When safety failures are investigated, attention often focuses on decisions, actions and technical causes.
Less attention is given to conversations.
Yet many incidents can be traced back to a conversation that never took place. A concern that was never raised. A question that was never asked. An assumption that was never challenged.
The information likely existed somewhere within the system. The problem was that it never moved to where it was needed.
This is one of the reasons communication is so important in safety-critical environments.
Communication is not simply the transfer of information. It is the process through which understanding is created.
When important conversations fail to happen, organisations begin making decisions with incomplete pictures of reality.
The challenge is that missing conversations leave no evidence behind. We can see what was said, documented and reported. It is far harder to identify what remained unspoken.
Most people do not intentionally avoid important conversations. More often, they assume somebody else will raise the issue, ask the question or address the concern.
Sometimes they do not.
Many failures begin long before the incident itself. They begin when a conversation that should have happened never takes place.