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INFORMED SOURCES November 2004

Safety critical comm's – culture or procedure?

GSM-R means big challenges ahead

Here is Captain Deltic, in aviator mode, somewhere over Eastern England . He presses the transmit buttom on the control yoke.

‘ Cambridge approach, Golf Bravo Zulu Whiskey Golf'

‘Golf Whiskey Golf, Cambridge approach, pass your message'.

Deep breath.

‘Golf Bravo Zulu Whiskey Golf, PA 28 on a navex Panshanger Soham, routing to the east of your zone, Passing Duxford, heading zero two zero, altitude two thousand feet, estimate abeam Cambridge time 35 request flight information service .

Golf Whiskey Golf, one aircraft in circuit, there's a helicopter operating to the north of the airfield at 800ft, report when abeam. Cambridge approach.

‘Copy traffic, report when abeam, Golf Whiskey Golf.

After the airborne amateur trying to sound professional. Let's eavesdrop on two people for whom safety critical communications are a professional tool. I have sanitised the recording to protect the guilty.

Signaller (S): Awre Junction

Tamper driver (D): Hello Awre Junction, this is the driver of six Tango five seven six

S: Hello there

D:… standing at Whiskey five four two signal at danger.

S: Yeah.

D: Is this the blocking signal?

S: It certainly is.

D: Thank you

S: 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

S: Yeah, yeah but its 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?

S: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.

So here we have a driver trying to communicate by the book and the bloke-railway culture rampant in Awre Junction box. It gets worse. Much worse.

Next the signalman phones the PICOP (P)

PICOP: X speaking

S: That tampers 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 .

S: Yes?

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.

There then follows a long and increasingly acrimonious argument where the driver clearly wants the Signaller to authorise him to pass the signal at danger.

S: 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, with 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

S: Yes

D: Thank you signaller for that. I'll carry that out.

After which the signaller gets onto the PICOP and asks ‘Where do you get these blokes from?' The PICOP explains the driver is off the region and is known as Charlie on the TRAMM.

This driver won't pass a signal without the signaller's permission because he's ultra cautions. ‘He's a pain in the bloody arse' comments the signaller.

But more is to come. The PICOP comes back on saying. ‘Am I getting grief or what?'

It seems that the tamper driver is still unhappy because he wants the signaller to formally give permission, instead of responding ‘yes' to the prompting.

‘He wants to hear the words, right. Your OK' says the PICOP. ‘Have a go at him, wake him up' he adds.

‘Well, I,' stalls the signaller.

‘'I've had his control on the phone asking what's going on', complains the PICOP. ‘F**** arsehole' replies the signaller.

When the driver calls in, still at the signal, he eventually he coaches the signaller in what he needs to hear.

S: ‘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”.

D: I will carry that out, thank you, message understood signaller.

The signaller then tells the PICOP what has happened, ending the transmission ‘Alright bruv, cheers ta'.

Now, it's hard to say what should have happened, for reasons I'll explain later. But this is my version

D: Hello Awre Junction, this is the driver of six Tango five seven six standing at Whiskey five four two signal at danger.

S: Driver of six Tango five seven six, pass your message, Awre Junction.

D: Tamper six Tango five seven six requests permission to pass Whiskey five four two signal at danger to enter possession.

S: six Tango five seven six has permission to pass Whiskey four five two signal at danger, report to PICOP before entering possession which is protected by flags and dets. Will notify PICOP of your arrival.

Driver: Permission given to pass Whiskey five four two signal at danger, report to PICOP before entering possession. Six Tango five seven six.

All done in not much over 30 seconds, compared with the seven and half page transcript of what really happened which takes around five minutes to read aloud.

 

Vernacular

Now as far as I know communications between drivers and signallers were always in mate-speak. ‘Eh up Bobby, I've been at this signal for ten minutes, what's going on'. And when radio supplemented signal post telephones no effort appears to have been made to update communications procedures, other than the use of protocols such as the phonetic alphabet.

This is odd, given that other services had been using radio effectively and professionally for decades. Oldsters will remember Z-cars.

Now, with GSM-R promising a standard voice and data communications network used by all parts of the industry, the importance of safety critical communications is greater than ever before. And the railway is struggling a bit to catch up, as the introduction shows.

 

Focus Group

Rail Safety & Standards Board set up a Safety Critical Communications focus Group (SCCFG) a year ago. Its objective is to ‘facilitate the progressive improvement of frontline operational communications'.

And it knows it has a task and half on its hands. The Group believes that to see ‘ a significant and long lasting improvement in the standard of safety critical communication' the railway industry's communication culture ‘must change'. The aim must be to ‘develop and maintain a culture where structured, disciplined communication is the norm'.

So far, RSSB has produced a Railway Group Standard and accompanying code of Practice (GE/RT 8406 Safety communications and GE/RT8546 Approve code of Practice Safety Communications). But these detail the management arrangements a duty holder must have in place to promote safety critical communications.

In other words they are about ensuring that staff are trained and monitored in communicating correctly, not what they are taught to say.

Similarly, Section 3 of the Rule Book is all about when and when not to communicate using telephone, radios or bell codes. But it doesn't tell you what to say or how to say it.

Extract from Rule Book

d) Using NRN in an emergency

You should use the emergency call facility to give advice for trains to be stopped immediately or cautioned in connection with an accident, obstruction or other exceptional incident.

 

If you have not spoken to the signaller because you used the emergency call procedure to speak to operations control, you must:

• bring your train to a stand immediately and tell the signaller using any available telephone

• carry out any protection of the line, if necessary, as shown in module M1 Train stopped by train accident, fire or accidental division

• not restart your train until you have received authority to do so from the signaller.

 

Procedures

What information is to be provided is specified as part of the procedures for specific activities elsewhere in the Rule Book. Thus the Tamper Driver was giving the correct information to the signaller but the signaller's section of the rule Book does not appear to contain a format for the reply.

One area where SCC is especially critical is the new T 12 possession, where people are carrying out short term work (no longer than 30min) on the track protected solely by signals. This is how the Rule book handles it. Section 3.1 sets the scene.

Before asking for the T12 protection the person arranging it must know the details of what is needed, including:

*the nature of the activity

* the location of the activity

* the time needed to complete the activity (no more than

30 minutes)

* the protecting signals

* the method of communication with the signaller.

 

They must also know whether the activity will be carried out beyond any points or crossover that

need to be used for train movements towards an unaffected route.

 

Next comes Section 3.2 Telling the signaller

‘The person planning the T12 protection must give the signaller the information described in section 3.1 before the protection is requested.

Section 4.3 covers the IWA (Individual Working Alone) or COSS (Controller of Site Safety) contacting the signaller.

First, the following i nformation has to be given to the signaller controlling the protecting signals:

* your name, employer and telephone number

* where you are speaking from

* the time.

The signaller has to reply with his telephone number.

 

Having established communications, Section 4.4 requires the IWA/COSS and the signaller to reach a complete understanding with each other about:

*the nature of the activity

* the locations between which the blockage will take place

*the time needed for the blockage

* the lines that need to be blocked to traffic

* whether any lines that need to be blocked are bi-directional

* which signals will be kept at danger to protect the activity

* whether any points are involved

* the time the activity will start.

 

They must also know clearly whether the activity will be carried out beyond any points or crossover that need to be used for train movements towards an unaffected route.

Finally a call-back time must be agreed for the IWA/COSS to report to the signaller on the progress of the activity.

 

HMRI active

Now while it is fashionable to anathematise the HMRI, they seem to be on the ball when it comes to this area of SCC. A s part of its Network Rail Intervention Plan (NRIP) for 2004/05 HMRI is tackling the subject of SCC and trackworker safety.

This year, the focus is specifically on the communications between signalers and COSS when setting up safe systems of work. This follows several recent potentially serious near-misses caused by a failure of communications between track workers and signalers.

Inspectors are examining transcripts of conversations between signalers and COSS, identifying any problems and then taking these up with the relevant duty holders.

Key issues for Inspectors are clarity, both in purpose and speech, correct use of protocols, whether the workers reached a good understanding of what was being done (or needed to be done) and where, and, finally, whether the workers reviewed and verified that they had reached a correct understanding at the end of the conversation.

 

SCCFG Review

Now, of course, few railway communications are as complex as setting up a T12 possession, but it seems to me that at all levels there is a lack of structure in what is said and how. This view is supported by the SCCFG.

As part of its remit the Group has proposed nine medium to long term objectives. All but one of them require action by ‘each industry partner'. The exception proposes a ‘fundamental review', in conjunction with RSSB, of the industry protocols for safety critical communications, the aim being to enhance the protocols where needed and develop ‘scripts or checklists to support their use'.

Current checklists are spread throughout the rule book under activities. Is there a case for bringing them together in a railway equivalent of the Civil Aviation Authorities Publication CAP 413 ‘Radio telephony manual'?

CAP 413 covers what is said, and how, in every conceivable situation. It also provides sample communications. This one is from the section on read back.

 

 

Of course you don't need aircraft. Here's a road vehicle which has to cross a runway.

 

But, a word of caution. While CAP 413 is a good example of how to handle SCC, we should not forget that here in the low-tech coming-on-for-two-centuries-old railway, some of the tasks handled by SCC are far more complex than anything needed in the air. Setting up a T12 possession for example.

Thus while simple tasks, like obtaining permission to pass a signal at danger, could be scripted, many procedures, especially where work on the track is involved, can't be done by rote. In a complex task negotiation or discussion of options can be involved and then people will need to drop into a conversation – which needs to be summed up in a safety critical manner.

SCCFG's review is urgently needed, but meeting the railway's needs will not be easy.

 

 

 

Current work

Meanwhile there is a lot going on to improve what we have. Network Rail has a Safety Critical Communications Resource Centre on its website, from which I have taken this poster. Also available is a wide range of supporting material for trainers.

For example, in the ‘Be first' SCC campaign staff are told to:

Say who you are and where you are

Say what you want

Listen carefully

Repeat back to confirm understanding

And, of course, use protocols.

But, once again this omits the important detail of how you say who ‘you' are and where you are and make the request. Fortunately, as observations of simulator training shows, the TOCs are filling in the gap for their train crew, but once again shouldn't everyone already be using the same procedures and checklists?

And, is the person to whom you are ‘listening carefully' giving the information you need in the sequence you expect.

 

Culture

When I went to see RSSB in September to research this piece I was shown a new video for use by trainers called ‘Bat it back'. This used humour and sporting metaphors to get across the importance of reading back messages.

It was clever and, I guess, different enough even to get attention during the post-lunch graveyard slot on a training course. But I can't help wondering who it is aimed at?

It's clearly useful as part of an induction course, but surely drivers, signallers and COSS should not need such elementary training? Or perhaps they do, given the horror story above.

All this is not to minimise the positive work being done by all parts of the industry on improving safety critical communications. But I do wonder about the focus on ‘culture'.

Railway people behave as they have been trained. Go on a work site and you get a safety briefing. Go on a work site where work has stopped for a press visit and you get a safety briefing. You get a safety briefing in the prescribed format because that is what the COSS been trained to do.

And this disciplined approach has been created in just over a decade. How long have safety critical communications been around in the railways? Long before air traffic control, my Great Grandfather was ringing the bell codes in Awre Junction box.

So it can be done and the people who give punctilious safety briefings are often the people who are dependent on SCC – possible for their lives. Perhaps there a lessons to be learned from track worker safety?

 

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