Was it Communicated?


Some may recall the statement made in the 1967 “What we’ve got here is failure to communicate.” Clear and understood communication is important in almost all interactions we have. As important as good communication is, we still have challenges in making it happen.

Communication of information has changed a lot in just the last couple of decades. For example, a short time ago I was discussing an ammonia release that occurred in the 80’s. Information that may have changed what was planned and done in that incident actually had been available since the late 60’s, but communicating that information was slow. Information was shared by print, telephone conversation, attending a meeting/conference, or watching the “reel” movie of the test. (Today a lot of people have no idea what a reel movie is.) Now, if something happens literally anyone in the world can have access to or know of that information in minutes, maybe even seconds. Also, a good share of communication now is done by email and/or text, which is convenient and fast, but can lose some important meaning that is transmitted by in-person, one-on-one communication.

Having quick access to important data can improve safety, if we put in the effort to read and/or listen, and understand the information as it relates to what we are doing, or plan to do. However, with the speed at which we can now access data, many have the tendency to skip over information that doesn’t “pop up” fast enough.

Communication between people can lead to good results or unaccepted consequences. Here are a few examples where there was a “failure to communicate”.

Many years ago I was a ski patrol working most winter weekends helping injured skiers, but also skiing some amazing powder runs. At the resort I worked at we allowed ski patrol from other resorts to also patrol, if they could prove their qualifications.

One Saturday a guy from another State checked in, and after reviewing his qualifications we told him “OK, let’s go see how you ski.” He was interested in skiing “steep and deep”, which we had lots of.

Two of us took the visitor up to the top of the highest lift, and told him. “Stay with us”. We took off down a steep chute, which opened onto a moderately steep open area. When we reached the top of the open area we stopped and let the visitor catch up. He was very excited, and couldn’t wait to get more. I told him, “OK, you stay with us, and follow us.” His response “Great! Let’s go!” So, off we slid, with powder flowing over our shoulders, and into our mouth’s as we snaked our way down through the powder.

We were having a lot of fun, but my final words “follow us” completely left our visitor’s conscious mind. This particular open slope area was located above a 15 to 20 foot cliff band, with lots of trees below it. We knew this, and having skied this many times knew where to go. The visitor became so thrilled with the run that he didn’t follow us, but skied right off the cliff.

We were somewhat in shock, thinking “Oh man this is going to be bad!” We cut around the end of the cliff band and traversed over to where the visitor would have landed. We found him stuck deep in the snow. He was a very lucky man. He didn’t break anything, except one pole. He was still a little in shock, but told us “I remembered what you said, about following you, but that was after I was in the air with nothing but tree tops below me”.

ree tops below me”. Fortunately, he had landed right between trees and tumbled for a short distance in the soft powder snow.

When someone communicates to us, we need to listen and understand, not assume what is being communicated. It can also help if we verify the other persons understanding of what we are trying to communicate. If we or they don’t clearly understand the communication “we or they” should ask for clarification. Also, as illustrated by the above example, not getting distracted, could save our life.

Communication in some form and the training process are inseparable.

Training to safely and properly do a procedure in a refrigeration system is very important. At one fairly large facility, they had developed both operating and maintenance procedures and trained on those procedures. A new person had recently started working in the refrigeration department and was going through training to be qualified to perform various procedures. One, was oil draining.

The written oil draining procedure was read by the new person. The next step was for the new person to watch a qualified refrigeration operator actually do the procedure. Then the new person would do the actual procedure while being observed by a qualified refrigeration operator.

This three step process could have qualified the new person to perform the oil drain procedure by himself. However, additional means of verifying understanding was not done. It was assumed that from reading the written procedure, observation of the procedure being done, and hands-on under supervision the knowledge of how to properly and safely do the procedure should have been communicated, unfortunately not in this case.

The trainee did not understand the importance of the sequence of steps in the procedure. He did not ask questions for clarification, but assumed he knew and the procedure was “No big deal”. When he did the draining procedure, which involved an oil pot, he did not wear the required gloves for protection, nor did he close off the hot gas pressure to the vessel. He was surprised and shocked at the speed that the oil and ammonia vapor came out of the drain valve. The ammonia oil mixture covered about half of his right hand, resulting in blistering of his thumb and index finger. Fortunately, he had no other injuries. However he was strongly motivated to transfer to another department.

Here is another example of failure to communicate that was nearly deadly.

At a recent new system construction, half of the system was being started up while the other half had some punch list items being corrected. The refrigeration foreman had instructed one of the workers to complete some work in a particular zone. In this case both the foreman and the worker had both assumed they understood each other. Neither did. The worker went to the specified work area and in his mind, knew that a correction needed to be made on the liquid supply line feeding into a vessel. There was an isolation valve marked, located in the line just downstream of where the workers was going to make his modification. He started cutting into the liquid line, but very fortunately made the cut slow, and he stopped when he noticed the smell of ammonia.

The line he was cutting into was high pressure liquid ammonia. The foreman did not intend for the line to be cut, since it had previously been reviewed, pressure tested, and accepted. The foreman also assumed the worker understood that the liquid supply lines were under ammonia liquid pressure throughout the facility. The workers assumption of doing work that didn’t need to be done, nor verifying what he was actually supposed to do very nearly resulted in a major release, with potentially significant injury or worse to the worker.

Whenever we are communicating some important information we should try to confirm that the information is being understood. This can be done by:

  • Verbal questioning to confirm understanding
  •  A written sign-off that the person indicates they understand (although this can be an assumption, and a person is just signing a form to get it over with)
  •  A written test to verify understanding
  •  Observation (hands on) verification of understanding.

Communication is a two-way street, each party fully participating, listening, questioning, and understanding. At work, home, or wherever, learning the lessons to good communication can make life happier and safer. Don’t have a “failure to communicate”.