203: Verification/Repeat-back Not Used

Node Verification/Repeat-back Not Used

Definition/Typical Issues

Was a communication error caused by failure to repeat a message back to the sender for the purpose of verifying that the message was heard and understood correctly?

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. The operator understood D-2. No repeat-back or other type of verification was used. When he opened Valve D-2, a process upset occurred.

Example 2

  • During a test, a field operator was working with a control room operator on a valve test. When the control room operator asked the field operator how it was going, the operator said "everything is fine." However, the control room operator thought he heard "one more time." So, he cycled the valve again. As a result, a small spill occurred.

Example 3

  • A tank transfer was in progress when Operator A went on break. He mentioned to Operator B that the transfer was taking place, but Operator B did not realize that he needed to stop the transfer. As a result, the tank overflowed.

Example 4

  • A tank overflowed because maintenance had taken the liquid level instrumentation out of service for calibration. A misunderstanding with production occurred over which equipment was out of service. Believing that it was another instrument that was being calibrated, production started a transfer into the tank, resulting in an overflow.

Typical Recommendations

  • Encourage employees and personnel at all levels to use the repeat-back communication method to ensure thorough understanding of related job tasks.
  • If employees/workers forget to use the repeat-back method, instruct supervisors and work-team leaders to request that the employee repeat-back.
  • Solicit feedback to ensure that the communication was understood.
  • Develop and use verbal communication protocols.

Cross-References

Version 10 Element(s)
Node ID Node Name
202 Verification/Repeat-back Not Used

 

Maritime Element(s)
Node ID Node Name
231 Verification or Repeat-back Not Used
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