2014 – DuPont LaPorte Toxic Chemical Leak Nearly 24,000 pounds of the toxic chemical, methyl mercaptan, was released after a series of shift communication mistakes. The U.S. Chemical Safety Board investigation reported that the errors began five days previous to the incident. DuPont was fined $372,000 for safety violations at the LaPorte plant and The Occupational Safety and Health Administration put the company in it’s “Severe Violator Enforcement Program. Four employees were killed as a result of the leak.
2013 – KiwiRail Train Derailment Poor communication during an overnight shift change led to a Wellington-bound train carriage derailing. The Transport Accident Investigation Commission in New Zealand investigation found that 10 weeks before the derailment, maintenance staff had forgotten to fit split pins to bolts that held the part in place that caused the derailment. Employees were not given the proper instructions to follow and the repair task was left out. Four passengers were injured as a result.
2010 – BP Deepwater Horizon Oil Spill Due to a lack of appropriately analyzing all the information on hand, BP made several poor decisions that lead to the Macondo well blowout. According to the BOEMRE and the US Coast Guard’s reports, BP failed to share critical information from their onshore staff as well as reports from Halliburton, their drilling partner, to the Deep Water Horizon rig crew which lead to the incident. Sadly, eleven men lost their lives due to this communication failure and almost five million barrels o oil was discharged in the Gulf of Mexico.
2010 – Kleen Energy Natural Gas Explosion According to a U.S. Chemical Safety and Hazard Investigation Board report workers a the plant had received mixed communications regarding natural gas blows. Some were informed that blows would be occurring the day before whilst others did not learn about the planned natural gas blows until they reported to work that morning. This delay resulted in some contractors being instructed to continue working inside the dangerous building during the natural gas blow activities. The death of six workers and at least 50 others were injured due to this breakdown in communication.
2005 – BP Texas City Refinery Explosion A total of 15 people were killed by explosions and fires due to poor shift turnover communications at the BP facility with another 180 injured. The U.S. Chemical Safety and Hazard Investigation Board report found that BP did not have a shift turnover communication requirement for its operations staff. Supervisors and operators poorly communicated critical information regarding the startup procedure during the shift turnover. Over $1.5 billion in financial losses resulted from this incident.
2005 – Buncefield Fire 43 injuries were reported after a fire resulting from shift handover confusion. An HSE report suggests that supervisors were confused on which pipeline was filling the tank. Large quantities of unleaded fuel were being fed from both the UKOP South line as well as the Finaline. The confusion occurred from poor shift handover procedures and the overlapping screens on the ATG system. Handovers also only captured information at the end of the shift. No measures to record incidents that happening during the shift were in place.
1998 – Esso Longford Gas Explosion Ineffective usage of shift handovers and log book entries lead up to and accident in which 2 workers were killed. The Longford Royal Commission reported that poor handoff between shifts meant that the pump shutdown was not communicated to the following shift. Management also failed to communicate previous incidents to the appropriate parties. Basic operator procedures were also ignored in a number of instances. Esso was ordered to pay $32.5 million to businesses which suffered property damage as a result of the incident.