197: No Communication or Not Timely

Definition/Typical Issues

Was the problem caused by a failure to communicate? Did a method or system exist for communicating between the groups or individuals? Did the communication take place too late? Did obstacles hinder or delay communication?

Note 1: Each individual involved in the occurrence should be questioned regarding messages he or she feels should have been received or transmitted. Determine what means of communication were used (i.e., the techniques). Persons on all sides of a communication link should be questioned regarding known or suspected problems.

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Examples

Example 1

• An operator failed to close a valve when needed, resulting in a process upset. He should have received an instruction from control room personnel to close the valve. The instruction was not given to the operator in time because the two-way radios did not work in the area in which the operator was located.

Example 2

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

Example 3

• Operations were supposed to shift production from one mixture to another. However, the first shift never communicated this to the second shift. As a result, the mixture was not changed.

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Typical Recommendations

• Provide a backup means of communication when the primary system is inoperable.
• Establish formal means of verbal communications when required.
• Conduct meetings between shift workers and management.
• Encourage employees to alert others on their shift of changes in job tasks that may affect others (tell others when you plan to take a break, tell others when you move from one job location to another, etc.).

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Cross-References

Version 10 Element(s)
Node ID	Node Name
194	No Communication or Not Timely

 

Maritime Element(s)
Node ID	Node Name
221	No Communications or Untimely
237	Information Not Communicated
238	Information Ignored