Handing over the safety baton in high-risk systems

Abstract

Successful, round-the-clock operations in high-risk and complex organizations rely on the proper transfer of critical information through skilled team communication and a reliable system for handing over the operations to the next shift. Handovers, by nature, pose a risk to processes when information is lost or corrupted between the sender and the receiver. This paper reviews some of the large-scale accidents that have occurred in the past 25 years, whose investigations reveal a failure in handover as one of the underlying causes of the accident. The paper then discusses the results of a qualitative study on the handover activity at the Norwegian User Support and Operations Center’s (N-USOC). The N-USOC has a control room for experiments on plant breeding in closed growth systems inside the International Space Station (ISS). This study provides an invaluable insight into the HO variability of a specific team in the use of two different control room consoles. Finally, the paper expounds on why there is a difference in the HO of two consoles by the same operators and why thorough planning is vital to efficient and safe operations.