After 15 years safety remains at risk
In 2003 the Rail Safety & Standards Board (RSSB) set up a Safety Critical Communications Focus Group. This was in response to Network Rail’s introduction of GSM-R (Global System for Mobile Communications – Railway) with the promise of a standard radio communications network.
With GSM-R being used by all parts of the industry, safety critical communications procedures would be more important than ever before. The aim of the Focus Group was to ‘facilitate the progressive improvement of front-line operational communications’.
This work was reported in the November 2004 ‘Informed Sources’ under the headline ‘Safety critical comms – culture or procedure?’. I brought some first-hand experience to the subject because at that time I was learning to fly and Safety Critical Communications (SCC) were very much on my mind.
With the signal post telephone, and even train radio, the signaller knew which train he was speaking to and where it was. With GSM-R that certainty was removed. To maintain safety, the established colloquial railway mate-speak – ‘eh up Bobby’ – would have to be replaced by the structured communications I was getting to grips with in the air.
RSSB suggested that I might report on their SCC work. The background briefing included an example of what they were then up against in the form of an anonymised recorded radio conversation between the driver of a tamper and a signaller (Transcript 1). Awre Junction was my great grandfather’s box.
At the time, the aim of the Focus Group was to ‘develop and maintain a culture where structured, disciplined communication is the norm’. RSSB had already produced a Railway Group Standard and accompanying Code of Practice.
However, these focused on ensuring that staff were trained in communicating correctly. They did not cover the content of these communications.
Similarly, Section 3 of the then-current Rule Book was all about when and when not to communicate using telephone, radios or bell codes. It listed the required information, but not how to communicate it.
This was in contrast to the Civil Aviation Authority’s CAP413 publication ‘Radio telephony manual’. CAP413 provides pilots, Air Traffic Services personnel and aerodrome drivers with ‘a compendium of clear, concise, standard phraseology and associated guidance for radiotelephony communication in United Kingdom airspace’. First published in 1978, it is now in its 22nd edition.
In 2017 RSSB published ‘Safety Critical Communications: The Manual’, intended as a day-to-day reference guide. Like CAP413 it includes ‘cue cards’, or scripts, for typical conversations (see box opposite). It supplements the six modules in the SCC training package, also provided by RSSB.
For a document aimed at professionals the tone of the manual is frankly condescending. Take this explanation of safety critical: ‘Of course, we discuss our lives, hobbies, and news with our colleagues. But if we’re talking about operations and actions that can affect our safety and that of our colleagues, the public or the railway, then our communication is safety critical’.
When an RSSB research project reviewed the take-up of the SCC Training Programme in 2019 the results were disappointing. The 176 respondents came from Network Rail, passenger and freight operators and contractors. Nearly 40% had worked in the railway industry for more than 20 years.
While 17% of those surveyed had used the training materials, less than half were aware of their existence. Given that it is 15 years since the SCC Focus Group began working, the current situation is worrying.
According to the research, ‘the primary issue is that there is currently no overarching strategy to address SCC across the industry’. Meanwhile, SCC training is ‘slowly’ being integrated into other safety initiatives, such as Network Rail’s Home Safe Plan. SCC training should be embedded within all Track Safety and Operational Network Rail training courses, the report recommends.
An updated Rail Industry Standard RIS-8046-TOM ‘Spoken safety critical communications’ was published in September 2019. But its focus is on the management of SCC, such as training, assessing competence and monitoring.
2.4 Using standardised safety critical communications protocols
2.4.1 Transport operators shall use standard spoken safety critical communications protocols, including words, phrases and the phonetic alphabet.
G 2.4.2 Using standard words, phrases and protocols promotes a clear understanding and reduces confusion.
G 2.4.3 Achieving a clear understanding is the goal of spoken safety critical communications. Standardised structures and a professional approach to communications help to achieve this.
SIGNALLER (S1): Awre Junction.
TAMPER DRIVER (D): Hello
Awre Junction, this is the driver of six Tango five seven six…
S1: Hello there.
D: …standing at Whiskey five four two signal at danger.
D: Is this the blocking signal?
S1: It certainly is.
D: Thank you.
S1: The PICOP knows, I told him you’re on the way and he’s gonna send someone round there so I should wait there.
D: I can see someone standing by the lamps and dets so…
S1: Yeah, yeah but it’s from 542 signal, so I mean, you know.
D: OK so what would you like me to do, er wait by the signal for further instructions?
S1: Yeah that’s where the block is possession is from you know as it’s booked it’s 46 from 542 signal so wave ’im up there if you want. If you can see the chap shout at him.
In this initial encounter we have a driver trying to communicate by the book coming up against the bloke-railway culture. Next the signalman phones the Person in Charge of Possession, the PICOP.
PICOP: X speaking.
S1: That tamper’s gone in there ’as he? Oh he’s ringing me, hang on, hang on there a minute.
D: Hello Awre Junction, this is the driver of six Tango five seven six at Whiskey five four two.
And it turns out that the driver has spoken to the PICOP who is telling him to pass the blocking signal. But the driver explains he has always had the permission of the signaller to pass the blocking signal at danger and not the PICOP.
What he wants is formal authority from the signaller to pass the signal at danger.
S1: What more do you want, you don’t need my permission to go into the block you need the PICOP’s permission.
D: I need the permission of the signaller to pass the protecting signal at danger, which is Whiskey five four two, that’s what I require.
Eventually the signaller gives in.
D: So you’re giving me permission to pass Whiskey five four two at danger. S1: Yes.
D: Thank you signaller for that. I’ll carry that out.
However, it seems that the tamper driver is still unhappy because he wants the signaller to formally give permission, instead of responding ‘yes’ to his prompting.
‘He wants to hear the words, right. Your OK’ says the PICOP. ‘Have a go at him, wake him up’ he adds.
When the driver calls in, still at the signal, he eventually coaches the signaller in what he needs to hear.
S1: ‘Didn’t I say that before? I’m certain I did at the end of it all. I said “well you pass five four two at danger and proceed up to the lamps and dets”’.
SCRIPT FOR TRAIN ENTERING POSSESSION
The train arrives at the protecting signal and the driver contacts the signaller.
DRIVER (D): Driver of train XXXX at XXXX signal
SIGNALLER (S): Hello Driver of train XXXX at XXXX signal. Signaller XXXX at workstation XXXX. As you are aware, you are required to enter a possession. I have spoken to the PICOP and he has given me instructions to give you.
D: Hello signaller. Ok, understood. I am awaiting your instructions.
S: Driver of train XXXX, the PICOP has asked, when I give you authority, to proceed down to the stop board and detonator protection for the possession. This is located on approach to XXXX junction where you will be met by the PICOP. He will give you further instructions.
D: Signaller, when you give me authority, I am to proceed down to the stop board and detonator protection for the possession, which is located on approach to XXXX junction where I will be met by the PICOP to give me further instructions.
S: Driver, that is correct. I now authorise you to pass XXXX signal at danger, proceed at caution, and be prepared to stop short of any obstruction. Additionally, the signal is fitted with TPWS.
D: Signaller, I am now authorised to pass XXXX signal at danger, proceed at caution and be prepared to stop short of any obstruction. The signal is fitted with TPWS.
S: That is correct, driver.
D: Thanks signaller.
Judging by the transcripts in an RAIB Report into a near miss at Balham on 20 April 2019 the industry continues to struggle to embed SCC. To set the scene, a tamper, running as engineering train 6J91, had been working wrong direction on the Down Brighton Fast from Selhurst to Streatham Common.
Having completed its task, the plan was for the tamper to continue to Crossover 334 at Streatham North Junction. Still in the possession, it would then set back onto the Up Brighton Fast and continue through Balham station to Clapham Junction en route to its destination sidings at East Croydon.
These movements were documented in the possession briefing pack provided to the two Persons in Charge of Possession (PICOP). But due to a concatenation of errors and miscommunication, 6J91 is now still on the Down Brighton Fast with the driver expecting to run forward to Balham. He contacts Victoria Area Signalling Centre (Transcript 2).
In this case, Signaller 1 is trying to impose SCC protocols on the Conductor Driver, but without much success. And note a critical error.
Although the Conductor Driver correctly identifies his location as on the Brighton Down Fast running wrong direction, the signal he can see (VC636) is on the adjacent Brighton Up Fast.
SIGNALLER 1 (S1): Victoria panel 2 Bravo speaking.
CONDUCTOR DRIVER (CD): Good afternoon Victoria, yeah, this is the Route Conductor on Six Juliet Nine One, just south of Balham Junction. Um, have you got… … ?
S1: Six nine one sorry, uh, whereabouts, are you?
C: Just south of Balham Junction. We’re uh, I think it’s Victor Charlie six three six we can see. We’re in a worksite anyway at the moment, at the stop boards.
S1: What line are you on, sir?
CD: We’re actually… wrong direction. We’re on the uh, on the down fast in… travelling in the up direction.
S1: On the down fast going in the up direction?
CD: Yeah, well we’re not moving obviously. Yeah, we’re… yeah. I was just wondering if you’ve got a number for the PICOP please because they’re meant to be up here and we’ve got nobody to come and remove the detonators and stop boards yet.
S1: You’re wanting to know whether we’ve got the PICOP details.
CD: Yes. Have you got any number or anything for the PICOP?
S1: Yes, I do…
CD: You do? Okay.
S1: His details… it’s (name of night PICOP provided)
S1: Yeah um, it’s (telephone number of night PICOP provided)
CD: Lovely. Thank you very much signaller, I’ll give him a quick call.
S1: Sorry, what’s your name?
CD: My name’s (name provided). I’m the Route Conductor on this uh, six Juliet nine one.
S1: (Name confirmed) and its six Juliet… Nine One…
CD: That’s right, yeah. We’re on the down fast but we’re making um, we’re going to go across onto the fast up obviously and then we’re changing at Clapham Junction. But I mean we can do it Balham actually, and, um, shoot up towards Streatham Hill that way, so instead of going all the way into town, you know what I mean?
S1: Right… right… right, right. Okay. Yeah, speak to the PICOP.
CD: I’ll speak to the PICOP anyway. Thanks for your help signaller.
S1: Alright then, no worries.
CD: Cheers then, bye-bye.
Time for a brief digression on culture and what is termed ‘situational awareness’, in other words having an accurate mental picture of what is going on, such as the location of trains and how the service is running.
To help signallers maintain good situational awareness they are trained to use the ‘finger’ test. This involves using a finger to trace or follow the details being provided during a conversation on the display monitor or panel. The aim is to ensure that the details in the message match the situation displayed.
According to RAIB, both signallers at Victoria had been trained to use this method. However, they did not feel comfortable about using it in front of their colleagues. RAIB notes that the finger test could have identified that the Brighton Down Fast was occupied and the Up Fast unoccupied.
Subsequently, the tamper left the possession under the impression that it would stop at signal VC632 and ask for further instructions. However, it continued into platform 3 at Balham station, when the tamper driver realised something was wrong and the conductor driver agreed.
He reported to a signaller that the tamper was in platform 3 at Balham, travelling ‘bang road’. The signaller took charge, ordering that the tamper should stay where it was until further notice. Only 75 seconds earlier another train had left platform 3 and crossed over the junction from the down Brighton fast line, via 308 points, to the down Crystal Palace line.
RAIB’s report is scathing over the standard of SCC ‘throughout’ which was ‘well below that expected’. Nobody had a clear understanding of the location of the tamper or the actions to be taken.
Analysis of 33 voice recordings of conversations relating to this incident revealed a range of problems starting with communications not meeting the requirement to be Accurate, Brief and Clear (ABC).
‘The railway industry’s strategy for improving and maintaining the standard of safety critical communications has been ineffective, and has not changed the workforce culture or secured the adoption of good practice in respect of communications with and between infrastructure operations staff.’
According to the Rule Book, signallers should lead SCC. It was not clear from the conversations who was actually taking the lead.
Nor, faced with a poor standard of communication being used by one party, did the other party correct. Both parties ‘mirrored’ the poor standard of communications.
RAIB also notes that in addition to the voice recordings, verbal evidence showed that several of the witnesses involved in the incident felt embarrassed to use correct SCC methods, both when conversing with colleagues they were familiar with and with members of staff they had not previously encountered.
Overall, RAIB concluded that that over the past 20 years safety critical communication has not been embedded as standard practice in the rail industry. Causes include competence and training, monitoring and social and cultural issues.
RAIB adds that while several attempts have been made to enhance training and improve the standard of communications, the standard of verbal safety communication is poor across the different sectors of the rail industry. There is a ‘particular concern’ with infrastructure operations where ‘it is clear that many staff have not adopted the necessary protocols, and that some staff still feel ‘socially embarrassed’ by using formal methods of communication.
Naturally, I asked Network Rail and the rail safety regulator for their reaction to this report.
Shaun King, Network Rail Route Director, Sussex said: ‘We have received the RAIB report into the near miss at Balham in April 2019. The safety of all those who use the railway is our top priority, and we take our responsibilities very seriously to ensure safety is maintained. We understand that communication at this time was not at the level expected and we will continue to work closely with RAIB and consider any recommendations made.
‘We’re continually improving our health and safety procedures to make sure that any dangerous occurrences are reported, investigated and analysed so that we can prevent them from happening again.’
An Office of Road & Rail spokesman told me: ‘Network Rail has effective systems in place for Safety Critical Communications, these are both regularly tested and thoroughly reviewed. There does however appear to be an inherent cultural issue when it comes to dealing with issues arising from their implementation.
‘As in the case of Balham, we are engaging at the most senior level within Network Rail to ensure there is a more rigorous approach in holding to account those who may misuse any Safety Critical Communications systems’.
Paraphrasing the ORR reply, ‘on paper Network Rail has all the right procedures needed to satisfy us, but out on the real railway people aren’t taking any notice, and we want to ensure any miscreants are punished’.
G 2.9.8 In cases where spoken safety critical communications protocols have not been followed (for example, failure to use the phonetic alphabet or a failure to reach a clear understanding) a development plan for the individual is one method of addressing the issues identified. This development plan can be agreed between the individual and the nominated manager and be included as part of the individual’s competency record. Corrective actions may include:
a) Additional training and briefing;
b) Additional monitoring and assessment;
c) Use of a simulator as part of a training or assessment development plan;
d) Coaching or mentoring in the workplace; and
e) Development and use of job aids to remind the individual how to communicate clearly.
SIGNALLER 2 (S2): Hello, Victoria signaller panel two B signaler.
CONDUCTOR DRIVER (CD): Hello signaller, yeah driver, I’m the conductor driver on six Juliet nine one, you wanted to speak to me about a route we’re going back?
S2: Yeah hello there driver of six Juliet Nine One, um, where are you at the moment?
CD: Uh...we’re just south of Balham Junction at the moment.
S2: Okay, you’re still there. What signal are you actually… going to start coming out from? Do you know?
CD: Um, I can tell you if you bear with me a moment… just bear with me a moment… yeah… I’ve got a… Balham junction at Victor Charlie Six Three Two…
S2: Okay yeah, that’s what I thought it would be, alright. Um, you have to go to East Croydon now I hear. Is that correct?
CD: Yes, that’s correct. East Croydon, into the siding there yeah.
S2: Do you sign platform sixteen in Clapham Junction?
CD: Do I sign platform sixteen in Clapham?… yeah.
S2: You do. Yeah okay. You know where to shunt back from when you go through platform sixteen?
CD: Go through platform sixteen, the dummy’s down past the platform isn’t it in the middle there?
S2: Yeah well if you go through platform sixteen then obviously you’ve got one four seven shunt signal there, or the signal before it as well six nine five, I think it is… sorry five nine five sorry that’s where you can get back onto the down slow and then via Crystal Palace afterwards.
CD: Yeah that’s right. I’m going back via Streatham Hill yeah.
S2: That’s the one, that’s the one. Yeah alright, so just give me a call once you’re at six three two and what we’ll do is once we’ve got a good path for you, what we’ll do is we will get you going via platform sixteen and turn you around from there and then get you back by Streatham Hill alright?
CD: No worries.
S2: Okay, Six Three Two, no problem, thanks very much, cheers.