Communication Breakdowns That Lead to Disaster

Introduction: The Memo Nobody Read

We’ve all experienced it: the important company memo about a new process, posted to a shared drive or tacked to a bulletin board, that goes completely ignored. The result is usually minor confusion or an annoying, preventable mistake. But what happens when that missed memo involves the O-ring seals on a jet engine? In high-stakes environments like aviation maintenance, the consequences of failed communication are catastrophic. The principles that prevent disasters in an aircraft hangar are the same ones that can make or break any team. Drawn from aviation safety reports, these are the critical, life-saving lessons on how communication truly works—and what happens when it doesn't.

1. The Illusion of Communication: Why Posting a Memo Isn't Enough

The first critical failure is assuming that making information available is the same as communicating it. True communication only happens when a message is received and understood, and simply posting a procedure doesn't guarantee either. This passive approach was a direct contributor to an Eastern Airlines accident in 1983.

The airline issued a revised work card for master chip detector installation, a procedure that included the correct fitment of O-ring seals. This crucial update was posted, and mechanics were expected to read and comply with it. However, the investigation found there was no supervisory follow-up to ensure anyone had actually seen or understood the new guidance. The National Transportation Safety Board (NTSB) report highlighted this systemic failure:

“Use of binders and bulletin boards is not an effective means of controlling the dissemination of important work procedures, especially when there is no accountability system in place to enable supervisors to ensure that all mechanics had seen the applicable training and procedural information.”

This highlights a common cognitive bias: the assumption that our own context and understanding are universally shared. True communication requires an accountability system to bridge that gap and confirm that the message has been received and understood. Without it, you’re just posting memos in the dark.

2. The Active Process: Treat Every Conversation Like a Pre-Flight Check

In any safety-critical environment, clarity cannot be left to chance. Communication must be an active, two-way process with shared responsibility between the person sending the information and the person receiving it.

As the Sender, Your Job Is to Be Understood:

• Provide information as required;

• Deliver information clearly and concisely;

• Verbalize plans—surprises belong at birthday parties, not in hangars;

• Use appropriate non verbal communication;

• Provide relevant information without being asked;

• Ask for confirmation that the message is understood (“what did you hear me say”).

As the Receiver, Your Job Is to Understand:

• Be an active listener;

• Acknowledge and repeat information as required;

• Paraphrase what you have heard (“repeat what I heard”);

• Pay attention to non verbal as well as verbal communication;

• Clarify uncertainties and ask questions as necessary;

• Provide useful feedback.

3. The Unspoken Message: How Cues and Context Shape Reality

Communication involves far more than just written or spoken words. The unspoken signals we send are a vital part of the overall message and can either reinforce or contradict what we say. These signals fall into two categories:

• Non-verbal cues: This includes body language and tone of voice. A hesitant tone or dismissive gesture can undermine even the clearest verbal instruction.

• Physical cues: This involves the environment itself, such as the positioning of tools and equipment. The state of the workspace sends a powerful message about priorities and professionalism.

This is why the responsibility of an active communicator extends beyond mere words. A sender must consciously "use appropriate non-verbal communication" to reinforce their message, while a receiver must "pay attention to non-verbal as well as verbal communication" to decode the full context. Paying attention to these unspoken elements is a surprisingly impactful part of maintaining a strong safety culture.

4. The Most Dangerous Assumption: Silence is Not Agreement

The final, and perhaps most dangerous, communication breakdown is assumption. It is the human tendency to avoid asking a "dumb question" or to let a conversation end with unresolved ambiguities. In a professional setting, this must be overcome.

The core rule for both senders and receivers is simple: Never assume.

If you are the sender, never assume your message was understood. If you are the receiver, never assume you know what the sender means if there is even a shred of doubt. If a disagreement or uncertainty exists, the responsible path is always to take the most conservative and safe action until more information is available. Reframing clarification not as a sign of ignorance but as a non-negotiable part of professional responsibility is essential for preventing errors.

Conclusion: Is Your Team Cleared for Takeoff?

The principles that ensure safety on an aircraft assembly line are directly applicable to any team that relies on clear, accurate information to succeed. Communication is not a passive act of broadcasting information; it is an active process of creating shared understanding and shared responsibility. Some of the most serious accidents have resulted from simple failures in this process. By treating every critical exchange with the diligence it deserves, we can prevent small misunderstandings from becoming major disasters.

What 'bulletin board' in your own work is waiting to be ignored, and how will you ensure your next critical message truly lands?