You told them, but did you communicate?

Brian Seaman

15 minutes ago

7 min read

This article discusses a workplace fatality and the leadership lessons that emerged from the investigation.

In my line of work, I have heard some version of this statement many times:

“I told them what to do. I don’t know why they didn’t follow the instructions.”

That response assumes the instructions were understood, the risks were recognized, and the people performing the work had everything they needed to succeed. Those are significant assumptions.

Telling someone what to do is not the same as confirming that meaningful communication has occurred.

Throughout my career, I had the unfortunate responsibility of participating in numerous workplace fatality investigations. One contractor incident, in particular, continues to influence how I think about communication, supervision, and the controls necessary to protect people performing high-risk work.

The Work and The Hazard

A customer’s product was unloaded from ships and railcars, moved by conveyor, and stored in a large indoor stockpile. The product had to remain dry to be usable.

Over time, dust and material accumulated throughout the storage building and around the conveyor system. An industrial cleaning contractor was hired to remove the buildup using a vacuum truck staged outside the building, along with fixed piping and flexible hoses inside.

The conveyor system included several elevated landings from which the contractor employees would perform the cleaning. The crew planned to begin at the top and work downward.

On the day of the incident, the conveyor remained in operation. That made it essential for the crew to stay within the designated work areas and away from the running equipment.

Instructions Were Given

Before beginning the job, the contractor crew attended a detailed safety briefing led by the site safety specialist.

The briefing was engaging, specific, and directly related to the work being performed. The specialist identified the conveyor hazard, explained that the crew was not permitted to work near the operating equipment, and pointed out the areas where the work could be performed safely.

During the briefing, the specialist noticed that one crew member appeared distracted or disengaged. He stopped the discussion, regained everyone’s attention, and repeated the restriction against working near the conveyor.

The crew acknowledged the instructions and went to work.

From a traditional perspective, communication occurred. The hazard was identified, the expectations were explained, and the workers confirmed that they understood.

But acknowledgment is not always evidence of understanding.

Trust But Verify

A few hours after the briefing, the safety specialist walked through the work area and observed the same employee working dangerously close to the running conveyor.

He immediately stopped the employee and spoke with him and the crew lead. The specialist reminded them that no one was permitted to work near the conveyor while it was operating and again explained the hazard.

Both the employee and the crew lead said they understood. The crew lead also committed to monitoring the crew more closely.

The instructions had now been delivered twice. Both individuals had acknowledged them.

From a compliance standpoint, the communication box had been checked. But the work still depended on the employee consistently recognizing the danger, remembering the restriction, and choosing to remain outside the hazardous area. It also depended on the crew lead having enough time and attention to continuously oversee every member of the crew.

Those were not reliable controls for exposure to a potentially fatal energy source.

The Incident

Despite the initial briefing and the subsequent intervention, the employee was again inside the restricted area near the operating conveyor.

Tragically, he became caught in the conveyor system and was killed.

It was a devastating event for his family, coworkers, the contractor, and everyone associated with the facility. It also forced the organization to confront a difficult question:

How could someone participate in a thorough safety briefing, receive a direct warning in the field, and still enter a hazardous area?

The easy answer would have been that the employee failed to follow instructions.

The responsible answer required us to look deeper.

Moving Beyond Blame

Not that many years ago, an incident like this might have been investigated primarily to determine who was involved and who was at fault. Someone might have been disciplined, fired, or retrained. A new rule might have been added, and the organization would have moved on.

Our approach to investigations was evolving, however. We were beginning to look beyond the actions of the individuals involved and examine the processes, systems, and conditions surrounding the work.

This broader approach reflects principles commonly associated with Safety II and Human and Organizational Performance, or HOP. Instead of asking only, “Who made the mistake?” we began asking:

“What conditions made this action possible or understandable at the time?”

The investigation could not determine exactly what the employee was thinking when the incident occurred. We did know that he was in his early 20s and had little experience working in an industrial environment, including around equipment such as conveyors.

His coworkers described him as a hard worker who could sometimes be overzealous. Although the conveyor hazard had been identified, his limited experience may have affected his ability to appreciate the speed, force, and potentially fatal consequences of contacting the equipment.

He may have known where he was not supposed to work without fully understanding why entering that area could cost him his life.

The investigation also identified limitations in the way the work was supervised. The crew lead was responsible for multiple aspects of the job and did not have sufficient capacity to continuously monitor every crew member.

The work plan relied heavily on verbal instructions, individual compliance, and supervision. It did not provide a reliable physical control to prevent someone from entering the hazardous area.

That distinction became one of the most important lessons from the incident.

Communication Requires More Than Acknowledgement

Leaders often interpret a verbal response such as “I understand” as proof that their message was successfully communicated. But people may acknowledge instructions without understanding the hazard, the reason behind the direction, or the consequences of getting it wrong.

Effective communication requires more than delivering information. It requires leaders to confirm that the information was:

Heard
Understood
Interpreted correctly
Connected to the actual work
Reinforced by appropriate safeguards

This is especially important when employees have different levels of training, experience, confidence, and familiarity with the work environment.

An experienced industrial worker may immediately recognize the destructive energy associated with an operating conveyor. Someone entering that environment for the first time may simply see a piece of equipment moving at what appears to be a manageable speed.

The words may be the same, but the meaning may not be.

Leaders cannot assume that experience, knowledge, or risk perception is shared equally across a team.

Understanding High Energy Hazards

The incident also reinforced an important principle: a verbal warning should never be the primary defense against a potentially fatal energy source.

Training, procedures, supervision, and pre-job briefings are all important. But none of them can guarantee perfect human performance.

People become distracted. They misunderstand instructions. They underestimate hazards.

They lose situational awareness. Supervisors become overloaded. Work conditions change.

Human fallibility is not a moral failure. It is an operational reality that leaders must consider when designing work.

When exposure to high energy could result in a serious injury or fatality, the better question is:

What will protect someone when attention, judgment, communication, or supervision fails?

Whenever possible, the energy source should be eliminated or isolated before work begins. When that cannot be done, effective controls must be established, reviewed with the people performing the task, and verified in the field.

If those controls are missing, inadequate, or impaired, the work should stop until proper protections are restored.

The ultimate goal is not to create a perfect procedure or deliver the perfect safety briefing. The goal is to create a work system in which a single mistake, misunderstanding, or momentary lapse does not result in a life-altering injury or fatality.

From Telling To Understanding

Leaders responsible for high-risk work can strengthen communication by applying five practical principles.

Explain the hazard, not just the rule

People need to understand what could happen, not merely what they are prohibited from doing. A restriction becomes more meaningful when workers understand the energy involved and the potential consequences of exposure.

Ask workers to explain the plan in their own words

A nod, signature, or verbal acknowledgment does not confirm understanding. Ask employees to describe the hazard, the boundaries of the work, and the controls that will protect them.

Account for differences in experience

Instructions should reflect the knowledge and experience of the people performing the work. Someone new to an industrial environment may require more context, demonstration, and verification than an experienced worker.

Build controls around human fallibility

Do not rely solely on memory, attention, good judgment, or continuous supervision. Whenever possible, remove the energy, isolate the hazard, prevent access, or establish safeguards that protect people when human performance varies.

Continue verifying conditions

Communication is not a one-time activity completed during a pre-job briefing. Leaders must remain engaged, observe the work, identify changing conditions, and confirm that controls remain effective.

A Question for Leaders

When something goes wrong, it is easy to say, “But I told them what to do.”

That statement may be factually correct, but it does not answer the more important questions:

Did they understand the instructions?
Did they appreciate the risk?
Did their experience prepare them to recognize the hazard?
Were the expectations realistic under the conditions?
Did the work plan account for human fallibility?
Were effective controls in place if someone made a mistake?

Communication is not measured by what the leader said. It is measured by what the other person understood and by whether the work system supported the desired outcome.

The difference between telling and communicating can influence productivity, trust, and team performance.

In high-risk work, it can also be the difference between life and death.

Pursuit Peak Is Here to Help

Communication breakdowns are rarely solved by simply telling people to communicate better. Leaders need practical systems that clarify expectations, confirm understanding, strengthen accountability, and make it easier for people to raise concerns before the consequences become serious.

At Pursuit Peak LLC, I help safety leaders, operational teams, and organizations strengthen leadership communication and turn lessons learned into practical improvements. My approach combines 30 years of firsthand safety leadership experience with tools that build self-awareness, improve team communication, and help leaders create environments in which people can perform at their best.

Has your organization mistaken delivering information for achieving understanding?

If unclear responsibilities, ineffective communication, or inconsistent leadership practices are limiting your team’s performance, let’s talk. Schedule a brief strategy conversation with Pursuit Peak, and we will identify one practical step you can take to strengthen communication and accountability within your team.