfocusedonbuildingonthisinformationtoplanandstrategisetheexecutionoftheworktobedoneinthecomingshift.Akeydifferencebetweenthesetwoprocessesisthatashifthandoverrequirestheactiveparticipationorinputofatleastonememberfromthepreviousshift,whileapre-startdoesnot.Accordingly,ashifthandovermayoccurandondepartureoftheoutgoingshiftthe incoming shift may then conduct their pre-start meeting using the information handed to them from the previous shift. Againreinforcingourdefinitionofshifthandoverasanexchange,ifapre-startisconductedbasedonlyonrecordsorlogsfrom a previous shift, then the record or log essentially takes on the function of a shift handover.

LEGISLATION (ACTS & REGULATIONS), CODES, STANDARDS, GUIDELINES

Asthereareonlyafewpublicationsthatoffergeneraldefinitionsofshifthandover,therearenowidelyacceptedstandardsofwhatactivitiestheterm“shift handover”doesordoesnotinclude,andwhy.Asearchtoidentifyexistingshifthandovermaterialsthatstipulateregulations,standardsorcodesorpracticeproducedonlyarelativelyfewresources,mostofwhichofferonlygenericguidancematerials.However,observationofsearchoutcomesdididentifythattheconceptofshifthandoverisexperiencingincreasedregulatoryattentionacrossanumberofindustries.Specificallythisattentionisdrivenbytheincreasingacknowledgementoftheimportanceoftherolethattheshifthandoverprocessplaysinworkplacehealthand safety.

Legislative Framework

ModernOccupationalHealthandSafety(OH&S)lawisdescribedasperformancebased,highlightingtheachievementofsafetyoutcomesratherthandefiningingreatdetailthewayinwhichtheoutcomeistobeachieved.AccordinglywhilenotspecificallynamedthegeneralfunctionofashifthandovercanbeinferredfromrelevantsectionssetoutinAustralianOH&Slegislation,examplesofwhichareprovidedinthefollowingtable:


ACT & JURISDICTION

SECTION DETAIL

WORKPLACE HEALTH AND SAFETY ACT (2011) National Uniform Legislation

Part 2: Health and safety duties Division 2:PrimarydutyofcareSection 19:Primarydutyofcare

(3)Withoutlimitingsubsections(1)and(2),apersonconductingabusinessesorundertakingmustensure,sofarasreasonablypractical:(c)theprovisionandmaintenanceofsafesystemsofwork;

and (f) the provision of any information, training, instruction or

supervision that is necessary to protect all persons from riskstotheirhealthandsafetyarisingfromworkcarriedoutaspartofthebusinessorundertaking

Part 2: Health and safety duties Division 4:Dutiesofofficers,workersandotherpersonsSection 28:Dutiesofworkers

TheActalsospecifiesthatindeterminingwhetheraworkerfailedtotakereasonablecare,‘regardmustbehadtowhattheemployeeknewabouttherelevantcircumstances’.

Part 5:Consultation,representation and participationDivision 1:Consultation,cooperation and coordination betweendutyholdersSection 46:Dutytoconsultwithother duty holders

Even more specifically the Act stipulates that if more than one person has a duty in relation to the same matter, each person withtheduty,mustsofarasisreasonablypractical,consultcooperateandcoordinateactivitieswithallotherpersonswhohaveadutyinrelationtothesamematter.

MINES SAFETY & INSPECTION ACT (1995) Western Australia

Part 2: General duties relating to occupational safety and healthDivision 2: General dutiesSection 9: Employers, duties of

Anemployermust,sofarasispracticable,provideandmaintainatamineaworkingenvironmentinwhichthatemployer’s employees are not exposed to hazards and, in particular,butwithoutlimitingthegeneralityofthatgeneralobligation,anemployermust:(a)provideandmaintainworkplaces,plant,andsystems

ofworkofakindthat,sofarasispracticable,theemployer’s employees are not exposed to hazards; and

(b)providesuchinformation,instructionsandtrainingtoandsupervisionofemployeesasisnecessarytoenablethemtoperformtheirworkinsuchamannerthattheyarenotexposed to hazards;

COAL MINING SAFETY AND HEALTH ACT (1999) Queensland

Part 3: Safety and health obligationsDivision 3:Obligationsofholders,coal mine operators, site senior executives and othersSection 42:Obligationsofsitesenior executive for coal mine

Asiteseniorexecutiveforacoalminehasthefollowingobligationsinrelationtothesafetyandhealthofpersonswhomaybeaffectedbycoalminingoperations (f) to provide for(v)appropriateinspectionofeachworkplaceatthemine

including,wherenecessary,pre-shiftinspections.

MINING AND QUARRYING SAFETY AND HEALTH ACT (1999)Queensland

Part 3: Safety and health obligationsDivision 3:Obligationsofholders,operators, site senior executives and othersSection 39:Obligationsofsitesenior executive for mine

“as above”

Table 1: Relevant Australian safety legislation pertinent to shift handover.


InsupportofthevariousActs,workplacehealthandsafetyregulationswerealsoreviewedforprescribedprocedural,othermandatedapproaches,waysdutiesimposedbytheActcouldbeperformed,orforanyspecificmentionofshifthandover.AswiththevariousActsthemajorityofshifthandoverreferenceswerelocatedinminingspecificregulations,whichalignswiththeprevalenceofshiftworkintheminingindustryaspreviouslydiscussedfromtheABS(2009).Table2outlinestherelevantregulationsreferencingorrelevanttoshifthandover,below.

REGULATION & JURISDICTION

SECTION DETAIL

WORK HEALTH AND SAFETY REGULATION 2011Queensland

Part 3.2: General workplacemanagementDivision 1: Information, training and instructionSection 39: Provisionofinformation, training and instruction

(1) This section applies for section 19 of the Act to a person conducting abusinessorundertaking.(2) The person must ensure that information, training and instruction providedtoaworkerissuitableandadequatehavingregardto:(a)thenatureoftheworkcarriedoutbytheworker;and(b)thenatureoftherisksassociatedwiththeworkatthetimethe

information, training or instruction is provided; and (c) the control measures implemented.(3)Thepersonmustensure,sofarasisreasonablypracticable,thatthe information, training and instruction provided under this section is providedinawaythatisreadilyunderstandablebyanypersontowhomit is provided.

OCCUPATIONAL HEALTH AND SAFETY REGULATIONS(2007)Victoria

Part 5.3: MinesDivision 2: Safety duties of mine operators5.3.19:Communicationinrespect of shift change-over

Theoperatorofaminemustensurethatthereisasystembywhich:(a)thesupervisorofeachoutgoingshiftprovidesawrittenreporttothe

supervisor of the incoming shift, in relation to the state of the mine workingsandplantandanyothermattersthatrelatetohealthorsafety; and

(b)thesupervisoroftheincomingshiftcommunicatesthecontentofthe report provided under paragraph (a) to the employees on the incoming shift.

MINE HEALTH AND SAFETY REGULATION (2007)New South Wales

Part 3:Dutiesofoperators relating to health, safetyandwelfareatminesDivision 1: Mine safety management planClause 14: Additional contents of mine safety management plan

Forthepurposesofsection30(3)(d)oftheAct,theminesafetymanagementplanforaminemustincludethefollowing:(f)thearrangementsforcommunicationatthemine,including(butnot

limited to):(i)theexchangeofinformationbetweenshiftsregardinghazardsthat

may affect the health and safety of persons at the mine

MINES SAFETY AND INSPECTION REGULATIONS (1995)Western Australia

Part 10: Specific requirements for underground minesDivision 2: GeneralSection 10.30: Shift communications

The manager of an underground mine must ensure that if any hazard toanyemployeeinaworkplaceintheminehasnotbeenremediedorremovedbeforetheendofashift:(a)arecordismadeinwriting,andsigned,bythesupervisoroftheshift

fortheworkplaceconcernedsettingout: (i) the nature of the hazard and its location; and (ii) the state of corrective measures taken to remedy the hazard; (b)therecordisreadandcountersignedbythesupervisorofthe

nextshift(thenewshift)fortheworkplaceconcernedbeforeanyemployeedoesanyworkinthenewshiftintheworkplace;and

(c)beforeanyemployeedoesanyworkinthenewshiftintheworkplace,thesupervisorforthatshifthasadvisedtheemployeeof:

(i) the nature of the hazard and its location; (ii) the state of corrective measures taken to remedy the hazard; and (iii)theworkandprecautionsrequiredtobetakentoremoveor

remedy the situation.

Table 2: Australian safety regulations referencing shift handover.


Codes of Practice and Industry Standards

Therewerenoidentifiedcodesofpracticethatdirectlyrelatedtoshifthandover.Thevastmajorityofstandardsandcodesofpracticeinthisarenawerefocusedonshiftworkandthemanagementoftheriskfactorsassociatedwithextendedworkinghoursandfatigue.However,noneofthesecodesand/orstandardsdevotedtothehealtheffectsandmanagementofshiftwork,mentionedtheroleorprovidedguidancearoundtheimpactofshifthandoveronhealthandsafety.Severalexamplesofthesebroadershiftworkmaterialsarelistedbelow:

• AustralianMedicalAssociation(2006)-NationalCodeofPractice:HoursofWork,ShiftworkandRosteringforHospitalDoctors

• WorkSafe,DepartmentofCommerce,WesternAustralia(2006)-Codeofpractice:Workinghours

• SafeWork,DepartmentofthePremierandCabinet,SouthAustralia(2010)-Codeofpractice:Workinghours

• MinesOccupationalSafetyandHealthAdvisoryBoard,DepartmentofIndustryandResources,WesternAustralia(2000)-GuidelineforFatigueManagementfortheWesternAustralianMiningIndustry

• RoyalAustralasianCollegeofSurgeons(2007)-StandardsforSafeWorkingHoursandConditionsforFellows,SurgicalTrainees and International Medical Graduates

Leadingfromthesethereweretwocodesofpractice,listedintable3,whichlinkedtoorreflectedupontheshifthandoverprocess.However,inboththesecasesthecodesreferredtoprocessesthataugmentshifthandover(i.e.logsand training) rather than directly providing guidance on the inclusions required for an effective shift handover. The third guidelinereviewedintable3istheUKsafetyandenvironmentalstandardsforfuelstoragesites,whichprovidesthemostdetailed account of the recommended suggestions for shift handover inclusion identified. The majority of regulatory and guidancematerialsreviewedthatreferredtoshifthandoverhighlightedtheimportanceofitsfunctionbutrarelydetailedtheelementswhichshouldbepresentforeffectivecommunication,i.e.analysisofinformationneeds,facetoface,twowaycommunication,andwrittenandverbalcommunication(Lardner,1996).


PUBLISHER TITLE REFERENCE

SAFE WORK AUSTRALIA

The Mine Record – draftCodeofPractice(2011)

A mine record provides essential information on incidents that may impact upon the safetyofworkers.Thecontentsoftheminerecordmustinclude:•writtenrecordsfromthesupervisorofeachoutgoingshifttothesupervisoroftheincomingshifttoincludeinthestateofthemineworkingsasattheendoftheoutgoingshift•allrecordsorreportsaboutsafetyincidentsandanyhighpotentialincidents,and•allnotices,reports,findingsandrecommendationswhicharisethroughmonitoringandenforcementactionbytheRegulatorundertheWHSActandRegulationsaswellasanynoticesissuedunderPart5(consultation,representationandparticipation),Division7(provisionalimprovementnotices)oftheWHSAct.

AUSTRALIAN SAFETY AND COMPENSATION COUNCIL

NationalCodeofPracticeforInduction for ConstructionWork (2007)

Task-specific induction is required to provide information and instruction to anyone undertaking a particular construction activity to involve the risk factors and control measures relating to that task.

BUNCEFIELD STANDARDS TASK GROUP

Safety and environmental standards for fuel storage sites (2007)

Operatorsshouldsetandimplementastandardforeffectiveandsafecommunicationofissuesrelevanttofueltransferandstorageatshiftandcrewchangehandover.

Thehandoverprocedureshouldcarefullyspecifywhatkeyinformationneedstobecommunicatedatshiftandcrewchange,atkeypositionsintheorganisation.Therequirementsmaywellbedifferentfordifferentpositions,butshouldconsiderissuessuchas:•productmovements,bothongoingandplanned;•controlsystemsbypassed;•equipmentnotworkingoroutofcommission;•maintenanceandpermits;•isolationsinforce;•tripsdefeated;•criticalorhigh-priorityalarmsactivatedandactionstaken;•health,safetyorenvironmentincidentsorevents;•modifications;and•personnelonsite;•usesuitableaids,suchaslogs,computerdisplaysetc.toprovideastructuredhandoverofkeyinformation,whileaimingtocutoutunnecessaryinformation;•capturekeyinformationthatneedstobecarriedforwardacrosssuccessiveshifts(e.g.

equipment out of service);•allowsufficienttimeforhandover,includingpreparationtime;•ensurethatkeyinformationistransmittedbothverballyandinwriting;•encourageface-to-face,andtwo-waycommunication,withtherecipientaskingfor

confirmation, repetition, clarification etc. as appropriate; and•specifywaystodevelopthecommunicationskillsofemployees.

Thehandoverprocedureshouldtakeaccountofsituationsthatareknowntobeespeciallyliabletoproblems,including:•duringmaintenance,iftheworkcontinuesoverashiftchange;•duringdeviationsfromnormalworking;•followingalengthyabsencefromwork(eitherasaresultofaregularlongshiftbreakorindividualabsence);and•handoversbetweenexperiencedandinexperiencedstaff.

Techniquesthathavebeenreportedfromtheindustry,andthatcompaniesmaywishtoconsider in development of their procedure, include: •useofelectroniclogs,withpasswordsystemsforacceptance;•systemstoprojectelectroniclogsontoascreen(forteambriefing);•useofteambriefings,e.g.withstaggeredshiftchangesbetweensupervisorsandoperators;•useofpre-printedpaperlogsinastructuredformat;and•useofwhiteboardsforrecordingsystemsthatmaybeoutofserviceforseveralshifts.

Companiesmusthavethefacilitiesandmanagementarrangementsnecessarytoensurethatthestandardsetareindeedcompliedwith.Theseinclude:•arrangementstominimisedistractionsduringhandover;•instructionandtrainingofemployeesinhandoverprocedures;and•supervision,auditandreviewtoensurethattheprocedureiscompliedwithandthe

necessary information is communicated and understood.

Table 3: Codesofpracticeandstandardsforshifthandover.


Inadditiontothesecodesofpracticeandstandards,internationalguidelinesandcodesofpracticearoundpermittoworkproceduresreinforcethegeneralflavourguidancematerialsavailableonshifthandover.Usingaspecificapplicationofinformationtobeexchanged,permittoworkguidelines(outlinedintable4)haveagreateropportunityforspecificityoftheshift handover process for the continuation of permits.

However,theexistenceofformalcommunicationsystemsforpermitstoworkdoesnotoutlinegreaterdetailfortheinclusionsofaneffectiveshifthandoverprocess.Similarlytable5,whichoutlinessomeexamplesofthemoregeneralguidancematerialsontheshifthandoverprocessalsogenerallyreinforcethisobservation.


INTERNATIONAL ASSOCIATION OF OIL & GAS PRODUCERS

Guidelines on permit to work(P.T.W.)systems(2001)

ReportNo.6.29/189

•Installationownersshouldtakeintoaccount,whendevelopingP.T.W.systems, the importance of planning the shift change such that there is sufficientoverlaptoallowproperreviewanddiscussionofthestatusofallpermitstowork.•Writtenmeansofcommunicatinginformationcanbeby:•PermitLogBook•PermitFile•DisplayBoards•ComputerScreen/PrintOutoracombinationofanyoftheabove.•Whicheverarrangementsareadopted,theshifthandoverarrangementshouldbemonitoredregularlytoensureitscontinuedeffectiveness.

ABU DHABI EMIRATE ENVIRONMENT, HEALTH AND SAFETY MANAGEMENT SYSTEM

CodeofPractice21.0PermittoWork(2012)

3.3 When is a permit to work required?PTWSystemsarenormallyconsideredmostappropriate:(v)wherethereisatransferofworkorgroupsfromonegroupto

another.

3.10 CommunicationAformalhandoverprocessshallbeimplementedtoensure(i)effectivecommunicationofallrelevantworkdetailsandcontrol

measuresbetweenoff-goingandon-comingshifts;and(ii)handoverofPermitAuthority,PermitHolderandWorkParty

responsibilities.

3.13 Management of ChangeIfworkcoveredbyaPTWproceedsfromoneshifttothenext,thePTWshallbere-validatedwiththenew(on-comingshift)AP(permitissuer)confirmingthatitissafetorecommencework.

UK HEALTH AND SAFETY EXECUTIVE

GuidanceonPermitToWork Systems (2005)

Ifworkiscarriedovertoanothershift,e.g.thejobtakeslongerthanexpected,thenashifthandoverprocedureshouldbeinplace.Thishandoverprocedureshouldensurethattheincomingshiftisawareofanyoutstandingpermit-controlledjobs,thestatusofthosejobs,andthestatusoftheplant.Work-in-progressshouldbeleftinaconditionthatcanbereliablycommunicatedto,andunderstoodby,theoncomingshift.Apermitlog,permitfileordisplayboardsarewaysofrecordingongoing permits. It is essential that there is good communication betweenincomingandoutgoingissuingandperformingauthoritiesanditisrecommendedthattheincomingissuingauthoritysignstoallowthecontinuation of a permit.

Table 4: Codesofpracticeandguidelinesforthehandoverofpermitstowork.



NORTHERN TERRITORY WORKSAFE (2003)

Safety Management - A GuideRegulation 44: Consultation

Theseareaveryimportantformofconsultationwherechangesofshiftareinvolved.Safetyissuesshouldbeincludedasaroutineitemforthebriefhandovermeetingsbetweenstaffstartingandfinishingshifts.

ACTU OHS UNIT (2000)

Health and Safety Guidelines for Shift Work and Extended Working HoursD No. 66/2000

Appropriatemechanismsshouldbeinplacetoenableefficientandsafehand-overbetweenshiftsandtoensurethatnewshiftsareadequatelyinformedaboutallissuesthathavearisenintheworkplace.

UK HEALTH AND SAFETY EXECUTIVE (2006)

HSG256 - Managing ShiftworkGuidelineTable 3: ShiftPattern

Improvecommunicationatshifthandovertoensurethatnewshiftteamsarefullyawareofissuesthathavearisenduringthepreviousshift.

HSG256 - Managing ShiftworkGuidelineTable 9: Management Issues

Agree on, and make sure timing and procedures for transmitting information tothenextshiftteamareclear,availabletoallstaffandfollowedatalltimes.Avoidextendingshiftsbygoodplanningofthehandover,e.g.bybuildinginasmalloverlapbetweenstartandfinishtimesonconsecutiveshifts.Ideally,shifthandoversshouldbeconductedface-to-faceandbetwo-way,withallparticipantstakingresponsibilityforensuringaccuratecommunication,usingbothverbalandwrittenmeans,bebasedonapre-determinedanalysisoftheinformationneedsofincomingstaffandbegivenasmuchtimeasnecessarytoensure clear and accurate communication.

SYDNEY SOUTH WEST AREA HEALTH SERVICE, NSW HEALTH (2007)

CLINICAL HANDOVER GUIDELINE NO: SSW_GL2007_002

Liststenkeyprincipleswitheachprinciplehavingtwotothreespecifiedactionsorguidelines.1. Clinicalhandoverissupportedbyappropriatepolicies,proceduresandresources. 1.1 Each facility/ service has documented policy in place for clinical handover. 1.2 There are clear protocols outlining the minimum information requirements for effective nursing,

medical&multidisciplinaryhandoverforthefollowingcircumstances:•Shifttoshifthandover•Afterhoursandweekendhandover•Transferofcarefromoneteam/cliniciantoanother•Transferofcarefromonefacilitytoanother2.Clinicalleadershipisakeycomponentofclinicalhandover 2.1Theclinicalhandoverprocessesarestructuredandareled/facilitatedbythemostseniormemberof

the clinical team. 2.2Clinicalhandoverisaninteractiveprocess,whichprovideslearningopportunitiesandguidancefor

junior staff. 2.3Clinicalhandoverisissue/problemfocusedtomaximisethetransferofkeyinformation.3.Rosteringofmedical&nursingstaffallowsclinicalhandovertobetimeprotected 3.1Clinicalhandoveroccursinworktimeandismonitoredtoensureefficientuseofallocatedtime. 3.2Attendanceathandoverismandatory,ismonitored/recordedandreviewed.Reasonsfornon

attendance are analysed and strategies to reduce non attendance rates are implemented. 4. Multidisciplinary handover in specified areas is fundamental to continuity of care 4.1 Specialty units should have at least one multidisciplinary handover per day •ICU&HDU•Emergency 4.2 Night medical handover should involve the after hours nurse managers.5.Patientinvolvementinclinicalhandover,whichisseenasthekeytosaferhealthcare,isaccommodated

and promoted. 5.1Optionstoincreasepatientinvolvementinclinicalhandovershouldbeidentified,piloted,&

evaluated,e.g.useofpatientnotebooks. 5.2Clinicalhandoveroccursatthepatientbedsidewhenappropriateandpatientsaregiventhe

opportunity to validate information as necessary.



6.Transferofcareposessignificantpatientsafetyriskandthereforerequiresbothhighqualityverbalandwrittencommunication.

6.1Allpatientsareprovidedwithinformationabouttheirhealthcareteam(medicalnursing&alliedhealth)andprovidedwithdocumentedinformationwhenthisteamchanges.

6.2AllpatientsaremadeawareofwhichRNisresponsiblefortheirnursingcareonashift-to-shiftbasis.

6.3Transferofcarefromoneteamtoanotherisclearlydocumentedwithinpatient’smedicalrecordsandsignedanddatedbythereferring&receivingteam.E.g.useofastampwithpredeterminedfields including date, time, referring team, receiving team, date time and referring /receiving officer signature.

6.4Receivingteams/staffareprovidedwithasummaryofcareincludingadocumentedlistofproblems&issuesandtasksoutstandingatthetimeoftransferofcare.

7. Handover documentation is integral to safe transfer of information. 7.1Documentationrelatedtopatienthandovermustbeinaformwhichprotectspatientprivacyandbe

retained and stored accordingly. 7.2Useofelectronichandovermodalitiesbeexploredandpiloted. 7.3Handoverdocumentationmustenablecorrectidentificationofpatients(useofbednumbers

is discouraged). 8.Clinicalrecordsarecentraltocontinuityofcare. 8.1ClinicalRecordsshouldbeutilisedtofacilitatecontinuityofcare(medicalhandover)byprovidinga

summaryofcare,includingissues/problemsandmanagementplanforrelievingstaff.(Especiallyweekendsandafterhours).

9. Evaluation of handover processes demonstrates the effectiveness of the processes in terms of patient safety and quality of care

9.1Incidentsrelatedtoclinicalhandoveraremonitored,reportedinIIMSandtrendedtoallowadjustments/improvements to the handover processes.

9.2 Audit process for clinical handover is developed and implemented. 10.Educationalstrategiestoimproveclinicalhandoverskills/competencyareeffective,&patientsafety

focussed.Clinicalhandoversareusedaseducationalopportunities 10.1ClinicalhandoverrequirementsareincludedinallorientationprogramsandRMO/Nursing

informationhandbooks. 10.2Educationprogramsbasedontheguidelinesforclinicalhandoverareimplementedandevaluated

in terms of impact on patient safety. 10.3 Clinicalhandoverispromotedasalearningenvironment.

Table 5: Examplesofgeneralguidancematerialspublishedonshifthandover.


The key points from guidance materials on shift handover is that processes need to ensure that the right information is communicated to the right people at the right time and thatinformationiscommunicatedunambiguouslyandthat the recipient properly understands it. Weaknesses in communication systems can cause a lack of co-ordination orunderstandingbetweendifferentshifts.Acrosstheguidancematerialsreviewedthedetailastohowtobestconductshifthandoverhasbecomemoreapparentincontemporaryresources.Priortofouryearsagoalotofguidelinesandnonmandatorystandardswerequitegenericwithdetailandsupportfromtheseresourcesincreasinginrecentyearswitheffortstoattaingreaterlevelsof standardisation. The health care industry in Australia is one of the leading sectors in this regard.

Trends and Observations

Shift handover is a fundamental and dynamic process thathasprominenceinlegalOH&Srequirements,yetitisnotwidelydocumentedastoitseffectiveemploymentorapplication.Asnoted,itwasoftenabsentfrommuchoftheregulatorymaterialsandstandardsreviewed,withthenotableexceptionofthe“Safety and environmental standards for fuel storage sites” (Buncefield Standards Task Group, 2007). International reports confirm that this lack ofguidancematerialistranslatingtoanabsenceofpolicy.Wallis (2010) reports that a progress report into patient safetyinNewZealandHospitalsshowedthathandoverpracticesandtheinformationthatwashandedoverrangedwidelywithnoconsistencyofpractice.Further,Alvaradoetal.(2006)reportthatmanyCanadianhospitalsalsohavenopolicy or standards for shift handover.

Most industry standards that did refer to shift handover often only did so to reinforce its importance rather than to providepracticaladviceonhowtoincreasethevalueofitsengagement. A consequence of this vagueness of scope, standards and regulations is that organisations seeking to improveshifthandoversbystandardisingtheirprocedures,confrontuncertaintyabouttherangeofactivitiesthatshouldbesubjecttosuchefforts.Reinforcingthisassertionanddemonstrating its impact, the introduction of a mandatory shifthandoverapproachthatwastobestandardisedintheUScausedwidespreaduncertaintyin2006.Thejointcommissionwhosemissionisto“improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organisations”intheUSbymeansofitsaccreditationstandards,addedtoitsNationalPatientSafetyGoalsRequirement. 2E: “Implement a standardised approach to ‘hand off’ communications, including an opportunity to ask and respond to questions.”Further,theflowoneffectsfromastandardisedorconsistentapproachwhichisbeingmorestronglypursuednowthanpreviously,isthedetailthat the associated research is identifying in the criteria for aneffectiveshifthandoverprocesse.g.ClinicalHandoverGuidelineNo:SSW_GL2007_002,(SydneySouthWestAreaHealthService,2007).Likewise,theapplicationofthese

standardsthroughtheabilitytotransferthemintovarioussettings is also appearing in matrices that detail a variety of handover options for differing situations as listed in:

• “Clinical Handover: critical communication” Medical JournalofAustraliaSupplement(AustralianCommissiononSafetyandQualityinHealthCare,2009a).

• TheOSSIEGuidetoClinicalHandoverImprovement–forclinicianleadersandmanagers(AustralianCommissiononSafetyandQualityinHealthCare,2009b).

• SafeHandover:SafePatientsGuideline(AustralianMedical Association, 2006).

Wallis(2010)statesthatcontinuednationalcollaborationisneeded in Australia to maintain the priority of standardising handoversofbothnursingandmedicine.However,theimportanceforresearchinvestigatinghowshifthandoversareaccomplishedandhowtheycouldbeimprovedisnot isolated to the Australian healthcare sector. The shift handoverprocessisafocusoftheFAAandNASAresearch(Parke&Kanki,2008).TheU.S.DepartmentofEnergy(1998)haslongbeeninterestedinshiftturnoversandhas issued shift turnover guidelines for nuclear facilities in anattempttoimproveprocedures.TheUnitedKingdomDepartmentofHealthandSafetyExecutive(2000)hassponsoredresearchonbestshiftturnoverpractices,ashastheFrenchNationalResearchandSafetyInstitute.

LITERATURE REVIEW

Asillustratedthroughthereviewofthelegislativeandguidelineresources,thelargebodyofrelevantliteratureshowsshifthandovertobehighlysensitivetovariationsincontext.Further,shifthandoverisanactivitythatisessential for multiple important functions that range far beyondsafety,andissubjecttodifficulttensionsthataredrivingeffortstostandardiseapproachwithinhighlydifferentiated settings. In addition, there is little empirical evidence regarding the magnitude of the impact of handover on safety and service quality, making the potential gains and complications from standardisation uncertain.

Accidentshavecommonlybeenrelatedtoshifthandoveranderrorshavealsobeenreportedtooccurdisproportionately after shift handover in dynamic industries.Lardner(1996)citedseveralinternationalstudiessupporting this finding across a range of industries such as oil and gas, healthcare, manufacturing and industrial settingssuchassawmills(Cloutier&LaFlamme,1994;Cullen,1993;Werner,1979).Similarreportshaveappearedinanalysesofoffshorerigaccidents(Dobson,1999),andin expensive “stuck pipe” errors for the oil industry (Bradley, 1991).HighererrorratesalsooccurinU.S.andCanadianairtrafficcontrolintheperiodafterpositionreliefbriefings(Stager&Hameluck,1988).InoneU.S.study,itwasfoundthat a quarter of all operational errors occurred in the first 15minutesafterpositionreliefbriefingsinairroutetrafficcontrolcentresandterminalradarcontrolfacilities(DellaRocco,Cruz,&Clemens,1999).Likewiseinthehealthcare


industrycaserecordreviewssuggestthatbetween15and28%ofmalpracticeclaimsandadverseeventsareduetodeficiencies in handover (Symons et al., 2012).

Collectively,incidentsandresearchsuggeststhatthereisaneedforamoreefficientwaytoguaranteethatthenextshift gets the information needed for shared situational awareness.Themostcommoncausesofincidentsrelatedto shift handover include poorly conducted shift handovers (e.g. lack of complete and accurate reporting, reliance onoperatormemory,timepressures,ineffectivetwowaycommunications) and poor records and structure (e.g., lack ofstructure,noclearindicationaboutwhattologandhowtostructureentries)(Thompson&Plocher,2011).Researchsuggests that the critical role of communication and its effectivenessalongwithbetterstructureandorganisationare the keys to more comprehensive and effective shift handoversandrecords.Consideringthesegeneralfindingsrelating to areas of common deficiency in shift handover, wewillconsiderthepracticeintermsofbothitscontent(i.e.whatisincludedinshifthandovers)anditsprocess(i.e.howitisconducted).

SHIFT HANDOVER CONTENT

Since the exchange of information is a core function of shift handover, the selection of appropriate content is central to itssuccess.Inreviewingtheliteraturekeyindicationsweresoughttoidentifywhatinformationtoincludeduringshifthandover,therolethatinformationartefactsplay,andhowlanguage can further complicate the communication of handover content.

Handover Inclusions

Fromourdefinitionofshifthandover,thedecisiveintrinsic feature that distinguishes handover from other communicationabouttheworksiteisthetransferofresponsibilityorcontrol.Itisthisthatestablishesoneofthecentral purposes governing handover content: to convey conciselywhatthenewlyresponsiblepartymayneedtoknowintheensuingcourseoftheshift.Communicationproblemsattheshifthandoverleadtolossofinformation,misalignmentofknowledgeormisunderstandingsaboutthejobathand.Researchsuggeststhatkeyinformationneedstobecommunicatedatshiftchange(AustralianCommissiononSafetyandQualityinHealthCare,2012;Bhabra,Mackeith,Monteiro,&Pothier,2007;BuncefieldStandardsTaskGroup,2007;Currie,2002;Judice,2009;Klee,Latta,Davis-Kirsch,&Pecchia,2012;Lardner,1996;Mikkelsen,Ringstad,&Steineke,2004;NTWorkSafe,2003;Parke&Mishkin,2005;Porteous,Stewart-Wynne,Connolly,&Crommelin,2009;SydneySouthWestAreaHealthService,2007;UKHealthandSafetyExecutive,2005)thoughtheserequirementsmaywellbedifferentfordifferentpositionsandindustries,butshouldconsiderissues such as:

• productandplantmovements,bothongoingandplanned;

• controlsystemsbypassed;

• equipmentnotworkingoroutofcommission;

• maintenanceandpermits;

• isolationsinforce;

• tripsdefeated;

• criticalorhigh-priorityalarmsactivatedandactions taken;

• health,safetyorenvironmentincidentsorevents;

• modifications;

• theworkscheduleandworkundertaken;

• recentauditorinspectionreports;

• personnelandorsubcontractorsonsite;and

• unusualoccurrencesconveyedasproblems,hypotheses,andintent,ratherthansimplylistingwhatoccurred.

Toconsiderthebreadthofshifthandoveracrossindustriesitseemsveryunlikelythatthereisasinglebestlistofrequired handover information content. While measures of handovercontentseemratherstraightforwardandusuallyinvolvekeyinformationtobetransmitted,theagreementastowhichitemsshouldbeincludedinsuchalistisfrequentlydebated,andexistingshifthandoverprotocolsvaryconsiderablyinthisrespect(Bhabraetal.,2007;Chuang&Lee,2009;Cohen&Hilligoss,2010;Odell,1996).However,handoverofasmallnumberofhighlyrelevantitemsmaybemoreeffectivethanthehandoverofalargernumberof less relevant items. The importance of inclusion in shift handovercontentgoesbeyondthehandoveritselfasitalsoprovidesinsightsintothebestwaysthathandovereducation,toolsandpracticecouldberestructuredtofacilitate more effective, efficient shift transitions.

However,inlinewiththeconceptualisationofhandoversasepisodes of information transfer, the evaluation of handover quality has mostly concentrated on the completeness and accuracyofinformationandrelatederrors(Cullen,1993;Lardner,1999).Thesestudiesfrequentlyfoundverbalhandovertobeincompletewhencomparedwiththeinformationavailableinlogsorrecords(Bhabraetal.,2007)orwhencomparedwithapre-definedhandoverprotocol(Dayton&Henriksen,2007).

Handover Artefacts

A lack of documented structure in shift handovers increasesthelikelihoodthatcriticalinformationwillbemissedandmisunderstandingswilloccur.Approximately80%ofindustrialoperationslackastructuredapproachtoshifthandovers(Thompson&Plocher,2011).Further,engaginginverbalhandoveronly,comparedtoverbalhandoverwithsomedocumentation,reliesheavilyonmemoryskillsandhasbeenclassedasahighriskstrategy(Bhabraetal.,2007).Theperformanceofdoctorson


simulatedhandovercyclesshowedthatonly33%ofinformationwasretainedafterthefirsthandovercycleandonly2.5%ofinformationafterfivehandovercycles(Pothier,Monteiro,Mooktiar,&Shaw,2005)usingpre-prepareddatasheetsresultedinthefullretentionofdata.Reviewof the designs of the artefacts, documents, information systems and other such tools used during shift handover indicatesthattheseassistbyautomatingtheprocessasmuchaspossibleandprovidenumerousfunctionsandprocedures that ensure handovers are as comprehensive andconsistentaspossible.Also,artefactsmakeinformationmorevisibleandthismeansthattherearemorestakeholderswithaninterestinmaximisingthequalityofshifthandoversandwhoaremorelikelytointervenewherethese requirements are not achieved.

Typically,shifthandoverartefactswhichincludeitemsthatprovide structure and standardisation such as forms or checklists(Ahmed,Mehmood,Rehman,Ilyas,&Khan,2012;Porteousetal.,2009)serveasmemoryaids.Records of activity such as logs or run sheets (e.g. Klee etal.,2012;Parkes,2012)provideexpertinputthroughrelevant standards procedures or guidance materials (e.g. AustralianCommissiononSafetyandQualityinHealthCare,2012;TheKeilCentre,2006)andevencapturesomedetailsfromthehandoverforsubsequentuseandlearning(Thompson&Plocher,2011;Yurkovich&Smyer,1998).Keycriteria for the increased utility of these artefacts for use in shift handover are:

• Facilitate recording of information: Whatever method of capturingoperationalinformationisused,itwillbe,tosomedegree,animpositiononthescribeandhencethe more efficient the design of the proposed approach (written,electronicorotherwise)thelowertheimpost.Likewiseifthescribeisguidedthroughtherecordingprocessinastructuredway,ensuringallessentialinformation is captured, the greater the quality of the information captured.

• Provide a structured recording environment: It is essentialthatanyapproachprovidestheflexibilitytocapture all the varied operational activities required in records across the operation. At the same time, it is important to impose a level of structure on the record to encourage consistency of input.

• Allow for easy sharing of information: The approach shouldallowrecordstobeeasilysharedacrossmultiplesites throughout the operation. This is to ensure that importantinformationishighlyvisibletotheappropriatepeople and/or issues are effectively escalated.

• Allow quick searching and reporting of records: The approachshouldalloweasyaccesstorecords,whetheritisthecurrentshiftreviewingthepreviousshiftrecords,engineers carrying out analysis of historic records or management reporting across multiple records. Providingastructuredtemplateallowsreportstobeveryeasily compiled. This helps turn the records from an operationalregistertobefiledawayintoaliverepository

ofvaluableinformation.Thelogsbecomevaluableassetsofthebusiness.

Approaches to handover records and artefacts general take theformofpaperbasedbooksorcomputeriseddatabasesfor log or plod records, forms and checklists, and more recentlytechnologyenabledagendasupportedbyvisualaids. These approaches in their advances are increasingly seeking to engineer out the human factor aspects (discussed in the process section) of shift handover. However,historyislitteredwithexampleswheretechnologybasedproductshavefailedtoachievetheirpotentialbecausetheywerenotusedasintended.Indevelopingmodernised systems and information technology engineered solutions, it is essential that these improve the shift handover process. Therefore, as a minimum shift handoverartefactsshouldallow:

• asimplemethodforrecordinginformation;

• structureinrecordingandconveyinginformation;

• informationtobehighlyvisiblesothatpeopleknowwhatis happening;

• reportingofvaluableinformationtonotonlyindicatewhathashappened,butexplainwhy;

• compliancewithlegislativerequirements;

• recordkeepingtoevidenceoccurrence,attendanceandagreed outcomes; and

• analysisofhistoricalinformation.

Language used in Handover

Attention to the language and terminologies used at shift handover and the development of practices to measure and ensure comprehension have also received research attention(Friesen,White,&Byers,2008;Lardner,1999;McMullan,2007;Odell,1996).Languageproblemshavebeenfoundtocontributetoproblemsduringshifthandoversinseveralways.Asafunctionofasecondlanguage different dialect, explanations, accents, terms, andnuancesmaybemisunderstoodormisinterpretedbytheshiftworkerreceivingthehandover.Similarly,unfamiliarjargon,abbreviationsandacronymsthatareuniquetocertainsettings,professionsandexperiencesmaybeconfusingtoaworkercomingfromadifferentbackground,workinginadifferentsettingorconductingaspecialisedtask.Finally,ambiguityalsoincreasestheriskforconfusionandiscommonthroughtheuseofsubjectiveterms,normsand cultural references and misalignment in experience of workersandfamiliaritywiththesite.

Onesuggestedremedyfortheselanguageissuesistoensure comprehension of recipients, through the use of linguisticcheckssuchashavingtherecipientrepeatbacktheirunderstandingoftheinformationbeingconveyed(TheKeilCentre,2006).Thesestrategiesandgreaterexploration of communication processes are discussed in thefollowingsection.


SHIFT HANDOVER PROCESS

Symons et al. (2012) noted that information transfer alone does not capture all aspects of a shift handover’s quality.Particularlygiventhat“exchange” is a defining characteristicofshifthandover,beyondwhatisbeingexchanged, the methods employed in enacting the exchangearefundamentaltoitssuccess.Furthertothis point, research into shift handovers of nurses in European countries highlighted that the percentage of dissatisfactionwithshifthandovers,whichrangedfrom22%inEnglandto61%inFrance,wasprimarilydueto“too many disturbances”,followedby “lack of time” (Meissner et al., 2007). Accordingly, a key for participant engagement in shift handover and ultimately the effectiveness of its outcome is dependent upon the process.

The most important person in any handover is the person finishing their shift. The quality of the information they provideandtheircommunicationskillswillhavethegreatestinfluenceonhowwellinformedthepersonstartingtheirshiftis.However,attheendofashifteventhemostconscientiouspersonwillbeinterestedingettinghome.Also,somemayhavetheattitudethatanyproblemstheyleavearegoingtobedealtwithbysomeoneelse(i.e.theincoming shift). It is true that the person starting their shift can influence the quality of the handover they receive. Askingquestionsandbeinginterestedwilltendtoimprovethequalityofthehandover.However,theyarenotinaparticularlypowerfulpositionbecausetheydonotknowwhatquestionstoask,especiallyifkeydatahasnotbeenlogged. The process of shift handover and its associated researchfindingsarepresentedinfollowingsections.

Handover Guidance and Support

Itisimportantthatindividualsareawareofwhatisexpected of them and the support afforded to them through the handover process. The literature suggests that the emphasis and support of the organisation play aconsiderableroleintheeffectivenessandperceivedimportance of the shift handover process. Key roles andresponsibilitiesneedtobeexplicit,astheyassistin defining a structured and consistent approach and avoiding confusion of individuals for their involvement and expectationsduringtheprocessofhandover(McFetridge,Gillespie,Goode,&Melby,2007).Furtherthephysicalenvironment can affect the handover conversation negativelywhenitdistractswithbackgroundnoisesand interruptions or hinders confidentiality (Hunns, 1986;McMullan,2007).Researchhasidentifiedseveralkey processes for improving shift handover that are symptomatic of organisational support and include:

• clearlyassignedhandoverrolesandresponsibilities

• providetimetoprepareforshifthandovers

• fosterasafelearningenvironment/cultureforthehandovertotakeplacewithinsuchthatparticipants:

–arewillingtosayiftheydonotunderstandwhattheyhavebeentold

–arewillingtochallengewhattheyhavebeentold

–areabletopredictwhatsomeoneelseneedstoknow

–demonstratethattheyareinterestedinwhattheyarebeingtold;

– make time for and prioritise the handover process

• providingadefinedspacefreefrominterruptionsand distractions

• definedhandoverpolicies,procedures,guidelinesandstandards (defining performance and informing training and development of existing staff)

Handover Capability and Training

Technological advancements, construction materials, differing design approaches, the social, economic, geographic and regulatory environment, and the complexity ofconstructioncontractsareallremarkablydynamic.Constructionandthepeopleworkingintheindustryneedto engage in continuous learning in order to adapt to these unrelentingchanges.Someofthislearninghasbeenviaexplicittraining,butamuchlargerparthasoccurredthroughaccumulatingthelessonsembeddedindaytoday experience. Since shift handovers are one of the more frequent and consequential moments of considering construction progress, they are the inherent locus of a large share of this vital learning.

Howevertraininginconductingshifthandoverwasnotexplicit in construction focused literature. Health care wastheonlyfieldinwhichresearchmentionedtraininginconducting shift handover. Even then Yurkovich and Smyer (1998)highlightthelimitedemphasisoneducationandtraining on handover for medical and nursing students. Theirpaperdescribesalearningprojectanditsuseofreflection and analysis of audiotape records during the psychiatricrotationandhowthispreparedthestudentstoengageinprofessionalnursingpracticeandbehaviour(Yurkovich&Smyer,1998).Likewise,theUSFederalAviationAdministration(FAA)isnowrequiringthatpositionbriefingsbeaudiorecordedinallairtrafficcontrolfacilitiessothathandovertechniquescanbestudiedandimproved(Parke&Kanki,2008).

Nestel,Kneebone,andBarnet(2005)reportonatrainingprogram on handover presentation skills developed using adult learning theory to train specialists to conduct the handoverprocess.Arora,Johnson,Meltzer,&Humphrey(2008)alsodescribeacasestudythatdemonstratescapabilitydevelopmentusingaconceptualframework.Thepaperdefinestwoaspectsofacompetencybasedapproachtoimprovehandover:communication(transfer of information) and professionalism (transfer ofresponsibility).Thepaperthenpresentssomestrategies to ensure development of these competencies including the development of dedicated educational


materials and a “train the trainer” dissemination method. Howevernopapersreportedevaluationoftheirtraininginterventions against outcomes measures related to safety or handover performance.

Itisgenerallyacknowledgedthattrainingincommunicationskillsandthedevelopmentofjuniormemberstoconducthandoverisbeneficial(AustralianCommissiononSafetyandQualityinHealthCare,2009b).Howeveritshouldbehighlighted that training courses are not the only means ofdevelopinghandoverandcommunicationskills.Othertechniquesincludeonthejobrehearsalaccompaniedbycoachingwithexperiencedstaffandcomputerorvideobasedtraining.Educationandtrainingofthosefacilitatingiscritical to improving handover and more research is required into the utility and validity of different methods to ensure the developmentofbestpracticeinapproachesused.

Handover Communication

Peopletendtounderestimatehowcomplexthecommunication process is and consequently overestimate theirabilitytocommunicateeffectively.Therealityisthaterrorisanaturalandinevitableaspectofcommunicationbecauselanguageisinherentlyimpreciseandambiguous.Asuccessfulcommunicationisonewhereapersonreceiving a message achieves exactly the same understanding of that message as the person transmitting itintended.However,thefollowingfactors,aslistedbyLardner(1999)caninterferewiththisprocess:

1. Itisnotpossibletotransfermeaningsfromonepersonto another directly. Rather, the receiver creates meaning in his or her mind;

2. Anythingisapotentialmessage,whetheritisintendedor not;

3. The message received is the only one that counts;

4. Takingtheabovetogether,unintentionalmeaningislikelyand potential miscommunication is the norm.

Experimental evidence gained from studies of social interaction in small groups has also highlighted the essentialcontributionoffeedbacktoensuringaccuratecommunication(Lardner,1999).Increasedfeedbackisassociatedwithgreateraccuracyof,andconfidencein,communication.Greateraccuracyisobtainedattheexpenseoftimetaken.Theroleoffeedbackinaccuratecommunicationhasalsobeenemphasisedincognitivetheoryofreliablecommunication(Hunns,1986).Accordingly, communication channels should encourage staff to raise potential concerns as a standard course throughout the handover process.

Takencollectively,astudybyParke,Patankar,&Kanki(2003) applies these principles in an experimental design to investigate the alternatives communication processes for shift handover. Their findings suggest that the order ofeffectivenessforthefollowingapproachesfromleasteffective (i.e. static handover) to most effective (i.e. dynamic

face to face):

1. Statichandover–writtenlogsordiarypassedonwithoutexplanation

2. Shift supervisor to shift supervisor – the supervisor on theoutgoingshiftbriefsthesupervisorontheincomingshift to pass the information on to his or her personnel. Thisapproachcreatesabottleneckwheretherecipientoftheinformationcouldatbestexpecttoreceiveitsecondhand.Filteringwilloccurfromoutgoingcrewtosupervisor, supervisor to supervisor and supervisor to incomingcrew.

3. OutgoingshiftsupervisortoIncomingshift-thesupervisorontheoutgoingshiftbriefstheincomingshiftas part of their pre-start.

4. Staticfacetoface–allmembersoftheoutgoingshiftbrieftheircounterpartontheincomingshift.Aroletorole handover comprising a one to one information downloadandquestionandanswer.Thisapproachdoesnotallowforinteractionofactivitiesorsystemicriskunforeseenwithinasinglerole.

5. Dynamicfacetoface–allmembersoftheoutgoingshiftcollectivelyhandovertoallmembersoftheincomingshiftasleadbytheoutgoingsupervisor.FurthersupportingthisapproachamorerecentstudybySymonsetal(2012)hasfoundthatimprovedteamworkmightbeexpectedtoreduceadverseeventsfollowingteam handover, as opposed to one to one.

Communicationrequireseffortbybothpartiestoavoidmiscommunication.Althoughnotinfallible,facetofacecommunicationisgenerallythemostreliable,notnecessarilybecauseitisabetterwayoftransferringunderstanding,butbecauseitallowsimmediatediscussion(Lardner,1999).Incontrast,writtencommunicationisgenerallylessreliablebecauseofthislackofimmediatefeedback.Howeverfacetofacehandoversimproveexponentiallywhencombinedwithwrittensupportasusedinmanyhighriskdomainssuchasnuclearpower,airtrafficcontrol,offshoreoil,andmissioncontrolforbothshuttle and the space station. In aviation maintenance, facetofacehandoverbriefingsbetweenoutgoingandincomingtechnicians,withwrittensupport,havebeenshowntoreduceerrorscomparedtohavingjustverbalcommunication(Parkeetal.,2003).Improvedcommunicationnotonlyimprovesaccuracyandreliabilityoftheinformationexchangedbutwhencombinedwithleadership increases engagement of staff, especially those whohaveonlyaperipheralroleinashifthandover(Symonset al., 2012).


Teamwork During Handover

Shiftworkcanberegardedasateamworksystemthatrelies on cooperation across different shifts requiring buildingandupdatingasharedknowledgebaseandcoordinatingworkactivities(LeBrisetal.,2012).Improvements in cooperation and team coordination benefitplanningoffuturework,prioritisationandallocationoftasks.Enhancedmonitoringorsituationalawarenessmayallowhandoverparticipantstobeawareofstaffwhohavenotunderstoodorneglectedaspectsofthehandover(Symonsetal.,2012).Despitethisresearchevidenceandtheimportanceofkeyteambehaviourssuch as communication, leadership and development of sharedmentalmodelstohandover,theuseofteamworkskills in the assessment and training of handover is rare. Thisisarelativelynewareaofresearch.Symonsetal.,(2012)foundthatteamworkskillsdidnotcorrelatewiththecompletenessofinformationtransferandwithoutasuitablemethodofassessingteamworkinhandoveritisnotpossibletoidentifytheeffectsofanyinterventiontoimprove handover quality.

Review and Auditing of Shift Handovers

Inreviewinghandoverprocessmeasurestheseareoftengrouped into environmental (e.g. interruptions, noise level andworkload)andinbehaviouralaspects(e.g.sharedplanning,shareddecisionmaking,criticalreviewofexistingdocumentation,verbalreportandacknowledgementofinformationreceived)(Manser&Foster,2011).Researchinthisareathatgoesbeyondtheinformationtransmissionaspectforthereviewofshifthandovereffectivenessisonlyinitsinfancy.Forexample,Apker,Mallak,&Gibson(2007)provide a detailed account of the communication activities performedduringhandover.However,itisstillanopenquestionhowthevariousprocessmeasurestranslateintosafe outcomes.

Outcomemeasuresforhandoverusuallyincludesatisfactionwiththehandoverandshouldalsoassessthesafetyrelevantconsequencesonsubsequentworksites.Onlythenwillwebegintoassesshandoversafetyaswell.So far, many studies investigated the satisfaction of health careproviderswiththecurrentpracticeofhandoversinaspecific clinical setting (e.g. paramedics to resuscitation room). In this type of study, the perspectives of transferring aswellasreceivingcliniciansareconsidered.Inastudyofhandover assessments in three different clinical settings (paramedic to emergency room, anaesthetist to recovery roomandrecoverroomnursetowardnurse),Manser,Foster,&Gisin(2010)foundthatalthoughinformationtransferwasthekeycharacteristic,overallhandoverqualitywaspredictedbythreefactors:informationtransfer,sharedunderstandingandworkingatmosphere.

In understanding the complex dynamics of effective patient handover, it is essential not to consider the different quality aspectsinisolationbuttoinvestigatetheirinterrelationsaswell.Sofar,fewstudieshavetriedtolinkhandovercontent

orprocesscharacteristicswithoutcomemeasures.Onlytwostudieswerefoundthatexperimentallymanipulatedahandover characteristic and assessed the effect in terms of handoveroutcomes(Bhabraetal.,2007;Dowding,2001).InthestudybyBhabraetal.,(2007)participantsweregivenhandoverinformationandthensimplyhadtowaituntiltheyhanded the patient information over to another participant. Thatis,noworkwascarriedout(i.e.thecontextofclinicalworkwasmissing).AsimilarproblemispresentinthestudybyDowding(2001)inwhichparticipantshadtowritedownaplanafterreceivingashifthandover,andthisplanwasthen judged against an expert solution. Again, no actual workwascarriedout.Thus,beforewecanactuallyanswerthe question “What constitutes a handover that contributes to the quality and safety of patient care?” there is a need forrandomisedcontrolledtrialstoestablishacausallinkbetweencertainhandovercharacteristicsandtheireffects.

Followingfromthisthereareveryfewauditingtoolsorauditing guides for shift handover. Given the complexity fromalackofresearchintothecontributionofhandoverprocesstosafetyoutcomes,andthevariabilityofhandovercontentwhichiscontextdependent,anyrelatedauditingtoolswouldneedtobestronglygroundedintheirbeliefs.TheonlyguidereviewedfortheauditingofshifthandoverwaspublishedbytheKeilCentre(2006),andwhileitisverygeneric(toaccommodatereasonsstatedabove)itispresented in addendum 1 of the shift handover appendices of this report.

Organisational Learning

Organisationallearningthatoccursviashifthandoverscantakeanumberofforms(Yurkovich&Smyer,1998).Becauseithasbeenuncommonforresearchersstudyinghandoverstoinquireabouttheseissues,thiscommentaryaboutorganisationallearningislessoftensupportedbycitations from the existing literature. Exchanges during handovers can spread, reinforce, or undermine informal norms,changingthewaythegroupperceivesitsdutiesandobligationsandimpactuponthesitebasesafetyculture.Forexample,Lally(1999)says“During shift handovers observed, junior nurses learnt ‘the way things are done around here’. The shaping and guiding of nurses which takes place at the report not only socialises nurses into the ward culture, but by enhancing a shared value system, also increases the cohesiveness of the group.” Although theroleofhandoverinreinforcingnormsisparticularlywelldocumented in the nursing report literature (e.g. Holland, 1993;Miller,1998).

SUMMARY AND CHALLENGES

The role of shift handover is integral to the safe functioning ofaworksitethroughatransitionofpersonnel.However,giventhespecificriskprofilesofdifferentworksites,variableconstructionmethodologiesandworkplacehazards,prescribingthecontentforshifthandoverisproblematicandinclusionalwayschallenging,andwhile


the literature suggests some shift handover process inclusions have proven value, there is little empirical evidence as to the linkage of these to safe outcomes. Adding to these complexities there is compelling evidence from accident analyses that miscommunication of maintenance issues over a shift change can have serious safetyimplications(Lardner,1996).Incomingpersonnelmaytakeactionswithoutafullunderstandingofcurrentstatus.Also,handoversfollowingalengthyabsence,orbetweenexperiencedandinexperiencedstaff,requireextraefforttobridgetheirgapinunderstanding(Parkes,2012).Furthertothiscollectionofhighriskorpotentiallyproblematichandoversituationsaretheaddeddemandsonshiftsupervisorswhoarerequiredtobepresentforshifthandoveratbothendsofanoperatingshift.

Inthiscontextofshifthandoverresearchregulatorybodiesare also seeking greater standardisation of handover processes in the healthcare industry. Hence, efforts tostandardisehandover,whilesimultaneouslypairingexperienced and less experienced staff for learning, acknowledgetheconflictingroledemandsbeingplacedonthefunctionandexecutionofshifthandovers.Likewise,thereisarecognitionthatthehandoverprocesswouldbesimilarthroughoutanorganisation,butpracticallythehandoverprocesswoulddifferfromonesettingorfunctionto another.

It is not surprising that the most recent research in this areaisfocusingontheroleofteamworkandrelationalcommunication competencies that support effective exchangeofinformationandproductiveworkingrelationships(Carrolletal.,2012).

However,itisapparentthatwithappropriateworkpractices,theriskofshifthandovererrorscanbereduced(Parke&Kanki,2008).Insummary,thereviewofhandoverresearchindicatesthatleadingpracticeisdefinedby:

• thelevelofpriorityshifthandovercommunicationisaffordedonaworksite;

• theexistenceofstandardshifthandoveroperatingprotocols, policies or procedures and their integration withinthesafetysystem;

• theallocationoftimetoprepareshifthandovermaterialsprior to the end of the shift;

• theinclusionofaminimumstandardisedstructureandsuggestive content on shift handover forms;

• theallocationofappropriatespacetoconducttheshifthandover that minimises distractions and interruptions;

• ashifthandoverenvironmentthatencourageschallenging of assumptions and seeks assurance of understanding;

• shifthandoversconductedfacetoface,crewtocrew;

• twowayshifthandovers,withbothparticipantstakingjointresponsibilityforensuringaccuratecommunicationand understanding;

• shifthandoversthatusearangeofverbalandwritten/recorded means of communication;

• shifthandoversthatusesupportsandartefacts(logs,plods,databasesorITsolutions)designedonthebasisof the incoming shift’s information needs and that are structured and easy to use;

• shifthandoversareaffordedthetimenecessarytoensure accurate communication;

• therecognitionoflongerormoredetailedhandoverswhenstaffhavereturnedfollowingalengthyabsencefromwork;duringplantmaintenance;duringdeviationsfromnormalworking/duties;andwhenhandoverstakeplacebetweenexperiencedandinexperiencedstaff. As these high risk scenarios for shift handover areconsistentwiththosesituationsandprocessesthatconsistentlyemergeascontributingfactorsinincident investigations.

• inclusionofcommunicationskillsinselectioncriteriaforshiftworkers;

• investmentinthedevelopmentofthecommunicationand presentation skills of key handover staff to improve confidence and effectiveness in delivering shift handover;

• existenceofchecklistsforthereviewandratingoffaceto face handovers ;

• involvementofemployeesintheexaminationandimprovement of the practices;

• existenceofchangemanagementprocessestoupdatesystems in light of information from incidents and accidentsduetoshifthandoverproblemsandbringingthis to the attention of employees;

• maintenanceandanalysisofshifthandoverrecordsforlearning opportunities;

• auditofshifthandoverrecordsforbothcontentand process.

INDUSTRY CONSULTATION

Keyfindingsfromthereviewofshifthandoversystemsprovidedbyarangeoforganisationsacrossavarietyofheavy industries (e.g. mining, engineering, construction etc.) consistently included:

• considerationorreferencetolegalOH&Srequirementsorobligationsinhandoverprocedures;

• anoutlineofthekeypurposeforconductingashift handover;

• identificationofkeypersonnelandresponsibilitiesinconducting a shift handover;

• explanationofthehandoverprocedureandrecordkeeping protocols;


• agenericrecordkeeping/pre-planningformthatprovidedstructurebutmainlyfreeformfieldsinwhichtorecordwhatwastobe,orwhatwasactuallydiscussed.Most commonly these forms included topics/headings such as:

– personnel in attendance

– tasks and progress (forecast and actual)

–hazardnearmissobservationsreportedandresolved/unresolved

– safety issues resolved/unresolved

– equipment issues resolved/unresolved

– Safe Work Method Statements (SWMS) and permits relevant to the oncoming shift

– safety concerns/task concerns

– non conformances

– environmental issues

– inspections completed/checks required.

Arangeorganisationsthatwereengagedthroughtheconsultation of this report did not have mature systems forshifthandover.Inseveralcasesdocumentationwasoften limited to a shift handover form rather than an integratedprocedureorspecifiedpractice.Consistentwitha “risk based”approachtoshifthandoverallformswerecommonly free form.

Oneofthemainlimitationsinproceduresreviewedwasthestipulationthatshifthandover,whileconductedfacetoface,wasdonesobetweensupervisorsorsuperintendentswiththeoutcomeofthehandovertobefedintotheoncomingshift’spre-startmeeting.Inafewinstancesworkcrewresponsibilitiesidentifiedtheneedforthemtobepreparedforquestionsfromtheincomingsupervisor/superintendent.Also,logsorplodswererarelymentionedorusedandtherewasnoreferenceastowheretheshifthandovershouldbeconducted.Theinclusionofauditingarrangements, analysis of shift handover records and the inclusion of communication skills in selection criteria could notbeevaluatedfromthematerialsprovided.

Oneexceptiontothegeneralapproachtoshifthandoverhasbeendevelopedandisbeingemployedacrossallsitesof a large engineering/maintenance organisation. Termed SH2 (or Shift Handover 2) this approach utilises cutting edge technology and real time reporting to maintain up to date communications across its operations. SH@ is aniOS(apple)basedsoftware,utilisingiPadsandAppleTVtointegratetoTVscreens.Thesoftwarefeaturesaninteractivecommunicationplatformthatprovidesvisibilityof operational status, hazards, maintenance schedules andproductivityperformance.Usingthelatesttechnology,thesystemrunsoffawebbaseddataserverwhichdeploysdatatoandfromsites,andintegrateswithexistingapplications. All shift hand over records are archived and fullysearchable,andhavereportingsoftwarethatcan

analyse trends, including the most common hazards, timesspentondifferenttopics,attendeesandwhatwasdiscussed. Also, SH2 can receive real time input from corporate to include key organisational messages, safety alerts or reports from other sites. The roll out of this applicationiscurrentlytakingplaceandissupportedwithtraining in use of the technology (Apple touch and type) as wellaspresentationandfacilitationskillstraining.Allshifthandovers accompanying the SH2 rollout are conducted teamtoteam,facetofacewiththeaid/assistanceofthevisualdisplayandstructuredagendaprovidedbythesoftware.Allsupervisorsresponsibleforconductingthehandovers are afforded time during and at the end of shift toplantheshifthandovermeeting.Culturallythisrolloutis also reinforcing the phrase “shift handover – your most important conversation of the day”.


CONCLUSION & RECOMMENDATIONS


GRID MESHDOCUMENTED INDUSTRY STANDARDS FOR THE SELECTION AND INSTALLATION OF GRID MESH

Itiscriticaltoensurethatallaspectsoftheareainwhichthegridmeshwillbeinstalledhavebeenconsideredpriorto selecting a product. While the manufacturer or supplier of thegridmeshshouldberequestingallrelevantinformationregarding the application/use of the grid mesh in order to assist in providing the correct product, it is critical to ensure thatthefollowinginformationisconsideredpriortoselection:

• Location(restrictedarea,adjacenttomachinery).

• Supportstructure.

• Possiblevibration.

• Vehicletraffic(ifany).

• Pedestriantraffic(maximumandminimum).

• Loadbearingcapacity(willtherebeworkingloads/loaded trolleys or carts / stationary loads).

• Environmentalconditions.

• Easeofinspection/maintenance.

• Accessibilityoffixingmechanisms.

DOCUMENTED INSTALLATION, FIXING AND REMOVAL PROCEDURES

Priortotheinstallationofgridmeshthefollowingarerequiredtoallowtheworkactivitytobecommenced:

• Ariskassessmentorjobhazardanalysisoftheactivityinrelationtothespecificareawheretheworkwillbeconducted.

• Communicationoftheriskassessmentorjobhazardanalysistotheworkpartiesimpactedbytheworksorinthevicinityoftheworkzone.

• Aworkspermitissuedbyacompetentauthorityrepresenting the company.

Fromreviewoftheproceduresandprocessesprovidedbyindustry,thefollowingappeartobethekeycomponentsofan installation process:

• Wherepossible,thestructuralsupportmembersaretobeinstalledandfullysecuredpriortotheinstallationofthe panels.

• Alledgeprotectionandfallarrestequipmentistobeinplacebeforeinstallationactivitiescommence,includingbarricadingoftheareabelowtheworkzone.

• Temporaryfixingofpanelsduringtheinstallationprocessto ensure limited movement of panels.

• Wherepanelsarenotabletobefittedinaccordancewiththedesign,allactivitiesaretoceaseuntilthisissuehasbeenrectified.

Whencommencingremovalactivitieswithregardtogridmesh,theremustbeaworkspermitissuedbyacompetentauthorityandhardbarricadingmustbeinplacesurroundingtheworksareatopreventaccessbyunauthorised personnel.

INSTALLATION, FIXING AND REMOVAL CHECKLIST PROCEDURES INCLUDING PERMITTING REQUIREMENTS

Ensure that a checklist is developed assessing the completed installation, fix or re-instatement of grid mesh panelstoensurethatthegridmeshhasbeenleftinaconditionsuitablefortheactivitiesitissupporting.

INDUSTRY TRAINING IN RELATION TO THE USE, INSTALLATION, FIXING AND REMOVAL OF GRID MESH

It is recommended that all personnel involved in the installation, fixing and removal of grid mesh are trained in workingatheightsandfallarrestasaminimumandintheinternalcompanyproceduresfortheworkactivityinvolvinggrid mesh.


Auditing and inspection of grid mesh installations is to beconductedregularly.Inspectionisnottoexceedfiveyearsbymanufacturer’srecommendation,howevermorefrequentinspectionsaretobeconsideredbasedonthecriteria detailed in the selection process and documented above.Considerationtobegiventoamechanismtoidentifyclearlywhichpanelshavebeeninspectedandapprovedforuseandwhichhaveyettobeinspected.


BARRICADINGTYPES OF BARRICADING INCLUDING SELECTION CRITERIA AND FITNESS FOR PURPOSE

The standards (legislation, codes, standards, guidelines andpublishedliteratureandindustryconsultation)reviewedshowedthatthereisno“single / magic”barricadethatissuitableforallsituationsandrisks.Rather,thatamulti-tieredapproachisbestpractice.Thisconsistsof:

• Definingthetypesofbarricadesavailablethataresuitedtothesitesandactivitieswhereworksarebeingundertakenandcategorisingtheseintotwotothreelevelse.g.hardbarricadesandsoftbarricades.Someorganisationschosetocategorisebarricadesintothreelevelse.g.Level1,2,3orClassA,B,C.Theseweregenerallyassociatedwithlevelsofrisk–high,medium,low.

• Identifyingwithineachcategorythespecificbarricadesthatarepermittedtobeused.Forexample:

–Hardbarricading–tobeconstructedofscaffoldtube,mesh,metalorwoodenpostsorrails,etc.Hardbarricadesmayincludefences,buildingwalls,concrete structures, standalone A’frames, earthen berms,waterfilledplasticbarriersetc.

–Softbarricading–includescolouredrope/ribbon,bunting,cones,flagging,bollardsetc.

• Adoptingariskbasedapproachfortheselectionofsuitablebarricading.Thisshouldalsomandatecertaintypesofbarricadingforcertainlevelsofriskorhazardoussituationssuchasidentifiedhighriskswillusehardbarricadingonly;fallriskswillusehardbarricadingonly etc.

• Considerthedevelopmentofaquickreferenceguideforusebysitepersonnelthatoutlinesthetypesofbarricadesandtherequirementsassociatedwiththeirinstallation and use.

DOCUMENTED INSTALLATION AND REMOVAL PROCEDURES

It is recommended that installation and removal procedures giveconsiderationtothefollowingrequirements:

• Barricadesmustbeinstalledbeforethecommencementofworks.

• Thebarricadedareaistoencompasstheentirepotentially affected area of the hazards.

• Barricadingistobeinstalledatleasttwometresawayfromthehazard.Wherethiscannotbedone,ariskassessmentshouldbeundertaken.

• Barricadingistobemaintainedingoodconditionensuring that it remains effective.

• Ahardbarricadeshallhaveasolidtopandmidrail(e.g.scaffoldtubeorequivalent).Thetoprailmustbebetween900mmand1200mmhighandthemidrailshallbenomorethan560mmfromthefloor,ifnotoeboardisfitted,and450mmbetweenrails.Beabletowithstandaforceof0.55–0.90kN(approximatelyequivalent to 55 – 90 kg) applied at any point.

• Hardbarricadingistobeaccompaniedatalltimeswithrelevant flagging / tape.

• Barricadingmaterialssuchasmesh,and/ortapeshallbeinstalledwiththetopedgeataheightbetween900mm and 1200mm.

• Plasticmeshbarriersshallbeaminimum900mmhighsupportedbycappedstarpicketsorotherupright structures.

• Barricadesupportsshallbeatmaximumspacingofthree metres.

• Barricadesshallbemaintainedinatautandlevelposition to prevent sagging.

• Waterfilledplasticbarricadesareclassedasasuitablebarricadingmethod.Wherethereispotentialforavehicleimpacttheyshallbelinkedtogetherandfilled.

• Barricadingshallnotbetiedtovalvehandles,conduit,instrumenttubing,electricalgear,orotherfragileitems.

• Barricadesshallbeinstalledinsuchawayastoeliminateaccidentalentryintothebarricadedzone.

• Entrypointsinbarricadingshallbearrangedsuchthatpersonnelenteringtheareacannotwalkdirectlyintothe hazard.

• Whereabarricadewouldnotsupportaperson’sweight,itshallbeplacedsothatanypersonfallingthroughitwouldnotreachthehazard.

• Nopersonshallenteradangerbarricadeareaunlessauthorityisobtainedfromthebarricadeowneraslistedonthebarricadetag.

• Capsshallbefittedtostarpicketsorstakes.

• Warninglights,suchasamberflashingbeacons,areprovidedatappropriateintervalswheretheriskassessmentindicatestheneedtowarnpeopleofthepresenceofabarricadeduringdarkness.

• Barricadingsignageshallbeinstalledonallbarricadesinaccordancewithrequirementsoutlinedbelowunder“Barricading signage requirements”.

• Barricadesaretoberemovedimmediatelyoncetheworkiscompletedorthehazardnolongerexists.


BARRICADING SIGNAGE REQUIREMENTS

Therecommendedbestpracticeforsignagerequirementsisasfollows:

• Typesofsignage,definition,size,colouringetc.shouldbeinaccordancewithStandardsAustralia(1994)AS1319.

• Signageneedstoidentifydateandtimeerected,nameandphonenumberofresponsiblepersonormeansofcontact,durationofproject/barricadeandreasonsforthebarricade(hazardpresent).Thisinformationshouldberecordedonaninformation/barricadetagthatisattachedtothebarricade.

• Informationtagsandsignageistobeattachedatallfacesand designated access points. The intervals of signage andtagsattachedatbarricadefacesshallbedeterminedbyariskassessment.

• Signsshouldbelocatedwherethemessagesarelegible,and so that they attract the attention of, and are clearly visibletoallconcerned.

• Signsshouldbemountedascloseaspracticabletotheobserver’slineofsightandpositionedsoastogivetheviewerampletimetoheedthewarning.

• Signsshallbeconstructedanderectedsothattheydon’tcreateahazardandshallbemaintainedingoodcondition,keptcleanandwellilluminated.

• Themeaningofsafetysignsusedonasitemustbecommunicatedtotheworkforceattheinduction,toolboxmeetings and pre-start meetings.

• Ifthereisamultilingualworkforce,wordsonsignsshouldbeintherelevantmultiplelanguages.

• Graphicsonsignsshouldbecolourfulandboldandimmediately convey the message.

• Appropriatesignsshouldbeplacedatthepointof danger.

• Consistentformatforsignsandlabelsshouldbeusedthroughout the facility for clarity.

• Customisedmessagesshouldbecreatedtoclearlyidentify requirements for entering a specific area or operating a specific piece of equipment.

• Materialsusedforsignsandlabelsshouldbeabletoendure their environment. Specially designed and tested materialsareneededtowithstandharshenvironments.

INSTALLATION AND REMOVAL CHECKLIST PROCEDURES INCLUDING PERMITTING REQUIREMENTS

While the research did not identify any specific installation and removal checklist procedures including permitting requirements,considerationshouldbegiventoestablishingsuchrequirements,especiallywhereentrytothebarricadedareamayposeanimmediaterisktoemployeessuch as open holes, dangerous ground conditions, structuralcollapseetc.wherelifemaybeendangeredwithoutwarning.

INDUSTRY TRAINING IN RELATION TO THE SELECTION, INSTALLATION AND REMOVAL OF BARRICADING

Therecommendedbestpracticefortraininginrelationtotheselection,installationandremovalofbarricadingincludes:

• Thesiteinductioncontainsinformationandinstructionregardingbarricadingandassociatedsignageincludingtypesofbarricades/signageandkeyrequirements/rulesassociatedwithbarricadeseg.entryrequirements,meaning, signage etc. for all site personnel to ensure thatrelevantrequirementsareunderstoodbyall.

• Forpersonnelresponsiblefortheselection,installation,removalandinspectionofbarricading,trainingshallbecompetencybased(reflectingthestandard)andinclude:

–Systemsofworkneededforthesafeuseofbarricades.

–Typesandselectionofcorrectbarricadesandsignage.

– Barricade equipment.

–Care,maintenanceandinspectionofbarricades.

• Additionalretrainingshallbeconductedwhenevera periodic inspection reveals, or there is a reason to believe,thattherearedeviationsfrominadequaciesintheemployees’knowledgeofbarricadinghazards.

• Employersshallconductadditionalretrainingwheneverabarricadingofhazardsprocedurefails.

• Wherebarricadingisofaproprietarynature,guidanceoncompetencyrequirementsshallbesoughtfromthemanufacture / supplier.



Therecommendedbestpracticeforensuringcomplianceis:

• Developingandimplementinganauditprogramforthebarricadingstandard.Thisauditprogramshouldlookat the effectiveness and level of implementation and compliancewiththebarricadingstandard.

• Developingandimplementinganinspectionprogramwhichincludesregularformalinspectionsundertakenat the commencement and conclusion of each shift /workactivity.Detailsoftheinspectionsshallberecordedincludingidentificationmarkofthebarricade,datethebarricadewasfirsterected,dateoflastinspection and name of person carrying out the inspection.Also,thepersonresponsiblefortheerectionofthebarricadeshouldconductregularinspectionsthroughouttheshift/workactivitytoensurethatthebarricadehasnotbeencompromised.

• Wheredefectsareidentifiedwiththebarricadingcomponentsortheerectedbarricadeisnotfitfor purpose:

–Allcomponentsshouldbetaggedoutofservice/notfor use and repaired or replaced.

–Allworksintheaffectedareashouldceaseuntilthebarricadingiscorrectedanddeemedtobefitfor purpose.


SHIFT HANDOVERShift hand over requires skills and systems for effective communication and information management. Also, there is anopportunitytoexplorehowtechnologycanhelpwiththistask:certainly,contentmanagement(thewayinformationis collected and structured) to assist in the maintenance of site and specifically shift safety.

CRITERIA (TYPE OF PROJECT, TYPE OF ACTIVITY ETC.) TO TRIGGER SHIFT HANDOVER REQUIREMENT

Recommendedindustrybestpracticeidentifiesthatatransferofresponsibilityoraccountabilityforaspecifictaskor range of activities requires a handover or exchange of information.Shifthandoverbeingaspecificcaseofthisdefinedby:

“the exchange between shifts of information and risks relating specifically to the job or tasks being performed which accompanies either a transfer of control over, or of responsibility for, the work.”

DOCUMENTED INDUSTRY STANDARDS AND PROCEDURES FOR THE DOCUMENTATION OF SHIFT HANDOVER INCLUDING METHOD OF SHIFT HANDOVER

Recommendedindustrybestpracticefordocumentingshift handover includes the provision of clear procedures/writtenguidancedescribingthekeyinformationtobeexchangedandhowthisshouldbedone(e.g.wordofmouth,inwritingorboth),aswellasastructuredrecord(usually provided to prepare for shift handover) and typically intheformatofawrittenform(thoughtheadoptionofnewtechnologies is currently leading edge and holds great promiseinthisarea).Othershifthandoverdocumentationincludedaidssuchaslogbooks(plods,databases,etc.)during handover, using more than one communication medium(forexample,bothwrittenandverbal),andaddition to modified procedures and specialist information (e.g.MaterialDataSafetySheets[MSDS]orinspection/audit reports that are amended to the handover form). Alsochecklistsforthereviewandratingoffacetofacehandovers and shift handover audit forms.

DOCUMENTED INDUSTRY STANDARDS AND PROCEDURES FOR THE DOCUMENTATION OF SHIFT HANDOVER INCLUDING ITEMS / ISSUES TO BE DISCUSSED AND INCLUDED IN SHIFT HANDOVER

Recommendedindustrybestpracticefordocumentationof shift handover content inclusions:

• productandplantmovements,bothongoingand planned;

• controlsystemsbypassed;

• equipmentnotworkingoroutofcommission;

• maintenanceandpermits;

• isolationsinforce;

• tripsdefeated;

• criticalorhighpriorityalarmsactivatedandactions taken;

• health,safetyorenvironmentalincidentsorevents;

• modifications;

• theworkscheduleandworkundertaken;

• recentauditorinspectionreports;

• personnelandorsubcontractorsonsite;and

• unusualoccurrencesconveyedasproblems,hypotheses, and intent, rather than simply listing whatoccurred.

DOCUMENTED INDUSTRY STANDARDS AND PROCEDURES FOR THE DOCUMENTATION OF SHIFT HANDOVER INCLUDING COMMUNICATION OF INFORMATION AT SHIFT HANDOVER

Recommendedindustrybestpracticeindicatesthathandovercommunicationworksbestifitcapturesproblems,hypotheses,andintent,ratherthansimplylistingwhatoccurred.Addendum2containsalistofguidelinesbasedontheliteratureonbestpracticesinshifthandover(Parke&Mishkin,2005;Parkeetal.,2003).Whilethesummary of communication practices suggest:

• theallocationoftimetoprepareshifthandovermaterialsprior to the end of the shift;

• theallocationofappropriatespacetoconducttheshifthandover that minimises distractions and interruptions;

• ashifthandoverenvironmentthatencourageschallenging of assumptions and seeks assurance of understanding;


• shifthandoversconductedfacetoface,crewtocrew;

• twowayshifthandovers,withbothparticipantstakingjointresponsibilityforensuringaccuratecommunicationand understanding;

• shifthandoversthatusearangeofverbalandwritten/recorded means of communication;

• shifthandoversareaffordedthetimenecessarytoensure accurate communication;

• therecognitionoflongerormoredetailedhandoverswhenstaffhavereturnedfollowingalengthyabsencefromwork;duringplantmaintenance;duringdeviationsfromnormalworking/duties;andwhenhandoverstakeplacebetweenexperiencedandinexperiencedstaff. As these high risk scenarios for shift handover areconsistentwiththosesituationsandprocessesthatconsistentlyemergeinascontributingfactorsinincident investigations;

• inclusionofcommunicationskillsinselectioncriteriaforshiftworkers;

• involvementofemployeesintheexaminationandimprovement of the practices;

• existenceofchangemanagementprocessesforupdating systems in light of information from incidents andaccidentsduetoshifthandoverproblemsandbringingthistotheattentionofemployees;

• maintenanceandanalysisofshifthandoverrecordsforlearning opportunities.

INDUSTRY TRAINING IN RELATION TO SHIFT HANDOVER METHODS AND COMMUNICATION

Recommendedindustrybestpracticeincludes:

• Providingtrainingandhavingsystemstoensure that employees are competent in using handover procedures.

• Providingtrainingandhavingsystemstoensurethatemployees are competent in using logging, plod sheets, databaseorassociatedtechnologiesthataccompanyshift handover processes.

• Investinginthedevelopmentofpresentation,facilitationand communication skills of staff to improve confidence andeffectivenessindeliveringshifthandover(beitonthejob,mentoring,formaltraining,orjobrehearsalaccompaniedbycoachingwithexperiencedstaffandcomputerorvideobasedtraining).


Recommendedindustrybestpracticeforthissectionwasnot uncovered.


REFERENCES


GRID MESHAS/NZS1657(1992)Fixedplatforms,walkways,stairwaysand ladders

OccupationalHealth&SafetyRegulations1996 (Western Australia)

BARRICADINGAbuDhabiEHSCentre.(2012).EHSRI-CoP22.0-Barricading of hazards, version 2.0.

AustralianSafetyandCompensationCouncil.(2008).National code of practice for the prevention of falls in generalconstruction.CommonwealthofAustralia.

Bruner,L.(2007).STAYINGSAFE-TheImportanceofEffectiveSafetySignageandLabelling.OccupationalHazards,69(3),57-58.

Chan,A.H.S.,&Ng,A.W.Y.(2010).Investigationofguessabilityofindustrialsafetysigns:Effectsofprospective-user factors and cognitive sign features. International JournalofIndustrialErgonomics,40(6),689-697.

K.L.Chan,AlanH.S.Chan,(2011),“Understanding industrial safety signs: implications for occupational safety management”,IndustrialManagement&DataSystems,Vol.111Iss:9pp.1481-1510.

Laughery,K.R.,&Wogalter,M.S.(2012).Athree-stagemodelsummarizesproductwarningandenvironmentalsign research. Safety Science(0).

OccupationalSafetyandHealthRegulations1996.(2012).WesternAustralia.StateLawPublisher.

Standards Australia. (1994). AS1319 Safety signs for the occupational environment. Standards Australia.

Townsend,D.(2008).“Signs” of safety: Send a clear messagewithOSHA-compliantandeye-catchingsignage.ISHN, 42(3), 44-45.

WorkplaceHealthandSafetyQueensland.(2011).ManagingtheriskoffallsatworkplacesCodeofPractice11.QueenslandGovernment.

WorkSafeWesternAustralia.(2009).Constructionworkandthepublic.DepartmentofCommerceWesternAustralia.

SHIFT HANDOVERAhmed,J.,Mehmood,S.,Rehman,S.,Ilyas,C.,&Khan,L.U.R.(2012).Impactofastructuredtemplateandstafftraining on compliance and quality of clinical handover. InternationalJournalofSurgery(0).

Alvarado,K.,Lee,R.,Christoffersen,E.,Fram,N.,Boblin,S.,Poole,N.,etal.(2006).TransferofAccountability:TransformingShiftHandovertoEnhancePatientSafety.HealthcareQuarterly,9(Sp),75-79.

Apker,J.,Mallak,L.A.,&Gibson,S.C.(2007).Communicatinginthe“gray zone”:perceptionsaboutemergency physician hospitalist handoffs and patient safety.AcademyofEmergencyMedicine,14(10),884-894.

Arora,V.M.,Johnson,J.K.,Meltzer,D.O.,&Humphrey,H.J.(2008).Atheoreticalframeworkandcompetency-basedapproachtoimprovinghandoffs.QualityinSafetyandHealthCare,17(1),11-14.

Australia Bureau of Statistics. (2009). Working Time Arrangements,Australia(ReportNumber6342.0).Canberra,Australia.

AustralianCommissiononSafetyandQualityinHealthCare.(2009a).Clinicalhandover:criticalcommunications.MedicalJournalofAustraliaSupplement,190(11).

AustralianCommissiononSafetyandQualityinHealthCare.(2009b).TheOSSIEGuidetoClinicalHandoverImprovement.Sydney:ACSQHC.

AustralianCommissiononSafetyandQualityinHealthCare.(2012).SafetyandQualityImprovementGuide:Standard6:ClinicalHandover.Sydney,Australia.

AustralianCommissiononSafetyandQualityinHealthcare.(2012).SafetyandQualityImprovementGuide:Standard6:ClinicalHandover.Sydney,Australia.

Australian Medical Association. (2006). Safe Handover: SafePatientsGuideline.Kingston,ACT.

Bhabra,G.,Mackeith,S.,Monteiro,P.,&Pothier,D.D.(2007). An experimental comparison of handover methods. AnnalsofTheRoyalCollegeofSurgeonsofEngland,89(3),298-298.

Bradley, W. B. (1991). Task force reduces stuck-pipe costs. OilandGasJournal,89(21),84-88.

Buncefield Standards Task Group. (2007). Safety and environmental standards for fuel storage sites. Sudbury,Suffolk.

Buxton,S.(2003).ShiftWork:AnOccupationalHealthandSafetyHazard.MurdochUniversity,Perth,Australia.

Carroll,J.S.,Williams,M.,&Gallivan,T.M.(2012).Theinsandoutsofchangeofshifthandoffsbetweennurses:Acommunicationchallenge.BMJQualityandSafety21(7),586-593.


Chuang,L.-Y.,&Lee,C.-T.(2009).Nursingstaffcommunication during nursing shift changes. Hu li za zhi The journal of nursing, 56(3), 93.

Cloutier,E.,&LaFlamme,L.(1994).Analysisof94occupationalaccidentswhichoccurredinsawmillsbetween1stJanand31stOctober1993.Quebec,Canada:IRSSTQ,QuebecOccupationalHealthandSafetyResearchInstitute.

Cohen,M.D.,&Hilligoss,P.B.(2010).Thepublishedliterature on handoffs in hospitals: deficiencies identified in anextensivereview.Quality&SafetyinHealthCare,19(6),493-497.

Cullen,L.(1993).InquiryintothePiperAlphaoilplatformdisaster,Vols.1&2.Volume2,Chapter5.London:HMSO.

Currie,M.B.(2002).PSRs:don’texpandyourlegalliabilities[Pre-starthealthandsafetyreviews].EngineeringDimensions,23(4),19.

Dayton,E.,&Henriksen,K.(2007).Communicationfailure:basiccomponents,contributingfactors,andthecallforstructure.JournalOnQualityAndPatientSafety/JointCommissionResources,33(1),34-47.

DellaRocco,P.,Cruz,C.,&Clemens,J.A.(1999).Operationalerrors/deviationsandshiftworkinairtrafficcontrol(Tech.Rep.No.DOT/FAA/AM-99/2).Springfield,VA: National Technical Information Service.

Dobson,J.D.(1999).Rigflooraccidents:Who,when,andwhy?PaperpresentedattheSPE/IADCDrillingConference,Dallas,Texas.

Dowding,D.(2001).Examiningtheeffectsthatmanipulating information given in the change of shift report hasonnurses’careplanningability.JournalofAdvancedNursing,33(6),836=846.

Friesen,M.A.,White,S.V.,&Byers,J.F.(2008).Handoffs:ImplicationsforNurses.InR.G.Hughes(Ed.),PatientSafetyandQuality:AnEvidence-BasedHandbookforNurses.Rockville,MD:AgencyforHealthcareResearchandQuality.

Grusenmeyer,C.(1995).Sharedfunctionalrepresentationin cooperative tasks: The example of shift changeover. JournalofHumanFactorsinManufacturing,5(2),163-176.

Holland,C.K.(1993).Anethnographicstudyofnursingculture as an exploration for determining the existence of asystemofritual.JournalofAdvancedNursing,18, 1461-1470.

Hunns,D.(1986).Humanfactorsinreliabilityandthepsychologyofcommunications.InternationalJournalofQualityandReliabilityManagement,3(1),22-37.

Judice,K.(2009).TheImportanceofthePre-JobMeeting.MaterialsPerformance,48(6),50.

Klee,K.,Latta,L.,Davis-Kirsch,S.,&Pecchia,M.(2012).UsingContinuousProcessImprovementMethodologytoStandardizeNursingHandoffCommunication.JournalofPediatricNursing,27(2),168-173.

Lally,S.(1999).Aninvestigationintothefunctionsofnurses’communicationattheinter-shifthandover.Journalof Nursing Management, 7(1), 29-36.

Lardner,R.(1996).EffectiveShiftHandover- ALiteratureReview.

Lardner,R.(1999).Safecommunicationatshifthandover:Setting and implementing standards.

LeBris,V.,Barthe,B.,Marquie,J.-C.,Kerguelen,A.,Aubert,S.,&Bernadou,B.(2012).Advantagesofshiftchangeoverswithmeetings:Ergonomicanalysisofshiftsupervisorsactivityinaircraftbuilding.AppliedErgonomics,43(2), 447-454.

Manser,T.,&Foster,S.(2011).Effectivehandovercommunication:Anoverviewofresearchandimprovementefforts.BestPractice&ResearchClinicalAnaesthesiology,25(2),181-191.

Manser,T.,Foster,S.,&Gisin,S.(2010).Assessingthequalityofpatienthandoffsatcaretransitions.Quality&SafetyinHealthCare,19(6),1-5.

McFetridge,B.,Gillespie,M.,Goode,D.,&Melby,V.(2007). An exploration of the handover process of critically illpatientsbetweennursingstafffromtheemergencydepartmentandtheintensivecareunit.NursingCriticalCare,12(6),261-269.

McMullan,A.(2007).Communicationinpatientcarehandoffsandimplicationstosafety.UnpublishedDissertation/Thesis.

Meissner, A., Hasselhorn, H.-M., Estryn-Behar, M., Nezet, O.,Pokorski,J.,&Gould,D.(2007).Nurses’perceptionof shift handovers in Europe: results from the European Nurses’EarlyExitStudy.Journalofadvancednursing,57(5), 535-542.

Mikkelsen,A.,Ringstad,A.J.,&Steineke,J.M.(2004).WorkingtimearrangementsandsafetyforoffshoreworkersintheNorthSea.SafetyScience,42(3),167-184.

Miller,C.(1998).Ensuringcontinuingcare:Stylesandefficiencyofthehandoverprocess..AustralianJournalofAdvanced Nursing, 16(1), 23-27.

Nestel,D.,Kneebone,R.,&Barnet,A.(2005).Teachingcommunication skills for handover: perioperative specialist practitioners. Medical Education, 39(11), 1157.

NT WorkSafe. (2003). Safety management...a guide.

Odell,A.(1996).Communicationtheoryandtheshifthandoverreport.BritishJournalofNursing,5(21), 1323-1326.


Parke,B.,&Kanki,B.G.(2008).BestPracticesinShiftTurnovers: Implications for Reducing Aviation Maintenance Turnover Errors as Revealed in ASRS Reports. The InternationalJournalofAviationPsychology,18(1),72-85.

Parke,B.,&Mishkin,A.(2005,25-27October).Bestpractice in shift handover communication: Mars explorationroversurfaceoperations.PaperpresentedattheProceedingsoftheInternationalAssociationfortheAdvancementofSpaceSafetyConferencesponsoredbyESA,NASA,andJAXA,Nice,France.

Parke,B.,Patankar,K.,&Kanki,B.G.(2003,April14-17).ShiftturnoverrelatederrorsinASRAreports.PaperpresentedattheProceedingsoftheTwelfthInternationalSymposiumofAviationPsychology,Dayton,Ohio.

Parkes,K.R.(2012).ShiftschedulesonNorthSeaoil/gasinstallations:Asystematicreviewoftheirimpactonperformance, safety and health. Safety Science, 50(7), 1636-1651.

Porteous,J.M.,Stewart-Wynne,E.G.,Connolly,M.,&Crommelin,P.F.(2009).iSoBAR--aconceptandhandoverchecklist:theNationalClinicalHandoverInitiative.TheMedical journal of Australia, 190(11 Suppl), S152.

Pothier,D.,Monteiro,P.,Mooktiar,M.,&Shaw,A.(2005).Pilotstudytoshowthelossofimportantdatainnursinghandover.BritishJournalofNursing,14(20),1090-1093.

Stager,P.,&Hameluck,D.(1988).Factorsassociatedwithairtrafficcontroloperatingirregularities:ananalysisofFactFindingBoardreports,ReportpreparedunderTransportCanadaContractNo.AP-0264forAirTrafficServicesBranch,EvaluationDivision.Ottawa,Canada.

Sydney South West Area Health Service. (2007). Guidelines forClinicalHandover.Sydney,NSW.

Symons,N.R.A.,Wong,H.W.L.,Manser,T.,Sevdalis,N.,Vincent,C.A.,&Moorthy,K.(2012).Anobservationalstudyofteamworkskillsinshifthandover.Internationaljournalofsurgery(London,England),10(7),355.

TheKeilCentre.(2006).ImprovingCommunicationatShift Handover.

Thompson,B.,&Plocher,T.(2011).StructuredApproachtoShiftHandoverImprovesSituationAwareness.Houston,TX.

U.S.DepartmentofEnergy.(1998).DOEstandard:Guideto good practices for operations turnover (Tech. Rep. No. DOE-STD-1038-93).Washington,DC.

UKHealthandSafetyExecutive.(1999).Reducingerrorandinfluencingbehaviour.Sudbury,Suffolk:HSEBooks.

UKHealthandSafetyExecutive.(2000).Improvingmaintenanceaguidetoreducinghumanerror.Sudbury,Suffolk: HSE Books.

UKHealthandSafetyExecutive.(2005).Guidanceonpermit-to-worksystems:Aguideforthepetroleum,chemicalandalliedindustries.Sudbury,Suffolk:HSE Books.

UKHealthandSafetyExecutive.(2006).Managingshiftwork:Healthandsafetyguidance.Sudbury,Suffolk:HSE Books.

Wallis.(2010).NursingHandoverResearchProject:Howisnursinghandovertalkedaboutintheliterature?.WaikatoInstitute of Technology, Waikato.

Werner, E. (1979). Working hours and accidents. Dortmund,Germany:BundesanstaltfurArbeitsschutzundUnfallforschung.

Yurkovich,E.,&Smyer,T.(1998).Shiftreport:atimeforlearning.TheJournalofnursingeducation,37(9),401.


APPENDICES


ATTACHMENT 1: SCRIPT FOR CONVERSATIONS WITH INDUSTRY RE RESEARCH PROJECTThiswouldalsoformthebasisofwritten(email)requestfollowinganyconversations…

INTRODUCTION Hello,mynameis….IamfromIbisBusinessSolutions/PeopleKnowledgeConsulting…

PURPOSE IamundertakingresearchforourclientJohnHollandregardingindustrybestpracticeinsomespecificareasofworkplacesafetymanagement.

Ifaskedwhy???Thisisaboutproactiveresearchundertakentoaddresssomeidentifiedimprovementissuesinthebusiness.

IwaswonderingifIcouldhaveapproximately15minutesofyourtimetodiscussthesespecific areas.

If response is not now / busy ask – Would you mind if I called you back at a more suitable time and make an appointment to call back.

Theresultsofthisworkareintendedtobenefitindustryandresultswillbemadepublicallyavailable.

SPECIFICS Ourprojectaimstoidentifyindustry(worldwide)leadingpracticeinthefollowingareas:

• Gridmesh.

• Barricading.

• Shifthandover.

• Managementofspecialistsubcontractors.

Specifically,weareseekinginformation(standards,practicesandprocedures)coveringthefollowingareastoidentify:

GRID MESH

• Documentedindustrystandardsfortheselectionandinstallationofgridmesh.

• Documentedinstallation,fixingandremovalprocedures.

• Installation,fixingandremovalchecklistproceduresincludingpermittingrequirements.

• Industrytraininginrelationtotheuse,installation,fixingandremovalofgridmesh.

• Industryacceptedauditingprocessesforensuringcompliance.

BARRICADING

• Documentedindustrystandardsfortheselectionandinstallationofbarricading.

• Typesofbarricadingincludingselectioncriteriaandfitnessforpurpose.

• Documentedinstallationandremovalprocedures.

• Barricadingsignagerequirements.

• Installationandremovalchecklistproceduresincludingpermittingrequirements.

• Industrytraininginrelationtotheselection,installationandremovalofbarricading.



SHIFT HANDOVER

• Industryaccepteddefinitionof“Shift Handover”.

• Criteria(typeofproject,typeofactivity,etc.)totriggershifthandoverrequirement.

• Documentedindustrystandardsandproceduresforthedocumentationofshifthandover including:

– Method of shift handover.

–Items/issuestobediscussedandincludedinshifthandover.

–Communicationofinformationatshifthandover.

• Industrytraininginrelationtoshifthandovermethodsandcommunication.


CONFIDENTIALITY Anyinformationwillbetreatedwithstrictconfidence.

MaterialprovidedwillonlybeviewedbytheIbis/PKresearchteam.

Copiesofprocedures,forms,standards,etc.willnotbeprovidedtoJohnHolland(ourclient)oranyotherthirdparty,andwillbereturned/erasedfollowingreportcompletion.

However,itshouldbenotedthatinformationcontainedwithinyourdocumentsmaybeusedintheresearchandreporting,e.g.ahardbarricadeisdefinedas...NB There will be no link / reference as to where this information came from.

Useofspecificexamplesoranyofyourcompanymaterialsinourreportwillnotbemadewithoutwrittenpermissionfromyourcompany.

Yourcompanywillbelistedasaparticipant/contributorinthereportforthepurposesofdemonstratingthebreadthofconsultationundertaken,however,nocontactdetails,orothercompanyorpersonalinformationwillbedocumented.

RESULTS AVAILABILITY Weareabletoprovideyouwithacopyofourresearchreportaftercompletionofthework.

TheonlyrestrictionisthatthiswillbeprovidedafterreviewbyJohnHolland.

TIMEFRAME Canyoupleaseprovidethismaterialinasshortatimeaspossible(oneweek?)aswehave limited time to complete the project.

OTHER CONTACTS Canyousuggestanyotherorganisation/individualsthatweshouldcontact?

WRITTEN FOLLOW UP Wewillsendyouawrittenrequest(ifrequired).

QUESTIONS Canweclarifyanything?

THANKS Thankyouforyourcooperationwiththisproject.


APPENDIX A: SHIFT HANDOVERADDENDUM 1: SHIFT HANDOVER AUDIT TOOL (THE KEIL CENTRE, 2006)

DOCUMENT OBTAINED NOTES

COPY OF SAFETY SYSTEM (Are shift handover arrangements referencedinthesafetysystem?)

MINIMUM STANDARD (Doestheorganisationdefineaminimumstandard for shift handovers to make it clearwhatisexpectedofindividualsandprovidedabasisformonitoring/auditing?)

WRITTEN GUIDANCE (Iswrittenguidanceavailabletooperationalpersonnelonhowtoconductaneffectiveshifthandover?)

WRITTEN REQUIREMENT FOR SUPERVISION/ AUDITING (Isthereawrittenrequirementforperiodicmonitoringorauditingofshifthandovers?)

PERSON SPECIFICATION/ SELECTION CRITERIA (Are communication skills amongst the selection criteria for the operations supervisor/superintendent?Dooperationssupervisor/superintendentjobspecifications list shift handover as their taskand/orresponsibility?)

DETAILS OF COURSE/ RESOURCES (relevant training and development undertaken to improve communication skills for shift handover – note many communicationskillsaretransferable.

CHART ILLUSTRATING SHIFT SYSTEM (Evidencethatthereisawelldesignedstructured log and/or computer display to help ensure the most important topics are discussedatshifthandover?)

COPY SHIFT LOG (Copyofthelogforthelastcompleteshiftworkedbythekeypostholdercollected?)

EXAMPLES OF GOOD PRACTICE

OTHER DOCUMENTS (SPECIFY)


ADDENDUM 2: CHECKLIST FOR EFFECTIVE SHIFT HANDOVER (PARKE & MISHKIN, 2005; PARKE ET AL., 2003)

1. Is sufficient schedule overlap time and distraction-free space allocated for effective one on one, face to face shiftturnovers?

2. Is sufficient time and distraction-free space allocated fornecessarygroupturnovers?

3. Are turnovers face to face, or if not, is there an opportunityfortwowaycommunicationregardingtasks;thatis,canquestionsbeasked?Forexample,priorarrangementscanbemadetohavequestionsansweredviaothertechnologies(phonesore-mails)orthird parties.

4. Is time allocated and are resources provided for the outgoingshifttoprepareanyturnovermaterial?

5. Are the necessary information sources readily accessibletotheincomingworker?

6. Is time allocated and are resources provided to develop writtensupportofturnovers,suchasstructuredshiftturnoverworksheetswithspecificquestionsoralistofmaterialtobecovered?

7. Wasthiswrittenmaterialdevelopedwiththeinputofthosewhowilluseit?

8. Wasthewrittenmaterialevaluatedbytheworkersinatrialperiodwiththeopportunitytorecommendadditionsordeletions?

9. Doesthewrittenmaterialhavesomeblankfieldsforworkerstodescribeunusualoccurrences?

10.Doesthewrittenmaterialdemandinclusionofrelevantinformationasascertainedbyworkerinput,critical incident analysis, and careful consideration of risksassociatedwithnothandingoverthematerialinquestion?

11.Inbothwrittenandverbaldescriptionsoftasksandoccurrences,isthereanefforttocaptureproblems,hypotheses, and intent, rather than simply listing whatoccurred?

12. If there are multiple tasks or sources that must bereviewedbeforecomingontoashift,isthereachecklisttoensurethatallwillbeaccomplished?

13. Aretheshiftturnoverprocedureswrittenup?

14. Aretheshiftturnoverproceduresspecificallytrained?

15.Areshiftturnoversperiodicallymonitored?

16.Ishandingoverknowntobeanequalresponsibilityofbothincomingandoutgoingworker?

17. Isthereanefforttopromoteaculturewherecommunication mistakes are expected, and efforts are made to avoid them or mitigate their consequences whentheyoccur?Inthistypeofculture,phrasessuchas “Good catch!” are heard.

18. Areworkersalertedtothenecessityforlengthierandmorethoroughturnoversinabnormaloperations,wheneitherpersonisnewatthejob,andwhentheonetakingoverhasbeenawayfromworkforafewdays?

19. Are days off staggered in a team to preclude their all returningatonce?

20.Arecomputerdatabases,wordprocessingprograms,andothersoftwareandhardwaretoolsusedwhenpossibletoreduceturnoverworkloadandtoprovidegraphicdisplays?

21. Areturnoverdatabasessearchable?

22.Areturnoversseennotonlyaserrorprone,butassometimespotentiallybeneficial?Problemsencounteredinthefirstshiftcanbeviewedbyasecond pair of experienced eyes and personnel frombothshiftscanengageincollaborativeproblemsolving.


Ibis Business Solutions Pty Ltd Suite 3, 27-33 Raglan Street SouthMelbourne Victoria 3205

Telephone: 03 9005 4615 Facsimile:0390054616 Email:[email protected]

www.ibis-solutions.com.au

People Knowledge Consulting 14CoverdaleStreet Indooroopilly Queensland4068

Telephone:0738781509 Facsimile:0738781509 Email:[email protected]

www.peopleknowledge.com.au

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http://www.ibis-solutions.com.au

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Documents

RESEARCH & DISCOVERY PROJECT...research & discovery project research and review of industry best practice – grid mesh, barricading & shift handover final report 1 december 2012