200: Communication Misunderstood/Incorrect
Definition/Typical Issues
Was an error caused by misunderstood communications between personnel? Was there an error in verbal communication? Did someone misunderstand a hand signal? Was a sign misunderstood? Were oral instructions given when written instructions should have been provided?
Examples
Example 1
- An operator located in a noisy part of the plant was given an instruction by "walkie-talkie" to open Valve B-2. He though the verbal instruction was to open Valve D-2. No repeat-back or other type of verification was used. He opened D-2, resulting in a process upset.
Example 2
- Two mechanics were working together to perform maintenance on a tank agitator. During one step, the mechanics had to work together to remove the motor from the shaft. Because of a miscommunication between the two mechanics, the motor was damaged.
Typical Recommendations
- Establish standard terminology for equipment and operations.
- Use the repeat-back method of communication.
- Provide written instructions when necessary.
- Minimize interference from noise.
- Solicit feedback to ensure that the communication was understood.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 200 | Misunderstood Communication |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 228 | Communication Misunderstood/Incorrect |
| 236 | Unclear Communications |