Lack of communication

Lack of communication (alternatively known as lack of proper communication; hereinafter, the Factor) is the absence of proper communication when information to be transferred is available. The Factor is one of the Dirty Dozen of Human Factors; it is characterized by a lack of clear direct statements on the sender side and/or good, active listening skills on the receiver side. The Factor differs from silence, which is either (a) the absence of information available to transfer or (b) intentional or unintentional refusal or delay in that transfer.

In aviation maintenance

According to the FAA AMT Handbook,

Lack of communication is a key human factor that can result in suboptimal, incorrect, or faulty maintenance. Communication occurs between the aircraft maintenance technician and many people (i.e., management, pilots, parts suppliers, aircraft servicers). Each exchange holds the potential for misunderstanding or omission. But communication between aircraft maintenance technicians may be the most important of all. Lack of communication between technicians could lead to a maintenance error and result in an aircraft accident. This is especially true during procedures where more than one technician performs the work on the aircraft. It is critical that accurate, complete information be exchanged to ensure that all work is completed without any step being omitted. Knowledge and speculation about a task must be clarified and not confused. Each step of the maintenance procedure must be performed according to approved instructions as though only a single technician did the work.

A common scenario where communication is critical and a lack thereof can cause problems, is during shift change in an airline or fixed base operator (FBO) operation. A partially completed job is transferred from the technician finishing his or her workday to the technician coming on duty. Many steps in a maintenance procedure are not able to be seen or verified once completed due to the installation of components hiding the work. No steps in the procedure can be omitted and some steps still to be performed may be contingent on the work already completed. The departing technician must thoroughly explain what has occurred so that the arriving technician can correctly complete the job. A recounting of critical steps and any difficulties encountered gives insight. A lack of communication at this juncture could result in the work being continued without certain required operations having been performed.

The approved steps of a maintenance procedure must be signed off by the technician doing the work as it is performed. Continuing a job that has been started by someone else should only occur after a face-to-face meeting of technicians. The applicable paperwork should be reviewed, the completed work discussed, and attention for the next step should be drawn. Absence of either a written or oral turnover serves as warning that an error could occur.

It is vital that work not be continued on a project without both oral and written communication between the technician who started the job and the technician continuing it. Work should always be done in accordance with the approved written procedure and all of the performed steps should bear the signature of the technician who accomplishes the work. If necessary, a phone call can be made to obtain an oral turnover when technicians cannot meet face-to-face at the work area. In general, the technician must see his or her role as part of a greater system focused on safe aircraft operation and must communicate well with all in that system to be effective.

Mitigating the risk: (a) Properly use logbooks and worksheets to communicate work accomplishments, (b)Never assume that the work has been completed, (c) Ensure that maintenance personnel are discussing exactly what has been and needs to be completed to the next shift. Maintainers must communicate with one another and explain what work has and has not been completed when changing shifts.