196: Verbal and Informal Written Communication Issue

Node Verbal and Informal Written Communication Issue

Definition/Typical Issues

This major root cause category addresses issues related to verbal and informal written communications. It includes communications using the following methods:

  • Face-to-face
  • Telephone
  • Radio
  • Short written messages
  • E-mails
  • Signs
  • Hand signals

It does not address more formal methods of communications like procedures, logs, and design specifications.

Was the problem caused by a failure to communicate? Did a method or system exist for communicating between the groups or individuals? Was an error caused by misunderstood communication between personnel? Was there incorrect, incomplete, or otherwise inadequate communication between workers during a shift or between workers during a shift change? Was there a problem communicating with contractors or customers?

Note 1: Communications is defined as the act of exchanging information. This node addresses many informal modes of communication (e.g., face-to-face, telephone, radio, short written messages, e-mails, signs, and hand signals). It does not address the more formal methods of communication involving written procedures, logs, specifications, etc. These more formal methods of communicating information are addressed under the Procedure Issue (#122) and Documentation and Records Issue (#58) nodes.

Examples

Example 1

  • An operator opened the wrong valve, resulting in a process upset. He misunderstood the verbal instructions from a coworker. No repeat-back or other verification method was used.

Example 2

  • A tank transfer was in progress during shift change. During shift change, the shift going off duty did not tell the one coming on duty that the transfer was in progress. The tank overflowed.

Typical Recommendations

  • Provide a backup means of communication for times when the primary system is inoperable.
  • Establish standard terminology for equipment and operations.
  • Use the repeat-back method of communication.
  • Encourage a culture that is feedback oriented (i.e., repeating instructions back to ensure understanding).
  • Conduct shift-change meetings to alert oncoming shifts of special job tasks, safety issues, or problems that occurred during the previous shift.

Cross-References

 

Version 10 Element(s)
Version 10 Element(s)
Node ID Node Name
192 Communications

 

RBPS Element(s)
Conduct of Operations

 

Maritime Element(s)
Node ID Node Name
220 Communications
Back to top